Moving exercise research in multiple sclerosis forward (the MoXFo initiative): Developing consensus statements for research.

Exercise as a subset of physical activity is a cornerstone in the management of multiple sclerosis (MS) based on its pleotropic effects. There is an exponential increase in the quantity of research on exercise in MS, yet a number of barriers associated with study content and quality hamper rapid progress in the field. To address these barriers and accelerate discovery, a new international partnership of MS-related experts in exercise has emerged with the goal of advancing the research agenda. As a first step, the expert panel met in May 2018 and identified the most urgent areas for moving the field forward, and discussed the framework for such a process. This led to identification of five themes, namely "Definitions and terminology," "Study methodology," "Reporting and outcomes," "Adherence to exercise," and "Mechanisms of action." Based on the identified themes, five expert groups have been formed, that will further (a) outline the challenges per theme and (b) provide recommendations for moving forward. We aim to involve and collaborate with people with MS/MS organizations (e.g. Multiple Sclerosis International Federation (MSIF) and European Multiple Sclerosis Platform (EMSP)) in all of these five themes. The generation of this thematic framework with multi-expert perspectives can bolster the quality and scope of exercise studies in MS that may ultimately improve the daily lives of people with MS.

[Conceptual Basis of Exercise Therapy in Medical Rehabilitation: Results of a National Survey in Germany]. / Konzeptionelle Grundlagen der Bewegungstherapie in der medizinischen Rehabilitation: Ergebnisse einer bundesweiten Bestandsaufnahme.

AIM: The aim of this article is to obtain nationwide information about contentual and conceptual characteristics of exercise therapy in medical rehabilitation. It investigates the question to what extend these characteristics differ, depending on indication fields and structural features of rehabilitation centres. METHODOLOGY: In a nationwide cross-sectional study, 1146 rehabilitation centres of all indication fields have been contacted in order to recruit exercise therapists in charge for a pseudonymised written survey. RESULTS: For the analysis, 713 questionnaires from 529 rehabilitation centres were consulted. Analysis of variance of the indication fields has shown significant differences in evaluation of influenceability of the rehabilitants' starting conditions as well as in the estimated importance of exercise-therapy-related content. Also structural features of the rehabilitation centres contributed to further clarification of variance. CONCLUSION: There is a contentual and conceptual variety in exercise therapy. Besides indication-specific differences, there are considerable variances which suggest differences between rehabilitation centres within the same indication field.

Systematic Review of Correlates and Determinants of Physical Activity in Persons With Multiple Sclerosis.

OBJECTIVE: To review the current evidence regarding correlates and determinants of physical activity (PA) in persons with multiple sclerosis (pwMS). DATA SOURCES: PubMed and Scopus (1980 to January 2015) and reference lists of eligible studies. STUDY SELECTION: Eligible studies include adults with multiple sclerosis; have a cross-sectional or prospective observational design; or examine the effect of a theory-based intervention trial on PA, including a mediation analysis. Eligible studies also apply a quantitative assessment of PA and correlates or proposed mediators and are published in English or German language. DATA EXTRACTION: Two reviewers independently evaluated the risk of bias, extracted data, and categorized variables according to the International Classification of Functioning, Disability and Health. DATA SYNTHESIS: Consistency and the direction of associations were evaluated with a semiquantitative approach. Fifty-six publications with data from observational studies and 2 interventional studies provided evidence for 86 different variables. Consistent correlates of PA were the disability level, walking limitations in particular, PA-related self-efficacy, self-regulation constructs, employment status, and educational level. One interventional study provided evidence for a causal relation between self-regulation and PA. However, 59 of the 86 investigated variables in observational studies are based on 1 or 2 study findings, and most results stem from cross-sectional designs. CONCLUSIONS: Beside the importance of the general disability level and walking limitations, the results highlight the importance of personal factors (eg, PA-related self-efficacy, self-regulatory constructs, sociodemographic factors). Limitations and implications of the current review are discussed. Research that is more rigorous is needed to better understand what affects PA in pwMS.

Internet-Supported Physical Exercise Training for Persons with Multiple Sclerosis-A Randomised, Controlled Study.

Physical exercise is effective in improving functional outcomes in persons with multiple sclerosis (pwMS). We evaluated the feasibility and effectiveness of internet-based exercise training (e-training) for pwMS on health-related quality of life (HrQoL). Secondary outcomes were muscle strength, aerobic capacity, lung function, physical activity, and fatigue. This is a randomised, controlled trial with a wait-list control group. Data were collected at baseline, after three and six months, and analysed using a hybrid linear model. One-hundred twenty-six pwMS participated in the home-based aerobic (1×/week) and strength training (2×/week) intervention that was supervised and documented via an internet-platform. The intervention group received e-training for six months, and the control group received e-training after a three months waiting period. Significant differences between the groups were only observed for muscle strength (knee flexion (effect size ES = 0.3, p = 0.003), knee extension (ES = 0.24, p = 0.015)), peak expiratory flow (ES = 0.2, p = 0.039), and sports activity (ES = 0.33, p = 0.001) after three months. E-training had no effect on HrQoL but did on muscle strength, lung function, and physical activity. It is a promising and feasible approach to facilitate large-scale, yet individual, training support.

Long-term physical activity in people with multiple sclerosis: exploring expert views on facilitators and barriers.

Purpose: To explore the views of experts on facilitators and barriers of long-term physical activity among people with multiple sclerosis living in different European countries.Methods: We conducted semi-structured telephone or face to face interviews with twelve multiple sclerosis and physical activity experts (scientists, practitioners, patient representatives) from five European countries. Interviews were audio-recorded, transcribed verbatim and analyzed using thematic analysis.Results: We identified 20 themes and categorized them into environmental and personal factors. The most frequently mentioned and intensively discussed themes were environmental factors. The themes were structured according to possible intervention level: organizational, interpersonal and intrapersonal level themes. Themes at the organizational level comprised availability, access and quality of exercise/physical activity options; health system characteristics like services and organization, health professionals and information provision. The interpersonal level comprised social support and peer support. Disease related factors were the most frequently mentioned intrapersonal level theme. In our study, more codes were obtained for environmental factors than for personal factors.Conclusions: The results suggested that environmental factors may need to be addressed in particular to increase long-term physical activity adherence. This study will inform the design of a survey questionnaire assessing possible barriers and facilitators among people with multiple sclerosis. Implications for rehabilitationLong-term physical activity among people with multiple sclerosis is subject to a number of modifiable determinants: personal and environmental factors.Multiple sclerosis exercise experts emphasized the importance of environmental factors on the organizational and interpersonal level.Future physical activity interventions should be guided by a social-ecological perspective.Addressing environmental and personal factors simultaneously to reach optimal long-term outcomes should be considered in future interventions.

Efficacy of an Internet-Based Program to Promote Physical Activity and Exercise after Inpatient Rehabilitation in Persons with Multiple Sclerosis: A Randomized, Single-Blind, Controlled Study.

BACKGROUND: Multimodal rehabilitation improves fatigue and mobility in persons with multiple sclerosis (PwMS). Effects are transient and may be conserved by internet-based physical activity promotion programs. OBJECTIVE: Evaluate the effects of internet-based physical activity and exercise promotion on fatigue, quality of life, and gait in PwMS after inpatient rehabilitation. METHODS: PwMS (Expanded Disability Status Scale (EDSS) ≤ 6.0, fatigue: Würzburg Fatigue Inventory for Multiple Sclerosis (WEIMuS) ≥ 32) were randomized into an intervention group (IG) or a control group (CG). After rehabilitation, IG received 3 months of internet-based physical activity promotion, while CG received no intervention. PRIMARY OUTCOME: self-reported fatigue (WEIMuS). SECONDARY OUTCOMES: quality of life (Multiple Sclerosis Impact Scale 29, MSIS-29), gait (2min/10m walking test, Tinetti score). MEASUREMENTS: beginning (T0) and end (T1) of inpatient rehabilitation, 3 (T2) and 6 (T3) months afterwards. RESULTS: 64 of 84 PwMS were analyzed (IG: 34, CG: 30). After rehabilitation, fatigue decreased in both groups. At T2 and T3, fatigue increased again in CG but was improved in IG (p < 0.001). MSIS-29 improved in both groups at T1 but remained improved at T2 and T3 only in IG. Gait improvements were more pronounced in IG at T2. CONCLUSIONS: The study provides Class II evidence that the effects of rehabilitation on fatigue, quality of life, and gait can be maintained for 3-6 months with an internet-based physical activity and exercise promotion program.

A systematic critical review of physical activity aspects in clinical guidelines for multiple sclerosis.

OBJECTIVE: This paper aims to evaluate the quality of clinical guidelines (CGs) for MS and to critically appraise physical activity-related recommendations. DATA SOURCES: Medical databases (MEDLINE, TRIP), clearinghouses, and guideline developers. An expert was asked to confirm if the list of CGs was complete. STUDY SELECTION: Evidence-based CGs specific to MS with recommendations including aspects of rehabilitation or physical activity were included. DATA EXTRACTION: Two reviewers independently first assessed the methodological quality of the CGs based on the 23 items of the Appraisal of Guidelines for Research and Evaluation Instrument version two (AGREE II) and second evaluated the physical activity-related content quality using an instrument containing 14 items that was used for the development of the National Recommendations for Physical Activity in Germany. DATA SYNTHESIS: For the AGREE II domains and the criteria for content quality, standardized domain scores were calculated. RESULTS: Three CGs were included. The average scores for the methodological quality of the domains were: scope and purpose (91%), stakeholder involvement (81%), rigor of development (78%), clarity of presentation (93%), applicability (53%), and editorial independence (83%). The mean scores for physical activity-related content quality did not exceed 56% for any criteria. CONCLUSIONS: Overall, this critical review shows that the methodological quality of CGs were moderate to good but physical activity-related content quality was heterogeneous and low. Results emphasize the need for more specific physical activity recommendations that incorporate multiple aspects of physical activity prescription.

Exercise therapy in medical rehabilitation: Study protocol of a national survey at facility and practitioner level with a mixed method design.

BACKGROUND: The importance of physical activity and the orientation of exercise therapy in rehabilitation has changed for many chronic health conditions. Exercise therapy is the most applied therapy form within multidisciplinary rehabilitation programs for almost all chronic health conditions. Despite the scientifically discussed need to refine exercise therapy, there is relatively little knowledge of how exercise therapy is actually conducted. This study protocol describes the methodological procedure used in the project "Exercise therapy in medical rehabilitation: a survey at facility and practitioner level", which aims to take a national survey of exercise therapy in rehabilitation practice in Germany. METHODS: The project was implemented using an explanatory sequential mixed method design. Quantitative and qualitative methods were integrated in two consecutive project phases. Phase 1 used a standardized, quantitative written survey of the heads of exercise therapy departments to compile a national overview of concepts and process features of exercise therapy of individual rehabilitation facilities. Phase 2 recorded individual perspectives and opinions concerning exercise therapy goals, content and methods and current developments in the rehabilitation context (e.g., physical activity promotion, interdisciplinarity, standardization) of exercise therapy practitioners. Over the course of two one-and-a-half day workshops, central themes were introduced and prepared with standardized written individual surveys from Phase 1 and combined with qualitative surveys using facilitated group discussions (focus groups in mixed methods design). DISCUSSION: The project generates a comprehensive picture of exercise therapy in medical rehabilitation at facility level and inserts further information at the practitioner level into this context. The chosen methodology of a mixed method design combines the perspective of the facility with that of the practitioner, thus allowing for a complex and multifaceted description of the status quo in exercise therapy practice and makes it possible to identify facilitators and barriers for the refinement of exercise therapy in specific everyday rehabilitation. These findings form the basis for the systematic development of quality exercise therapy in rehabilitation, in particular in terms of the refinement, implementation and dissemination of biopsychosocial concepts of exercise therapy.

Effects of a brief, pedometer-based behavioral intervention for individuals with COPD during inpatient pulmonary rehabilitation on 6-week and 6-month objectively measured physical activity: study protocol for a randomized controlled trial.

BACKGROUND: Pulmonary rehabilitation programs often fail to substantially enhance long-term physical activity in patients with chronic obstructive pulmonary disease (COPD). The reasons for successful physical activity changes in patients with COPD are not well understood. The need to better understand the determinants of physical activity in patients with COPD and effective rehabilitation strategies to improve physical activity is evident. METHODS/DESIGN: The STAR study (Stay Active after Rehabilitation) investigates, in a randomized controlled trial, the additional effect of a pedometer-based behavior-change intervention during inpatient pulmonary rehabilitation on objectively measured physical activity 6 weeks and 6 months post rehabilitation. The intervention uses the behavior-change techniques (1) instruction on how, where and when to perform the behavior, (2) prompt goal setting for physical activity, (3) prompt self-monitoring of behavior, and (4) feedback on behavior. The primary outcome of physical activity will be measured using a physical activity monitor (Actigraph wGT3X-BT) for a period of 7 days, firstly 2 weeks before rehabilitation begins (t0) as well as 6 weeks and 6 months after rehabilitation (t3, t4). Additionally, to predict physical activity progression after rehabilitation, a complex personal diagnostics battery, including questionnaires as well as functional assessments, is to be carried out at the start and end of rehabilitation (t1, t2). This battery is based on the foundational ideas of the Physical Activity-Related health Competence model. Five hundred and two patients with COPD, aged 18 years or older and admitted for an approved pulmonary rehabilitation, will be enrolled in the STAR study. DISCUSSION: The STAR study is designed as a randomized controlled trial to gain a better understanding of the personal determinants of physical activity in patients with COPD and to evaluate a pedometer-based physical activity-change intervention in the context of inpatient pulmonary rehabilitation. The results enable the future identification of patients with COPD who will find it difficult to engage in long-term physical activity after rehabilitation. Based on this, intervention strategies to promote physical activity in the content of pulmonary rehabilitation can be optimized. TRIAL REGISTRATION: Clinicaltrials.gov, ID: NCT02966561 . Registered retrospectively after the start of the recruitment in June 2016 on 22 November 2016. All protocol modifications will be registered in the trial registry.