Exercise as it relates to Disease/Reducing falls in MS patients: Exercise beyond the therapy room

This is a critique of the journal article "Home-based exercise program and fall-risk reduction in older adults with multiple sclerosis: phase 1 randomized controlled trial" by Sosnoff et al 2013.

What is the background to this research?
There is a high incidence of falls that occur in patients with Multiple Sclerosis. Greater than 50% of people who suffer from MS report an incident of falling over a 6 month period. Currently there are approx. 23 000 people in Australia diagnosed with MS and over two million worldwide. The disease primarily affects those aged 20-40 however the prevalence of falls are greater in older adults with the disease.

What is Multiple Sclerosis?

MS is the most common inflammatory demyelinating disease of the CNS with the mean age of onset approx. 30 years old. The pathogenesis of MS is complex with the primary hallmark of the disease being lesions or 'plaques' forming on various aspects of the white and grey matter of the brain. Clinical symptoms vary greatly depending on the location of the lesion and is therefore difficult to identify however falls and impaired balance are a common issue associated with the disease. There are 4 types of MS including:

a) Benign

b) Relapsing-Remitting

c) Primary Progressive

d) Secondary Progressive

Whilst supervised exercise programs have been shown to decrease the incidence of falls in those suffering MS, these interventions are costly and there is emerging evidence highlighting that a home based exercise program is a feasible alternative.

Where is the research from?
The research was conducted at the following institutions:

a)   Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign Illinois.

b)   School of Rehabilitation Therapy, Queens University, Kingston, Ontario, Canada.

c)    School of Physical Therapy and Athletic Training, Old Dominion University, Norfolk, Virginia, USA.

The research received funding and support from the Consortium of Multiple Sclerosis Centres.

What kind of research is this
This study design was a two arm Randomised Controlled Trial spanning a period of 12 weeks. The two groups were the home based exercise group vs a wait list control. A randomised controlled trial allocates participants at random to either the intervention or control group. RCT's are useful in accurately determining the effect of an intervention compared to a control group however are limited by ethical, practical and financial constraints.

What did the research involve?
27 participants with MS were recruited for the study. To be eligible for the trial participants had to meet both inclusion and exclusion criteria demands.

Inclusion Criteria:

1.    Neurologist-confirmed diagnosis

2.    Ability to walk 25 feet independently or with a cane, crutch or walker

3.    Comprehension of written and spoken English

4.    Self-reported fall in the last 12 months

5.    Range in age from 50-75

6.    Live within a 125 mile radius of the research centres

7.    Had been relapse free for 30 days prior to participation

Exclusion Criteria:

1.    Non-Ambulatory

2.    Reported no falls in the last 12 months

3.    Outside the age range

4.    Lived outside the catchment area

5.    Had a relapse within 30 days of baseline assessment

Participants underwent two assessments: Baseline and post intervention. The primary outcome measure used was fall risk score as determined by the short form of the Physiological Profile Assessment. The PPA is a battery that assesses vision, lower limb proprioception, strength, postural sway and cognitive function. Each outcome was assessed individually and combined to generate an overall fall risk score with higher scores indicative of a greater risk of falling.

What were the basic results?
The study highlighted that there was a significant difference between groups in the PPA fall risk score at the end of the intervention when compared to the control group.

a)   Overall the exercise group had a lower fall risk score than the control group (0.73 vs 1.9) following the intervention.

b)   There was a significant between group difference in postural sway assessment at the end of the intervention (22.1mm vs 51.5mm).

c)    Significant group difference in balance confidence at retest was revealed.

d)   Significant between group difference in the timed 25 foot walk at the end of the intervention.

e)   The exercise group had a faster walk time than the control group.

f)    While there was no between group differences in the number of fallers prior to the intervention there was a greater proportion of fallers in the control group vs the exercise group during the intervention (94% vs 50%).

g)   No significant difference in the TUG, 6MWT or MS walking scale scores.

How did the researchers interpret the results?
The authors of this study have interpreted that in the older adult population group suffering from multiple sclerosis a home based exercise program was a safe and feasible option to reducing falls. This was seen through significant reductions in the falls risk score. They also noted differences between groups for both confidence and walking speed however this was believed to be due maintenance of function rather than improvements in the exercise group.

What conclusions can we take from this research?
This research has deciphered that a home based exercise program is a safe and feasible option for reducing falls in patients with multiple sclerosis. There is a growing body of literature emphasising the importance of exercise for patients with MS. For those patients who are either financially limited to the capacity of supervised intervention or for those who live in rural areas / cannot access therapy appointments a home based program targeted at improving balance is appropriate. Further research is indicated to determine whether a home exercise program is equal to supervised intervention and to determine the specific effects of different interventions.

Practical advice ?
For clinicians who have limited access to their patients with MS, a home based exercise program targeting balance and strength is appropriate in reducing falls and maintaining function.

Further information/ resources ?
For further information regarding MS and how to best manage it, visit the links below:

https://www.msaustralia.org.au/

http://brainfoundation.org.au/disorders/multiple-sclerosis

https://www.physiotherapy.asn.au/APAWCM/The_APA/National_Groups/Neurology/APAWCM/The_APA/National_Groups/Neurology.aspx?hkey=e61c59fd-0b6c-4ea4-a33f-f964dd92861f

https://www.msif.org/