Friday, 6 March 2015

ClinicSpeak: impact of exercise on walking

Can we afford to continue to ignore the positive effect exercise has on MS? #ClinicSpeak #MSBlog #MSResearch

"The meta-analysis below shows that exercise improves walking speed and endurance in MSers. This is another piece of evidence that supports exercise as such an important part of the management of MS. In addition to physical performance exercise also boosts cognitive outcomes and boosts cognitive reserve. I can't think of any reason why MSers should not exercise, even MSers with disability. There is an exercise programme for everyone."

"Yesterday, thanks to you I won a debate making the case for pelvic floor exercises in all MSers. My case was based on the argument that pelvic floor exercises are simply part of a general exercise programme and supported by evidence that it improves bladder function and possibly sexual dysfunction. Why wouldn't you do pelvic floor exercises? As with all lifestyle interventions is how do you get people to do exercise and adhere to a long-term exercise programme? All ideas and suggestions welcome."

"If you have not sure how to start an exercise programme please ask your MS team to refer you to the physiotherapists."

Epub: Pearson et al. Exercise as a therapy for improvement of walking ability in adults with multiple sclerosis: A meta-analysis. Arch Phys Med Rehabil. 2015 Feb 21.

OBJECTIVE: To quantify improvements in walking performance commonly observed in patients with Multiple Sclerosis (pwMS). A systematic literature search and meta-analysis was conducted quantifying the expected benefits of exercise on walking ability in pwMS.

DATA SOURCES: Potential studies were identified by systematic search using PubMed (1966 to 31st March, 2014), EMBASE (1974 to 31st March, 2014), CINAHL (1998 to 31st March, 2014), SPORTSDiscus (1991-31st March, 2014) and the Cochrane Central Register of Controlled Trials (1966 to 31st March, 2014). The search used key concepts of "Multiple Sclerosis" AND "exercise".

STUDY SELECTION: Randomised controlled trials of exercise training in adult patients with MS.

DATA EXTRACTION: Data on patient and study characteristics; walking ability; 10metre walk test (10mWT); Timed 25-foot walk test (T25FW); 2 minute walk test (2MWT); 6 minute walk test (6MWT); Timed up and go (TUG) were extracted and archived.

DATA SYNTHESIS: Data from 13 studies were included. Exercise produced significant improvements in walking speed, measured by 10mWT, mean difference (MD) reduction in walking time of -1.76 seconds (95%CI -2.47 to -1.06, p<0.001), but no change in the T25FW MD = -0.59s (95%CI -2.55 to 1.36, p=0.55). Exercise produced significant improvements in walking endurance as measured by 6MWT and 2MWT, with increased walking distance of MD=36.46 metres (95%CI 15.14 to 57.79, P<0.001) and MD=12.51 metres (95%CI 4.79 to 20.23, p=0.001), respectively. No improvement was found for TUG MD = -1.05s (95% CI -2.19 to 0.09, p=0.07).

CONCLUSIONS: Our meta-analysis suggests exercise improves walking speed and endurance in pwMS.

CCSVI should be dropped?

Tsivgoulis G, Faissner S, Voumvourakis K, Katsanos AH, Triantafyllou N, Grigoriadis N, Gold R, Krogias C. "Liberation treatment" for chronic cerebrospinal venous insufficiency in multiple sclerosis: the truth will set you free. Brain Behav. 2015; 5:3-12.
BACKGROUND:Chronic cerebrospinal venous insufficiency (CCSVI) has recently been introduced as a chronic state of impaired cerebral or cervical venous drainage that may be causally implicated in multiple sclerosis (MS) pathogenesis. Moreover, percutaneous transluminal angioplasty of extracranial veins termed "Liberation treatment" has been proposed (based on nonrandomized data) as an alternative therapy for MS.
METHODS: A comprehensive literature search was conducted to identify available published, peer-reviewed, clinical studies evaluating (1) the association of CCSVI with MS, (2) the reproducibility of proposed ultrasound criteria for CCSVI detection (3) the safety and efficacy of "Liberation treatment" in open-label and randomized-controlled trial (RCT) settings.
RESULTS: There is substantial heterogeneity between ultrasound case-control studies investigating the association of CCSVI and MS. The majority of independent investigators failed to reproduce the initially reported high prevalence rates of CCSVI in MS. The prevalence of extracranial venous stenoses evaluated by other neuroimaging modalities (contrast or MR venography) is similarly low in MS patients and healthy individuals. One small RCT failed to document any benefit in MS patients with CCSVI receiving "Liberation treatment", while an exacerbation of disease activity was observed. "Liberation treatment" has been complicated by serious adverse events (SAEs) in open-label studies (e.g., stroke, internal jugular vein thrombosis, stent migration, hydrocephalus).
CONCLUSION: CCSVI appears to be a poorly reproducible and clinically irrelevant sonographic construct. "Liberation treatment" has no proven efficacy, may exacerbate underlying disease activity and has been complicated with SAEs. "Liberation treatment" should stop being offered to MS patients even in the settings of RCTs.

No comments needed. Are there any RCTs on the go?

ClinicSpeak: pelvic floor excercises

I won the debate; all MSers should do pelvic floor exercises. #MSBlog #MSResearch #ClinicSpeak

Urgent survey needed for a public debate. #MSBlog #MSResearch #ClinicSpeak

Did you know pelvic floor exercises help with sexual dysfunction? #MSBlog #MSResearch #ClinicSpeak


"I won the debate and made the argument that as part of routine MS practice all MSers should be informed of the benefits of exercise and pelvic floor exercises. This recommendation is based on evidence and the fact that pelvic floor exercises are cheap and can be included as part of a self-management programme."

Debate: Pelvic floor exercises should be recommended to all patients with bladder and/or sexual dysfunction. 

For: Prof Gavin Giovannoni /  Against: Dr James Overell.

"There is an emerging literature on the subject. Do any of you have experience with this form or therapy? I would appreciate it if you could let me know via this short survey if you have heard of this treatment or not? Have you been offered it or not? If you have has it been of benefit or not? I have been researching the issue and it occurred to me that everyone with MS should be made aware of this topic and sex, a form of exercise, could be defined as part of a pelvic floor exercise programme. This topic falls into my holistic approach to MS very well. "

Aims: Evaluate the role of Pelvic Floor Muscle Training (PFMT) on the treatment of Lower Urinary Tract Dysfunction (LUTD) in Multiple Sclerosis (MS) patients.

Methods: In this randomized controlled trial, twenty seven female patients with a diagnosis of MS and LUTD complaints were randomized, in two groups: Treatment group (GI) (N = 13) and Sham group (GII) (N = 14). Evaluation included urodynamic study, 24-hr Pad testing, three day voiding diary and pelvic floor evaluation according to PERFECT scheme. Intervention was performed twice a week for 12 weeks in both groups. GI intervention consisted of PFMT with assistance of a vaginal perineometer. GII received a sham treatment consisted on the introduction of a perineometer inside the vagina with no contraction required.

Results: At the end of the treatment GI was complaining less about storage and voiding symptoms than GII. Furthermore, differences found between groups were: reduction of pad weight (P = 0.00) (Mean: 87,51 grams initial and 6,03 grams final in GI. 69,46 grams initial and 75,88 grams final in GII), number of pads (P = 0.01) (Mean: 3,61 initial and 2,15 final in GI. 3,42 initial and 3,28 final in GII) and nocturia events (P < 0.00) (Mean: 2,38 initial and 0,46 final in GI. 2,55 initial and 2,47 final in GII) and improvements of muscle power (P = 0.00), endurance (P < 0.00), resistance (P < 0.00) and fast contractions (P < 0.00), domains of PERFECT scheme.

Conclusions: PFMT is an effective approach to treat LUTD in female with MS.

Paper 2

OBJECTIVE: To compare pelvic floor muscle training and a sham procedure for the treatment of lower urinary tract symptoms and quality of life in women with multiple sclerosis. 

METHODS: Thirty-five female patients with multiple sclerosis were randomized into two groups: a treatment group (n = 18) and a sham group (n = 17). The evaluation included use of the Overactive Bladder Questionnaire, Medical Outcomes Study Short Form 36, International Consultation on Incontinence Questionnaire Short Form, and Qualiveen questionnaire. The intervention was performed twice per week for 12 weeks in both groups. The treatment group underwent pelvic floor muscle training with assistance from a vaginal perineometer and instructions to practice the exercises daily at home. The sham group received a treatment consisting of introducing a perineometer inside the vagina with no exercises required. Pre- and post-intervention data were recorded. 

RESULTS: The evaluation results of the two groups were similar at baseline. At the end of the treatment, the treatment group reported fewer storage and voiding symptoms than the sham group. Furthermore, the differences found between the groups were significant improvements in the following scores in the treatment group: Overactive Bladder Questionnaire, International Consultation on Incontinence Questionnaire Short Form, and the General Quality of Life, and Specific Impact of Urinary Problems domains of the Qualiveen questionnaire. 

CONCLUSIONS: The improvement of lower urinary tract symptoms had a positive effect on the quality of life of women with multiple sclerosis who underwent pelvic floor muscle training, as the disease-specific of quality of life questionnaires demonstrated. This study reinforces the importance of assessing quality of life to judge the effectiveness of a treatment intervention.

Paper 3

Vahtera et al. Pelvic floor rehabilitation is effective in patients with multiple sclerosis. Clin Rehabil August 1997 vol. 11 no. 3 211-219.

Objective: To determine the effect of pelvic floor muscle exercises combined with electrical stimulation of pelvic floor on lower urinary tract dysfunction in MSers with near normal (<100 ml) postvoid residual volumes.

Design: Open, controlled, randomized study in two parallel groups.

Setting: Rehabilitation centre for MSers.

Subjects: Fifty women and 30 men with definite MS and current symptoms of lower urinary tract dysfunction.

Outcome: The muscle activity of the pelvic floor muscles was tested using surface EMG. Subjective urinary symptoms were assessed using a questionnaire.

Interventions: Pelvic floor muscles were stimulated using electrical stimulation at six sessions. During and after the final session the MSers were taught to exercise their pelvic floor muscles and advised to continue these exercises regularly for at least six months. The control group was not treated.

Results: The maximal contraction power and endurance of the pelvic floor muscles increased after six sessions of electrical stimulation with interferential currents. Symptoms of urinary urgency, frequency and incontinence were significantly less frequent in the treated group than in the untreated subjects. Male MSers appeared to respond better to the treatment than female MSers. Compliance with the pelvic floor exercises was over 60% at the end of a follow-up for six months. Most drop-outs were due to the disappearance of urinary tract symptoms or to severe relapses in MS.

Conclusions: The present study indicates that pelvic floor muscle exercises combined with electrical stimulation of the pelvic floor constitute an effective treatment for lower urinary tract dysfunction at least in male MSers with MS.