Multiple Sclerosis Rehabilitation: A Systematic Review and Dose-Response Meta-Analysis

Iris Brunner^*
*Correspondence: Iris Brunner, Department of Medicine, Hammel Neurorehabilitation Centre and University Research Clinic, University of Aarhus, Denmark, Email:

Introduction

Balance deficits, defined as difficulty in keeping an upright position under static, demanding, or reactive postural control circumstances, are common in people with Multiple Sclerosis (PwMS), resulting in falls in 46% of PwMS over the course of six months. Balance problems and falls have highlighted the need of balance rehabilitation. The intervention site, disability, and type of treatment all have the potential to affect the outcomes of balance rehabilitation; nevertheless, two crucial elements are the treatment methodologies and intervention dose. Several rehabilitation treatments have been developed in recent decades to enhance balance in people with Parkinson's disease [1,2].

Even though a variety of rehabilitation methods have been shown to work, it is important to know how much improvement in mobility and balance can be achieved by increasing the therapeutic dose. "The amount of active ingredient(s) expected to produce the desired effect and the frequency and duration at which the agent is taken" can be used to define the dose. According to Kwakkel, dose is a crucial and complex factor that influences the effectiveness of therapeutic interventions, including their frequency, intensity, duration, and timing. For evidence-based practice to be implemented and interventions to be more effective [3], it is essential to know the best dose for a given therapeutic intervention. The test of finding the best portion for recovery is that the dynamic fixings, their objectives and components of activity stay indistinct hampering the advancement of hypothetical models on restoration. Proof about the fitting portion of restoration mediations is horribly missing for neurological illnesses. Only a few studies on brain injury and stroke rehabilitation support contradictory findings regarding the dose-response relationship between high practice intensity and improved outcomes. However, Lohse et al.'s review showed a strong positive correlation between dose and response, indicating that therapy time is a strong predictor of recovery in stroke patients across interventions. The lack of an appropriate dose for rehabilitation interventions is emphasized in international clinical guidelines for multiple sclerosis rehabilitation. According to our knowledge, only two studies on balance intervention in PwMS suggest that rehabilitation programs that include a high dose of challenging balance exercise may have the greatest impact on balance outcomes, despite the absence of a formal analysis of the dose-response relationship in PwMS mobility and balance interventions [4,5].

As a result, our systematic review aims to: i) determining whether or not balance interventions are effective, ii) determining the relationship between the effect of dose and rehabilitation on balance outcomes, and iii) locating variables that may have an impact on balance interventions in PwMS. Strategy for the search From the beginning to January 2021, we searched the following databases for relevant literature: MEDLINE, Embase, the CENTRAL database of the Cochrane Library, Scopus, the Web of Science, and the PEDro Database. Discussions among the study authors led to the creation of appropriate keywords and MeSH headings. We also manually searched the reference list of included articles and reviews that had already been published to find articles that were not covered by the databases search. In addition to the literature search, Google Scholar searches and citation lists of the articles that were returned were used [3].

Selection of the study

Two reviewers—GP and CC—screened each article's title and abstract independently. Following this step, potentially relevant articles were retrieved for full-text evaluation, and the same reviewers independently evaluated each potential full-text paper to determine which studies were eligible. In case of conflict, a third commentator (EG) assessed the article to accomplish a joint agreement. Statistical analysis Random-effects models weighted by inverse variance were used to calculate the pooled effect size (ES) in accordance with the DerSimonian and Laird procedure. The sample size is the number of participants in the experimental group and the control group as well as the number of participants who dropped out. It also includes the name of the first author. In order to summarize studies using the same balance scale, we estimated the pooled ES of interventions using either standardized mean difference (SMD) or mean difference (MD). We used the bias-corrected Hedges' g to estimate SMD because of the small sample size of the included studies. This yields more conservative results than a Cohen's d with an additional correction factor for small samples. Positive ESs indicated that the experimental intervention improved balance more than the control intervention [4].

The Cochran's Q-value and the I2 index were used to measure heterogeneity and variance between studies, respectively. We regarded I2 values below 40 percent as marginal, 30 to 60 percent as moderate, and 50 to 90 percent as substantial heterogeneity. On the assumption that studies demonstrating a lack of benefit might not have been published, the Egger's test of asymmetry and Orwin's fail-safe N test for estimating the number of missing studies to be incorporated to make the observed ES trivial were used to assess the risk of publication bias. When the balance was not established as the primary endpoint, we carried out a sensitivity analysis to verify our findings [5].

Discussion

This is, to the best of our knowledge, the first systematic review and meta-analysis of randomized controlled trials that aims to quantify the dose– response relationships of balance intervention for various dose characteristics (intensity, duration, and frequency) in PwMS. Balance interventions have a moderate effect on balance outcomes, according to this review, which provides evidence of the short-term efficacy of physiotherapy for the treatment of multiple sclerosis. Even though the majority of the differences between the two treatment groups were medium, the Berg Balance Scale showed improvements that were clinically significant. Our first meta-relapse examination uncovered areas of strength for an in power balance results, proposing more grounded impacts in preliminaries having treatment meetings enduring in excess of 40 min. Additionally, not all treatments result in the same outcomes: guidelines that are task-oriented. Significantly improved PwMS mobility and balance [3].

Adequacy of equilibrium intercession

Results on the 20 RCTs with 'deduced' characterized balance-based endpoint showed a practically medium impact size (SMD = 0.41) leaning toward intercessions zeroed in on further developing portability and equilibrium abilities substantiating discoveries from a past meta-examination on PwMS showing a SMD of 0.55. According to the three-point BBS cut-off score established by Gervasoni et al., a more in-depth examination of the studies with BBS as the primary outcome revealed clinically significant improvement as well as a difference of minimal clinical significance. This appears to be a consistent improvement considering the total duration of the test ranges between 7 and 25 s for PwMS, but results for dynamic balance measured by TUG are less clear, with a difference between groups of approximately 1.2 but estimation inconstancy was huge to give an exact assessment of MD and no slice off score is accessible to characterize a clinically significant improvement. Although more research is needed to better understand the impact of rehabilitation on dynamic balance, quality of life, social participation, depression, and anxiety— all outcomes that are frequently overlooked in RCTs—the results suggest that a physiotherapy intervention may have a clinically significant effect on balance during transfers and static postures. Notably, when the balance was not the primary outcome, we found no clinically significant changes and a small effect size, indicating that the specificity of the intervention is an important factor in the effectiveness of the balance intervention. This was at that point brought up in a previous report showing that explicitness of mediation improves multiple times the probability of a clinically significant enhancement for the BBS contrasted with vague treatment. When compared to generic exercises, this emphasizes the significance of individualized treatment. Even though efforts have been made to establish a consensus on the best practices for multiple sclerosis rehabilitation over the past ten years, no clear recommendations have been made regarding how to treat this complicated condition in a way that tailors interventions to a particular person's complaints, lifestyle, and interests rather than taking a “one size fits all” approach [5].

Conclusion

The findings of our review provide level I evidence regarding the effects of a balance intervention on MS patients' mobility and balance. PwMS often present with mobility impairments and falls, so it is essential to prescribe and provide physiotherapy to improve mobility and balance. Our findings are consistent with two fundamental tenets of neurological rehabilitation, namely that the level of practice (dosage) and the specificity of the intervention are two essential components of motor recovery. According to task-oriented principles, it would appear that a high dosage of rehabilitation interventions lasting longer than 40 minutes should be specifically provided to improve balance impairments. To develop recommendations for balance and gait treatment for clinicians treating PwMS, additional high-quality experimental studies with large samples and longer follow-ups are required. A new rehabilitation intervention taxonomy would also make it easier to categorize balance interventions.

Acknowledgement

None.

Conflict of Interest

Not applicable.

References

1. Picelli, Alessandro, Stefano Tamburin, Michele Passuello and Andreas Waldner, et al. "Robot-assisted arm training in patients with Parkinson’s disease: A pilot study." J Neuroeng Rehabil 11 (2014): 1-4.

Google Scholar, Crossref, Indexed at

2. Hachem, Laureen D., Christopher S. Ahuja and Michael G. Fehlings. "Assessment and management of acute spinal cord injury: From point of injury to rehabilitation." J Spinal Cord Med 40 (2017): 665-675.

Google Scholar, Crossref, Indexed at

3. Ontaneda, Daniel, Alan J. Thompson, Robert J. Fox and Jeffrey A. Cohen. "Progressive multiple sclerosis: Prospects for disease therapy, repair, and restoration of function." Lancet 389 (2017): 1357-1366.

Google Scholar, Crossref, Indexed at

4. Tamburin, Stefano, Stefano Paolucci, Francesca Magrinelli and Massimo Musicco, et al. "The Italian consensus conference on pain in neurorehabilitation: Rationale and methodology." J Pain Res 9 (2016): 311-318.

Google Scholar, Crossref, Indexed at

5. Maki, Yohko, Takashi Sakurai, Jiro Okochi and Haruyasu Yamaguchi, et al. "Rehabilitation to live better with dementia." Geriatr Gerontol Int 18 (2018):1529-1536.

Google Scholar, Crossref, Indexed at