Davis, Cindy
(2008)
Physiotherapy or self-selected exercise in multiple sclerosis: a comparative evaluation of community-based interventions.
PhD thesis, University of Nottingham.
Abstract
Multiple Sclerosis is a major cause of neurological disability in the population of the UK with an incidence of 2,500 new cases diagnosed each year. The estimated number of people affected with MS in the UK is currently believed to be 85,000. (MS Trust 2006). The disease affects those in the prime of their lives as well as those more advanced in years. The reality of living with a progressive neurological condition requires self-management strategies as well as professional involvement. One method of encouraging self-management is the use of exercise to ameliorate some of the problems presented by MS and thus to encourage independence.
This study was developed to compare the effects of a home-based physiotherapy exercise programme against readily accessible self-selected exercise opportunities. It was conducted entirely in the community with a convenience sample of 40 subjects recruited from the caseload of the Rehabilitation Medicine Service in Lincolnshire, 39 people eventually completed the study. The participants were of mixed MS presentations but were capable of fulfilling the exercise requirements of the study.
The study was in two parts, a pre-exercise phase and an exercise phase. Assessments were carried out at three stages during the study at week 1, week 12 and week 36. A baseline assessment taken at study onset, focused on physical function using the Amended Motor Club Assessment, (AMCA), as the primary outcome variable. The Health Assessment Questionnaire, (HAQ) and Timed Walk were also used to assess function. Muscle tone and muscle strength, were assessed using the Modified Ashworth Scale, (MAS), and the Medical Research Council, (MRC), strength scale. Psychological state was gauged using the MSQOL 54 and a Numerical Rating Scale. Symptom presentation was assessed using the Guys Neurological Disability Scale, (GNDS). The participants were given a journal at week 1 and this remained with the participant until week 36. It was returned to the researcher after the final assessment. Indications of psychological state and exercise experiences were extracted from the journals where unfettered comments regarding the regimes and any other MS or personal issues were recorded. The first and second assessments were carried out by the investigator. The third assessment was completed by one of the two independent physiotherapy assessors.
Phase one of the study, the pre-exercise phase, extended over 12 weeks during which time educational material plus the MS Trust booklet “Tips to Living With MS” was distributed. This time also provided a washout period negating the effects of previous exercise involvement.
In phase two the participants joined their respective exercise groups. Group 1 participants received the home physiotherapy programme consisting of a three-part exercise regime administered over eight weeks. The regimes included exercises in lying, sitting, standing with a strengthening element using red, medium strength theraband. The group 2 participants selected their own activity regime providing it was compatible with their exercise capabilities. The activities selected included progressive walking, gym attendances, swimming, Pilates, yoga and motorcise, a motorised cycling routine. The exercise phase lasted for 24 weeks. Total study involvement lasted for 36 weeks.
The results from the pre exercise phase indicated that there were no improvements in physical or psychological function except a perceived improvement in symptom presentation as shown by a significant improvement in the GNDS score. This could be attributable to the nature of the information offered and the previous extensive knowledge already in the possession of the participants.
Exercise positively influenced the AMCA, the primary outcome variable in both groups but the benefit of one approach over the other was not conclusively demonstrated. Physiotherapy appeared to produce significantly better results than self-selection in the HAQ, the NRS, lower limb tone, and lower limb strength. The Timed Walk did not improve in either group. Neither group showed improvement after exercise on the GNDS. The MSQOL 54 was affected but significant differences were only seen in one domain in each of the two groups. Supporting evidence from analysis of the participants’ journals indicated the desire for exercise and showed subjectively how those in the study benefited from it. These results did not offer definitive proof as to the most beneficial regime but they provided compelling evidence to support the relevance of exercise to those with MS to maintain physical and psychological wellbeing.
A follow-up questionnaire was issued to each participant 26 weeks after the study completion to assess whether they had continued to exercise. Of the 39 people who completed the study, 34 responded to the follow-up questionnaire. Of these 34 people, 33 were still engaging in some type of exercise indicating that the changes necessary to embed the new behaviour had been successfully achieved.
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