To identify the extent to which exercise intervention studies in multiple sclerosis rehabilitation are addressing comorbidities and if researchers consider comorbidities as possible moderators or mediators of exercise outcomes.
Methods:
Five databases were searched from inception to January 8, 2016, for exercise-related terms in combination with multiple sclerosis. Studies were screened and limited to randomized control trials, full text, and English language. We assessed whether comorbidities were excluded or included, how they were reported and described, and if they were examined as possible moderators or mediators of exercise outcomes.
Results:
We reviewed 99 articles that included various exercise interventions, where the most common were general multi-faceted exercise training (n=34), cardiovascular training (n=18), progressive-resistance training (n=12), and balance and gait training (n=12). In total, 77 of 99 studies reported one or more comorbidities as an exclusion criterion. The most commonly excluded comorbidities were cardiovascular diseases, cognitive impairments or psychiatric disorders, and unspecified conditions or contraindications. Only nine studies reported details on excluded participants with comorbidities. Across studies that reported comorbidities of included participants (n=8), none examined comorbidities as possible moderators or mediators of exercise outcomes.
Conclusion:
Although a variety of exercise interventions have positive outcomes, there is limited evidence that these interventions are generalizable to people with multiple sclerosis who have comorbid conditions.
SandroffBMDlugonskiDWeikertMSuhYBalantrapuSMotlRW.Physical activity and multiple sclerosis: new insights regarding inactivity. Acta Neurol Scand. 2012; 126: 256–262.
2.
MotlRW.Physical Activity and Irreversible Disability in Multiple Sclerosis. Exerc Sport Sci Rev. 2010; 38: 186–191.
3.
MotlRW.The Importance of Physical Fitness in Multiple Sclerosis. J Novel Physiother. 2013; 3:2.
4.
MotlRWMcAuleyE.Physical activity and health-related quality of life over time in adults with multiple sclerosis. Rehabil Psychol. 2014; 59: 415–421.
5.
MotlRWFernhallBMcAuleyECutterG.Physical activity and self-reported cardiovascular comorbidities in persons with multiple sclerosis: evidence from a cross-sectional analysis. Neuroepidemiology. 2011; 36: 183–191.
6.
MarrieRACohenJStuveOet al. A systematic review of the incidence and prevalence of comorbidity in multiple sclerosis: overview. Mult Scler. 2015; 21: 263–281.
Latimer-CheungAEPiluttiLAHicksALet al. Effects of Exercise Training on Fitness, Mobility, Fatigue, and Health-Related Quality of Life Among Adults With Multiple Sclerosis: A Systematic Review to Inform Guideline Development. Arch Phys Med Rehabil. 2013; 94: 1800–1828.
9.
SnookEMMotlRW.Effect of Exercise Training on Walking Mobility in Multiple Sclerosis: A Meta-Analysis. Neurorehab Neural Re. 2009; 23: 108–116.
10.
PaltamaaJSjogrenTPeuralaSHHeinonenA.Effects of physiotherapy interventions on balance in multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials. J Rehabil Med. 2012; 44: 811–823.
11.
PiluttiLAGreenleeTAMotlRWNickrentMSPetruzzelloSJ.Effects of exercise training on fatigue in multiple sclerosis: a meta-analysis. Psychosom Med. 2013; 75: 575–580.
12.
AsanoMFinlaysonML.Meta-analysis of three different types of fatigue management interventions for people with multiple sclerosis: Exercise, education, and medication. Mult Scler Int. 2014; 2014: 798285.
13.
EnsariIMotlRWPiluttiLA.Exercise training improves depressive symptoms in people with multiple sclerosis: Results of a meta-analysis. J Psychosom Res. 2014; 76: 465–471.
14.
MotlRWGosneyJL.Effect of exercise training on quality of life in multiple sclerosis: a meta-analysis. Mult Scler. 2008; 14: 129–135.
15.
Latimer-CheungAEPiluttiLAHicksALet al. Effects of exercise training on fitness, mobility, fatigue, and health-related quality of life among adults with multiple sclerosis: a systematic review to inform guideline development. Arch Phys Med Rehabil. 2013; 94: 1800–1828.
16.
LeeIMShiromaEJLobeloFPuskaPBlairSNKatzmarzykPT.Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. The Lancet. 2012; 380: 219–229.
17.
GijsenRHoeymansNSchellevisFRuwaardDSatarianoWvan den BosG.Causes and consequences of comorbidity: A review. J Clin Epidemiol. 2001; 54: 661–674.
18.
MarrieRAHanwellH.General health issues in multiple sclerosis: comorbidities, secondary conditions, and health behaviors. Continuum (Minneap Minn). 2013; 19: 1046–1057.
19.
ThompsonPDBuchnerDPinaILet al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003; 107: 3109–3116.
20.
FagardRHand VA. C. Effect of exercise on blood pressure control inhypertensive patients. Eur J Cardiovasc Prev Rehabil2007; 1412–17.
21.
SeronPLanasFPardo HernandezHBonfill CospX.Exercise for people with high cardiovascular risk. Cochrane Database Syst Rev. 2014: CD009387.
FakoladeABissonEJPetrinJLamarreJFinlaysonM.Scoping review indicates that little is known about the impact of comorbidities on outcomes of neurorehabilitation interventions in MS. International Journal of MS Care. 2016; 18: 282–290.
24.
TheouOStathokostasLRolandKPet al. The effectiveness of exercise interventions for the management of frailty: a systematic review. J Aging Res. 2011; 2011: 569194.
25.
CaspersenCPowellKChristensonG.Physical Activity, Exercise, and Physical Fitness: Definitions and Distinctions for Health-Related Research. Public Health Rep. 1985; 100: 126–131.
26.
KlefbeckBHamrah NedjadJ.Effect of inspiratory muscle training in patients with multiple sclerosis. Arch Phys Med Rehab. 2003; 84: 994–999.
27.
Lozano-QuilisJAGil-GomezHGil-GomezJAet al. Virtual rehabilitation for multiple sclerosis using a kinect-based system: randomized controlled trial. JMIR Serious Games. 2014; 2: e12.
28.
FeysPConinxKKerkhofsLet al. Robot-supported upper limb training in a virtual learning environment : a pilot randomized controlled trial in persons with MS. J Neuroeng Rehabil. 2015; 12: 60.
29.
KurtzkeJ.Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Neurology. 1983; 33: 1444–1452.
30.
LearmonthYCMotlRWSandroffBMPulaJHCadavidD.Validation of patient determined disease steps (PDDS) scale scores in persons with multiple sclerosis. BMC Neurol. 2013; 13: 37.
31.
SolariAMartinelliVTrojanoMet al. An information aid for newly diagnosed multiple sclerosis patients improves disease knowledge and satisfaction with care. Mult Scler. 2010; 16: 1393–1405.
32.
RombergAVirtanenARuutiainenJ.Long-term exercise improves functional impairment but not quality of life in multiple sclerosis. J Neurol. 2005; 252: 839–845.
33.
RombergAVirtanenARuutiainenJet al. Effects of a 6-month exercise program on patients with multiple sclerosis: a randomized study. Neurology. 2004; 63: 2034–2038.
34.
TarakciEYeldanIHuseyinsinogluBEZenginlerYEraksoyM.Group exercise training for balance, functional status, spasticity, fatigue and quality of life in multiple sclerosis: a randomized controlled trial. Clin Rehabil. 2013; 27: 813–822.
35.
PlowMAMathiowetzVLoweDA.Comparing individualized rehabilitation to a group wellness intervention for persons with multiple sclerosis. Am J Health Promot. 2009; 24: 23–26.
36.
MillerLPaulLMattisonPMcFadyenA.Evaluation of a home-based physiotherapy programme for those with moderate to severe multiple sclerosis: a randomized controlled pilot study. Clin Rehabil. 2011; 25: 720–730.
37.
HansenDWensIKeytsmanCEijndeBODendaleP.Is long-term exercise intervention effective to improve cardiac autonomic control during exercise in subjects with multiple sclerosis? A randomized controlled trial. Eur J Phys Rehabil Med. 2015; 51: 223–231.
38.
PlowMBethouxFMcDanielCMcGlynnMMarcusB.Randomized controlled pilot study of customized pamphlets to promote physical activity and symptom self-management in women with multiple sclerosis. Clin Rehabil. 2014; 28: 139–148.
39.
Castro-SanchezAMMataran-PenarrochaGALara-PalomoISaavedra-HernandezMArroyo-MoralesMMoreno-LorenzoC.Hydrotherapy for the treatment of pain in people with multiple sclerosis: a randomized controlled trial. Evid Based Complement Alternat Med. 2012; 2012: 473963.
40.
BeckASteerRBallRRanieriW.Comparison of Beck depression inventories IA and II in psychiatric outpatients. J Pers Assess. 1996; 67: 588–597.
41.
CakıtBDNacirBGencHet al. Cycling progressive resistance training for people with multiple sclerosis: a randomized controlled study. Am J Phys Med Rehabil. 2010; 89: 446–457.
42.
PetajanJGappmaierEWhiteASpencerMMinoLRWH.Impact of Aerobic Training on Fitness and Qdty of Life in Multiple Sclerosis. Ann Neurol. 1996; 33: 432–441.
43.
ConklynDStoughDNovakEPaczakSChemaliKBethouxF.A home-based walking program using rhythmic auditory stimulation improves gait performance in patients with multiple sclerosis: a pilot study. Neurorehab Neural Re. 2010; 24: 835–842.
44.
HansenDWensIKeytsmanCVerbovenKDendalePEijndeBO.Ventilatory function during exercise in multiple sclerosis and impact of training intervention: cross-sectional and randomized controlled trial. Eur J Phys Rehabil Med. 2015; 51: 557–568.
45.
MarrieRHorwitzRCutterGTyryTCampagnoloDVollmerT.Comorbidity, socioeconomic status and multiple sclerosis. Mult Scler. 2008; 14: 1091–1098.
46.
MarrieRAYuBNLeungSet al. Rising prevalence of vascular comorbidities in multiple sclerosis: validation of administrative definitions for diabetes, hypertension, and hyperlipidemia. Mult Scler. 2012; 18: 1310–1319.
47.
MarrieRAYuBNLeungSet al. Prevalence and incidence of ischemic heart disease in multiple sclerosis: A population-based validation study. Mult Scler Relat Disord. 2013; 2: 355–361.
CraftL. Potential psychological mechanisms underlying the exercise and depression relationship. In: E P, (ed.). Handbook of Physical Activity and Mental Health. London: Routledge, 2013, p. 161–168.
50.
MarrieRAReingoldSCohenJet al. The incidence and prevalence of psychiatric disorders in multiple sclerosis: a systematic review. Mult Scler. 2015; 21: 305–317.
51.
MarrieRMillerASormaniMet al. The challenges of comorbidity in clinical trials for multiple sclerosis. Neurology. 2016; 88: 1437–1445.
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