Multiple Sclerosis Clinical Trial
Official title:
How Does Strength Training and Balance Training Affect Gait Function and Fatigue in Patients With Multiple Sclerosis?
Introduction: Multiple sclerosis (MS) is characterized by decreased strength and motor
control, and compromised gait function. Reduced walking speed, balance, and fatigue are the
cardinal symptoms. In rehabilitation, strength and balance training are commonly used. There
is increasing scientific support of strength training for improving walking function. The
evidence for balance training remains flawed. It is known that neurological damage in MS
leads to increased cognitive processing in the planning of movements, which predisposes
fatigue. Since fatigue is also associated with impaired balance, it can be hypothesized that
motoric/balance training with an emphasis on cognitive load can affect gait and fatigue.
Purpose: The aim of the study is to determine whether there is a differentiated effect
between strength and balance training measured by motor function, strength, balance, and
fatigue.
People with MS experience a wide variety of symptoms including impaired muscle strength and
balance, fatigue, impaired cognition, depression and spasticity. Of these, impaired balance
and severe fatigue are described as two of the most debilitating symptoms leading to
limitations in activities such as upright posture and gait. Generally, pharmacological
symptomatic treatment has not proven efficient in the treatment of balance problems, fatigue
and walking impairments, with the exception that Fampridine has beneficial effects on gait
performance in a subgroup of patients. Consequently, non-pharmacological interventions that
effectively target these symptoms are warranted.
In the last decade progressive resistance training (PRT) has proven to be one of the
promising interventions in patients with MS showing a consistent and positive effect on
muscle strength. However, the effect of PRT on functional outcomes are heterogeneous but with
promising effects on daily activities such as walking and chair rise. The evidence for a
beneficial effect of PRT on balance and postural control is divergent and yet inadequately
investigated. Regarding fatigue, a recent Cochrane review reported that one could expect
improvements in MS fatigue after exercise interventions, despite methodological flaws in the
existing literature, but only few studies evaluating PRT were located.
Another promising intervention is task specific training of motor function that is widely
used by physiotherapists in neurorehabilitation. In this study protocol, motor function is
limited to gait related functions with a particular focus put on balance and motor control,
why the term Balance and Motor Control Training (BMCT) is applied. There is no universally
accepted definition of human balance, but balance defined as "the inherent ability of a
person to maintain, achieve or restore a specific state of balance and not to fall, with
reference to the motor and sensory systems and to the physical properties of the person", is
applied in this study.
Effects obtained from BMCT partly result from plastic changes in the nervous system. To
induce such effects, repetition of a simple task only has limited efficiency in order to
improve performance. Once a task has been learned to a certain level, further practice of the
same task will not be accompanied by further induction of plasticity and little is therefore
gained by continued practice of the task. To provide challenges that ensures continued
learning, training exercises have to progress from simple movement trajectories to more
complex movements, that also incorporates goal setting. Moreover, it has been shown that
shaping and variation of tasks in combination with feedback on movement quality is of great
importance for the learning outcome. The underlying concept for performing BMCT is,
therefore, that improved motor control will optimize the movement strategy, which further
leads to improved gait function.
Regarding the effects of BMCT on fatigue, there are diverging results in the literature, but
the literature on BMCT for patients with MS is generally of low quality with an inadequate
description of interventions, why further studies are warranted.
Interestingly, the principles of task specific training do fundamentally contrast the
principles of PRT, that normally consist of monotonous movement patterns performed under
heavy loading for a low number of repetitions. Consequently, studies comparing the effects of
BMCT and PRT on gait function would add to the current literature as no studies doing so
could be located. Such a comparison would help clarify whether potential effects are
overlapping or differentiated and would therefore help guiding future rehabilitation
interventions in persons with MS.
The primary objective of this study is, therefore, to investigate and compare the effects of
10 weeks of PRT to BMCT on gait function, balance and fatigue in mobility limited persons
with MS.
It is hypothesized that PRT will be superior in improving maximal straight gait speed,
whereas BMCT will have a greater impact on balance, fatigue, and more complex walking tasks
that include elements of balance and coordination.
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