The Effect of Strength Training on Gait for Individuals with Multiple Sclerosis

Contents

Introduction

Methodology

Data collection

Results

Discussion

Gait outcome measures; speed, endurance and quality

Interventions

Sample populations and study designs

Conclusion

References

Introduction

Characterised by the demyelination of motor and sensory axons in the central nervous system, multiple sclerosis (MS) is an autoimmune, neurodegenerative disease most commonly affecting young women (Halabchi et al., 2017). The chronic course of the disease involves either stable phases interrupted by periods of degeneration (relapsing-remitting MS) or progressive, continuous disease progression (primary and secondary progressive MS) (Callesen et al., 2018). Due to the varying progressive nature of MS and the significance of lesion location, symptom severity and experiences can range, including impaired cognition, balance and sensory deficits, spasticity, muscle weakness and fatigue (Halabchi et al., 2017).

More specifically, gait limitations were reported in 93% of people with MS (PwMS) 10 years following diagnosis, signifying the importance of rehabilitation approaches targeting gait restoration (Manago et al., 2019). Cerebellar dysfunction and lower limb muscle weakness have been identified as the primary contributing factors to gait ataxia; generally typified by reduced walking speed, shortened step length and longer stance phase in individuals with MS (Heine et al., 2018). In the past, PwMS were advised by health professionals to abstain from exercise amid concerns of triggering neurodegenerative progression and excessive fatigue (Dalgas et al., 2008). However, Halabchi et al. (2017) outlined that it has since been discovered that inactivity in MS patients leads to deconditioning, eventually resulting in the lower extremity muscle weakness partly responsible for gait impairment. It can thereby be deduced that interventions targeting muscle weakness, such as strength training (ST), serve as a promising strategy towards combatting MS gait dysfunction as a consequence of inactivity (Halabchi et al., 2017).

The suitability of a multidisciplinary approach towards MS rehabilitation is assured as the heterogenous nature of the disease complicates the possibility of a consistent, universally effective treatment strategy (Smedal et al., 2006). As a part of this approach, physiotherapy is a common, widely accepted form of MS intervention delivery proven to reduce neurodegeneration and improve functional outcomes (Smedal et al., 2006). Frequently utilised by physiotherapists, ST is recognised as an appropriate intervention for MS as the findings of numerous studies align in proving its tolerability by PwMS and effectiveness towards improving muscle strength (Dalgas et al., 2008). For instance, Heine et al. (2018) identified limited ankle push-off power as a key element reducing gait efficiency in PwMS, subsequently assigning a sample of 10 PwMS an eight-week resistance training program and detecting improvements in plantarflexion strength and gait efficiency.

Although Manago et al. (2019) along with Dalgas et al. (2008) supported the effectiveness of ST towards promoting muscle strength, they questioned its ability to improve functional outcomes, such as gait, in PwMS. This lack of consensus was mirrored by the work of Hayes et al., (2011) failing to establish a positive link between ST and gait, or even muscle strength, thereby warranting further investigation. Accordingly, the following review aimed to explore and evaluate the literature surrounding the effectiveness of ST in improving gait in PwMS.

Methodology

Study search parameters: Inclusion and exclusion criteria A literature search was conducted on the 9th and 10th of April 2020, utilising four databases: PubMed, Scopus, Ovid and CINAHL. The title, abstract and keyword search terms entered were “(“strength training” OR “resistance training”) AND gait AND (“multiple sclerosis” OR “disseminated sclerosis”)”, with temporal restrictions set to only include articles published from 2010 to 2020 and filters applied to include peer reviewed articles. Following the initial search, duplicate publications were removed and the title and abstract of each study were screened using the inclusion and exclusion criteria. Randomised control trials or reputable case control studies surrounding the effect of ST on gait in PwMS were deemed eligible and meta-analyses, systematic reviews and studies surrounding irrelevant populations, interventions or outcomes were excluded. The remaining articles were then screened in full-text form and further refined to exclude those with combined interventions, absence of a comparison group, lack of full-text availability or published in a language other than English.

Data collection

Once the search refinement was complete, the articles’ sample selection, interventions, outcomes and main findings were extracted and tabulated. The findings and conclusions of each study, along with their reputability, were then compared and critically analysed in order to reach a substantiated conclusion.

Results

An initial literature search surfaced 92 articles from the selected databases. The search refinement was completed and displayed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram, as shown in figure 1 (Moher et al., 2009). Following the removal of duplicates, 58 publications remained. Title and abstract screening facilitated the further exclusion of 48 studies in line with the inclusion and exclusion criteria. 10 articles were then screened in full; five were excluded due to combined interventions and one due to the lack of a comparison group. The remaining four studies were deemed suitable and data extraction involved the tabulation of the authors, study designs, sample populations, interventions, outcomes, statistical analyses and conclusions of each study, shown in table 1.

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Figure 1. PRISMA flow diagram detailing literature search and selection (Moher et al., 2009)

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Notes: EDSS scores are recorded as mean ± SD, Results are recorded as (pre-post change, p-value)

Abbreviations: abd, abduction; α, alpha value; AI, ambulation index; ANOVA, analysis of variance; ANCOVA, analysis of covariance; APaccRMS, anteroposterior acceleration root mean square; a.u., arbitrary unit; BMCT, balance and motor control training; CST, contralateral strength training; df, dorsiflexion; DST, direct strength training; EDSS, Expanded Disability Status Scale; ext, extension; FAP, Functional Ambulation Profile; flex, flexion; FWS, fast walking speed; inc, increased; MLaccRMS, mediolateral acceleration root mean square; min, minutes; MSWS, Multiple Sclerosis Walking Scale; pf, plantarflexion; PRT, progressive resistance training; reps, repetitions; RM, repetition maximum; RRMS, relapsing-remitting multiple sclerosis; sec, seconds; SSST, Six Step Spot Test; SD, standard deviation; ST, strength training; TT, treadmill training; T25FW, Timed 25 Foot Walk; VaccRMS, vertical acceleration root mean square; wk, week; WWE, walking work economy; 2MWT, 2 Minute Walk Test; 6MWT, 6 Minute Walk Test.

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