Multicentric Studies Assessing Effective Nonpharmacological Rehab Techniques in Multiple Sclerosis Ataxia Needed


Most of the studies included highlighted the increasing level of difficulty in all exercises performed and that the transition from one kinematic protocol to the other depended on the patient’s rate of improvement.

In a recently published meta-analysis assessing the effectiveness of non-pharmacological interventional protocols of cerebellar ataxia (CerA) in multiple sclerosis (MS), investigators concluded that the quality of the studies were moderate, emphasizing the need for high-quality multicentric studies where all protocols will be available without any demographic, clinical, or methodological limitations.1

"CerA in MS requires the acknowledgement of a plethora of different parameters related to both the disease and the versatility of the rehabilitation protocols, to achieve more efficient methods accessing the matter," senior investigator Sotirios Giannopoulos, MD, PhD, professor at the Attikon University Hospital, Athens, Greece, and colleagues, wrote.

Published in the Journal of Neuroscience Research, the meta-analysis assessed the effectiveness of 6 non-pharmacological intervention protocols of CerA in patients with MS. Three of these were randomized controlled trials, which included 2 task-oriented training protocols (physiotherapy exercises based on mundane kinematic individual actions in order to perform those more efficiently) and a functional rehabilitation training approach. The remaining 3 were pilot studies comprising of 10 to 20 patients that included a combination of NDT-Bobath and conventional physiotherapy protocol.

Regarding the quality of the studies, 4 were rated as a B and 2 were rated as A, indicating an overall moderate quality rating of the data. Functional rehabilitation techniques assessed in a 2018 study by Scheidler et al and a 2022 study by Rahimibarghani et al, were rated as B quality based on the Moore and Wolfson criteria. In Scheidler’s research, the use of a targeted ballet program to improve balance in ataxic female patients with relapsing-remitting MS showed a significant improvement in static and dynamic gait patterns and in gait plasticity (P <.001). In Rahimibarghani et al’s pilot study, the effects of cycling on patients with secondary progressive MS with CerA revealed significant gait improvement in stability, speed, and stride length (P <.001).

One of the pilot studies, published in 2013, compared trunk exercises based on the Bobath concept with routine neurorehabilitation approaches in MS. Both groups joined a 3 d/wk rehabilitation program for 8 weeks. When the groups were compared, no significant differences were found in any of the efficacy parameters. Although trunk exercised based on the Bobath concept are rarely applied in MS rehabilitation, the results suggested that they are as effective as routine neurorehabilitation exercises.

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Another pilot study assessed subjective visual vertical deviations and balance using a robotic and visual biofeedback reeducation approach. Published in 2019, results showed significant increase in Activities of Daily Living (P <.05) and consequently, that adaptive robot training improved upper limb kinematics and functional ability. Based on the Moore and Wolfson criteria, the rating of this study was B.

The only 2 studies with a rating grade of A were task-oriented training (TT) approaches. The first, which examined the effects of balance training (BT), lumbar stabilization (LS), and TT in 42 patients with MS with CerA, showed significant benefits in kinetic function in both LS and TT groups (P <.05). The second, published in 2017, indicated major improvement in functional scores among patients with relapsing-remitting MS who underwent a TT program. Above all, these investigators concluded that an effective rehabilitation protocol regarding CerA should be based on TT (P <.05).

Despite the limitations of the analysis, the results of 5 studies were significant, without however reporting the effect size in all cases, and highlighted a beneficial effect of all the rehabilitation protocols in CerA because of MS. "Hence, the authors may concluded that a hypothetical effective rehabilitation protocol regarding CerA due to MS could have included all 3 trainings and techniques starting from Conventional Physiotherapy and NDT-Bobath methodology and moving to Robotic visual Rehabilitation for kinetic program reeducation and then to task-oriented training," Giannopoulos et al wrote.1

"This procedure would provide ample time for the ataxic MS patient to familiarize with the reeducated program procedures, before moving to Functional Rehabilitation techniques which demand a higher level of coordination and significantly better balance capabilities. Such a process, although demanding, provides the opportunity to achieve a higher kinetic functional level and by that the possibility to interact anew within the social environment," the study authors added.

1. Chasiotis AK, Kitsos D, Stavrogianni K, et al. Rehabilitation on cerebellar ataxia patients with multiple sclerosis: a systematic review. jnr. 2023;101(12):1773-1780. doi:10.1002/jnr.25235
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