The Influence of Physiotherapy and Climate on Functioning in Multiple Sclerosis. Aspects of physical performance, fatigue and health-related quality of life

Multiple sclerosis (MS) is a chronic, immune-mediated disease affecting the central
nervous system (CNS), caused by interplay between predisposing genes and
environment. The disease may result in a wide spectre of functional problems, best
treated by a multidisciplinary team of professionals. Physiotherapy has shown to
improve physical functioning related to mobility and has been advocated as a major
component in rehabilitation in MS. The CNS has the ability to change its function and
structure depending on demands, and this neuroplasticity also occurs after damage.
The Bobath concept is one of the most used treatment approaches in neurological
physiotherapy and is based on knowledge of neuroplasticity, aiming to relearn
appropriate movement strategies after damage.
The thesis includes two intervention studies in MS. The first study is presented in
Paper I. The second study (the climate study) is presented in Paper III. Data from the
climate study are also used to investigate psychometric properties of a translated
version of the self-reported health-related quality of life (HRQoL) questionnaire, the
Multiple Sclerosis Impact Scale (MSIS-29) (Paper II), and to analyse associations
between fatigue versus other variables (Paper IV).
A single-subject experimental design was used in the first intervention study (Paper I),
investigating the effect of three weeks of individualized daily outpatient physiotherapy
based on the Bobath concept, for two patients being their own controls. Twelve
repeated measures were performed over a time period of 17 weeks, using a wide
spectre of measurement-tools. We concluded that balance and gait were improved after
physiotherapy for the two patients, and that effect of treatment should be further
evaluated in a larger study.
In Paper II, the objective was to translate the MSIS-29 into Norwegian and to examine
psychometric properties of the Norwegian version for use in the climate study. The
questionnaire was answered by 64 patients prior to and at a screening session, and reanswered
by 59 patients before and after four weeks of physiotherapy. Internal consistency (Cronbach’s  ) was 0.92 for the physical- and 0.85 for the psychological
subscale. Reliability by intraclass correlation coefficients were 0.86 for the physicaland
0.81 for the psychological subscale, smallest detectable change being 18.4 and
21.1, respectively. The physical- but not the psychological subscale demonstrated
mostly satisfactory associations with other physical measures. Responsiveness by area
under the receiver operating characteristics (ROC) curve was satisfactory, 0.83 and
0.76, respectively. As hypothesized, effect size was larger for the physical (1.01) than
for the psychological (0.76) subscale after treatment. We concluded that MSIS-29,
Norwegian Version demonstrated satisfactory psychometric properties.
In the main intervention study (Paper III) the objective was to examine climate
influence on the effect of physiotherapy in MS by comparing the effect of inpatient
physiotherapy in a warm (Spain) versus a cold (Norway) climate in a short- and long
term perspective. Sixty patients with gait problems and without heat intolerance were
included in a randomized cross-over study of 4-week inpatient physiotherapy. Two
groups of 30 patients were treated the first year in either Spain or Norway, and
switching treatment centre the year after. The 6-minute walk test (6MWT) as the
primary outcome measure, and other physical performance and self-reported measures,
were used at screening, baseline, after treatment and at three- and six months followup.
Treatment effects were analysed by mixed models. All assessment tools
demonstrated improvement after treatment in both warm and cold climate, but to
different degrees. After treatment, the mean walking-distance had increased by 70m in
Spain and 49m in Norway (p=0.060), and improvement in favour of a warm climate
was demonstrated at six months follow-up, 43m (Spain) compared to 20m (Norway)
(p=0.048). The patients reported less exertion after walking (6MWT) in favour of
treatment in Spain at all time points (p<0.05). No significant differences in change
were detected for the other physical performance measures. Most self-reported
measures showed more improvement after treatment in Spain, but these improvements
were not sustained at follow-up. The results indicate that MS patients without heat
intolerance have additional benefits from physiotherapy in a warm climate. In Paper IV, we also used data from the first part of the climate study. The aim was to
investigate whether fatigue was associated with demographic-, clinical-, HRQoL- and
physical performance variables, and whether change in fatigue after treatment was
associated with changes in HRQoL and physical performance. Sixty patients were
included for inpatient physiotherapy, and fifty-six completed the study. Fatigue
(Fatigue Severity Scale; FSS), HRQoL (MSIS-29) and physical performance (walking
ability and balance) were assessed at screening, baseline, after treatment and at followup
after three and six months. We analysed possible associations between FSS and
other variables at baseline by regression models, and between change in fatigue versus
changes in HRQoL and physical performance variables after physiotherapy, by
correlation analysis. We found that fatigue at baseline was associated with HRQoL
(explained 21.9 % of variance), but not with physical performance tests. Change in
fatigue was correlated with change in HRQoL, but not with changes in physical
performance. All measures were improved after treatment (p 0.001). While
improvements in fatigue and HRQoL were lost at follow-up, improvements in physical
performance were sustained for at least six months (p 0.05). The findings suggest that
fatigue in MS is not associated with physical performance as assessed in our study, but
seemed to be associated with the patients’ experience of HRQoL.
The results from both intervention studies indicate that physiotherapy based on the
Bobath concept may cause improvement in physical performance in MS, in short- and
long term perspectives. For patients without heat intolerance, there seems to be a
favourable effect of treatment in a warm climate. The translated version of MSIS-29
demonstrated satisfactory measurement properties in line with the original English
version and may therefore be recommended used as a measurement tool of HRQoL in
patients with MS. If the aim of treatment is improvement of fatigue, a broader
intervention, accounting for both physical and psychological aspects, seems necessary