A novel exercise initiative to improve walking ability in people with multiple sclerosis having higher levels of disability.

Multiple Sclerosis (MS) is an auto-immune mediated inflammatory and degenerative disease of the central nervous system characterized by loss of myelin and axonal integrity. MS often leads to an accrual of walking disability and worsening of fatigue. Exercise-dependent plasticity in the central nervous system, which involves upregulation of growth-promoting neurotrophins and suppression of inflammatory cytokines, may help restore lost ability to walk. Although aerobic training is an intervention that can potentially improve walking disability and reduce fatigue, these factors are also significant barriers to participating in exercise. Furthermore, because of thermal dysregulation, exercise-induced increases in body temperature leads to temporary worsening of symptoms in some MS patients. The purpose of my doctoral work was to develop and determine the feasibility of implementing a progressively intense aerobic treadmill training, in a room cooled to 16°C, for people with MS having walking disability, fatigue, and heat sensitivity. In the first study, I critically appraised and consolidated the research in animal models and clinical trials in order to determine the optimal training dosage and outcomes for a future exercise trial. The second study showed that people with MS-related disability consumed about three times more oxygen to complete relatively simple mobility activities such as rolling in bed, when compared to age and sex-matched healthy controls. The results of this study supported the importance of testing therapeutic aerobic training for this cohort of patients with barriers to exercise, such as fatigue. The third study outlined the effects of maximal aerobic exercise on neurotrophins and inflammatory cytokines among people with MS and controls. The final study established preliminary evidence for the feasibility of conducting progressively intense aerobic training on a bodyweight supported treadmill in a room cooled to 16°C. The benefits included significant improvements in walking speed, fatigue, aerobic fitness, and quality of life, while simultaneously altering serum levels of blood biomarkers of recovery such as brain-derived neurotrophic factor and interleukin-6, shifting the balance between repair and inflammation. Randomized controlled trials are needed to substantiate these preliminary findings, which in turn could lead to effective training options for people living with MS-related barriers to exercise participation

The Effects of Aerobic Exercise on the Recovery of Walking Ability and Neuroplasticity in People with Multiple Sclerosis: A Systematic Review of Animal and Clinical Studies

Introduction. Walking is of high priority for people with multiple sclerosis (PwMS). It remains unclear whether aerobic exercise can improve walking ability and upregulate neurotrophins. This review aims to consolidate evidence to develop optimal aerobic training parameters to enhance walking outcomes and neuroplasticity in PwMS. Methods. Clinical studies examining aerobic exercise for ≥3 weeks, having outcomes on walking with or without neurotrophic markers, were included. Studies utilizing animal models of MS were included if they employed aerobic exercise with outcomes on neurological recovery and neurotrophins. From a total of 1783 articles, 12 clinical and 5 animal studies were included. Results. Eleven clinical studies reported improvements in walking ability. Only two clinical studies evaluated both walking and neurotrophins, and neither found an increase in neurotrophins despite improvements in walking. Patients with significant walking impairments were underrepresented. Long-term follow-up revealed mixed results. Two animal studies reported a positive change in both neurological recovery and neurotrophins. Conclusion. Aerobic exercise improves walking ability in PwMS. Gains are not consistently maintained at 2- to 9-month follow-up. Studies examining levels of neurotrophins are inconclusive, necessitating further research. Aerobic exercise enhances both neurological recovery and neurotrophins in animal studies when started 2 weeks before induction of MS

Effectiveness of Symptom Guided Therapeutic Approach in Treating Discogenic Pain with Radiculopathy Using a Combination of Directional Preference Exercises, Mobilisation and Neural Mobility Exercises — A Case Report

Researchers have reported various therapeutic approaches to treat patients with low back pain. The mechanical diagnosis and therapy as proposed by McKenzie, has been shown to be effective in diagnostic, therapeutic and prognostic inference. Most often, the treatment options considered in these studies was directional preference exercises and manual procedures utilising movement and positions. But the effectiveness of symptom guided therapeutic approach in treating discogenic low back pain with radiculopathy using directional preference exercises, mobilization and neural mobility exercises is unknown. A case of a forty three-year-old male presenting with discogenic low back pain along with radiculopathy was assessed with McKenzie approach. Appropriate treatment strategy was selected and prescribed based on the initial assessment. The patient was re-evaluated each session, and treatment modification was made according to his symptom presentation during each visit. He proved to be symptom free after seven visits. This could have been due to disc regression and enhanced neural mobility obtained due to treatment. This case report demonstrates the effectiveness of symptom guided therapeutic management to treat patients with discogenic low back pain along with radiculopathy using appropriate treatment strategies. Finally, the report summarizes the treatment offered and discusses the possible explanation of the specific treatment strategies implemented

Rural family physician perspectives on communication with urban specialists: a qualitative study

Objective Communication is a key competency for medical education and comprehensive patient care. In rural environments, communication between rural family physicians and urban specialists is an essential pathway for clinical decision making. The aim of this study was to explore rural physicians’ perspectives on communication with urban specialists during consultations and referrals.Setting Newfoundland and Labrador, Canada.Participants This qualitative study involved semistructured, one-on-one interviews with rural family physicians (n=11) with varied career stages, geographical regions, and community sizes.Results Four themes specific to communication in rural practice were identified. The themes included: (1) understanding the contexts of rural care; (2) geographical isolation and patient transfer; and (3) respectful discourse; and (4) overcoming communication challenges in referrals and consultations.Conclusions Communication between rural family physicians and urban specialists is a critical task in providing care for rural patients. Rural physicians see value in conveying unique aspects of rural clinical practice during communication with urban specialists, including context and the complexities of patient transfers

Fitness Shifts the Balance of BDNF and IL-6 from Inflammation to Repair among People with Progressive Multiple Sclerosis

Physical sedentarism is linked to elevated levels of circulating cytokines, whereas exercise upregulates growth-promoting proteins such as brain-derived neurotrophic factor (BDNF). The shift towards a ‘repair’ phenotype could protect against neurodegeneration, especially in diseases such as multiple sclerosis (MS). We investigated whether having higher fitness or participating in an acute bout of maximal exercise would shift the balance of BDNF and interleukin-6 (IL-6) in serum samples of people with progressive MS (n = 14), compared to matched controls (n = 8). Participants performed a maximal graded exercise test on a recumbent stepper, and blood samples were collected at rest and after the test. We assessed walking speed, fatigue, and maximal oxygen consumption (V·O2max). People with MS achieved about 50% lower V·O2max (p = 0.003) than controls. At rest, there were no differences in BDNF between MS and controls; however, IL-6 was significantly higher in MS. Higher V·O2max was associated with a shift in BDNF/IL-6 ratio from inflammation to repair (R = 0.7, p = 0.001) when considering both groups together. In the MS group, greater ability to upregulate BDNF was associated with faster walking speed and lower vitality. We present evidence that higher fitness indicates a shift in the balance of blood biomarkers towards a repair phenotype in progressive MS

The effects of a novel pilates exercise prescription method on people with non-specific unilateral musculoskeletal pain: a randomised pilot trial

Background: Pain alters the neuromuscular activation and results in altered movement adaptations. A new exercise prescription method proposes that we can restore the neuromuscular control by rehabilitating the deficient neural drive through Pilates exercises. This is done by identifying the postural control deficits using single-leg tests such as hopping, half squats and heel raises. The aim of this study was to find out if this method of prescribing exercises results in clinically relevant outcomes. Methods: Fifteen patients with chronic non-specific low back pain with unilateral musculoskeletal pain were recruited. Following consent, all patients were randomly assigned either to perform gym or Pilates-based individualised exercises once weekly for six weeks. The primary outcome was to measure the pain intensity using a 0–10 numerical rating scale. The secondary outcome measures were: the global perceived effect scale (GPE; 0–10), the patient-specific functional scale (PSFS; the patient-generated measure of disability) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; the condition-specific measure of disability). Results: There were statistically significant differences noted after intervention within the control group in the numerical rating scale ( P =0.041), GPE ( P =0.024), PSFS ( P =0.039) and within the experimental group in the WOMAC ( P =0.008), GPE ( P =0.007) and PSFS ( P =0.007). However, as there were clinically significant baseline differences, the within-group difference could be due to regression to the mean. There were no statistically significant results between the two groups after intervention. Conclusion: This new prescription method for Pilates-based exercises may improve disability and global perception of recovery. However, the outcomes are not different from a regular gym-based exercise programme

Using Kane’s framework to build an assessment tool for undergraduate medical student’s clinical competency with point of care ultrasound

Abstract Introduction Point-of-care ultrasonography (POCUS) is a portable imaging technology used in clinical settings. There is a need for valid tools to assess clinical competency in POCUS in medical students. The primary aim of this study was to use Kane’s framework to evaluate an interpretation-use argument (IUA) for an undergraduate POCUS assessment tool. Methods Participants from Memorial University of Newfoundland, the University of Calgary, and the University of Ottawa were recruited between 2014 and 2018. A total of 86 participants and seven expert raters were recruited. The participants performed abdominal, sub-xiphoid cardiac, and aorta POCUS scans on a volunteer patient after watching an instruction video. The participant-generated POCUS images were assessed by the raters using a checklist and a global rating scale. Kane’s framework was used to determine validity evidence for the scoring inference. Fleiss’ kappa was used to measure agreement between seven raters on five questions that reflected clinical competence. The descriptive comments collected from the raters were systematically coded and analyzed. Results The overall agreement between the seven raters on five questions on clinical competency ranged from fair to moderate (κ = 0.32 to 0.55). The themes from the qualitative data were poor image generation and interpretation (22%), items not applicable (20%), poor audio and video quality (20%), poor probe handling (10%), and participant did not verbalize findings (14%). Conclusion The POCUS assessment tool requires further modification and testing prior before it can be used for reliable undergraduate POCUS assessment

Delivering a Back School Programme with a Cognitive Behavioural Modification: A Randomised Pilot Trial on Patients with Chronic Nonspecific Low Back Pain and Functional Disability

Introduction: Chronic non-specific low back pain is a major health burden worldwide including Singapore. As literature shows inconclusive evidence on the benefit of various forms of exercises for chronic low back pain patients, we intended to investigate the efficacy of a four-week posture correction and movement re-education programme delivered through cognitive behavioural modification. Methods: A blinded randomised controlled pilot trial was conducted with the participants randomised into two different group exercise classes. The control group performed generic mat exercises. The experimental group performed functional back exercises and had training in activities like lifting, sitting, mopping to learn correct postures and body mechanics with proper ergonomics and activity pacing through cognitive behavioural modification. The following outcome measures were scored in this study: verbal numerical pain (VNP) scale, Roland Morris disability questionnaire (RMDQ), patient-specific functional scale (PSFS), and global perceived effect (GPE) score. Results: At baseline (n=15), the data was normally distributed between the control and the experimental groups, with the exception of BMI in the control group and VNP in the experimental group. In the experimental group, all outcome measures showed statistically significant difference between pre- and post-intervention scores, VNP (p=0.01), RMDQ (p=0.01), PSFS (p=0.01) and GPE (p=0.00). In the control group, a statistically significant difference between pre- and post-intervention was noted in the PSFS score (p=0.04). Conclusion: This pilot study demonstrated that an exercise class incorporating correction of postures and body mechanics in daily activities with a cognitive behavioural modification reduces pain and disability better than generic mat exercise class in patients with chronic non-specific low back pain