Multiple sclerosis is an inflammatory and neurodegenerative disorder of the central nervous system that can lead to severe motor disability. The aim of this study was to verify the health care effects of an integrated telerehabilitation approach involving dual-domains (motor and cognitive) in people with multiple sclerosis using a virtual reality rehabilitation system compared to a home-based conventional rehabilitative intervention usual care for patient-relevant outcomes (motor, cognitive and participation).
Methods
This multicentre interventional, randomized controlled trial included 70 participants with multiple sclerosis, 35 in the telerehabilitation group (30 sessions of home-based virtual reality rehabilitation system training, five sessions for week each lasting 45 min) and 35 in the usual care group (30 sessions of conventional treatment, five sessions for week). Participants completed the assessment of motor, cognitive and participation outcomes at baseline and after 6 weeks of treatment.
Results
In total, 63.3% of the telerehabilitation group exhibited improvement in the physical domain of the quality of life (p = 0.045). The telerehabilitation group showed greater improvement than the usual care group in Mini-BESTest domains of balance (p = 0.014), postural control (p = 0.024), and dynamic walking (p = 0.020) at post-treatment. Higher adherence was registered for telerehabilitation compared with usual care (86.67% vs. 80.0%).
Discussion
This study provides evidence that people with multiple sclerosis can benefit from telerehabilitation treatment in the physical domain of the quality of life and motor symptoms. Moreover, considering the persistent COVID-19 emergency, telerehabilitation can represent an effective telemedicine solution for safely delivering effective rehabilitation care to people with multiple sclerosis.
Trial registration number and trial register
This trial was registered at ClinicalTrials.gov (NCT03444454).
BeerSKhanFKesselringJ. Rehabilitation interventions in multiple sclerosis: An overview. J Neurol2012; 259: 1994–2008.
2.
CampbellECoulterEHPaulL. High intensity interval training for people with multiple sclerosis: A systematic review. Mult Scler Relat Disord2018; 24: 55–63.
3.
TavazziEBergslandNCattaneoD, et al.Effects of motor rehabilitation on mobility and brain plasticity in multiple sclerosis: A structural and functional MRI study. J Neurol2018; 265: 1393–1401.
4.
JonsdottirJGervasoniEBowmanT, et al.Intensive multimodal training to improve gait resistance, mobility, balance and cognitive function in persons with multiple sclerosis: A pilot randomized controlled trial. Front Neurol2018; 9: 800.
5.
AmatyaBKhanFGaleaM. Rehabilitation for people with multiple sclerosis: An overview of Cochrane reviews. Cochrane Database Syst Rev2019; 1: CD012732.
6.
CentonzeDLeocaniLFeysP. Advances in physical rehabilitation of multiple sclerosis. Curr Opin Neurol2020; 33: 255–261.
7.
ShawMTBestPFrontarioA,et al.Telerehabilitation benefits patients with multiple sclerosis in an urban setting. J Telemed Telecare2021; 27: 39–45.
8.
CharvetLEDobbsBShawMT,et al.Remotely supervised transcranial direct current stimulation for the treatment of fatigue in multiple sclerosis: results from a randomized, Sham-controlled trial. Mult Scler2018; 24: 1760–1769.
9.
CharvetLEYangJShawMT, et al.Cognitive function in multiple sclerosis improves with telerehabilitation: Results from a randomized controlled trial. PLoS One2017; 12: e0177177.
10.
Di TellaSPagliariCBlasiV,et al.Integrated telerehabilitation approach in multiple sclerosis: A systematic review and meta-analysis. J Telemed Telecare2020; 26: 385–399.
11.
YeroushalmiSMaloniHCostelloK,et al.Telemedicine and multiple sclerosis: A comprehensive literature review. J Telemed Telecare2020; 26: 400.
12.
KahramanTSavciSOzdogarAT,et al.Physical, cognitive and psychosocial effects of telerehabilitation-based motor imagery training in people with multiple sclerosis: A randomized controlled pilot trial. J Telemed Telecare2020; 26: 251–260.
13.
DlugonskiDMotlRWMohrDC, et al.Internet-delivered behavioral intervention to increase physical activity in persons with multiple sclerosis: Sustainability and secondary outcomes. Psychol Health Med2012; 17: 636–651.
14.
TarakciETarakciDHajebrahimiF,et al.Supervised exercises versus telerehabilitation. Benefits for persons with multiple sclerosis. Acta Neurol Scand2021 Sep; 144(3): 303–311.
15.
TallnerAStreberRHentschkeC, et al.Internet-supported physical exercise training for persons with multiple sclerosis: A randomised, controlled study. Int J Mol Sci2016; 17: 1667.
16.
PedullàLBrichettoGTacchinoA, et al.Adaptive vs. non-adaptive cognitive training by means of a personalized app: A randomized trial in people with multiple sclerosis. J NeuroEng Rehabil2016; 13: 88.
17.
StuifbergenAKBeckerHPerezF, et al.A randomized controlled trial of a cognitive rehabilitation intervention for persons with multiple sclerosis. Clin Rehabil2012; 26: 882–893.
18.
TurnerAPHartoonianNSloanAP, et al.Improving fatigue and depression in individuals with multiple sclerosis using telephone-administered physical activity counseling. J Consult Clin Psychol2016; 84: 297–309.
19.
StuifbergenAKBeckerHPerezF, et al.Computer-assisted cognitive rehabilitation in persons with multiple sclerosis: Results of a multi-site randomized controlled trial with six month follow-up. Disabil Health J2018; 11: 427–434.
20.
PlowMFinlaysonMLiuJ,et al.Randomized controlled trial of a telephone-delivered physical activity and fatigue self-management interventions in adults with multiple sclerosis. Arch Phys Med Rehabil2019; 100: 2006–2014.
21.
FettaJStarkweatherAGillJM. Computer-based cognitive rehabilitation interventions for traumatic brain injury: A critical review of the literature. J Neurosci Nurs2017; 49: 235–240.
22.
MolhemiFMonjeziSMehravarM, et al.Effects of virtual reality vs conventional balance training on balance and falls in people with multiple sclerosis: A randomized controlled trial. Arch Phys Med Rehabil2021 Feb; 102(2): 290–299.
23.
MassettiTTrevizanILArabC, et al.Virtual reality in multiple sclerosis - A systematic review. Mult Scler Relat Disord2016 Jul; 8: 107–112.
24.
GutiérrezROGalán Del RíoFCano de la CuerdaR, et al.A telerehabilitation program by virtual reality-video games improves balance and postural control in multiple sclerosis patients. Neuro Rehabil2013; 33(4): 545–554.
25.
ThompsonAJBanwellBLBarkhofF, et al.Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol2018; 17: 162–173.
26.
BrookeJ. Sus-A quick and dirty usability scale. In Usability evaluation in industry. 1996, Vol. 189(194), pp. 4–7.
27.
BangorAKortumPMillerJ. Determining what individual SUS scores mean: Adding an adjective rating scale. J Usability Stud2009; 4: 114–123.
28.
VickreyBGHaysRDHarooniR,et al.A health-related quality of life measure for multiple sclerosis. Qual Life Res1995; 4: 187–206.
29.
BeckATWardCHMendelsonM,et al.An inventory for measuring depression. Arch Gen Psychiatry1961; 4: 561–571.
30.
KruppLBLaRoccaNGMuir-NashJ,et al.The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol1989; 46: 1121–1123.
31.
HobartJCRiaziALampingDL,et al.Measuring the impact of MS on walking ability: The 12-item MS walking scale (MSWS-12). Neurology2003; 60: 31–36.
32.
CapraraGVScabiniEBarbaranelliC,et al.Autoefficacia percepita emotiva e interpersonale e buon funzionamento sociale. Giornale Italiano di Psicologia1999; 26: 769–790.
33.
SpielbergCGorsuchRLusheneR,et al.Manual for the state-trait anxiety inventory (STAI form Y), Palo Alto, CA: Consulting Psychologists Press, 1983.
34.
DesrosiersJBravoGHébertR,et al.Validation of the Box and block test as a measure of dexterity of elderly people: reliability, validity, and norms studies. Arch Phys Med Rehabil1994; 75: 751–755.
35.
FranchignoniFHorakFGodiM,et al.Using psychometric techniques to improve the balance evaluation systems test: The mini-BESTestJ Rehabil Med2010; 42: 323–331.
36.
FeysPLamersIFrancisG, et al.The nine-hole peg test as a manual dexterity performance measure for multiple sclerosis. Mult Scler J2017; 23: 711–720.
37.
ContiSBonazziSLaiaconaM,et al.Montreal cognitive assessment (MoCA)-Italian version: Regression based norms and equivalent scores. Neurol Sci2015; 36: 209–214.
38.
RaoSM. Cognitive function study group, Nmss: A manual for the brief repeatable battery of neuropsychological tests in multiple sclerosis. New York, NY:National Multiple Sclerosis Society,1990.
39.
SolariAMottaAMendozziL, et al.Computer-aided retraining of memory and attention in people with multiple sclerosis: A randomized, double-blind controlled trial. J Neurol Sci2004; 222: 99–104.
40.
MontedoriABonaciniMICasazzaG, et al.Modified versus standard intention-to-treat reporting: are there differences in methodological quality, sponsorship, and findings in randomized trials? A cross-sectional study. Trials2011; 12: 58.
41.
JakobsenJCGluudCWetterslevJ,et al.When and how should multiple imputation be used for handling missing data in randomised clinical trials – a practical guide with flowcharts. BMC Med Res Methodol2017; 17: 162.
42.
GallucciM. GAMLj: General analyses for linear models. [jamovi module]. 2019https://gamlj.github.io/.
43.
CohenJ. Statistical power analysis for the social sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.,1988.
44.
PalachollaRSFischerNColemanA, et al.Provider- and patient-related barriers to and facilitators of digital health technology adoption for hypertension management: scoping review. JMIR Cardio2019; 3: e11951.
45.
MaggioMGRussoMCuzzolaMF,et al.Virtual reality in multiple sclerosis rehabilitation: A review on cognitive and motor outcomes. J Clin Neurosci2019; 65: 106–111.
46.
Matamala-GomezMMaistoMMontanaJI, et al.The role of engagement in teleneurorehabilitation: A systematic review. Front Neurol2020; 11: 354.
47.
TieriGMoroneGPaolucciS,et al.Virtual reality in cognitive and motor rehabilitation: Facts, fiction and fallacies. Expert Rev Med Devices2018; 15: 107–117.
48.
IserniaSPagliariCJonsdottirJ, et al.Efficiency and patient-reported outcome measures from clinic to home: The human empowerment aging and disability program for digital-health rehabilitation. Front Neurol2019; 10: 1206.
49.
Ochoa-MoralesAHernandez-MojicaTPaz-RodriguezF, et al.Quality of life in patients with multiple sclerosis and its association with depressive symptoms and physical disability. Mult Scler Relat Disord2019; 36: 101386.
50.
MaistoMDianaBDi TellaS, et al.Digital interventions for psychological comorbidities in chronic diseases—a systematic review. J Pers Med2021 Jan 6; 11(1): 30.
51.
ConroySSZhanMCulpepperWJ2nd,et al.Self-directed exercise in multiple sclerosis: Evaluation of a home automated tele-management system. J Telemed Telecare. 2018; 24: 410–419.
52.
HoangPSchoeneDGandeviaS,et al.Effects of a home-based step training programme on balance, stepping, cognition and functional performance in people with multiple sclerosis—a randomized controlled trial. Mult Scler2016; 22: 94–103.
53.
MotlRWSandroffBMKwakkelG, et al.Exercise in patients with multiple sclerosis. Lancet Neurol2017; 16: 848–856.
54.
ProsperiniLFortunaDGianniC,et al.Home-based balance training using the Wii balance board: A randomized, crossover pilot study in multiple sclerosis. Neurorehabil Neural Repair2013; 27: 516–525.
55.
Ortiz-GutierrezRCano-de-la-CuerdaRGalan-del-RioF, et al.A telerehabilitation program improves postural control in multiple sclerosis patients: A Spanish preliminary study. Int J Environ Res Public Health2013; 10: 5697–5710.
56.
Casuso-HolgadoMJMartin-ValeroRCarazoAF, et al.Effectiveness of virtual reality training for balance and gait rehabilitation in people with multiple sclerosis: A systematic review and meta-analysis. Clin Rehabil2018; 32: 1220–1234.
57.
PorrasDCSiemonsmaPInzelbergR,et al.Advantages of virtual reality in the rehabilitation of balance and gait: Systematic review. Neurology2018; 90: 1017–1025.
58.
AmatoMPZipoliVPortaccioE. Multiple sclerosis-related cognitive changes: A review of cross-sectional and longitudinal studies. J Neurol Sci2006; 245: 41–46.
59.
ChiaravallotiNDDeLucaJ. Cognitive impairment in multiple sclerosis. Lancet Neurol2008; 7: 1139–1151.
