Yvonne C Learmonth

Purpose
Conduct a systematic review aimed to identify and synthesise evidence describing how walking impairment impacts the way persons with multiple sclerosis (MS) participate in activities within their homes and communities. Further, we assessed the sensitivity of the International Classification of Functioning, Disability and Health (ICF) framework to the lived walking experience for persons with MS.

Methods
Seven electronic databases were searched for peer-reviewed articles on the walking experience of persons with MS. Qualitative articles were included if they included quotes from persons with MS regarding community walking. Qualitative data were synthesised using a hybrid inductive and deductive thematic analysis, guided by the ICF framework and quality was appraised using the CASP tool.

Results
We included 90 eligible studies (214 quotes, 1813 participants). Study quality was high in 54% of studies. Four themes were identified: (1) adapting to physical barriers; (2) navigating society; (3) emotion and mindset; and (4) personal relationships.

Conclusions
The impact of walking impairment on community participation is perceived by persons with MS as negative and the cause of disconnect from those around them. Barriers are largely perceived as extrinsic to the self. Caution should be exercised when conceptualising walking experiences with MS using the ICF framework alone.

Implications for rehabilitation
This study reinforces the understanding of walking with multiple sclerosis (MS) as dynamic and multifaceted, shaped by physical, societal, relational, and psychological factors.

There is a need for enhanced advocacy efforts that extend beyond infrastructure, targeting the immediate social networks and broader communities of individuals with MS.

Consumer and community co-designed research is pivotal in recognising emotion and mindset as central, not peripheral, to the walking experience for persons with MS.

When conducting a walking-related needs analysis for persons with MS, we recommend that clinicians integrate psychological and physical outcomes.

Background
To improve the quality and standard of care, considerable resources are invested to produce clinical guidelines for multiple sclerosis (MS) management. We aimed to investigate MS clinicians’ use of guidelines and factors that influence use.

Methods
Interview guides were developed using Fisher’s framework to assess factors that influence guideline application (categorized as personal, guideline related, and external). Nurses and neurologists experienced in MS health care were recruited through convenience sampling. Semistructured online interviews were conducted from June 2023 to October 2023, and data were analyzed using inductive and deductive methods.

Results
We interviewed 16 MS clinicians (10 nurses, 6 neurologists). Despite most clinicians believing that guidelines can improve consistency, safety, and quality of care, the application of guidelines was highly variable. Participants reported that clinical decision-making in MS management involves integrating guideline recommendations with clinical reasoning while considering patients’ circumstances and preferences, the complex nature of MS, and resource constraints. Personal barriers to guideline application included low awareness and familiarity. Guideline-related barriers included evidence, plausibility, accessibility, layout, and complexity. External barriers included a lack of resources. Facilitators were mostly guideline related, including relevance to local protocols, covering complex treatment or unfamiliar topics, and when guidelines were up to date and credible. Participants suggested various strategies to overcome barriers to guideline use.

Conclusions
Australian MS clinicians reported low awareness and high variability in the application of national and/or international MS guidelines. Clinical practice guidelines should be adaptable to local contexts, accessible, and regularly updated. Multifaceted strategies to better distribute and champion guidelines should be employed.

Background
This study aimed to determine the self-reported impacts of COVID-19 on healthcare disruption for persons with multiple sclerosis (MS) in Australia and the personal characteristics and service factors associated with disruption.

Methods
We used 2020 data from the Australian MS Longitudinal Study survey. We used univariate and backward-stepwise regression to explore the disease-related and demographic predictors of: i) the self-perceived influence of COVID-19 on medical care; and ii) the impact of reduced access to health services on health. We also quantified the cumulative impact reduced access to each health service had on the cohort, incorporating the volume and severity of the impact on health.

Results
Of the 1484 participants who provided data, 548 (36.9 %) participants reported the pandemic influenced their medical care. Participants who reported the pandemic influenced their medical care had a younger age, more comorbidities and more disability. 454 (30.6 %) participants reported that reduced access to health services impacted their health. Reduced access was most commonly reported for general practice (311, 21 %), neurology (246, 16.6 %) and physiotherapy (214, 14.4 %). Reduced access to physiotherapy had the greatest cumulative impact on health. The cumulative personal impact of reduced access across all health services was associated with several factors, including younger age, female sex and disability.

Conclusions
One-third of Australians with MS experienced healthcare disruptions during the first year of the COVID-19 pandemic, with the reduced access to physiotherapy most significantly impacting health. The study underscores the importance of continuity of healthcare services during future crises and underscores the need for robust strategies such as hybrid healthcare models and telehealth frameworks to guard against risks to service delivery in the future.

Context
The double-leg Landing Error Scoring System (LESS) identifies noncontact ACL injury risk. However, its intersession reliability has been examined in only one study. As such injuries often occur during single-leg landings, research on the single-leg LESS (SLESS) in field settings remains lacking. Therefore, our study investigated the intersession, intrarater, and interrater reliability of single- and double-leg jump-landing tasks using SLESS and LESS.

Methods
Thirty-five team-sports players (age: 26.4 [6.7] years, n = 28 males and 7 females) performed 3 jump-landing variations (single-leg dominant and nondominant and double leg) across 3 sessions. We conducted sessions 1 and 2 on the same day, with session 3 one week later. Three assessors rated video footage to determine SLESS and LESS total scores. Reliability was assessed using the intraclass correlation coefficient (ICC), standard error of measurement, and coefficient of variation (CV) with 95% CIs.

Results
Intersession reliability for the SLESS and LESS scores showed good to excellent ICCs (dominant leg: .89, nondominant leg: .91, double leg: .79) with moderate CVs (dominant leg: 6.5%, nondominant leg: 6.6%, double leg: 7.9%). Intrarater reliability for the SLESS and LESS scores also demonstrated good to excellent ICCs (dominant leg: .94, nondominant leg: 0.92, double leg: .88) with moderate CVs (dominant leg: 5.0%, nondominant leg: 6.0%, double leg: 5.6%). Interrater reliability for the SLESS and LESS scores exhibited good ICCs (dominant leg: .82, nondominant leg: .83, double leg: .79) but poor CVs (dominant leg: 10.5%, nondominant leg: 11.5%, double leg: 11.5%). Single-leg LESS and LESS scores exhibited small standard error of measurement values between 1.05 and 1.11 for all reliability measures.

Conclusions
The SLESS and LESS are reliable field-based tools for assessing jump-landing tasks among team-sports players, facilitating confidence in sports and exercise science research.

Summary of: Lopez-Brull A, Perez-Dominguez B, Plaza-Carrasco M, Blasco-Ortiz C, Navarro-Ribera B, Casaña J, et al. Online graded motor imagery is effective in women diagnosed with pelvic pain: a randomized controlled trial. Phys Ther. 2025:105:pzae164.

Question: Does an online graded motor imagery (GMI) program reduce pain intensity and improve sexual function in women diagnosed with genito-pelvic pain/penetration disorder compared with no treatment? Design: Parallel-group, randomised, controlled trial with concealed allocation and blinded assessors. Setting: Physiotherapy clinics specialised in pelvic floor disorders in Valencia, Spain. Participants: Eligible participants were women aged >18 years who experienced pain with vaginal penetration during sexual intercourse for ≥ 6 months and who scored > 6 points on the Chronic Pelvic Pain questionnaire (0 to 27 scale). Key exclusion criteria were other medical conditions that could explain pain with vaginal penetration during sexual intercourse. One-to-one randomisation of 87 participants allocated 43 to the GMI group and 44 to a control group. Interventions: Participants in the GMI group received a tailored online program for pelvic pain, aligning with principles of neuroplasticity. It consisted of three 2-week phases over 6 weeks. In phase 1 (implicit motor imagery exercise), participants viewed pain-related images of the abdominoperineal area and judged left/right perspectives via an app. In phase 2 (explicit motor imagery exercise), participants listened to six audio recordings and imagined several exercises, with the recordings representing a gradual progression of potential painful activities. In phase 3, participants followed a graded exposure exercise program, starting with genital exploration and ending in intercourse. Researchers contacted participants over the 6 weeks to ensure adherence and address queries. The control group received no intervention during the study period. Outcome measures: The primary outcomes were pain intensity assessed using a visual analogue scale (0 to 10 cm) and sexual function assessed using the short form Female Sexual Function Index (FSFI-6, 2 to 30) at 6 weeks. Results: Eighty-three participants (96%) completed the 6-week follow-up. The GMI program resulted in a small but significant reduction in pain intensity (between-group MD –2.0, 95% CI –2.6 to –1.4) but did not result in improved sexual function (between-group MD in FSFI scores 1.1, 95% CI –0.7 to 2.9) when compared with no treatment. Conclusion: In adult women with genito-pelvic pain/penetration disorder, a 6-week online GMI program improved pain intensity but not sexual function compared with no treatment. [95% CIs calculated by the CAP Editor.]

Provenance: Invited. Not peer reviewed.

Summary of: Ali AS, Kumaran DS, Unni A, Sardesai S, Prabhu V, Nirmal P, et al. Effectiveness of an Intensive, Functional, and Gamified Rehabilitation Program on Upper Limb Function in People With Stroke (EnteRtain): A Multicenter Randomized Clinical Trial. Neurorehabil Neural Repair. 2024;38:243–256.

Question: Does a gamified upper limb training program improve upper limb function and activity after stroke compared with a task-based training program? Design: Randomised controlled trial with concealed allocation and blinded assessment. Setting: Three rehabilitation centres in India. Participants: Adults aged < 80 years with unilateral stroke and haemodynamic stability. Exclusion criteria were: global or receptive aphasia; complex regional pain syndrome; major medical issues or comorbidities that restricted study participation; and sensory loss that limited computer use. Randomisation of 120 participants allocated 64 to the gamified training group and 56 to a task-based comparator group. Interventions: Participants in both groups received conventional training consisting of mobilisation of limbs, facilitatory/inhibitory techniques, muscle strengthening, balance training and gait training. In addition to this, the intervention group received an intensive, functional, gamified upper limb program using the portable ArmAble™ device, while the comparator group received an upper limb task-based program, which included daily functional tasks. The intervention and comparator were delivered for 45 to 60 minutes, 6 days/week, under therapist supervision for 2 weeks. Participants in both groups then received an identical home-based program of 30 minutes, 6 days/week for 4 weeks, and this was supported by weekly phone calls to encourage adherence. Outcome measures: The primary outcomes were change in upper limb function via the Fugl-Meyer Assessment-Upper Extremity tool (FM-UE, 0 to 66) and upper limb activity via the Action Research Arm Test (ARAT, 0 to 55) from baseline to 2 and 6 weeks. Results: 115 participants (96%) completed the 2-week follow-up and 98 (82%) the 6-week follow-up. The gamified training program was superior for improving FM-UE scores at 2 weeks (MD –3.9, 95% CI –6.5 to –1.3) and 6 weeks (MD −3.9, 95% CI –6.5 to –1.3) but not ARAT scores at 2 weeks (MD −2.9, 95% CI −5.8 to 0.0) and 6 weeks (MD –3.0, 95% CI –5.9 to –0.0). Conclusion: In adult stroke survivors, a 2-week gamified upper limb training program, supplemented with a 4-week home-based program, improved upper limb function but not activity, compared with a 2-week task-based training program supplemented with a 4-week home program.

Provenance: Invited. Not peer reviewed.

Introduction
Persons with multiple sclerosis (MS) frequently experience symptoms of anxiety. There is a large unmet need for effective and accessible interventions.

Objectives
To assess the effect of exercise on symptoms of anxiety in persons with MS, consider characteristics associated with effectiveness, and evaluate intervention design reporting.

Methods
This systematic review and meta-analysis included randomised controlled exercise trials in persons with MS. MEDLINE, Embase, PsycINFO, CENTRAL, CINAHL, Scopus, Web of Science and PEDro were searched up to November 2024. The primary outcome was the post-intervention difference in anxiety symptoms between intervention and inactive control groups. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. We pooled standardised mean differences using a restricted maximum likelihood random-effects model.

Results
This systematic review of 18 randomised controlled trials identified a small positive effect of exercise on anxiety symptoms in persons with MS (SMD: 0.26, 95% CI: 0.04, 0.48) with moderate heterogeneity between trials (I2: 37.94%, τ2: 0.0962). All trials had a high risk of bias, as they relied on self-reported anxiety measures in unblinded participants. Few trials were pre-registered, and none focused on anxiety as the primary outcome. Authors infrequently reported intervention designs incorporating stakeholder engagement, expert engagement, and evidence-based and/or behavioural frameworks.

Conclusions
Exercise can reduce symptoms of anxiety in persons with MS. This is a promising result, given that exercise is beneficial for general health and is a safe and accessible treatment option.

Multiple sclerosis (MS) is the most prevalent neurological disorder in young adults, characterised by physical, psychological and cognitive dysfunction. Exercise training is a safe management strategy. Healthcare providers (HCPs) acknowledge deficiencies in awareness, counselling strategies, and resources that prevent them from promoting and prescribing this effective treatment. We implemented an online evidence-based educational programme and evaluated the effect, acceptability, appropriateness, and feasibility of the programme in improving HCP confidence, knowledge, and attitudes towards remote exercise prescription to persons with MS.
: Physiotherapists and exercise physiologists were recruited and received the educational programme (online theory and 16-week experience of prescribing to persons with MS). Participants' confidence, knowledge and attitudes towards exercise prescription, as well as their professional quality of life, were our primary outcomes-baseline (T1), immediately post-online theoretical learning (T2), post-application with clients (T3; approximately 16 weeks after T2), and at 12-month follow-up (T4). We gathered participants' acceptability, appropriateness, and feasibility evaluation at T2, T3 and T4. We analysed the effect on primary outcomes using generalised linear mixed models, with secondary and evaluative outcomes analysed as counts and qualitative themes.
: Of 40 participants who provided baseline data, 24 completed the theoretical programme, and 16 completed the experiential programme. Self-confidence improved significantly (|βs| ≥ 1.27, SEs ≤ 0.31, |zs| ≥ 5.28, ps < 0.001), with large effect sizes (percentage change: 256.8-479.4%). Some theoretical domains framework-based domains have improved, such as beliefs about skills to prescribe evidence-based principles. Participants expressed high satisfaction with the programme and showed increased delivery of implementation behaviour change strategies.
: An online evidence-based education programme for MS care improved HCPs' self-confidence, perceived skills and delivery of evidence-based exercise behaviour-based prescription.