Physical Therapy Reviews
ISSN: 1083-3196 (Print) 1743-288X (Online) Journal homepage: http://www.tandfonline.com/loi/yptr20
Physiotherapy and walking outcomes in adults
with multiple sclerosis: systematic review and
meta-analysis
Yvonne C. Learmonth, Ipek Ensari & Robert W. Motl
To cite this article: Yvonne C. Learmonth, Ipek Ensari & Robert W. Motl (2016): Physiotherapy
and walking outcomes in adults with multiple sclerosis: systematic review and meta-analysis,
Physical Therapy Reviews
To link to this article: http://dx.doi.org/10.1080/10833196.2016.1263415
Published online: 08 Dec 2016.
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Date: 27 December 2016, At: 06:53
Physiotherapy and walking outcomes in
adults with multiple sclerosis: systematic
review and meta-analysis
Yvonne C. Learmonth1, Ipek Ensari1, Robert W. Motl2
Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL,
USA, 2Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL, USA
1
Background: Physiotherapy treatment may result in improved walking performance among persons with multiple
sclerosis (MS). The existing literature is unclear as to what type of physiotherapy treatment has a larger effect
on walking performance. It is further unclear regarding which domain of walking performance is improved with
physiotherapy.
Objective: To systematically review and quantify the effect of physiotherapy on walking performance compared
with usual care in MS.
Methods: A literature search of five databases was undertaken to identify randomised controlled trials of
physiotherapy treatments that targeted walking outcomes. There were 21 studies that met our inclusion criteria
and yielded data for effect size (ES) generation. An overall ES was calculated using a random effects model and
expressed as Hedge’s g.
Major findings: Physiotherapy treatments yielded a small, but statistically significant overall improvement in
walking outcomes compared with usual care in persons with MS (ES = 0.25; 95% CI = 0.09–0.41; p < .05).
Moderator analyses provided no significant evidence that different types of physiotherapy treatment, or different
domains of walking performance, yield larger improvements in walking outcomes in persons with MS.
Conclusion: This evidence indicates that overall there is a significant improvement in walking performance
following physiotherapy in persons with MS.
Keywords: Physiotherapy, Physical therapy, Walking, Multiple sclerosis, Meta-analysis, Review
Introduction
Multiple sclerosis (MS) is a prevalent and chronic
­disabling neurological disease characterised by inflammatory demyelination and neuronal loss throughout
the central nervous system (CNS).1 The damage within
the CNS results in the slowing of nerve conduction and
decreased motor activation that coincide with impaired
motor performance.2 Walking dysfunction (i.e. abnormal
gait biomechanics, altered balance, muscle weakness and
fatigue) is one of the most commonly impaired domains
of motor performance associated with this disease.3 The
prevalence, cost and burden of walking dysfunction have
prompted the search for strategies that are effective for
improving walking function in MS.
Physiotherapy is one common rehabilitation strategy
that may be effective for improving walking dysfunction
in persons with MS. Physiotherapy can be thought of as
‘a physical treatment that may be used by a physiotherapist, including physical activity, exercise, and therapeutic
Correspondence to: Robert W. Motl, Department of Physical Therapy,
University of Alabama at Birmingham, 1705 University Blvd, Birmingham,
AL 35294, USA. Email: robmotl@uab.edu
© 2016 Informa UK Limited, trading as Taylor & Francis Group
DOI 10.1080/10833196.2016.1263415
modalities’.4 Physiotherapy treatments may include
­exercise (e.g. aerobic exercise, resistance training, neurophysiological approaches and yoga), electrotherapy
modalities (e.g. whole-body vibration), orthotic devices
(e.g. ankle splints), massage or hydrotherapy.5
Systematic reviews have examined the effect of physiotherapy on walking dysfunction in MS,4,6,7 yet full conclusions as to the overall effect and specific effects of
different physiotherapy treatment types on walking outcomes cannot be made from these review articles. This is
because the authors did not perform meta-analytic techniques to establish the magnitude of the overall effect for
physiotherapy on walking, and further did not perform
analyses to establish the possible differential effects of
specific physiotherapy treatment types. One meta-analysis
has focused on the effect of exercise therapy8 on walking
dysfunction in persons with MS by quantifying the minimal difference (MD) of exercise treatments compared
with control. The meta-analysis indicated that exercise
training yielded improvements in walking speed measured by the 10-metre walk test (10 mWT) (MD = −1.8 s;
95% confidence interval (CI) = −2.5,−1.1; p < .001),
Physical Therapy Reviews 2016 1
Learmonth et al.
Systematic review and meta-analysis
Two reviewers independently assessed the quality of the
included studies based on the 11-item physiotherapy evidence database (PEDro) scale.11 The PEDro scale offers
a comprehensive measure of the validity and quality of
RCTs. Descriptive domains in this tool assess external validity of the results (i.e. eligibility criteria) and
the quality of the trial (i.e. randomisation, concealed
group allocation, baseline similarities of groups, subject blinding, therapist blinding, assessor blinding, key
outcomes attained from 85% of the sample, intention to
treat analysis, statistics compared for at least one key
outcome and statistics compared at more than one timepoint). The RCTs are scored on 10 of the 11 criteria,
with the criterion involving eligibility criteria not being
included in the overall score. To allow for comparison
across studies, higher quality studies were categorised as
studies that had a PEDro score of ≥6, and lower quality
studies had a PEDro score of <6.
Methods
Characteristics of physiotherapy treatment
We conducted our meta-analysis in accordance with the
preferred reporting items for systematic reviews and
meta-analyses (PRISMA) guidelines.9 Our literature
search was informed by past systematic reviews of physiotherapy treatments in MS.4,6,10 We searched the following
databases without date limits: PubMed, Science Direct,
Scopus, SPORT Discus and Web of Science. The key
terms searched were MS and acronyms of physiotherapy
(e.g. physical therapy physiotherapy, physical therapy
modalities, physical fitness or rehabilitation), potential
physiotherapy treatments (e.g. physical activity, physical endurance, physical education and training, physical
medicine, exercise, exercise therapy, therapeutic exercise
or rehabilitation), and walking (e.g. gait disorders, gait
or walking). We added a search term for study type (e.g.
randomised controlled trial, controlled clinical trial or
randomised).
Inclusion criteria
Primary research studies were included that measured
walking performance using a valid quantitative outcome
assessment (e.g. 10 mWT, 6 MWT and TUG), and included
a physical treatment consistent with physiotherapy5 and
persons with MS. Studies were included if the comparative
control group involved no change in usual behaviour (e.g.
usual care).
Animal studies, reviews and non-RCTs were excluded.
Studies that did not have any of the desired outcome
measures or participants who did not have a diagnosis
of MS were excluded. Incomplete data or data from any
2
duplicated studies were excluded. Studies with data not
available or not provided in the required format for the
required analysis were excluded from the review and
meta-analysis.
walking endurance measured by the six-min walk test
(6 MWT) (MD = 36.5 m; 95% CI = 15.1,57.8; p < .001),
and dynamic functional walking measured by the timed-up
and go (TUG) (MD = −1.1 s, 95% CI = −2.2,0.1, p = .07).
Sub-group analysis compared exercise therapy type (i.e.
aerobic exercise, resistance training, combined training
and yoga) on walking speed (10 mWT) and walking endurance (6 MWT), and provided no clear evidence on what
type of exercise therapy has the largest effect on walking
performance.
The current systematic review and meta-analysis
extends previous research by examining the magnitude of
difference in walking performance between persons with
MS who received a physiotherapy treatment compared
with usual care. Usual care was defined as no change in
normal behaviour or treatment over the time-course of the
study. The results can provide a better understanding of the
improvement in walking outcomes associated with physiotherapy treatments in MS. The results can further identify the treatment types that maximise the improvement in
different domains of walking outcomes. Such information
can guide researchers and clinicians when planning focal
inquiries and treatments of walking dysfunction among
persons with MS.
Physical Therapy Reviews 2016 Study quality
Physiotherapy treatments vary depending on the type of
treatment and the body systems used to perform the task.
To allow for comparison across studies, physiotherapy
treatment types were divided into seven subgroups based
on past systematic reviews.4,6,7 These subgroups were aerobic exercise, balance and neurofacilitation, combined
training, massage, resistance training, vibration and yoga.
Aerobic exercise primarily targeted the aerobic system.
Examples of aerobic exercise treatments included indoor
stepper, bicycle or treadmill. Balance and neurofacilitation treatments targeted the cerebellar, vestibular and
sensory systems. Examples of balance and neurofacilitation treatments included multisensory and motor strategy training, and balance-retraining tasks. Combined
treatments involved more than one type of treatment.
Examples of combined treatments included aerobic, balance and resistance training, or a similar combination.
Massage treatments involved passive treatments primarily targeting the lymphatic system. Examples of massage treatments include whole-body Swedish massage.
Resistance training exercise primarily targeted the muscular system. Examples of resistance training included
plyometrics (e.g. squat jumps) or functional strength
movements (e.g. calf raise or chair raise). Vibration
treatments included whole-body vibration. Examples
of vibration involved maintaining or repeating a series
of strengthening poses (e.g. squat) while standing on a
vibrating platform. Yoga involved a series of poses to
stretch and tone the muscular system. Examples of yoga
treatments include Hatha yoga and Iyenger yoga.
Learmonth et al. Systematic review and meta-analysis
Characteristics of walking assessments
Walking assessments included gait and walking outcomes. To allow for comparison across studies, walking
assessments were divided into three subgroups. These
subgroups were walking endurance, walking speed and
walking with dynamic functional task. Walking endurance
required walking over a predetermined distance of 500 m
or greater, or for a prolonged period of 2 min or greater.
Examples of walking endurance tasks include the 500-m
walk test (500 mWT)12 the 2 MWT,13 the three-min walk
test (3 MWT)14 and the six-min walk test (6 MWT).13
Walking speed was assessed with single straight line walking over distances of 10 m or less. Examples of walking speed assessments included the timed 25-foot walk
test (T25FW),15 or the 10 mWT.16 Walking with dynamic
functional tasks required undertaking a walking task with
additional gait demands such as standing from sitting or
navigating objects. Examples of walking with dynamic
functional tasks included the TUG,17 and the dynamic gait
index (DGI).18
Statistical analysis
We computed effect size (ESs) expressed as Hedges’ g.19 To
do this, we computed the difference in mean scores for preand post-assessment (i.e. change) between the treatment
group and the control group. The resulting difference in
mean change between the groups was then divided by the
pooled baseline standard deviation (SD) of pre-assessment
scores for the treatment and control group. The ESs were
calculated so that a positive ES indicated an improvement
in mean walking performance in the treatment group versus
the control group. We completed the meta-analysis using a
single ES per study (i.e. an average ES when there was >1
ES per study computed by the software), as multiple ESs
from the same study are not independent 20 and can bias the
overall ES from the meta-analysis. We did include multiple
ESs per study when performing moderator analyses.
The ESs and the associated standard errors (SEs) were
entered into the Comprehensive Meta-Analysis software
(version 2.0; Biostat Inc. Englewood, NJ). We computed
the overall or mean ES using a random effects model.
The random effects model assumes the samples are from
populations with different ESs, and indicates that the true
effect will differ between studies.20 We computed a 95%
confidence interval (CI) around the mean ES. An overall
Q value and I2 value were calculated to test for homogeneity among ESs. The Q value is a measure of variance
among the ESs, and a statistically significant (p < .05) sum
of the squares of each ES around the weighted mean (Q)
indicates heterogeneity. The I2 value represents the magnitude of the heterogeneity, with a larger number indicating
greater heterogeneity.
We further performed post hoc moderator analyses.
The moderator analyses were conducted based on the
categorical variables of walking assessment (i.e. walking endurance, walking speed and walking with dynamic
functional task), physiotherapy type (i.e. aerobic exercise, balance and neurofacilitation, combined, massage,
resistance training, vibration and yoga), primary outcome
(i.e. walking outcome assessment) and study quality (i.e.
PEDro score < 6). The QB statistic was used to assess the
statistical significance of the difference between levels of
a moderator variable.
Results
Identified studies
A visual description of our literature search is provided in
Figure 1. Following the electronic database search, 566
abstracts were returned and 185 were duplicates across
search engines. We read the title and abstract of each of
the remaining 381 studies for reporting of physiotherapy
effects on walking performance in MS. We further read the
full text of any remaining study if the title and abstract did
not provide sufficient information to infer a judgement on
inclusion. Irrelevant studies were excluded and ultimately
21 studies were identified which met our inclusion criteria.14,21–40 We excluded 360 studies which were returned
from the literature search, but were not randomised
Figure 1 PRISMA flow chart of literature search
Physical Therapy Reviews 2016 3
4
Physical Therapy Reviews 2016 119*/RR, SP,
PP/<6.5
Carter et al.
(2014)
35/RR, P, CP,
B/1–6.5
24/NR/2.83
(0.73)
30/RR, SP/NR
DeBolt and McCubbin 2004
Eftekhari et al.
(2012)
Eftekhar-sadat
et al. (2015)
Geddes et al.
(2009)
22/RR,PP,NC/≤6.
31/RR/3-6.5
Dalgas et al.
(2009)
47/NR/5.2 (1.2)
30/NR/3.1 (1.4)
Carter et al.
(2013)
Claerbout et al.
(2012)
33/RR, SP/≤6.0
Cakit et al.
(2010)
N (baseline)/
Type/EDSS
31/NR/1.0–4.0
10 mWT
33–69/13:4
35.1(6.9(/12:0
34.7/3:1
6 MWT
TUG
TUG
33.8(5.3)/12:0
33.4 (8.1)/10:5
37.0 (8.3)/12:3
51.3/6:2
No
No
Unclear
Yes
Unclear
Yes
No
No
10 mWT, 6 MWT No
3 mWT, TUG
6 MWT, T25FW
T25FW
10 mWT, TUG,
DGI
Outcome measures
Walking out- Walking as pricome measure mary outcome
assessed
measure
10 mWT, 2 MWT Yes
49.1 (8.4)/10:6
40–67/14:4
47.6(8.3)/11:6
47.7 (10.4)/10:5
39.1 (8.2)/4:14
43.8 (12.6)/6:15
46.0 (6.4)/43:17
45.7 (9.1)/43:17
40.9 (8.7)/12:2
35 (10.9)/6:3
39.5 (6.5)/13:2
43 (10.2)/8:2
36.7 (9.3)/10:0
36.4 (10.5)/9:5
Age (y)/F:M
36.8 (9.2)/10:0
32.3 (8.7)/11:0
Participants
Participant, outcome measure and intervention information
Study
Ahmadi et al.
(2013)
Table 1
Usual National Health Service care. Post-study offered
advice and supervised training
Aerobic: rowing, walking, upright cycle, recumbent bike
and cross-trainer 50–69% APHRmax (intervals) RT: 1–3 sets
× 5–20 reps
10/3/60
–
–
10/3/60
8/2/60
–
8/2/30
Control
Offered participation in the home walking program with
monitoring upon completion of the study
–
–
Physiologist/Exercise science
laboratory
–
PT/PT clinic
–
Self led with PT phone calls/
community
–
–
PT (supervised) then self-led/
PT clinic then home
–
Unclear/Hospital clinic
PT/PT clinic
PT/PT clinic
–
Exercise researchers/Exercise
science laboratory
–
–
Exercise researchers/Exercise
science laboratory
Self-led/home
–
Physiatrist/unclear
Duration (w)/
frequency (d/w)/
time (m)
Delivered by/setting
8/3/40
PT/PT clinic
8/3/60
Yoga teacher/unclear
Usual National Health Service care, offered advice and
–
supervised training post-study
Vibration full
Whole-body vibration plate (lower body static poses). Pro3/3.3/7–13
gression of time; 30 – 45 – 60 s and vibration frequency;
30–35–40 Hz
Vibration light
Whole-body vibration plate (lower body static poses). Pro3/3.3/7-13
gression of time; 30 – 45 – 60 s and vibration frequency;
(on 10 cm mat)
30 to 35 to 40 Hz
Control group
No additional training sessions
–
RT
Lower extremity RTWk1–2; 3 × 10 at 15 RMWk 3–4; 3 ×
12/2/unclear
12 at 12 RM Wk 5–6; 4 × 12 at 10 RMWk 7–8; 4 × 10 at
10 RM Wk 9–10; 4 × 8 at 8 RM Wk 11–12;3 × 8 at 8 RM
Control
No change in activities
–
RT
Lower extremity RT Wk 1 & 3; 2 × 4–12 reps Wk 2 & 4; 3 × 2 (supervised) then
8–12 reps Wk 5 −8; 2 × 8–10 reps
8 (at home)/3/30–
6Control
Offered advice and supervised training post study.
–
Vibration
Whole-body vibration plate three set of 5–12 reps at
8/3/45–60
50–70% 1 RM/ Vibration postures 2–20 Hz
Control
No intervention
–
Balance and neurofacilitation Balance retraining tasks
12/2/20
Control
No intervention
–
Aerobic
Community walking
12/3/30
(Aerobic + RT)
Control
Combined
Control
Modality description: Intensity
Treadmill walking: 40–75% age predicted VO2 Max
Ashtanga:
Range of poses, supported by chair, wall or swiss ball
Control
Wait list
Combined (Aerobic/RT/ bal- RT on bicycle ergometry: 40% of total tolerated workload
ance and neurofacilitation)
for 2 min 30–40 W; 12 sets
Balance/strength; standing, walking and plyometrics
exercises
Combined
Balance/strength; standing, walking and plyometrics
(Aerobic/balance and neuro- exercises
facilitation)
Control
Normal living
Combined (Aerobic/RT)
Aerobic: rowing, walking, upright cycle, recumbent bike
and cross-trainer 50–69% APHRmax (intervals) RT: 1–3 sets
× 5–20 reps
Intervention Type
Aerobic
Yoga
Physiotherapy treatments
Learmonth et al.
Systematic review and meta-analysis
42/NR/6.0 (0.68)
No
30–65/7:1
47.2(28.2–
68.8)/27:15**
39.7 (11.2)/30:18
30–65/7:1
43.9 (7.1)/31:17
41.5 (9.4)/34:17
52.5 (14.3)/12:3
43.8 (6.3)/30:17
49.4(11.1)/32:10
48.8 (10.8)/13:2
49.8 (7.4)/20:2
48.4 (9.8)/20:0
50.8 (7.4)/12:3
Yes
No
Yes
6 MWT
No
10 mWT 2 MWT Unclear
10 mWT
T25FW, 500mWT Yes
T25FW, TUG
10 mWT
TUG, T25FW, DGI Yes
–
8/2/45
Bicycle ergometer 65–75% of HRpeak; 11 to 14 on the
6/2/60
Borg
Series of standing and kneeling static postures plus dy6/2/60
namic walking; inclusion of eye movement exercise
Wait list
–
Aerobic (shuttle walking, bicycle ergometer), RT (lower
12/2/60
and upper body exercises), balance (functional sitting and
standing exercises). Intensity Borg 13–14
Usual National Health Service care, offered advice and
–
supervised training post-study
Domiciliary physiotherapy personal program. Tasks includ8/2/60
ed RT (lower and upper body exercises), balance (functional sitting and standing exercises emphasising flexibility ad
function. Intensity undefined
Usual National Health Service care
RT (straight leg raises and lunges), stretch (hip adductor
5/3/30
and calf muscles), aerobic (treadmill walking increased from
60 to 80% max heart rate and bicycle ergometry starting
at 40% maximum tolerated workload) and balance (wobble
board training)
Combined exercise as above. Swedish massage, petris5/3/30
sage, effleurage and friction to lower limb muscles
Swedish massage, petrissage, effleurage and friction to
5/3/30
lower limb muscles
Standard Medical Care
–
Computer determined games and movements to en6 or 7/2/30
courage movements of reaching and transferring weight.
Progression from simple to difficult games
Invited to start exercising after second data collection
–
Bicycle ergometer intensity 2–3/10 Borg until fatigue
24/1/maximum 60
Iyengar. Range of poses, supported by chair, wall or floor
24/1/60–90
Wait list
–
Aerobic, RT and balance. Content and intensity not
12/2/unclear
detailed
Usual care including advice on community exercise options
Aerobic supervised (aquatic training), aerobic unsupervised three supervised
(aerobic training or preferred aerobic training) and RT
and 24 unsupersupervised (2 × 10–15 reps) RT unsupervised (weeks 4–8 2
vised/2/30
× 10–12 reps, weeks 9–14 2 × 12–15 reps, weeks 15–24 2
× 10–12 reps with heavier load)
Advised to avoid any change in physical activity
–
Bicycle ergometry and RT not described Intensity <13/20
12/3/60
Borg
Phone call once per month to clarify clinical status
Treadmill walking 55–80% age-predicted maximum heart
4/3/30
rate
Wait list
–
Personalised functional problem solving activities
8/2/45
Control
Balance and neurofacilitation
(functional)
Balance and neurofacilitation Personalised facilitation techniques
(neurofacilitation)
Control
Wait list
Control
Aerobic
Control
Combined (Aerobic/RT)
Control
Aerobic
Yoga
Control
Combined (Aerobic/RT/ balance and neurofacilitation)
Control
Combined (Aerobic/RT)
Control
Balance and neurofacilitation
36.7(7.6)/10:2
36.8 (8.7)/10:2
50.0 (11.5)/32:10
Combined (Aerobic/RT/ balance and neurofacilitation)
Balance and neurofacilitation
Combined (as above) and
Massage
Massage
10 mWT, 2 MWT, Unclear
TUG
10 mWT, TUG
Control
36.33(7.62)/10:2
52.9(6.3)/7:8
36.7 (6.7)/10:2
56.3(9.0)/11:4
51.8(8.0)/8:4
Yes
Control
Combined (aerobic/RT/ balance and neurofacilitation)
T25FW, 6 MWT,
TUG
Aerobic
50.2(9.2)/11:2
51.4(8.06)/15:5
Yes
Balance and neurofacilitation
6 MWT
46.8 (10.5)/9:3
42.6 (10.4)/11:2
–
–
PT/PT clinic
PT/home
PY/Unclear
PT/PT clinic
–
–
-
–
PT initial 3 week then self-led/
PT clinic then community
–
PT remotely/home
PT/Unclear
PT/Unclear
PT/PT clinic
Massage therapist/unclear
Massage therapist/unclear
Unclear/Unclear
PT/Home
–
–
PT/community facility
PT/Exercise science laboratory
PT/Exercise science laboratory
Notes: 10 mWT, 10-m walk test; 2 MWT, 2-min walk test; 3 mWT; 3-metre walk test; 500 mWT, 500-metre walk test; 6 MWT, 6-min walk test; B, benign; DGI; Dynamic Gait Index; F, female; I, intervention group;
M, male; NC, not classified; NR, not reported; P, progressive; PP, primary progressive; PT, physiotherapist; RR, relapsing–remitting; RT, resistance training; SP, secondary progressive; T25FW, Timed 25-foot walk
test; TUG, Timed-up and go. EDSS mean (SD) unless otherwise described
*119 for T25FW and 116 for 6 MWT.
**Separate group information not available.
Wiles et al.
(2001)
16/NR/NR
van den Berg et
al. (2006)
95/NR/2.25(median) (1.0–5.5)
Romberg 2004
99/RR, PP,
SP/2.0–6.5T
30/RR, PP, SP,
B/5.9 (0.5)
Paul et al.
(2014)
Tarakci et al.
(2013)
57/NR/<6.0
Oken et al.
(2004)
84/RR, PP, SP/
NR
Nilsagard et al.
(2013)
30/PP/SP/7.1
Miller et al.
(2011)
24/RR,
SP/2.0–6.0
32/NR/5–6.5
Learmonth et al.
(2012)
Negahban et al.
(2013)
38/RR, SP/NR
Hebert et al.
(2011)
Learmonth et al. Systematic review and meta-analysis
Physical Therapy Reviews 2016 5
Learmonth et al.
Systematic review and meta-analysis
controlled trials (RCT) (i.e. case studies, cross sectional
or non-experimental (n = 243), discussions or reviews
(n = 69). We further excluded studies which contained an
active treatment control group (n = 21), were not solely
inclusive of persons with MS (i.e. animal study or healthy
control comparative group (n = 2), were not inclusive of a
whole- or lower body physiotherapy treatment (i.e. drug
treatment, upper body only or theoretical learning only)
(n = 3), did not include a walking outcome (n = 2), were
qualitative (n = 13) or were not in English (n = 4). We
excluded studies from which we could not extract data
in the required format for statistical analysis (n = 3). We
included characteristics of the 21 studies that met all of
the criteria for eligibility in Table 1.
Participants
All studies included adults (≥18 years) with MS, and
demographic information on participants in each study
is provided in Table 1. Complete data were provided for
555 persons who participated in treatments and 392 participants who participated in control treatments (i.e. usual
care). When studies reported type of MS, participants had
relapsing remitting, primary progressive secondary progressive and benign MS. Disability was measured using
the expanded disability status scale (EDSS) and participants had an EDSS score of less than or equal to 6.5.
Participants had a mean age of 44.5 years (SD = 7.1) and
there were 687 females and 260 male participants. Not all
studies provided clear information on type of MS, EDSS,
age and sex.
Outcome measures
Walking outcomes used in the studies are described in
Table 1. Walking endurance outcomes were used in 10
studies21,23,25,29–31,33,37,39,40 and the most common walking
endurance outcome measure was the 6 MWT. Walking
speed outcomes were used in 16 studies14,21–25,27,31–39
and the most common walking speed outcome was the
10 mWT. Dynamic functional walking tasks were used in
eight ­studies14,22,26,28,32–34,36 and the most common dynamic
­functional walking task was the TUG. Walking outcomes
were the primary focus of nine studies (Table 3); the
­primary outcomes in the other 12 studies were outcomes of
attention, balance, MS impact, muscle strength, ­mobility
and time-spent exercising.
Physiotherapy treatments
The physiotherapy treatments used in the studies are
described in Table 1. Aerobic treatments were used in five
studies,21,29,30,35,39 and the type of aerobic exercise modality
included treadmill walking,21,39 indoor bicycling30,35 and
community walking.29 The intensity of aerobic exercise
was quantified differently in each study using the following; 40–75% age predicted peak/maximal VO2,21 65–75%
of heart rate peak,30 RPE score of 2–3/10,35 55–85% of age
predicted maximum heart rate 39 and individualised based
6
Physical Therapy Reviews 2016 on 6 MWT results.30 The duration of the treatments ranged
from 4 to 24 weeks, participants undertook the treatment on
1, 2 or 3 days per week and each session lasted 30–60 min.
The sessions were led or directed by physiotherapists in
all five studies. Only two studies clearly identified the
venue where the treatment was completed, in these cases
the treatment was delivered at a physiotherapy clinic21 or
in a patient’s home.29
Balance and neurofacilitation treatments were used in
seven studies 23,24,28,30,32,34,40 and the modality of balance and
neurofacilitation methods included computer-suggested
movements or physiotherapist-led functional or facilitation movements. The intensity of balance and method of
neurofacilitation were not quantified. The duration of the
treatments ranged from 6 to 12 weeks, and participants
attended two sessions per week in all studies and each
session lasted 20–60 min. All treatments were delivered
by physiotherapists and were completed in either a physiotherapy clinic, exercise science laboratory or the participants’ home.
Combined training treatments were used in eight
­studies,22–24,31,33,36–38 and the types of combined training
involved a combination of aerobic, balance, resistance and
stretching training. The intensity of exercise was mainly
prescribed for the aerobic component as detailed in Table 3.
The duration of the treatments ranged from 5 to 24 weeks,
participants participated in sessions two or three times per
week and each session lasted 30–60 min. The treatments
were delivered by either exercise researchers,23,24 physiatrists,22 massage therapists33 or physiotherapists.31,33,36–38
The treatments were completed in participants’ homes or
community,22,36,37 an exercise science laboratory23,24, community sports facility31 and physiotherapy clinics.33,38
Massage treatments were used in one study.33 This
study further compared combined exercise with massage,
and this has been considered as a combined treatment.
The modality of massage was Swedish, and the intensity
was not quantified. The treatment duration was 5 weeks,
and was delivered three times per week. The length of
each session was 30 min. Treatments were delivered by a
massage therapist. Information was not provided on the
setting of treatment delivery.
Resistance training treatments were used in two studies,25,26 and the modality of resistance training involved
repeated sets and repetitions of lower body exercises. The
intensity of exercises was prescribed as indicated in Table 1.
The duration of the treatments were 10 and 12 weeks, and
were undertaken 2 or 3 days per week. The length of each
session was reported for one study26 as ranging from 30
to 60 min. In one study, the sessions were initially led by
a physiotherapist in a physiotherapy clinic26 before being
self-led at participants home, this level of detail was not
reported in the other study.
Vibration treatments were used in two studies,14,27 and
the type of treatment was whole-body vibration. The intensity of the vibration progressed from 30 to 40 HZ with
0
1
0
1
0
1
0
1
0
1
1
0
1
1
1
1
1
1
1
1
1
1
1
1
0*
1
1
1
1
1
1
1
1
1
1
0
1
1
1
1
1
1
1
1
1
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
0
0
0
1
1
1
1
1
0
0
0
0
0
1
0
0
0
1
0
0
1
6
PEDro criteria
1
0
1
0
1
1
1
0
1
0
1
1
1
0
1
1
1
1
0
1
1
7
0
0
1
1
1
1
0
0
1
1
1
0
1
0
1
1
0
0
1
1
1
8
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
9
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
10
4
4
7
6
7
7
7
5
7
5
6
5
6
5
7
7
7
6
5
5
7
Total/10
*Scores adjusted for baseline differences, PEDro categories 1 = random allocation, 2 = concealed allocation, 3 = baseline similarities, 4 = subject blinding, 5 = therapist blinding, 6 = assessor blinding, 7 = key
outcomes attained from 85% of participants, 8 = intention to treat analysis, 9 = statistics compared for one key outcome and 10 = statistics compared at both time points.
0
0
1
1
1
1
0
0
0
1
1
1
1
1
1
1
1
1
2
1
Ahmadi et al. (2013)
Cakit et al. (2010)
Carter et al. (2013)
Carter et al. (2014)
Claerbout et al. (2012)
Dalgas et al. (2009)
DeBolt et al. (2004)
Eftekhari et al. (2012)
Eftekhar-sadat et al.
(2015)
Geddes et al. (2009)
Hebert et al. (2011)
Learmonth et al. (2012)
Miller et al. (2011)
Negahban et al. (2013)
Nilsagard et al. (2013)
Oken et al. (2004)
Paul et al. (2014)
Romberg et al. (2004)
Tarakci et al. (2013)
van den Berg et al.
(2006)
Wiles et al. (2001)
PEDro scores for study quality
Reference
Table 2
Learmonth et al. Systematic review and meta-analysis
Physical Therapy Reviews 2016 7
8
Physical Therapy Reviews 2016 Dalgas et al. (2009)
Claerbout et al. (2012)
Carter et al. (2014)
Carter et al. (2013)
Cakit et al. (2010)
Control n = 17
RT n = 15
Control n = 16
RT n = 15
Control n = 16
Vibration light n = 14
Vibration light n = 14
Control n = 17
Control n = 17
Control n = 17
Vibration full n = 16
Combined n = 16
Control n = 14
Combined n = 53
Control n = 54
Combined n = 53
Control n = 54
Vibration full n = 16
Control n = 9
Combined = 10
Combined n = 10
Control n = 9
Combined n = 10
Control n = 9
Control n = 9
Control n = 9
Aerobic n = 14
Aerobic n = 14
Control n = 9
Aerobic n = 14
Yoga n = 11
Control n = 10
Yoga n = 11
Control n = 10
Physiotherapy treatment and sample size
Aerobic n = 10
Control n = 10
Aerobic n = 10
Control n = 10
Summary of studies with moderator analysis criteria
Study
Ahmadi et al. (2013)
Table 3
TUG (sec)
Speed
10 mWT (sec)
Endurance
6 MWT (m)
3 MWT (m)
Dynamic functional
7.7 (3.7)
7.3 (2.7)
440.9 (17.6)
437.8 (15.72)
6.6 (2.8)
7.7 (2.9)
495.4 (17.52)
436.2 (16.84)
11.4 (5.3)
14.8 (10.2)
162.3 (62.0)
143.3 (58.7)
14.5 (8.8)
15.6 (9.3)
209.6 (74.2)
14.8 (10.2)
162.3 (62.0)
12.6 (11.3)
5.2 (1.7)
5.1 (2.2)
398 (152)
406 (128)
9.9 (16.4)
6.7 (4.1)
195.9 (103.3)
17.3 (9.3)
14.4 (9.5)
14.6 (2.9)
12.2 (3.2)
15.0 (5.7)
16.8 (5.7)
9.3 (0.8)
14.4 (9.5)
119.05 (27.12)
8.13 (1.87)
9.47 (1.92)
120.36
(20.62)
119.05 (27.12)
10 (1.6)
12.3 (3.2)
20.1 (3.8)
16.8 (5.7)
Post-intervention mean
(SD)
7.07 (1.03)
9.47 (1.92)
139.9 (20.78)
172.2 (82.7)
15.6 (9.3)
13.4 (9.8)
Dynamic functional
TUG (sec)
Endurance
6.1 (2.0)
5.2 (2.0)
395 (140)
373 (134)
8.9 (10.6)
8.2 (6.6)
150.9 (89.4)
143.3 (58.7)
17.0 (8.8)
14.6 (9.1)
14.7 (1.4)
12.2 (3.1)
14.8 (4.6)
16.4 (4.9)
10.7 (1.4)
14.6 (9.1)
Pre-intervention mean (SD)
8.68 (1.93)
9.16 (1.88)
120.4
(20.29)
121.5 (27.73)
8.78 (1.79)
9.16 (1.88)
109.45
(17.44)
121.5 (27.73)
12.0 (2.4)
12.2 (3.1)
17.4 (4.4)
16.4 (4.9)
TUG (sec)
Speed
T25FW (sec)
Endurance
6 MWT (m)
Speed
T25FW (sec)
Endurance
3 MWT (m)
TUG (sec)
Speed
10 mWT (sec)
Dynamic
functional
DGI (score)
Dynamic functional
Dynamic functional
Speed
10 mWT (sec)
Dynamic functional
DGI (score)
Speed
10 mWT (sec)
Endurance
2 MWT (m)
Assessment characteristic and
outcome
Speed 10 mWT
(sec)
Endurance
2 MWT (m)
Learmonth et al.
Systematic review and meta-analysis
Endurance 2 MWT (m)
Dynamic functional TUG (sec)
Endurance 2 MWT (m)
Dynamic functional
Massage n = 12 Control n = 12
Combined + Massage n = 12 Control n = 12
Combined + Massage n = 12 Control n = 12
Balance and neurofacilitation n = 41
Speed T25FW (sec)
Combined n = 47 Control n = 48
Romberg 2004
Aerobic n = 8 Control n = 8
Balance and neurofacilitation (functional) n = 40
Balance and neurofacilitation (neurofacilitation)
n = 40
Note: sec = seconds, min = mins, m = metres.
Wiles et al. (2001)
Endurance 2 MWT M)
Endurance 6 MWT (m)
Endurance 6 MWT (m)
Speed 10 mWT (sec)
Speed 10 mWT (sec)
Speed TUG (sec)
Endurance 500 mWT (min)
Combined n = 15 Control n = 14
Combined n = 47 Control n = 48
Paul et al. (2014)
Combined n = 51 Control n = 48
Aerobic n = 8 Control n = 8
Speed T25FW (steps)
Speed T25FW (sec)
Speed T25FW (m/s)
Yoga n = 22 Control n = 20
Yoga n = 22 Control n = 20
Combined n = 15 Control n = 14
Tarakci et al. (2013)
Van den Berg et al. (2006)
Speed T25FW (steps)
Speed T25FW (sec)
Dynamic functional TUG (sec)
Speed T25FW (sec)
DGI (score)
Endurance 2 MWT (m)
Dynamic functional TUG (sec)
Combined n = 12 Control n = 12
Massage n = 12 Control n = 12
Control n = 39
Balance and neurofacilitation n = 41 Control
n = 39
Balance and neurofacilitation n = 41 Control
n = 39
Dynamic functional TUG (sec)
Endurance 6 MWT (feet)
Endurance 6 MWT (feet)
Endurance 6 MWT (m)
Speed T25FW (sec)
Dynamic functional TUG (sec)
Speed 10 mWT (sec)
Dynamic functional TUG (sec)
Endurance 6 MWT (m)
Speed
10 mWT (m/min)
Dynamic functional TUG (sec)
Dynamic functional TUG (sec)
Combined n = 12 Control n = 12
Aerobic n = 12 Control n = 13
Balance n = 13 Control n = 13
Combined n = 15 Control n = 10
Combined n = 15 Control n = 10
Combined n = 15 Control n = 10
Combined n = 15 Control n = 13
Combined n = 15 Control n = 13
Aerobic n = 8 Control n = 4
Vibration n = 12
Control n =12
Balance and neurofacilitation n = 15
Control n = 15
RT n = 19 Control n = 17
Aerobic n = 21 Control n = 20
Aerobic n = 21 Control n = 20
Oken et al. (2004)
Nilsagard et al. (2013)
Negahban et al. (2013)
Miller et al. (2011)
Learmonth et al. (2012)
Hebert et al. (2011)
Geddes et al. (2009)
Eftekhar-sadat et al. (2015)
Eftekhari et al. (2012)
DeBolt and McCubbin 2004
15.8 (7.6) 16.3 (5.9)
6.5 (2.1)
9.3 (6.5)
8.7 (4.9) 16.3 (5.9)
11.0 (5.1) 9.3 (6.5)
0.7 (0.4)
0.9 (0.5)
26.6 (27.8) 17.0 (8.1)
5.5 (1.2)
5.6 (1.4)
3.8 (0.9)
4.0 (1.1)
18.0 (2.9) 17.2 (3.9)
17.8 (5.4)
14 (5.5)
71 (22.8) 99.5 (30)
138 (110) 148 (129)
138 (108) 148 (129)
6.6 (3.4)
6.5 (3.1)
12.4 (6.9)
11.3 (5)
352.2 (150.1)
387 (82.2)
1066.1 (335.9) 1049.2 (328.9)
1335.6 (320.3) 1049.2 (328.9)
191.1 (102.2) 221.2 (120)
22.1 (21.8) 16.8(13)
22.3 (16.9) 19.7 (14.9)
41.2 (32.9) 43.4 (27.7)
6.2 (2.3)
5.8 (3.4)
10.3 (4.6)
13.6 (7.1)
116.8 (31.7) 105.8 (33.7)
17.8 (8.8)
13.6 (7.1)
88.8 (51.4) 105.8 (33.7)
21.6 (19.0) 13.6 (7.1)
82.8 (32.4) 105.8 (33.7)
17 (8)
18 (5)
8.67 (2.44) 10.87 (8.28)
60.73 (11.46) 51.47 (11.19)
11.28 (4.71) 11.09 (4.74)
9.7 (5.6)
13.3 (4.9) 13.5 (3.1)
8.3 (7.0)
8.1 (5.2)
7.2 (4.1) 13.5 (3.1)
7.2 (3.7) 81 (5.2
0.8 (0.4)
0.9 (0.4)
24.32 (21.9) 15.1 (5.4)
5.6 (1.4)
5.6 (2.0)
3.4 (2.0)
3.8 (2.1)
15.2 (2.5) 18.6 (4.2)
4.7 (2.1)
13.4 (1.4)
81.8 (6.7) 105.3 (7.8)
145 (115) 143 (117)
151 (125) 143 (117)
5.5 (3.21)
5.6 (3.4)
9.6 (5.5)
114.2 (34.9) 103.2 (35.1)
17.2 (11.2) 14.6 (7.9)
98.15 (36.9) 103.2 (35.1)
17.1 (4.6)
17.1 (4.7)
138.1 (24.7) 103.2 (35.1)
12.5 (5.3) 14.6 (7.9)
9.3 (4.1) 14.6 (7.9)
1112.1 (391.1) 1071.6 (375)
1420.7 (283.6) 1071.6 (375)
262.2 (127.4) 215.8 (175.7)
14.9 (13.6) 13.1 (8.6)
18.4 (15.0) 16.2 (11.0)
41.1 (31.6) 34 (24.5)
5 (1.9) 5.4 (2.1)
11.1 (9.3)
417.9 (199.2) 433.8 (84.0)
9.15 (2.26)
11.08 (5.21)
66.41 (10.83)
47.41 (10.3)
8.0 (2.2)
Learmonth et al. Systematic review and meta-analysis
Physical Therapy Reviews 2016 9
Learmonth et al.
Systematic review and meta-analysis
static lower body postures14 and 2–20 HZ with dynamic
lower body movements.27 The duration of the treatment
was 3–8 weeks, and undertaken three times per week. The
length of the session was 7–13 min in one study14 and
45–60 min in the other study.27 In one study, the treatment
was led by a physiotherapist at a physiotherapist clinic.14
In the other study, the treatment was led by a physiologist
at an exercise science laboratory.27
Yoga interventions were used in two studies,21,35 and
the type of treatment was Ashtanga yoga21 and Iyengar
yoga.35 The intensity of the treatment was described by
the length of time each pose was held, this ranged from
8 to 30 s, seated yoga and postures utilising the wall for
support were incorporated. The duration of the treatment
was 8 or 24 weeks, with participant completing sessions
on 1 or 3 days per week. The lengths of the sessions were
60–90 min. The treatment was led by a yoga instructor in
one study,21 however, it was not clear who led the treatment
in the second study.35 It was not clear where the treatments
were delivered in either study.
Figure 2
10
Methodological quality
The overall judgement of methodological quality for
each study is displayed in Table 2. After the initial independent review, agreement between the two reviewers
was 86%, and agreement reached 100% after further
discussion. 13 (62%) of the 21 studies received a PEDro
score of ≥6 on the PEDro scale. Allocation concealment
was adequate in 10 of the 21 studies. In three studies,
baseline characteristics of control and treatment groups
differed significantly, in one of these studies40 authors
adjusted for baseline differences. Participants were
blinded to group allocation in one study. Therapists
were not blinded to group allocation in any of the studies owing to the nature of the treatments. Assessors
were blinded in 8 of the 21 studies. Key outcomes were
obtained from ≥85% of participants in 15 studies, and
intention to treat analysis was used in 13 studies. All
studies compared statistics for a walking outcome
and all studies compared walking outcomes pre- and
post-treatment.
Summary of individual and overall ESs for studies comparing physiotherapy treatments with usual care
Physical Therapy Reviews 2016 Learmonth et al. Systematic review and meta-analysis
Table 4 Results of the random effects moderator analyses
Random effects
Moderator
Type (# of ES)
Walking assessment
Speed(18)
Endurance(17)
Dynamic functional task(17)
Aerobic(11)
Balance & neurofacilitation(11)
Combined training(16)
Physiotherapy treatment
Point estimate (SE)
Massage(2)
Resistance training(3)
Walking primary outcome
measure
High quality (PEDro
score ≥6)
Vibration(5)
Yoga(4)
Yes(21)
No(31)
Yes(33)
No(19)
Z value
0.14 (0.11)
0.44 (0.14)
0.17 (0.08)
0.20 (0.17)
0.19 (0.09)
1.32
3.01*
2.09*
1.20
2.24*
0.06 (0.07)
0.67 (0.30)
1.39 (0.79)
0.31 (0.16
0.12 (0.31)
0.87
2.27*
1.76
1.89
0.39
0.24 (0.07)
0.23 (0.09)
0.31 (0.08)
0.09 (0.08)
3.15*
2.53*
3.68*
1.25
Q statistic (df)
3.03 (2)
8.22 (6)
<.01 (1)
3.24 (1)
*p < .05.
Meta-analysis
All 21 studies were included in the meta-analysis. The
individual study results are presented in Table 3. Overall,
21 ES were included from 947 persons with MS. The
meta-analysis yielded a small, significant mean ES of
0.25 (SE = 0.08; 95% CI = 0.09, 0.43; z = 3.08; p < .05)
for physiotherapy treatments on walking in persons with
MS. The overall ESs per study are listed in Figure 2, and
the ES was positive in 18 (86%) studies. The ESs had
minimal skewness (g1 = 1.07, SE = 0.50) and moderate
kurtosis (g2 = 2.15, SE = 0.97). The weighted mean ES
was heterogeneous (Q20 = 53.31, p = < .001, I2 = 62.8) and
therefore we conducted a moderator analysis.
The moderator analysis included all 21 studies and this
comprised 52 ES. The moderator analysis did not reveal
any statistically significant between group differences in
any of the four categories of walking assessment, physiotherapy treatment, walking assessment as the primary outcome measure or study quality. For comparisons between
walking assessments the moderator variable had a Q value
of 3.03 (df = 2) and for the moderating effect of physiotherapy treatment type the Q statistic had a value of 3.03
(df = 2). Similarly, the moderator analysis which assessed
the specification of walking as a primary outcome established a Q value of <0.1 (df = 1) and for the moderating
effect of study the Q statistic was 3.24 (df = 1). The ES
for each level of the moderator categories are provided
in Table 4.
Discussion
Overall, physiotherapy treatments resulted in improved
walking performance in persons with MS, but the magnitude of improvement was small. Our results are consistent
with the previous literature reviews indicating that physiotherapy has a beneficial effect on walking dysfunction in
persons with MS.6,8 We sought comparison of our overall
results with a previous meta-analysis,8 but the comparison
was limited because that meta-analysis focused only on
exercise therapy and walking performance in MS.8 Overall,
we provide novel evidence regarding the magnitude of
improvement in walking outcomes with physiotherapy
resulting is a one-fourth standard deviation. These results
are comparable in magnitude with the effect of pharmacological therapy (i.e. fampridine) 41–43 on change in walking
speed (T25FW) in participants with MS. However, there is
a need to begin direct focal comparison of physiotherapy
with pharmacological therapy to determine the effect on
walking and possible participant characteristics that might
explain individual variability regarding the response to
treatment.
Overall, our results indicated that physiotherapy treatment has an effect on improving many aspects of walking performance, including walking endurance, walking
speed and dynamic functional walking in persons with
MS. There was no significant difference in the mean ESs
for the different walking outcomes. This suggests that
physiotherapy was a positive effect on different types of
walking dysfunction in MS (e.g. reduced walking endurance and slow walking speed). To date, we are unaware of
research examining physiotherapy on free-living walking
based on accelerometry,44 but the general effect of physiotherapy on walking outcomes in this meta-analysis would
suggest considerable promise for benefits that extend into
everyday life.
Our study included the largest number of RCTs and
the largest number of different treatments types compared
with other reviews and meta-analyses of physiotherapy
and MS. For example, one past meta-analysis of physiotherapy and its effect on balance included four treatment
types (i.e. balance and neurofacilitation, combined exercise and resistance training with electrical stimulation).10
We established that all physiotherapy treatments had a positive effect on walking performance and that there was no
significant difference in the mean ES for the different treatments. In the present meta-analysis, we included studies
which directly compared different treatment types,21,30,33,35
Physical Therapy Reviews 2016 11
Learmonth et al.
Systematic review and meta-analysis
however, there were small numbers of participants in these
studies (i.e. n ≤ 57) and only four treatment types were
compared. Future studies might establish the most common physiotherapy approaches used clinically in MS care
and then directly compare these with a usual care control
group in a large scale RCT. This will help provide a strong
evidence base for the effectiveness of the most common
physiotherapy interventions in MS.
The studies included a multitude of different outcome
measures and we compared the effects between studies that
included walking as a primary outcome measure against
those who did not include a walking outcome as part of the
primary measure (s). Our results suggest that physiotherapy
interventions may have a positive effect on walking performance irrespective of primary outcome measure. This result
may be explained as a possible demand characteristic, in that
participants in the treatment and control groups may have
research-based expectations from participating in the study.45
The quantity and quality of literature investigating the
effect of physiotherapy on walking performance in MS
have improved in recent years and serves as a representation of the degree of importance that has been placed on
this clinical outcome. Our results did not suggest that the
quality of the literature is important for demonstrating
the effect of physiotherapy on walking outcomes in MS.
We acknowledge that lower quality studies are at greater
risk of study bias, however, we currently recommend that
future reviews and meta-analyses on physiotherapy in MS
do not exclude studies based on lower study quality.
Limitations
Overall the results of the systematic review and meta-analysis are insightful, but caution must be applied particularly
with the results of the moderator analysis because of the
small number of studies in some categories. The results
are further limited to studies identified in our literature
search published prior to December 2015. We acknowledge the heterogeneity of the treatment protocols included
in this meta-analysis (e.g. variation in modality, intensity,
duration, frequency and time), however, we believe this
reflects the pragmatic nature of physiotherapy treatments
delivered clinically to persons with MS.
Conclusion
The prevalence, cost and burden of walking dysfunction
in MS has resulted in focal investigation of rehabilitation treatments such as physiotherapy in clinical care.
The number of studies included in this review is reflective of the growing clinical importance of physiotherapy
in MS research and clinical care. The literature confirms
that physiotherapy treatment can improve walking performance in MS.
Disclosure statement
No potential conflict of interest was reported by the
authors.
12
Physical Therapy Reviews 2016 Notes on contributors
Yvonne C. Learmonth is a senior lecturer at Murdoch
University in the School of Psychology and Exercise
Sciences. Ipek Ensari is a post-doctoral fellow in the
Center for Behavioral Cardiovascular Health at Columbia
University. Robert W. Motl is a professor of Physical
Therapy within the School of Health Professions at
University of Alabama at Birmingham (UAB). RWM
is further the associate director of the UAB/Lakeshore
Research Collaborative.
Funding
This work was supported by a mentor-based postdoctoral
fellowship from the National Multiple Sclerosis Society
[grant number MB 0029].
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