Reference: January 2025 | Issue 1 | Vol 11 | Page 23
Over the last decade the incidence of multiple sclerosis (MS) has increased by approximately 30 per cent and it is now estimated that globally, approximately 2.8 million people are affected by this condition. The average age at diagnosis is 32 years, with females two to three times more likely to get MS than males. In Ireland approximately 9,000 people are living with MS, with a societal cost of approximately €47,683 per person per year. Approximately 75 per cent are female.
Mobility disability
The number and type of MS symptoms vary significantly among individuals and are dependent on where the damage occurs in the brain or spinal cord. One of the most prevalent and impactful repercussion of MS is mobility disability, with over 90 per cent of people with MS (pwMS) experiencing a variable degree of mobility difficulty within 10 years post diagnosis. Walking or gait dysfunction is predominantly linked with the occurrence of symptoms consisting of disturbances in motor activity such as spasticity, muscular weakness, and ataxia.
Specifically, gait dysfunction includes reduced walking velocity and stride length, impaired walking balance, and reduced walking physical activities. MS-related motor fatigue can also affect walking speed as a result of altered muscle contraction patterns and activity and increased metabolic demand. Indeed, gait dysfunction is reported as the most challenging, limiting, and frustrating feature experienced by pwMS, with a considerable negative impact on quality of life, psychological health, and daily living activities. Additionally, postural instability during walking may be an inhibiting factor to mobility impairment, with over 50 per cent of pwMS falling at least once a year.
Neuroplasticity
Rehabilitation has been identified as the gold standard treatment for restoring function in pwMS. Crucially, neurorehabilitation therapeutic techniques are targeted at ameliorating MS symptoms and improving quality of life, underpinned by the principles of neuroplasticity.
For example, neurorehabilitation methods such as physical therapy and gait training may improve spasticity and muscle strength as the high-intensity repetition of task-specific exercises acts as a stimulus to promote reorganisation of both the structure and function in the CNS and ultimately improves mobility. However, pwMS face barriers in accessing specialised MS outpatient rehabilitation clinics. Travel time, costs of travel, and difficulty travelling to clinic appointments associated with the severity of neurological disability have a negative impact on clinic attendance.
Telerehabilitation
The World Health Organisation highlighted the need for stakeholders to strengthen and expand the accessibility of quality rehabilitation services with the launch of the ‘Rehabilitation 2030 – A Call for Action’ initiative. One potential solution to enable access and inclusivity to a greater range of people with differing levels of disabilities is telerehabilitation (TR).
TR can be defined as the delivery of rehabilitation remotely via a variety of technologies and encompasses a range of rehabilitation services that include evaluation, assessment, monitoring, prevention, intervention, supervision, education, consultation, and coaching. TR is a novel and evolving branch of telemedicine whose overarching aim is to deliver comprehensive rehabilitation services remotely.
Telerehabilitation offers a unique opportunity to deliver rehabilitation remotely through the use of cutting-edge information and communication technology using synchronous (ie, online, two-way real-time consultations with voice, video, or both) or asynchronous (therapist not online; review of data at a later time) technology.
TR enables time efficiency for the health practitioner as multiple patients can be assigned to the same exercise programme at once or modify existing templates quickly, enhancing workflow efficiency. In addition, TR uses a range of technologies to monitor and motivate patient adherence to therapy programmes, ensuring engagement and enhancing patient outcomes. Telerehabilitation provides motivation to the patient, as repetitive exercises can be monotonous; however with TR, patients engage with exercises through interactive tools embedding a fun element into various exercise regimes which increases patients’ engagement and motivation levels.
Applications
Telerehabilitation relies on a variety of technologies to deliver effective remote therapy. Examples include:
Video conferencing: Patients perform exercises in real time during which therapists can provide immediate feedback and corrections. Also enables therapists to take notes and document observations during live consultations.
Motion tracking: This type of technology employs computer vision through a smartphone camera to analyse user movements such as positions, angle, and speed of various body parts during exercises.
Wearable sensors: Wearable motion sensors are used to monitor and guide users during their exercise therapy sessions and track the users’ movements in real-time, capturing data on the range of motion, angles, speed, and overall movement patterns. For example, accelerometers measure linear acceleration in different directions, which help detect changes in speed and direction.
Artificial intelligence: Processes the motion capture data in real-time to provide immediate corrective feedback to the patient. AI technology is also used to enhance user engagement by sending personalised reminders, motivational messages, and educational content based on the user’s progress and behaviour. This helps keep users on track with their therapy and improves adherence to the programme.
Data analytics and tracking: Collects and analyses performance metrics to monitor progress and improve engagement via data obtained from wearable devices, motion capture systems, video conferencing, and telerehabilitation apps.
Exergaming
Exergaming can be described as fusing physical activity into a video game environment that involves body movement. Exergaming relies on multiple technologies for its functionality, including motion-tracking technology (eg, Microsoft Kinect), and AI technology to give patient corrective feedback, and can adapt gameplay based on user performance.
There are two types of exergaming platforms: Exergaming using commercial gaming platforms (games like Wii Fit and Just Dance promote physical activity by using motion controls and balance tracking) and serious gaming designed specifically for rehabilitation purposes. A key advantage of serious gaming platforms is they can be tailored according to the patient’s needs and permits the therapist to adjust the challenges of the exergames based on patient’s feedback.
Figure 1 illustrates a TR randomised control study which used a serious gaming platform (Step training system). The Step training system was tailored to perform balance and stepping exercises for people with MS. The participants could correct their movements in real-time using visual feedback technology.
Biofeedback systems play a crucial role in TR as they provide information on exercise technique, accuracy in real-time, correcting alignment during movement, and correct speed of movement which impacts on the efficacy of exercise. Patient adherence also impacts on the success of the rehabilitation. Biofeedback systems increase patient adherence and motivation by providing them with incentives to exercise
Effectiveness
In a recent study, telerehabilitation was found to be statistically and clinically effective in improving mobility and balance function in patients with MS. The main TR interventions used in the study were exergaming platforms (serious and commercial gaming) and a pilates video conferencing platform. The exergaming studies were delivered asynchronously (therapist was not monitoring the participants in real-time) in which biofeedback systems with visual, audio, or a combination of both, were built into the gaming technology to foster corrective movements and engagement by participants. See link to read full review: https://doi.org/10.1016/j.jns.2024.123214.
Conclusion
Telerehabilitation is emerging as a transformative approach for managing MS, offering patients accessible, flexible, and tailored care solutions. Recent evidence has identified an unmet need in MS rehabilitation and with increasing incidences of MS, novel telerehabilitation interventions have the potential to bridge the gap and work in tandem with conventional face-to-face rehabilitation services.
By leveraging technologies such as video conferencing, wearable sensors, and exergaming, telerehabilitation addresses the unique challenges faced by people with MS, including mobility impairments, fatigue, and geographic barriers to care.
As advancements in technology continue to evolve, telerehabilitation holds the potential to further transform the landscape of MS care, providing innovative, patient-centred solutions that improve quality of life and long-term outcomes.
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