Multidisciplinary rehabilitation for neuromyelitis optica spectrum disorders
General Hospital from January 2014 to November 2016. The
diagnosis of NMOSD fulfilled the 2015 Wingerchuk criteria (9).
The inclusion criteria for this study were: (i) disability as a result
of NMOSD (4≤ EDSS score ≤9); (ii) patient receiving 500 mg
methylprednisolone intravenously, which was reduced by half
every 3 days, followed by a gradual tapering until 40 mg was
reached (14–16 days from the acute attack). The exclusion criteria
were: (i) acute attack within 14 days; (ii) other conditions that may
affect motor function or impaired cognitive functioning; (iii) se-
vere concurrent diseases (i.e. cancer, cardiopulmonary diseases or
severe psychiatric disorders). The subjects were divided randomly
into 2 groups: a rehabilitation group (MDR) and a control group
(usual care; UC). A random sequence was created by a computer.
Patients in the UC refused or voluntarily ceased rehabilitation
treatment (due to dissatisfaction or for economic reasons).
Demographic and clinical data, including sex, age, and disease
duration, were collected. Informed consent was obtained from
all participants, and the study was approved by the Tianjin
Medical University General Hospital institutional review board
and ethics committee.
Intervention
Multidisciplinary rehabilitation (MDR). Medical rehabilita-
tion is defined as “a set of measures that assist individuals who
experience disability to achieve and maintain optimal physical,
sensory, intellectual, psychological and social functioning in
interaction with their environment” (8). Since clinical manifes-
tations of NMO and MS overlap and NMO was thought to be a
variant of MS, some rehabilitation therapies in this study were
co-opted from treatments used for MS and NMO.
For pyramidal function and walking ability, patients were
offered physiotherapy. Physiotherapy typically involved at
least 30 min of daily exercise. These exercises included active
or passive range-of-motion exercises; strengthening exercises;
hand function exercises; transfer exercises; balance training
aimed at increasing muscle strength, improving balance and gait,
decreasing spasticity and improving functional activities of daily
living; and 20 min of robot-assisted gait training according to the
patient’s needs. In addition, occupational, cognitive, respiratory
and/or phoniatric therapy were provided when necessary (10).
For sensory function, patients were provided sensory re-
education techniques and occupational therapy.
For bladder and bowel, patients received physical treatments,
including pelvic floor exercises and/or intermittent cleaning and/
or self-catheterization (11, 12), according to their dysfunction.
Patients were allowed to rest before becoming fatigued.
Multidisciplinary inpatient rehabilitation was performed 5
days/week for 2–4 h/day for 4 weeks. After 4-week inpatient
rehabilitation, the patients were guided to continue community
or home-based rehabilitation (walking training, wheelchair
operation training) for 3 months.
Robot-assisted gait training: LokoHelp (Germany) (13) prac-
tical design offered therapists economically feasible access to
quick and convenient body weight support (BWS), including
ergonomically adjustable seating for assistance with manual
treatment. This training was performed in the hospital.
Usual care. The control group (usual care; UC) did not receive
any specific rehabilitation treatment for gait performance and
mobility improvement.
During the entire study, both groups were authorized, at will,
to exercise in non-rehabilitative contexts.
693
Outcome measures
NMOSD impairment was evaluated using EDSS and Functional
Systems (FS) scores before the treatment and 4 weeks and 3
months after the treatment. EDSS is based on a detailed neuro-
logical examination that combines impairment and disability on
a 10-step ordinal scale, ranging from 0 (normal) to 10 (death),
and was performed by 2 neurologists who were both certified
by Neurostatus for EDSS competency (14, 15). The patients’
FS were described on 8 subscales, including visual (or optic)
functions, brain stem functions, pyramidal functions, sensory
functions, bowel and bladder functions, cerebellum functions,
cerebral (or mental) functions, and walking functions. If the
walking distance is < 500 m, the EDSS score depends on walking
ability (16). The EDSS scores were evaluated at the start and
end of the training period.
Statistical analysis
The data for the MDR group were compared with the respective
results of the parallel UC group. Descriptive statistics (median,
minimum and maximum) are given for all variables. Non-
parametric testing (Wilcoxon signed-rank) was performed to
compare the EDSS and FS scores. A p-value of 0.05 or less was
considered significant for all statistical analyses. All statistical
analyses and graphs were performed using GraphPad PRISM
5 (Graph Pad Software Inc., San Diego, CA, USA).
RESULTS
Demographic and clinical features
A total of 39 patients with NMOSD were assessed
for eligibility and randomized into 2 groups: an MDR
group (n = 21) and a UC group (n = 18). One patient in
the MDR group and one patient in the control group
were lost at the 4-week assessment due to relapse.
Three patients in the MDR group and 2 patients in the
UC group dropped out due to refusal to continue, and
these patients did not perform evaluations at 3 months
(Fig. 1). The patients’ demographic and clinical cha-
racteristics are reported in Table I. In total, 39 patients
with NMOSD (29 females, 10 males) were included
in the study. A final total of 32 patients completed the
study. The median EDSS score at admission was 7.5
(range 6.0–9.0) All patients with NMOSD had lesions
in the spinal cord. No statistically significant baseline
Table I. Baseline characteristics of people with neuromyelitis optica
spectrum disorders allocated to multidisciplinary rehabilitation
(MDR) or usual care
Patients’ characteristics MDR
n = 21 Usual care
n = 18
Age, year, mean (SD)
Number of women, n (%)
Number of relapses
Duration, months, mean (SD) 51.5 (14.0)
15 (88)
4.7
28 (22.9) 54.5 (7.8)
14 (93)
5.2
26 (32.5)
SD: standard deviation.
J Rehabil Med 51, 2019