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through sprouting and alterations of synaptic strength.
Appropriate rehabilitation could modify and enhance
the plasticity process (19). Vahdat and colleagues pro-
vided strong evidence for local spinal plasticity over
the course of human motor learning using functional
magnetic resonance imaging (20). Similarly, Nechemia
et al. (21) described 15 in-patients with NMO and 32
in-patients with MS who received MDR and found
that both groups benefitted. Moreover, at discharge, the
NMOSD group showed greater improvement in FIM
scores and lower EDSS scores.
The current study investigated bowel and bladder,
cerebral (or mental), pyramidal, and walking functions,
which may benefit more from MDR. However, sensory
dysfunction required the longest period for recovery.
Intermittent catheterization, suprapubic tapping, and
physical treatments, including pelvic floor exercises,
have been applied to aid voiding for urinary retention.
Thus, bowel and bladder functions were improved.
Similarly, a systematic review reported that physical
therapy techniques were effective for urinary disorders
in MS populations with mild disability (22).
Walking function is a central outcome of rehabilita-
tion intervention (23). Grasso and colleagues suggested
that rehabilitation for patients with MS should be ini-
tiated early while the patient can walk independently
or with assistance and lacks severe sphincteric and cog-
nitive deficits (23). Accordingly, in this study, patients
with NMOSD received MDR immediately after they
completed high-dose intravenous methylprednisolone
therapy (2–3 weeks after the acute attack). The regimen
achieved a good effect, even compared with previous
trials implementing rehabilitation in the MS population
(24). In the current study, patients’ disability levels
were more severe (EDSS score ≥ 6). Furthermore, there
were no adverse events during the entire rehabilitation
programme, indicating that it is relatively safe and ef-
fective to introduce MDR early to adults with NMOSD
despite severe disability. Nechemia et al. reported that
inpatient MDR programmes available for patients with
MS might be implemented successfully for patients
with NMO (21). In the control group, some patients
exhibited improvements in walking ability scores and
pyramidal function. We hypothesize that this therapy
may affect the natural course of the disease.
Sensory function recovery may occur over a long
time, and these changes may have cumulative effects.
Given the poor results for sensory function rehabili-
tation, we hypothesize that 4 weeks is not sufficient
for the amelioration of this disability, but continued
therapy may offer promising results.
None of the patients in our study had cognitive
impairment (MMSE score > 27), but all had fatigue to
different degrees. After 4 weeks of MDR, no obvious
www.medicaljournals.se/jrm
changes in patient fatigue were observed. This finding
suggested that rehabilitation training did not exacerbate
fatigue. However, after 3 months, the fatigue was resol-
ved to varying degrees. Rehabilitation with a focus on
relieving fatigue via an improvement in mood and car-
diovascular reconditioning was previously reported by
Judica et al. and Romberg et al. (25, 26). Therefore, our
results indicated that training for patients with NMOSD
should be continued in both hospital and home or com-
munity settings in order to maintain these benefits.
In this study, EDSS was applied to the evaluation
of NMOSD. The EDSS provided a detailed evaluation
(the 8 major system dysfunctions in MS are involved)
(27). However, the EDSS has the disadvantage that
it depends only on walking function in severe dys-
function (e.g. EDSS ≥ 6 points); therefore, the EDSS
score cannot reflect the situation in which the walking
function has not changed but other system functions
have improved. Therefore, there is a need to modify
the EDSS for use in the evaluation of NMOSD.
Study limitations
This study has some limitations. Most of the patients
exhibited more serious disability (EDSS ≥ 6), which
may affect the overall rehabilitation outcome (see
above). Furthermore, NMOSD is a rare disease; the-
refore, the sample was small. A well-designed study
should be performed on MDR of patients with NMOSD
at different levels of disability. In future clinical trials,
studies should compare the effectiveness of MDR in
treating different degrees of NMOSD, and further
research is required into the rationality of EDSS as an
indicator for evaluating NMOSD.
Conclusion
This study confirmed the short-term effectiveness of
MDR in patients with NMOSD in terms of improving
impairment, as determined using the EDSS. Bowel and
bladder, cerebral (or mental), pyramidal, and walking
functions may benefit more from MDR, while sensory
dysfunction required the longest period for recovery.
The control group showed some improvement in
walking ability scores and pyramidal function, alt-
hough this improvement may be an effect of the natural
course of disease.
Although this study is a pilot trial, the results
suggest that MDR is a safe and feasible therapy for
adults with NMOSD with severe disability. These
primary observations will be helpful to all medical
practitioners treating MDR in patients with NMOSD,
and they advocate that patients with NMOSD should
be candidates for early MDR in order to prevent the
progression of neurological disability. A randomized