Multiple sclerosis (MS) is a complex disease. A Profiling Study of People with Multiple Sclerosis Who Access Physiotherapy Services in Ireland

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1 A Profiling Study of People with Multiple Sclerosis Who Access Physiotherapy Services in Ireland Susan Coote, PhD; Grainne McKeown, BSc (Hons); Michelle Shannon, MSc; for the Physiotherapists Interested in Multiple Sclerosis (PIMS) Group In a survey of its members conducted by the MS Society of Ireland, access to physiotherapy was reported as the greatest unmet need. This national multicenter profiling study surveyed people with multiple sclerosis (MS) receiving physiotherapy services at a range of locations to determine their characteristics and the amount of intervention received. A standardized data-collection sheet was developed, and data were collected over a 3-month period. The lower-extremity section of the Guys Neurological Disability Scale was used to classify mobility level, which varied widely. A total of 295 people received physiotherapy at 17 services during the 3-month period. Of these, 72% were female, and most had relapsing-remitting (43%) or secondary progressive MS (39%). Those using walking aids made up the largest proportion of participants (47.5%). On average, participants received 3.6 hours of physiotherapy over the 3-month period, with 36% of participants receiving 1 hour or less and 9.5% of participants receiving more than 8 hours. The main problems cited were balance, fatigue, walking, mobility, and strength. Further research is required to determine whether the small amount of physiotherapy being received by MS patients in Ireland is sufficient to bring about improvement or prevent further deterioration in functional status. Int J MS Care. 2010;12: Multiple sclerosis (MS) is a complex disease of the central nervous system affecting primarily young to middle-aged adults, typically with a relapsing-remitting or gradual progressive deterioration of neurologic function. 1 The incidence of MS in England and Wales is between 3 and 6 per 100,000 population annually, 2 with a prevalence of 100 From the University of Limerick, Limerick, Ireland (SC); Dublin Physiotherapy Clinic, Dublin, Ireland (GM); and Beaumont Hospital, Dublin, Ireland (MS). Correspondence: Susan Coote, PhD, Department of Physiotherapy, Health Sciences Bldg., University of Limerick, Castletroy, Limerick, Ireland; susan.coote@ul.ie. Note on terminology: Although the term physical therapy is more commonly used in the United States than physiotherapy, the latter term is used throughout this article to reflect a distinction between the two terms in Ireland, the country in which this study was performed. In many countries physiotherapists are members of the World Confederation of Physical Therapy (WCPT); however, in Ireland a group of practitioners who are not eligible for membership in the Irish Society of Chartered Physiotherapists (a member organization of the WCPT) use the term physical therapist. The people with multiple sclerosis described in this article received services from physiotherapists eligible for membership in the Irish Society of Chartered Physiotherapists. to 120 per 100,000. In Ireland no incidence estimates are available, although epidemiological research is currently under way (St. Vincent s Hospital, Dublin). The MS Society of Ireland has approximately 5000 members with MS and estimates that there are 7000 people living in Ireland with a diagnosis of MS. People with MS make up the single largest diagnostic category in Ireland s National Physical and Sensory Disability Database. 3 Multiple sclerosis is an extremely variable and unpredictable condition in terms of both disease progression and presenting symptoms. Given the significant impact of symptoms on many aspects of daily life, it has been suggested that services should not be limited to pharmacologic treatment but should include the many rehabilitation disciplines that are designed to improve quality of life. 4 Among these, physiotherapy is considered by many to be a key component of the management of MS. Many of the symptoms of MS that can be addressed by physiotherapy (eg, balance, fatigue, mobility, spasticity, movement dysfunction) influence functional capacity. Studies have suggested that increased physical functioning acts as a moderator for improved quality of 115

2 Coote et al. life. 5,6 This finding highlights the role of physiotherapy not only in improving physical functioning but ultimately in optimizing quality of life in people with MS. It has been observed that community services for people with MS remain poorly organized, with service provision being a matter of chance. 4 Anecdotally, in the Irish context there is a perception that individuals with MS are not appropriately managed by existing physiotherapy services, with service provision affected by such variables as skill levels, resources, location, and funding. In a 2005 market research survey, members of the MS Society of Ireland cited access to physiotherapy services as their greatest unmet need. The rollout of the Irish Health Service Executives Transformation Programme 7 and the expansion of primary-care services in Ireland make investigation of current service provision and ways in which it can be improved especially timely. Clinical guidelines for the management of MS recommend timely referral for physiotherapy within a multidisciplinary setting to address the multitude of presenting problems. 2 A Cochrane review of multidisciplinary rehabilitation recommended regular assessment of the rehabilitation needs of people with MS and concluded that rehabilitation could positively influence activity and participation. 8 A second Cochrane review of exercise interventions suggested that such interventions, including physiotherapy, have many beneficial effects and are an important part of management of the symptoms of MS. 9 The cumulative evidence suggests that physiotherapy plays an essential role in the management of MS in many settings, including inpatient, outpatient, home, and community care In a review of interventions to improve mobility and functional independence, Freeman 16(p255) concluded that management by means of a multidisciplinary team must be considered from a long term perspective, rather than as a fragmented series of isolated quick fixes. Physiotherapists Interested in MS (PIMS) is a national group of therapists with both research and clinical interests in MS. These therapists are in regular contact with people with MS in hospital, community, private, and voluntary settings. In addition to providing a networking forum, another core aim of the group is to develop research ideas in the area of physiotherapy for MS. The group perceived a need for a multicenter study to ascertain the characteristics of people with MS who receive physiotherapy services in order to establish a more accurate profile of these people. Similar studies have been conducted for other categories of long-term illness, such as rheumatoid arthritis 17 and stroke. 18 PIMS anticipates that this information will be used to optimize the delivery and commissioning of physiotherapy services for this patient population. Furthermore, it may guide future research to determine and evaluate the range of physiotherapy interventions required in acute- and community-care settings. Thus, the aim of this study was to profile a sample of people with MS presenting consecutively to physiotherapy services in hospital, community, and voluntary settings in the Republic of Ireland over a 3-month period. Methods Before the commencement of this prospective study, the types of data to be collected were agreed upon through discussion among PIMS members. All PIMS members who represent a variety of hospital, community, and voluntary health-care settings were invited to participate in data collection. Ethical approval for the study was obtained from the relevant ethics committees of the participating physiotherapy services. All consecutive MS patients presenting through their usual referral pathways for physiotherapy assessment and/or treatment for whom informed consent was obtained were included. There were no exclusion criteria. Data collection for this study did not influence the physiotherapy provided to the patient. The participants were given an information leaflet and the study was explained to them at the start of their first physiotherapy session. In order to allow time for the patient to consider the study and ask questions about it, he or she was asked to sign the consent form at the end of the session. Data relating to MS type, pharmacologic management, level of mobility, patient self-reported problems, mode of transportation to the physiotherapy site, and location and duration of physiotherapy were collected prospectively from September 1, 2008, through November 30, Data were gathered locally and were coded and collated centrally at the University of Limerick physiotherapy department. Data were recorded on a standardized data-collection sheet. Mobility level was determined using the lowerlimb disability scores of the Guys Neurological Disability Scale (GNDS). 19 The scores range from 0 to 5 as follows: 0 = Walking is not affected; 1 = Walking is affected, but walks independently; 2 = Usually uses 116

3 unilateral support (stick, single crutch, or one arm) to walk outdoors; 3 = Usually uses bilateral support (two sticks or crutches, frame, or two arms) to walk outdoors; 4 = Usually uses wheelchair to travel outdoors, but able to stand and walk a few steps with or without help; 5 = Restricted to wheelchair, unable to stand and walk a few steps even with help. Results Profile of Participants A total of 295 data sets were collected from people with MS who received physiotherapy at 17 services from September 1 to November 30, Two patients had their data recorded at more than one service; these are considered separate data sets for analysis purposes. An additional six patients could not be included because consent could not be obtained from them or their caregivers, and an additional two patients declined to take part in the study. Data were collected from seven acute-care hospitals (n = 122), five of which had a neurologist on site; four community hospitals (n = 22); four primary, community, and continuing care (PCCC) services (n = 58); one private practice (n = 13); and the MS Society s Care Centre, which is a respite center (n = 80). The physiotherapy was administered at a range of locations, which are described later. The majority of the people with MS were members of the MS Society of Ireland, while 19% (n = 56) were not. At the time of their physiotherapy, the majority (79%) reported not currently receiving complementary or alternative therapies. Most of the patients taking part in the study (n = 213; 72.2%) were female. Data on type of MS were available for 291 people; 45 patients (15.46%) had primary progressive MS, 126 Percentage of Patients Inpatient Outpatient 117 Physiotherapy for People with MS in Ireland (43.30%) had relapsing-remitting MS, 113 (38.83%) had secondary progressive MS, and 7 (2.41%) had benign MS. Mobility Levels Of the people with MS who presented for physiotherapy, 5.76% had no difficulty walking (GNDS score, 0), 20% had mild gait difficulty (1), 14.92% walked with a stick (2), 16.95% walked with bilateral support (3), 15.59% primarily used a wheelchair but could still walk with assistance (4), and 26.10% were nonambulatory (5). The proportions of people with MS in each GNDS mobility category for each location type are shown in Figure 1. Duration of Intervention Information on treatment duration was available for 290 of the participants. On average, participants received 3.6 hours of physiotherapy during the 3-month study period. The maximum was hours in a community hospital, and the minimum was 0.5 hour in both an acute-care hospital and the respite center. More than one-third of participants (35.86%) had 1 hour or less over the 3-month period (Table 1). Physiotherapy was provided at a range of locations. The average duration of intervention by location is shown in Table 2. Participants in long-term care sites received the longest intervention, while those in the respite center received the shortest intervention (the PCCC Centre Location Figure 1. Proportions of people with different mobility levels, as indicated by Guys Neurological Disability Scale scores, seen at various locations. Refer to text for description of scale. PCCC, primary, community, and continuing care. Home Long-Term Care Private Practice Respite

4 Coote et al. Table 1. Duration of intervention Duration (h) No. (%) of participants (n = 290) (35.86) (43.10) (11.38) (4.14) (5.52) length of stay there is usually 1 week). When the 80 participants receiving physiotherapy in the MS Care Centre are removed from the analysis, the average duration of therapy increases to 4.49 hours per patient. The duration of intervention according to mobility category is shown in Table 3. Those using bilateral aids for walking (GNDS scores 3 and 4) had the greatest mean duration of intervention. Primary Complaint At the time of entry into the study, the participants were asked to identify their main problem. Data for this question are available for 293 participants. These qualitative data were analyzed thematically and codes were created for the different themes. The main presenting problems are listed in Table 4. Discussion As stated previously, the MS Society of Ireland has about 5000 members. Twenty percent of the participants in this study were not members of the society, suggesting that the actual number of people with MS in Ireland may be closer to An accurate number is essential for the development of appropriate primarycare and rehabilitation services for people with MS in Ireland. The proportion of people with relapsing-remitting disease was similar to that found in a Swedish population Table 2. Mean duration of intervention by location Location No. (%) of participants Mean duration of intervention (h) Hospital inpatients 44 (14.92) 6.43 Hospital outpatients 92 (31.19) 3.26 PCCC centers 30 (10.17) 5.38 Home 34 (11.53) 4.08 Long-term care 4 (1.36) 7.38 Private clinics 10 (3.39) 4.40 Respite centers 81 (27.46) 1.25 Table 3. Duration of intervention by GNDS category GNDS score Average duration of intervention (h) Abbreviation: GNDS, Guys Neurological Disability Scale. study. 20 However, our sample had a greater proportion of people with primary progressive disease and was similar to an Australian sample, in which Expanded Disability Status Scale (EDSS) scores ranged from 2 to Thus our sample may be representative of MS patients with greater disability rather than the total MS population. Level of Mobility One concern before this study was undertaken was that MS patients using walking aids were accessing physiotherapy to a greater degree than those with mild and severe mobility deficits. In a Swedish population survey, 20 55% of the people with MS did not use a walking aid, 22% used an aid, and 23% were nonambulatory. In our study, approximately 26% of the participants had minor or no gait problems, and 48% used a walking aid. Although the proportions of nonambulatory participants were similar, the proportion of those not using an aid was lower in our study. This may be related to lack of perceived need for physiotherapy or nonreferral. Only 61% of a Swedish MS population 22 perceived a need for physiotherapy, and this may be true in Ireland also. In a population survey in Northern Ireland, McDonnell and Hawkins 23 found that 50% of their sample could not walk 50 yards without an aid. Combining our nonambulatory and walking aid users (74%) suggests that those presenting for physiotherapy services are not representative of the MS population as a whole. The role of exercise and physical activity in reducing secondary risk of cardiovascular disease 24 and increasing quality of life 25 in MS patients with minimal disability has been emphasized. Therefore, there may be a need for development of physiotherapy and/or exercise-based interventions at a community level to promote the health of MS patients with mild gait limitations. The primary-care service would seem to be the appropriate 118

5 Physiotherapy for People with MS in Ireland Table 4. Reported main problem Main problem No. (%) of participants (n = 293) Balance 53 (18.09) Fatigue 42 (14.33) Walking 40 (13.65) Mobility 30 (10.24) Strength/weakness/power 29 (9.90) Continence/bladder/bowel 15 (5.12) Stiffness/flexibility 14 (4.78) Spasticity/spasms 11 (3.75) Vision 11 (3.75) Pain 10 (3.41) Problems moving one limb 7 (2.39) Transfers 6 (2.05) Sensation 5 (1.71) Independence/dependence 5 (1.71) Coordination/tremor 4 (1.37) No problems 2 (0.68) Memory/concentration 2 (0.68) Mood/depression 2 (0.68) Fear of falling 2 (0.68) Hearing/vertigo 2 (0.68) Ulcer 1 (0.34) mechanism to deliver health-promotion and rehabilitation services to these people, who are currently seen in hospital inpatient and outpatient settings. The primarycare strategy aims to provide services designed to keep people well, from promotion of health and screening for disease to assessment, diagnosis, treatment and rehabilitation as well as personal social services. 26(p15) The inclusion of people with minimal deficits should be considered as services are developed nationally. Duration of Intervention The most striking finding of this study was the short duration of physiotherapy received. The average duration was 3.6 hours, and 36% of people had 1 hour or less of physiotherapy over the 3-month study period. Only 9.5% of participants received 8 hours or more of physiotherapy over the same period. This may reflect the current system in Ireland in which, as recommended by the National Institute of Clinical Excellence (NICE) guideline, people are reviewed at regular intervals to assess their need for intervention. In studies demonstrating positive benefits from physiotherapy and exercise, participants have received between 8 and 12 hours of therapy. 10,11,15,27 Outcome data for those with shorter durations of physiotherapy are needed to determine whether this amount of therapy is sufficient to bring about change. Anecdotally, one or two sessions of physiotherapy have been reported to be of great benefit to some people with MS. It is possible that if the right intervention is delivered at the right time, this limited amount of therapy may make a difference from the patient s point of view. Conversely, when the intervention is not matched to the impairments seen or is delivered ineffectively over many sessions, the patient may perceive no benefit. If longer durations of physiotherapy are needed, it may be necessary to reorganize services to increase the amount of intervention and maintain a balance between review and intervention. Innovations such as telephone assessments may be of benefit. Most people with MS receive physiotherapy individually, and it may be more cost-effective and efficient to conduct therapy in a group setting. Recent research has demonstrated positive benefits from group intervention for people who use at most a stick to walk outdoors 28 and for those who use bilateral aids to walk. 29 Khan et al. 21 surveyed a community-based sample of people with EDSS scores of 2 to 7 and found that 33% were receiving physiotherapy, with an average of 11 visits per year. It is difficult to compare these results with our results because of the differing study methodologies. An interesting finding of our study was that the short duration of physiotherapy received was similar for all MS types, locations, and levels of disability. Freeman 16 recommended that physiotherapy be provided at all stages of the condition, responding to patients changing needs as the course of the disease progresses. It has been noted that access to community services has little correlation to need, 4 and this may apply to the Irish physiotherapy services. Kesselring and Beer 30 suggested that neurorehabilitation plays a key role in improving many of the primary symptoms of MS, with improvements often persisting for many months after treatment cessation. The focus of rehabilitation changes from preservation of independence in the early stages to maintenance and prevention of secondary complications in more advanced stages; thus physiotherapy plays a key role throughout this progressive disorder. Main Problems When people with MS were asked to identify their main problem, the top five complaints were balance, fatigue, walking, mobility, and strength/weakness. These 119

6 Coote et al. problems can significantly restrict a person s participation in family, work, and leisure pursuits and are among the core areas addressed by physiotherapists. The fact that balance was cited as the main problem by the greatest proportion of participants indicates the possibility that patients chose a problem they believed would be addressed by physiotherapists. Fatigue affects up to 85% of people with MS 31 and is often the key factor limiting performance of daily activities. In this study, however, fatigue was reported as the main problem by only 14% of participants. In a community-based disability profile study, 21 people with MS were asked to prioritize up to ten problems; fatigue was reported by 81% and mobility problems by 79%. The difference in methodologies across studies makes it difficult to compare the findings regarding extent of clinical problems. A recent study demonstrated significant improvements in fatigue following physiotherapy and exercise interventions. 28 Given the major impact of fatigue on quality of life, physiotherapists should place a high priority on the management of this symptom. Limitations The sample in this study consisted of people consecutively presenting to 17 physiotherapy services, rather than all physiotherapy centers in the Republic of Ireland. Thus different results may have been obtained at other centers. However, the sample included several PracticePoints The average duration of physiotherapy for people with MS in Ireland is very short, with only a small minority receiving an amount of treatment comparable to that for which therapeutic benefits have been found. The main problems reported by MS patients were appropriate for physiotherapy intervention, although fatigue was reported less frequently than in other studies. The proportion of MS patients with minimal gait impairment receiving physiotherapy is significantly lower than that of the general MS population. The increased risk of inactivity and cardiovascular disease in this group may warrant the development of community-based physiotherapy and exercise interventions intended to reduce secondary disease risk. of the larger Dublin teaching hospitals and a range of other services in all geographic areas of the country, and PIMS considers it to be representative of physiotherapy services nationally. This preliminary study profiled those receiving physiotherapy and did not consider intervention outcomes. The sample size of this study suggests the feasibility of an outcomes-based study involving these physiotherapy centers of the effectiveness of varying durations of intervention. Conclusion In response to an unmet need identified by people with MS, this study profiled MS patients receiving physiotherapy services in Ireland over a 3-month period. The participants had a range of mobility levels and were seen at a variety of locations. The results provide initial insight into the ability levels and amount of physiotherapy provided to these patients. The most concerning finding is the short duration of physiotherapy received by people with MS, with only a minority receiving a duration of treatment comparable to that for which therapeutic benefits have been demonstrated. The main problems reported were appropriate for physiotherapy intervention, although fatigue was reported less frequently than in other studies. The proportion of people using walking aids was greater than that in the general MS population, and this group had the highest average duration of intervention. o Acknowledgments: The following PIMS members contributed to this study: Deirdre Murray and Emer Maher contributed to the original study protocol. Data collection was coordinated by Anne Belton, AMNCH Tallaght; Fionnuala Ni Mhealoin, PCCC Clare; Sheelagh English, PCCC Limerick and Community Rehab Team Limerick; Emer Maher, Cork University Hospital; Barbara Mullaly and Mary Carberry, PCCC Dublin North Central; Grainne McKeown, Dublin Physiotherapy Clinic; Gregory Malice, Ennis General Hospital; Michelle Shannon and Deirdre Murray, Beaumont Hospital; Grainne Quilter, Kerry General Hospital; Catriona O Reilly, PCCC Kildare West Wicklow; Elaine Harrington, Mater Misericordiae Hospital; Eilish Clune, MS Care Centre; Sheila Sheridan, Sacred Heart Hospital Castlebar; Fiona McLaubhlin, Ramelton Community Hospital; Helen Flynn, St. James Hospital; and Debbie Clogher, Springfield Centre. Financial Disclosures: The authors have no conflicts of interest to disclose. References 1. Compston A, Coles A. Multiple sclerosis. Lancet. 2008;372: National Institute of Clinical Excellence. Multiple Sclerosis: Management of Multiple Sclerosis in Primary and Secondary Care. Clinical Guideline CG8. Published November

7 Physiotherapy for People with MS in Ireland 3. O Donovan M, Doyle A, Craig A. National Physical and Sensory Disability Database Committee Annual Report Health Research Board; Freeman JA, Thompson AJ. Community services in multiple sclerosis: still a matter of chance. J Neurol Neurosurg Psychiatry. 2000;69: Motl R, McAuley E, Snook E. Physical activity and quality of life in multiple sclerosis: possible roles of social support, self-efficacy and functional limitations. Rehabil Psychol. 2007;52: Turner AP, Kivlahan DR, Haselkorn JK. Exercise and quality of life among people with multiple sclerosis: looking beyond physical functioning to mental health and participation in life. Arch Phys Med Rehabil. 2009;90: Department of Health and Children. Executive HS Transformation Programme Dublin: Department of Health and Children; Khan F, Turner-Stokes L, Ng L, Kilpatrick T. Multidisciplinary rehabilitation for adults with multiple sclerosis. Cochrane Database Syst Rev Apr 18;(2):CD Rietberg MB, Brooks D, Uitdehaag BMJ, Kwakkel G. Exercise therapy for multiple sclerosis. Cochrane Database Syst Rev Jan 25;(1):CD Cattaneo D, Jonsdottir J, Zocchi M, Regola A. Effects of balance exercises on people with multiple sclerosis: a pilot study. Clin Rehabil. 2007;21: Castellano V, White LJ. Serum brain-derived neurotrophic factor response to aerobic exercise in multiple sclerosis. J Neurol Sci. 2008;269: Wiles C, Newcombe R, Fuller K, et al. Controlled randomised crossover trial of the effects of physiotherapy on mobility in chronic multiple sclerosis. J Neurol Neurosurg Psychiatry. 2001;70: Rasova K, Havrdova E, Brandejsky P, Zalisova M, Foubikova B, Martinkova P. Comparison of the influence of different rehabilitation programmes on clinical, spirometric and spiroergometric parameters in patients with multiple sclerosis. Mult Scler. 2006;12: DeBolt LS, McCubbin JA. The effects of home-based resistance exercise on balance, power, and mobility in adults with multiple sclerosis. Arch Phys Med Rehabil. 2004;85: McCullagh R, Fitzgerald AP, Murphy RP, Mater GC. Long-term benefits of exercising on quality of life and fatigue in multiple sclerosis patients with mild disability: a pilot study. Clin Rehabil. 2008;22: Freeman J. Improving mobility and functional independence in persons with multiple sclerosis. J Neurol. 2001;284: Kennedy N, Keogan F, Fitzpatrick M, Cussen G, Wallace L. Characteristics of patients with rheumatoid arthritis presenting for physio- therapy management: a multicentre study. Musculoskeletal Care Mar;5: Tobin C, Hevey D, Horgan N, Coen R, Cunningham C. Health related quality of life of stroke survivors attending the volunteer stroke scheme. Ir J Med Sci. 2008;176(suppl 6):S Rossier P, Wade DT. The Guy s Neurological Disability Scale in patients with multiple sclerosis: a clinical evaluation of its reliability and validity. Clin Rehabil. 2002;16: Einarsson U, Gottberg K, Fredrikson S, von Koch L, Holmqvist L. Activities of daily living and social activities in people with multiple sclerosis in Stockholm County. Clin Rehabil. 2006;20: Khan F, McPhail T, Brand C, Turner-Stokes L, Kilpatrick T. Multiple sclerosis: disability profile and quality of life in an Australian community cohort. Int J Rehabil Res. 2006;29: Ytterberg C, Johansson S, Gottberg K, Holmqvist LW, von Koch L. Perceived needs and satisfaction with care in people with multiple sclerosis: a two-year prospective study. BMC Neurol. 2008;8: McDonnell GV, Hawkins SA. An assessment of the spectrum of disability and handicap in multiple sclerosis: a population-based study. Mult Scler. 2001;7: White LJ, McCoy SC, Castellano V, Ferguson MA, Hou W, Dressendorfer RH. Effect of resistance training on risk of coronary artery disease in women with multiple sclerosis. Scand J Clin Lab Invest. 2006;66: Motl R, Gosney J. Effect of exercise training on quality of life in multiple sclerosis: a meta-analysis. Mult Scler. 2008;14: Department of Health and Children. Primary Care: A New Direction. Dublin: Department of Health and Children; Smedal T, Lygren H, Myhr K, et al. Balance and gait improved in patients with MS after physiotherapy based on the Bobath concept. Physiother Res Int. 2006;11: Garrett M, Larkin A, Saunders J, Hogan N, Coote S. Exercise significantly reduces the impact of fatigue in people with MS with minimal gait impairment [abstract]. Neurorehabil Neural Repair. Published online before print March 12, doi: / Hogan N, Garrett M, Coote S, Larkin A, Saunders J. The effect of group physiotherapy, one on one physiotherapy and yoga on balance in people with MS who use at least bilateral assistance to walk [abstract]. Neurorehabil Neural Repair. Published online before print March 12, doi: / Kesselring J, Beer S. Symptomatic therapy and neurorehabilitation in multiple sclerosis. Lancet Neurol. 2005;4: Petajan JH. Recommendations for physical activity in patients with multiple sclerosis. Sports Med (Auckland). 1999;27: WE NEED YOUR HELP! We are constantly trying to find ways to improve our services and to stay up-to-date with our members contact information. When there is a change in your address, phone number, or address, please contact us by phone at (201) , ext. 107, or by at nicole.liloia@mscare.org to update us. In addition, we would appreciate it if you would let us know when there is a change in your staff listing. This information will help the CMSC create and maintain an accurate centralized membership database. It will also help us minimize the cost of printing and sending materials to nonexistent staff members. Thank you for keeping in touch with us! 121