Chronic lower limb oedema in a population of Saudi Arabia residents with multiple sclerosis: an evaluation of progressive resistance exercise

Introduction: Chronic lower limb oedema (CLLO) is a common but often unrecognised problem amongst people with multiple sclerosis (pwMS), for which treatment is rarely provided. The prevalence of CLLO in pwMS has been examined in some countries such as Italy and the UK, however, due to the scarcity of evidence it is very difficult to approximate how common the problem is in developing countries. Added to this, research conducted to date on the management of chronic oedema and lymphoedema has focussed primarily on patients with cancer. CLLO related to other aetiologies warrants further investigation.
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\nMethodology: This mixed methods study aimed to gain an improved understanding of the prevalence and impact of CLLO in pwMS and the contribution of progressive resistance exercise on its remediation. The study was undertaken in two hospitals in Riyadh city, in the Kingdom of Saudi Arabia.
\nPhase one of this study aimed to evaluate the prevalence of CLLO in pwMS who are resident in the Kingdom of Saudi Arabia and attends one of the two hospitals and to determine the main characteristics of those at increased risk of developing CLLO. This study screened 269 pwMS for CLLO. Data were analysed using univariate and bivariate analysis using SPSS software version 26. Continuous and categorical variables were examined using the Students t and Chi-square tests.
\nPhase two of the study aimed to assess the effectiveness of Progressive Resistance Exercise (PRE) in the management of CLLO in pwMS who are resident in the Kingdom of Saudi Arabia and to determine the impact of CLLO on pain and quality of life. Those who were found to have CLLO during phase one screening were invited to participate in phase two. Fifteen participants with bilateral CLLO agreed to participate in this phase. They performed a biweekly PRE programme for 12-weeks. The participants were assessed before and following the intervention to determine if any changes occurred in lower limb circumference, Quality of Life (QoL) or pain. Limb circumference was measured at 4 cm intervals. QoL and pain were measured using the Quality of Life Measure for Limb Lymphoedema (LYMQOL) tool and the Short form of the McGill Pain Questionnaire (SF-MPQ).
\nPhase three of the study aimed to identify and explore factors that contribute to successful or unsuccessful use of PRE from the perspectives of participants. During this phase, the knowledge and understanding developed by physiotherapists of CLLO in pwMS was explored together with their knowledge of current practice in terms of exercise therapy. Ten pwMS and CLLO and five specialist lymphoedema physiotherapists were interviewed. Data were analysed using the Framework Method. 
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\nResults: Out of 269 pwMS screened during phase one, 21 (8%) were found to have bilateral CLLO. The bivariate analysis between two groups (with CLLO and without CLLO) shows statistically significant differences were found in CLLO group for all variables (namely: age, weight, BMI, MS duration, EDSS, categorical: MS type) except for gender. In phase two, fourteen participants completed the intervention with mean age of 44±7.11 years, EDSS 5.6±0.96, BMI 29.08±7.91 and disease onset 12.92±3.7 years. The result shows no statistically significant change in overall legs volume but there was a decrease in some segments. A reduction was reported in the SF-MPQ tool in both visual analog scale (VAS) and present pain intensity (PPI) domains. Moreover, statistical significance increase was found in the LYMQOL tool in the overall QoL domain. Three themes emerged from the CLLO participants’ data in phase three: life experience before receiving the PRE intervention; participants’ experiences after having PRE intervention, and “little changes but they matter”. Data from physiotherapists emerged with two themes: awareness about CLLO in pwMS and current lymphoedema practice. 
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\nConclusion: This study concluded that although PRE had no effect on CLLO in pwMS, QoL and pain improved significantly after the intervention. The qualitative data also showed improvements in physical and psychological well-being. There was lack of awareness of CLLO in pwMS among health care providers suggesting that this specific gap in knowledge needs to be addressed in order to provide a meaningful treatment plan.
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\nThe twelve-week PRE programme may have a secondary impact on some aspects of life and there is some evidence of changes in the legs. However, limb volume did not change overall.

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