16/03/2015
Exercise for people with MS:
a summary of the evidence and
recommendations for practice
Jenny Freeman
Faculty of Health and Human Sciences
Plymouth University
Lowered physical activity level
• During recent years application of exercise
therapy has become generally accepted in
MS rehabilitation.
Mult. Scler 2005; 11:4:459-63
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MS patients vs. healthy controls
MS patients vs.
healthy controls
Muscle strength
Muscle mass
Muscle activation
Aerobic capacity (VO2-max)
CVD risk
Depression
Fatigue
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Daily activity level
Functional capacity
Balance
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QoL
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ICF level
Body Functions
Activity
Participation
Red arrow = Impaired in MS patients
Motl & Pillutti, Nat Rev Neurol; Sep;8(9):487-97.2012
Dalgas et al. Mult. Scler.14(35);35-53:2008
Slide from Dalgas, RIMS 2014
Is this because people with MS
don’t value exercise?
• Exercise is ranked above conventional therapies such as
physiotherapy
(O’Hara 2000)
• 41% report exercise as the area about which they most commonly
want advice
(Somerset et al 2001)
Top three exercise barriers, regardless of gender
1. too tired
2. impairment
3. lack of time
(Survey n = 417, Asano et al 2013)
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MS Impairments impacting on ability to achieve
desired levels of exercise
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Fatigue
Weakness
Poor co-ordination
Spasticity
Sensory disturbance
Visual disturbance
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•
•
•
•
•
Bladder & bowel dysfunction
Communication difficulties
Pain
Vertigo
Cognitive difficulties
Depression & anxiety
Variable, unpredictable, multi-factorial, generally
progressive…. constantly changing over a lifetime
•
•
•
•
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Reduced speed
Shorter strides
Prolonged double limb support phase
Altered muscle activity and kinematics
Skeletal changes
(Gehlsen et al 1986, Benedetti 1999, Morris 2002; Savci 2005, Martin 2006)
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Balance impairment in those with
no / minimal functional disability
(Kurst 2005, Martin 2006)
Natural History of MS
Preclinical
Relapsing
Early / diagnosis
Relapse remitting
Progressive
Progressive
Time
MRI activity
MRI Total T2 lesion area
Relapses and impairment
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Other factors impacting on ability to exercise
Emotional
• Dependence on family / community support
• Coping skills
• Decreased motivation
Accessibility
• Equipment
• Location(s)
• Expertise
One of the first questions
(early on in the disease) is to ask….
What are you currently doing to manage your
health?
What exercise do you currently undertake?
Is there anything that is putting you off exercising?
Lets see how I can help as exercise has proven to
be beneficial.
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Exercise Research:
Bench to Bedside
Neuroplasticity
Muscle
Factors impacting
Neural health
and
on exercise
Immunology
neural physiology
capability
Evaluation of
effectiveness
Collaboration between basic scientists, clinical trialists and clinicians
Forms of exercise
used by pwMS
Explored in trials
of MS
Strengthening
Aerobic exercise
Combined aerobic /resistance
Treadmill training (regular, robot-asst’d
Cycling ergometry
Pilates
Yoga
Tai chi
Group classes general ex.
Swimming
Hydrotherapy
Wii
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Safety of Exercise
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Effects of Exercise therapy
MS patients vs.
healthy controls
Muscle strength
Muscle mass
Muscle activation
Aerobic capacity (VO2-max)
CVD risk
Depression
Fatigue
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


Daily activity level
Functional capacity
Balance
QoL
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Red arrow = Impaired in MS patients
Green arrow = Improved after exercise in MS patients
Motl & Pillutti, Nat Rev Neurol; Sep;8(9):487-97.2012
Slide from Dalgas, RIMS 2014
Dalgas et al. Mult. Scler.14(35);35-53:2008
Impact on Depression
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Impact on Cognition
Intervention:
An internet delivered
program for increasing
physical activity behaviour
plus one-on-one video chat
sessions with a behaviourchange coach.
Improved cognition
on Symbol Digit Modalities Test
Measures:
Self-report physical activity ,
disability status, 6MWT, and
Symbol Digit Modalities Test
at 0 and 6 months
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Potential Impact of Physical Activity
on Brain Health and the Immune System
Mediates processes:
• Neuroprotective,
• Neuroregenerative,
• Adaptive (Neuroplasticity)
enhancement of neurotrophic factors
enhance stress resistance
influences balance of pro/anti-inflammatory response
(Gold et al 2003; Heesen et al 2003; White et al 2006; White and Castellano 2008; Golzari et al. 2010)
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Guideline Recommendations:
for people with mild to moderate MS
Resistance Exercise:
• Resistance Exercise: 22-3/week
3/week
at moderate
moderate
intensity
(60-80% 1RM,
intensity
(60-80%
1RM,
10 – 15
repetitions,
1-3 sets)
minimum
weeks
10 –815
repetitions, 1-3
sets), minimum 8 weeks
Aerobic Exercise:
2-3/week
mod intensity (60-80% max HR)
30 minutes
minimum 4 weeks
1.4 Modifiable risk factors for relapse or progression of MS
1.4.1 Exercise
• Encourage people with MS to exercise. Advise them that
regular exercise may have beneficial effects on their MS
and does not have any harmful effects on their MS.
1.5 MS symptom management and rehabilitation
1.5.8 Fatigue
Consider a comprehensive programme of aerobic and
moderate progressive resistance activity combined with
cognitive behavioural techniques for fatigue in people with
MS with moderately impaired mobility (an EDSS[5] score of
greater than or equal to 4)
Mobility or fatigue
• 1.5.11Consider supervised exercise programmes
involving moderate progressive resistance training and
aerobic exercise to treat people with MS who have
mobility problems and/or fatigue.
• 1.5.13 Encourage people with MS to keep exercising after
treatment programmes end for longer term benefits
(see Behaviour change: individual approaches NICE
public health guideline 49).
• 1.5.14 Help the person with MS continue to exercise, for
example by referring them to exercise referral schemes.
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Relative dearth of evidence in those with:
progressive forms of MS
severe disability (> EDSS 6.5)
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Designing exercise programmes
Considerations:(1)
1.Individual differences
2.Specificity
3.Overload
4.Progression
5.Reversibility
6. MS Specific Issues
www.sportsmedicine.com
Slide from Dalgas, RIMS, 204
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MS Specific Considerations :(1)
Of particular importance in endurance programmes where rises in core
temperature are greater than in resistance programmes
(White 2013; Skjebaek et al 2013)
Heat sensitivity
An increase of 0.5 degrees slows and increased temperature ultimately blocks
nerve impulse conduction in demyelinated fibres
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ensure the exercise environment is not too hot
drink cold water before, during and after exercise
pre-exercise cooling can be beneficial (cool shower)
wear light clothing during the activity
work at a pace that does not allow overheating
build in rest breaks as needed
post exercise cooling (cool shower or bath, cold packs)
consider interval training
consider water training ( as water dissipates heat 25x faster than air)
Symptom exacerbation is proportional to degree of temperature elevation
MS Specific Considerations:(2)
Transient neurological symptoms
Common (e.g. fatigue, visual, sensory {~40%} disturbance)
In ~ 85% of people these resolve / return to
normal within 30 – 60 minutes, or more rapidly with
cooling (Smith et al 2006,White et al 1997)
• Start slowly - build up intensity & duration
• “Listen to your body” - monitor the impact of exercise
on changing symptoms
• “2 hour rule”
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…..what about balance interventions?
• 75% report balance problems, even in the very early stages
(Martin 2006)
• Balance characteristics
– ↑ sway in quiet stance
– delayed anticipatory & automatic postural adjustments
– ↓ ability to move towards the limits of stability
(Cattaneo 2009, Huisinga 2012)
• More impairment in progressive forms of MS
(Soyeur 2006)
• Associated with increased risk of falls
(Gunn et al 2013, Cattaneo et al)
Balance
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Literature review balance ix’s
(in submission Gunn et al 2015)
A range of exercise-based interventions
improved balance outcomes
Core Stability in MS
• Widely held clinical view that
people with MS have reduced
core stability
• Decreased trunk stability during
arm movements in PwMS
(Lanzetta et al 2004)
• Delayed onset times for trunk
muscles correlate with poor
sitting balance (Radebold et al 2001)
Transversus abdominis activates before
other limb and trunk muscles
• People with MS are increasingly
doing core stability training.
TrA invariably the 1st
muscle active
during leg
movement / weight
shifting (Hodges 1997)
(White & Mayston 2008. The multiple
sclerosis resource centre 2009).
•
Minimal low level evidence to
support effectiveness in MS
(Freeman et al 2010; van der Linden
2103)
(Dickstein 2004, Reeves et al. 2007)
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Pilates versus standardised exercise versus control ; a
blinded randomised multi-centre controlled trial
Community / Outpatients screened and
recruited (n = 100)
Blinded Allocation
Pilates (n= 34 )
Contract Relax Placebo (n= 33 )
Standard Exercise (n= 33)
Assessment 1:
At baseline
30 minute face to face intervention for 12 weeks
15 minute home ex programme
Assessment 2:
At 12 weeks
Independently continue with 15 minute home ex programme
(recorded)
Freeman 2012, Fox 2013
Pilates
Versus
Assessment 3:
At 16 weeks
Relaxation Control
versus
Standard Exercise
Fox 2013
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Results: Mobility & Balance Measures
•
Compared to Relaxation placebo Pilates exercises improved clinician rated
measures of balance and walking velocity; these changes were small and
not retained at 4 weeks follow up
•
Compared to Relaxation placebo Standardised physiotherapy exercises
improved both clinician rated and patient reported balance and mobility
measures. These changes were evident for 4 weeks after the therapist
contact time had ceased
• Patients improved with both exercise interventions, but the
standardised exercises produced a larger magnitude of
change across a broader range of measures, and had a
longer lasting effect
Fox 2013
Discussion and Clinical message
•
Task specific training in the standard exercise group could have accounted
for improvements made.
•
Automatic activation may be more effective in activating core stabilisers
than voluntary activation
•
Pilates develops proximal muscles, people with MS may have foot drop
due to distal demyelination.
•
In clinical practice therapists use combined interventions (FES, orthotics,
balance training, strength training and core stability exercise).
•
Enjoyment of Pilates expressed by people with MS (van der Linden, 2013).
Fox 2013
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Wii / exergaming
Theoretical basis:
• Frequent, repetitive, varied movement essential for
plasticity
• Ongoing feedback and progression of activities to ensure
they are challenging
Typically:• 3-5 sessions/week
• 30 minute sessions
• Supervised / Not supervised
• Balance activities progressed
• Patient choice of games incorporated
• Telephone support / monitoring provided in some studies
(eg Prosperini 2013)
Results of Wii studies suggest ….
• Standing balance (static and dynamic) improved
– clinical (Berg, TUG, 4Sq Step Test, Gait variability, Timed balance tests)
– lab based measures (force platform – reduced sway)
• Results compare to conventional balance training (but are not better)
• Increasing the training stimulus by playing on an unstable surface
further enhances improvements with dual task conditions
(Dettmer 2014)
• Adherence is very good in short term; although wanes over time
• Safety good (no incidents while training in any study) – some adverse
events related to knee pain / hip pain similar to healthy literature
(Prosperini 2013; Plow 2011)
• May reduce falls
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Web-based Physiotherapy
Telerehabilitation
• Using technology to deliver
rehabilitation services over
a distance
• Can provide an alternative
to face to face therapy
• Can support self
management through
personalised targeted
programmes
Targeted programme developed following a
face to face physiotherapy assessment:
Huijgen et al 2008, ; Finkelstein et al 2008; Paul et al 2014
General Summary
• Scientific evidence demonstrates exercise is effective
and safe
• People with MS remain less physically active
• There are many barriers and facilitators of exercise
• Adherence to exercise reduces over time
• Behaviour change interventions are required
• Crucial to translate this knowledge into practice
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Specific Considerations for
Physiotherapy Practice
• Early intervention is beneficial. Timely referral requires good
communication with MS nurses and Neurologists
• Exercise programmes of moderate intensity at 3 times / week are
well tolerated with no apparent negative affects
• The principles of frequency, intensity, specificity and progression is
required to optimise outcome, regardless of physiotherapy
intervention.
• Before designing programme; assess the individual (physical activity
patterns / physical effects of MS)
• Start conservatively and establish realistic expectations (30% rule)
• Supervise programmes to ensure workload progression
Useful reviews
Latimer – Cheung et al. The effects of exercise training on fitness, mobility, fatigue,
and health related quality of life among adults with multiple sclerosis: a systematic
review to inform guideline development. Arch Phys Med Rehab . 2013; 94(9): 18001828.
Kjolhede T, Vissing K, Dalgas U. Multiple sclerosis and progressive 643 resistance
training: a systematic review. Mult Scler 2012
Dalgas U, Stenager C. Exercise and disease progression in multiple sclerosis: can
Exercise slow down the progression of multiple sclerosis? Ther Adv Neurol Disord 840
2012;5(2):81-95.
Pilutti LA, Platta ME, Motl RW, Latimer-Cheung AE. The safety of exercise training in
multiple sclerosis: A systematic review. J Neurol Sci. 2014
Pilutti, L. A., et al. (2013). "Effects of exercise training on fatigue in multiple
sclerosis: a meta-analysis." Psychosom Med 75(6): 575-580.
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Thank you for listening
Questions?
Contact: jenny.freeman@plymouth.ac.uk
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