Exercise helps multiple sclerosis patients resist further debilitation

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Exercise helps multiple sclerosis patients resistfurther debilitation By: Louisa S. DeBolt, PhD, A. McCubbin, PhD,and Eduard Gappmaier, PT, PhD Multiple sclerosis is a demyelinating disease of thecentral nervous system, which is the most frequentform of neurologic disorder among adults. In the U.S.,approximately 400,000 persons have a diagnosis of MS,with as many as 200 persons being diagnosed eachweek.1 There is no known cure for MS, but patients' lifeexpectancy has been described as close to that of thegeneral population.1,2 Adults with MS have been foundto have rates of death for coronary heart disease,cancer, and stroke that were also similar to thegeneral population.3 Although most adults with MS havethe ability to ambulate 25 years after diagnosis,2many reduce their physical activity levels to belowthat of sedentary adults.4 Demyelination of nerve tissue causes a variety ofsymptoms that may affect levels of physical activity.These symptoms include excessive muscle fatigue,5muscular weakness,6 spasticity, impaired balance, andimpaired autonomic cardiovascular control.7,8 Symptomsmay lead to abnormal gait or immobility, and arefrustrating for patients with MS to the extent thatthey negatively affect daily activities. Othersymptoms, such as idiopathic lassitude, or MSfatigue,9 are also of concern, and, combined withinactivity, may lead to increased levels of muscularweakness and deconditioning. This vicious cycle (seefigure) may be stopped when physical activity replacesinactivity. Although the American College of Sports Medicine hasexercise guidelines available for adults with multiplesclerosis,10 the recommendations are developed fromresearch that has been based primarily on aerobicexercise. Heat intolerance,11 another symptom of MS,may make aerobic exercise difficult due to thecontinuous nature and duration of typical exerciseprograms (10 to 30 minutes). Research examining resistance exercise in patientswith MS has progressed from a descriptive nature,comparing subjects with and without MS, tointervention studies, using progressive resistanceexercise in many forms. Studies so far suggest thatpatients with MS may benefit from low- tomoderate-intensity resistance training (Table 1). Theresults of some of these studies also show functionalbenefits for patients with MS.12,13 Functional benefits such as improved mobility havefrequently been assessed using timed tasks (up andgo). Isokinetic dynamometry has the ability to measureforce and the effects of resistance training moreaccurately. This apparatus uses peak torque as ameasure of muscular strength, and total work outputduring 30 or 50 repetitions as a measure of muscularendurance. Isokinetic dynamometry used during researchhas not increased MS-related symptoms nor caused anyexacerbations (a sudden worsening of symptoms causedby an area of inflammation in the central nervoussystem). Although the appropriate number offamiliarization periods (prior to data collection) hasbeen debated, both studies examining reliability foundthat at least one familiarization period should beperformed14 and others have suggested one to twosessions.15 Strength and endurance Many studies have focused on the differences inmuscular strength and endurance between adults with MSand adults without MS matched for age, gender, andbody mass.14,15 In one study, 10 participants with MS were shown tohave had significantly lower values for peak torque ofthe knee flexor and knee extensor muscles at allvelocities (0 degrees to 275 degrees per second)compared to 10 age- and gender-matched controls.15Ponichtera and colleagues16 also found that nineambulatory adults with MS had significantly lessconcentric peak torque (at 30 degrees , 60 degrees ,and 90 degrees per second) in both the quadriceps andhamstrings than the matched group. The difference inaverage peak torque ranged from 25% to 29% for thequadriceps and from 19% to 22% for the hamstrings. Incontrast, there were no significant differences inpeak torque between groups for either speed duringeccentric contractions of quadriceps and hamstrings. A similar study examined the muscular strength,muscular endurance, and fatigue index in 15 adultswith MS and 15 adults without MS.14 After adjustingfor body mass and age, Lambert and colleagues founddifferences in concentric peak torque for the dominantflexors (25.7%) and nondominant flexors (20.8%), andthe extensors (16.9%) at speeds of 30 degrees , 60degrees , 90 degrees , 120 degrees , and 180 degreesper second between subjects with and without MS. Therewere also significant differences between groups formuscular endurance and fatigue index (work during last15 contractions/work during first 15 contractions).Therefore adults with MS may have less muscularstrength and muscular endurance and may experiencegreater muscle fatigue than adults without MS. A key finding of this study is that after adjustingfor age and fat-free mass, adults with MS were weakerthan controls, suggesting that they may have a reducedability to activate muscle fibers and/or that thelevel of force per unit of muscle mass they cangenerate is lower. Most of the research regarding therate of muscle tension development and peak torque ofadults with MS compared to controls has found similarresults.17 Another study found that adults with MS hadreduced maximum motor neuron firing rates compared tocontrols (47% to 93%).18 Activities such as chairraises, for which a large percentage of muscle fibersmay be needed, may take longer for adults with MS toperform. Exercise interventions One of the first exercise intervention studies to bereported examined the effects of a 10-week aquaticfitness program on upper and lower extremity muscularforce, torque, fatigue, and work in 10 adults withMS.19 Participants performed freestyle swimming andshallow-water calisthenics three times per week forone hour. Peak torque during knee extension wassignificantly greater after five weeks compared tobaseline, whereas there were no differences for kneeflexion. Lower extremity fatigue (percent of peaktorque decline) and muscular endurance improved at theend of 10 weeks, as did upper extremity power, work,and force measurements. An endurance-training program of the knee flexors infive adults with MS was initiated in a clinicalsetting.20 The five participants used weight cuffs, apulley apparatus, or an isokinetic dynamometer two orthree days per week for four to eight weeks. Aftertraining, peak torque, general well-being (fatigue,health, physical fitness, somatic health, and mood),and perception of fatigue had improved for three ofthe five participants. A point of interest was thefact that this study used both isokinetic dynamometryand typical weight training equipment as part of theintervention program. A similar study examined the effects of progressiveresistance exercise on muscular strength in nineadults with relapsing-remitting MS (see reference 1for an explanation of the disease categories). The10-week, community-based exercise program utilizedmachine-based resistance and free weights, two daysper week for one hour. The results of the studyindicated that the participants improved the averagepeak torque of their knee flexors/extensors by 16% to57%, elbow flexors/extensors by 6% to 29%, andshoulder abductors/adductors by 3% to 11%. The authorsconcluded that although some participants did notimprove, the results indicate that the majority of theparticipants improved their muscular strength.21 Kraft and colleagues22 also examined the effect of 12weeks of progressive resistance exercise on measuresof strength in ambulatory adults with MS. Three timesper week, four adults with mild MS and four adultswith moderate levels of MS exercised in auniversity-based human performance laboratory. Theadults with mild MS (mean Expanded Disability StatusScale score = 3) had greater levels of improvement forthe quadriceps, hamstrings, triceps, and biceps thanthose with moderate levels of MS. Individuals withmoderate levels of MS (mean EDSS = 6) significantlyimproved the strength of their biceps, triceps, andhamstrings.22 Another research study used resistance exercise butfocused on the functional skill improvements of theseparticipants.12 The results of the study indicatedthat adults with mild and moderate levels of MS bothsignificantly improved their self-selected stairclimbing speed. Improvements were also made in the "upand go" mobility test,23 as well as scores on thepsychosocial and physical dimensions of the SicknessImpact Profile.24 Participants reported feelingtypical activity-related fatigue that subsided within24 to 48 hours, and no participant experienced an MSexacerbation during the 12-week program. The resultsof these papers are important because they includedboth objective measures of strength and improvementsrelated to functional daily activities. When one examines research in this area, it becomesapparent that sample sizes have been small andexperimental designs have not included control groups.One study did randomize 37 participants into exerciseand control groups.25 That study assessed the effectof an eight-week, home-based resistance exerciseprogram on lower extremity power, functional mobility,and balance in ambulatory adults with MS. Twenty-ninewomen and eight men were adjusted for disability leveland age, and then randomized into exercise (n = 19)and control (n = 17) groups. The lower extremitystrength training intervention utilized weighted vestsand functional exercises (chair raises, forwardlunges, step-ups, toe raises, and leg curls). Theexercise group participated in six instructionalsessions prior to implementation of the eight-weekhome-based exercise program, while those in thecontrol group maintained their current levels ofphysical activity. Weekly phone contact and bimonthlyhome visits increased compliance with self-reportedexercise (95% of exercise sessions were completed).General fatigue was recorded daily using a visualanalog scale. The results of the study indicate that leg extensorpower improved significantly in the exercise group,although improvements in balance and mobility did notreach statistical significance. Anterior-posteriorsway decreased by 10.3% and mediolateral swaydecreased by 4% in the exercise group, whereas thecontrol group had increases in both areas. In the "upand go" test, patients in the exercise group decreasedtheir average time by 12.7% while the control groupshowed little improvement (1% decrease). Afterregressing daily fatigue over time to yield a fatigueslope for both groups, no significant differences infatigue between groups were found.26 The authorsconcluded that this type of resistance exercise mightbe a feasible way for adults with MS to improve lowerextremity power without increasing fatigue, using amodel accessible to many. Limitations Although research suggests that resistance exercise issafe and beneficial, most of the studies have hadsmall sample sizes and lacked control groups. Inaddition, intensity of exercise, in relation tomuscular weakness and fatigue, has not been examinedin adults with MS. It has been shown that individualswith stroke and muscular dystrophy have experiencedgreater levels of fatigue and weakness after intenseexercise in muscles with neurogenic disturbance.27,28Specifically it has been shown that weak respiratorymuscles generated greater levels of muscle fatigue inchildren with muscular dystrophy.27 In patients withstroke, researchers found lower levels of peak torqueand decreased work capacity in the stroke-affected legthan in the unaffected leg during high-intensityeccentric-concentric contractions of theplantar-flexors.28 This indicates that muscle groupswith neuromuscular weakness may respond tohigh-intensity resistance exercise differently and/orrespond to fatigue more quickly than nonaffectedmuscle groups. It is also not known whetherhigh-intensity exercise would damage these musclegroups over time. Recommendations We recommend that health professionals use low- tomoderate-intensity resistance exercise when trainingpatients with MS. This decrease in intensity may beoffset with an increase in repetitions, which may havea carryover effect of improving muscular endurance andduration of repetitive movements and activities suchas walking and gardening. A second recommendation isthat health professionals carefully monitor patients'exertional fatigue and recovery from exercise. A thirdrecommendation is to provide ongoing systematicevaluation during exercise. Lastly, resistanceexercise should be implemented by a trained healthprofessional who is understanding of and sensitive tothe specific needs of each individual with MS. The best approach to improving the health and wellnessof adults with MS may be to use a community-based teamof practitioners. Exercise and resistance training isa very important component of the overall program andshould not be overlooked. But physicians, therapists,and other health professionals need to keep current onongoing research regarding exercise and MS. In addition, all professionals on the team should makethemselves aware of adequately staffed community- oruniversity-based programs available in the area. Manyadults with MS are interested in exercise, yet theyoften have difficultly finding available, low-cost,community-based programs with support staff trained toprovide guidance. Transportation also may be difficultfor adults with disease-related vision impairments orparalysis. Patients who are still working part-timeand/or raising children may find it difficult tocommit to an exercise program in the community. Thus,home-based exercise may be an appropriate tool formany adults with MS. Therapists regularly prescribe home exercises only tohave patients fail to comply. A possible solution mayinvolve monthly phone calls to maintain contact andpromote compliance with home-based exercise programs.Participants could even return to the clinical settingfor retesting and updates to their programs. Conclusion Exercise prescription remains a topic on which adultswith MS most often ask for more information fromhealth professionals.29 Studies have shown that adultswith both mild and moderate levels of MS may improvetheir upper and lower body fitness with exercise.Progressive resistance exercise may improve muscularstrength endurance and lower extremity power, balance,and mobility, and may decrease musclefatigue.12,14,19-22,25,30 These changes can occurwithout increasing or exacerbating MS symptoms, orincreasing daily fatigue.25 Aquatics, as well astraditional rehabilitation centers, physical therapyclinics, and university-based settings have all beensuccessful at improving muscular strength or endurancein these adults. Louisa S. DeBolt, PhD,is an assistant professor ofexercise and sport science in the College of HealthSciences at Eastern Kentucky University in Richmond. A. McCubbin, PhD, is an associate dean andprofessor of exercise and sport science in the Collegeof Health and Human Sciences at Oregon StateUniversity, in Corvallis. Eduard Gappmaier, PT, PhD,is an associate professor of physical therapy, in theCollege of Health at the University of Utah in SaltLake City. References 1. National Multiple Sclerosis Society. "Just thefacts: 2004-2005,"www.nationalmssociety.org/Brochures-Just%20the.asp,accessed 9/21/04. 2. el DI. Multiple Sclerosis. In: Umphred DA, ed.Neurological rehabilitation, 2nd ed, SA. St. Louis: CVMosby, 1990:531-550. 3. Sadovnick AD, Eisen K, Ebers GC, Paty DW. Cause ofdeath in patients attending multiple sclerosisclinics. Neurology 1991;41(8):1193-1196. 4. Ng A, Kent-Braun JA. Quantitation of lower physicalactivity in persons with multiple sclerosis. Med SciSports Exerc 1997;29(4):517-523. 5. Sharma KR, Kent-Braun J, Mynhier MA, et al.Evidence of an abnormal intramuscular component offatigue in multiple sclerosis. Muscle Nerv1995;18(12):1403-1411. 6. Ponichtera-Mulcare JA. Exercise and multiplesclerosis. Med Sci Sports Exerc 1992;25(4):451-465. 7. Sterman AB, Coyle PK, Panasci DJ, Grimson R.Disseminated abnormalities of cardiovascular autonomicfunctions in multiple sclerosis. Neurology1985;35(11):1665-8. 8. Pepin EB, Hicks RW, Spencer MK, et al. Pressorresponse to isometric exercise in patients withmultiple sclerosis. Med Sci Sports Exerc1996;28(6):656-660. 9. Schwartz CE, Coulthard- L, Zeng Q.Psychosocial correlates of fatigue in multiplesclerosis. Arch Phys Med Rehab 1996;77(2):165-170. 10. Mulcare JA. Multiple Sclerosis. In: Durstine JL, GE, eds. ACSM's exercise management for personswith chronic diseases and disabilties. Champaign, IL:Human Kinetics, 1997:190. 11. Petajan JH, White AT. Recommendations for physicalactivity in patients with multiple sclerosis. SportsMed 1999;27(3):179-191. 12. Kraft GH, Alquist AD, Lateur BJ. Effect ofresistive exercise on physical function in multiplesclerosis. Rehabilitation R & D Progress Report1995:328-329. 13. Summers L, McCubbin JA. The effects of exercise onmuscular endurance and walking distance in adults withmultiple sclerosis. Proceedings of the North AmericanFederation Adapted Physical Activity Symposium, 1998,Minneapolis, MN. 14. Lambert CP, Archer RL, WJ. Muscle strengthand fatigue during isokinetic exercise in individualswith multiple sclerosis. Med Sci Sports Exerc2001;33(10):1613-1619. 15. Armstrong LE, Winant DM, Swasey PR, et al. Usingisokinetic dynamometry to test ambulatory patientswith multiple sclerosis. Phys Ther1983;63(8):1274-1278. 16. Ponichtera JA, Rodgers MM, Glaser RM, et al.Concentric and eccentric isokinetic lower extremitystrength in persons with multiple sclerosis. J OrthopSports Phys Ther 1992;16:114-122. 17. Chen WY, Pierson FM, Burnett CN. Force-timemeasurements of knee-muscle functions of subjects withmultiple sclerosis. Phys Ther 1987;67(6):934-940. 18. Rice CL, Vollmer TL, Bigland-Ritchie B.Neuromuscular responses of patients with multiplesclerosis. Muscle Nerve 1992;15(10):1123-1132. 19. Gehlsen GM, Grigsby SA, Winant DM. Effects of anaquatic fitness program on the muscular strength andendurance of patients with multiple sclerosis. PhysTher 1984;64(5): 653-657. 20. Svensson B, Gerdle B, Elert J. Endurance trainingin patients with multiple sclerosis: Five casestudies. Phys Ther 1994;7(11):1017-1026. 21. Kasser SL, McCubbin JA. Effects of progressiveresistance exercise on muscular strength in adultswith multiple sclerosis. Med Sci Sports Exerc1996;28(5):S143. 22. Kraft GH, Alquist AD, Lateur BJ. Effect ofresistive exercise on strength in patients withmultiple sclerosis. Rehabilitation R & D ProgressReport 1995: 329-330. 23. Posiodlo D, S. The timed "Up & Go": atest of basic functional mobility for frail elderlypersons. J Am Geriatr Soc 1991;39(2):142-148. 24. Bergner M, Bobbitt RA, WB, Gilson BS. TheSickness Impact Profile: development and finalrevision of a health status measure. Medical Care1981;19(8):787-805. 25. DeBolt LS, McCubbin JA. The effects of home-basedresistance exercise on balance, power, and mobility inadults with multiple sclerosis. Arch Phys Med Rehab2004;85(2):290-297. 26. DeBolt LS, McCubbin JA. The effect of resistanceexercise on fatigue and depression in women withmultiple sclerosis Res Q Exerc Sport 2001;72(1):A-103.27. JL. Respiratory function in children withneuromuscular disease. Monaldi Arch Chest Dis1996;51(3):230-235. 28. Svantesson UM, Summerhagen KS, Carlsson US, GrimbyG. Development o fatigue during repeatedeccentric-concentric muscle contractions of plantarflexors in patients with stroke. Arch of Phys MedRehab 1999;80(10):1247-1252. 29. Somerset M, R, Sharp DJ, s TJ. Whatdo people with MS want and expect from health-careservices? Health Expectations 2001;4 (1):29-37. 30. Petajan JH, Gappmaier E, White A, et al. Impact ofaerobic training on fitness and quality of life inmultiple sclerosis. Ann Neurol 1996;39(4):432-441. © 1996 - 2004 CMP Media LLC, a United Business MediacompanyPrivacy Statement - Terms of Service=====moderator, MS_Community

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Thanks for the kick in the butt to persue the rehab that I've been

putting off!

> Exercise helps multiple sclerosis patients resist

> further debilitation

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> By: Louisa S. DeBolt, PhD, A. McCubbin, PhD,

> and Eduard Gappmaier, PT, PhD

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