# Exercise as it relates to Disease/Home-based periodized training; a way to help adherence to exercise therapies for multiple sclerosis patients

This is a critique of the research article: C. Keytsmana, P. Van Notena, J. Spaasa, I. Niestea, P. Van Asch, B. O.Eijndea. Periodized home-based training: A new strategy to improve high intensity exercise therapy adherence in mildly affected patients with Multiple Sclerosis. Multiple Sclerosis and Related Disorders. 2019, Vol.28, p.91-97.
The critique was written as an assignment for the unit: Health Disease and Exercise in 2022

## Background and Research

Multiple Sclerosis (MS) is the demyelination of nerve cells by the immune system; this causes a wide range of issues unique to each individual, each is related to the way in which nerve signals are transmitted around the body. Exercise is positive in day-to-day life with further benefits to exercise in sufferers of MS. Cardiovascular fitness, strength, cognitive function, bladder and bowel function as well as general mood improvements have been identified by exercise interventions in MS sufferers. However, despite these benefits exercise adherence generally waivers, after initial interventions, as little as 4% report adherence at follow up sessions. This is not enough seeing the range of benefits with sustained physical activity. It is because of this the study aims to increase compliance through high intensity interval training (HIIT) in a periodised home-training situation.

## Research

This research was undertaken using a correlational study. Such studies entail investigating the relationship between two variables in a population. This is the use of HIIT training to improve activity adherence in MS sufferers, furthermore, a healthy control (HC) group was used to validate the results. The researchers’ utilised only those with mild (EDSS <4) cases of MS to participate due to the theory being largely untested, and higher intensity exercise affecting severe MS cases differently. This could possibly skew results when transferred to a more severely affected population. This because exercise that is too intense in more severely affected individuals can induce severe fatigue and exacerbate MS symptoms.
The experiment was completed through the Rehabilitation and Research Center of Hasselt University (REVAL) and the Belgian MovetoSport foundation. It was through these organisations that 33 HC and MS subjects were identified. Of these 66, 21 declined participation and 8 dropped out, thus leaving 37 individuals to complete the analysis.
* 9 Healthy Control
* 18 Multiple Sclerosis
The study aimed to see increases in overall health, as well as high levels of program adherence. The final goal of the program was related to the Awareness Project, with participants increasing their health enough to cycle their bikes to the peak of Mount Ventoux in France.
Of the six authors involved in this study; P. Asche works for the MovetoSport foundation, with the remaining authors working for various universities. Each of these individuals have further work in the field, with some focused around training and its’ effects in general, and others around the impact of training types on degenerative diseases.

## Study Methods

The study involved a pre-test body composition scan and a maximum cycle ergometer, with heart rate, gas analysis and blood testing undertaken while performing this. The ergometer test was completed as follows.
* Females- 20W at 70RPM with 10W increases each minute
* Males- 30W at 70RPM with 15W increases each minute
Blood lactate was recorded from the earlobe at maximal exhaustion (lactate max) and after recovery (lactate peak), with gas analysis and heart rate recorded every minute.
All participants were provided with a Polar® M200 (sport activity watch) to assist load management throughout the program. The program consisted of 8 recurrent 3-week cycles, with progress managed by researchers through the Polar® coaching platform. The sessions employed a high load/low volume or high volume/low load approach. This provided adequate recovery for MS affected subjects; consideration of recovery assisted with program adherence. By being approachable, transparent, and clear in their goals, the researchers improved attitude towards the program, leading to positive trends in adherence.

## Results

At the conclusion of the 6-month study there were huge improvements across the board in both groups of individuals. However, most impressive was of 64 training sessions; 61 were completed by the MS group and 57 by the HC group, with neither group missing sessions because of program design, instead citing personal issues or commitments. This showed great adherence to the program by the participants and demonstrated to the researchers the effectiveness of a home-based HIIT program when monitored.
This however, could be a downfall, due to the researchers constantly in contact perhaps the individuals were more likely to adhere, should the researchers have been less involved and made the population self-driven in the program, they may not have been so adherent.
Overall, the intervention saw increases in both body composition and exercise capacity measures, these are shown in table 1 and 2 below. The HC group didn’t see notable changes in the body composition category.
Body Composition :
| Body Weight | -3% |
| BMI | -2% |
| Total Mass | -2% |
Table 1- Body Composition Results
Exercise Capacity :
| | HC | MS |
| VO$_{2Max}$ | +6% | +5% |
| Workload | +11% | +11% |
| Time to Exhaustion | +11% | +14% |
| Recovery HR | +4% | +4% |
| Lactate Peak | +16% | +16% |
| Lactate Max | +30% | +30% |
| RER | +4% | +4% |
| Max HR | -2% | -2% |
Table 2- Exercise Capacity Results
It is from these results we can identify positive steps in the intervention in both adherence and health benefits.

## Conclusions

This research provides a solid foundation to build further research upon. The results provided are unbiased and fairly conclusive in the population provided, however due to the mild nature of the MS individuals it is just providing a base to build further research. The results gathered whilst positive are limited for this exact reason and with this in mind it should be concluded that further testing is required. The testing protocol is very sound (albeit expensive), and the testing could be repeated should more volunteers come forward and funding is provided.This testing should be modified to a lower intensity and repeated for more severe cases of MS to identify if the correlation is still present and see if this technique could further assist MS sufferers worldwide. It should not be discounted that the results presented so far are positive and a step in the right direction for promoting adherence to exercise programs for those suffering from MS.

## Practical Advice

The results from this study are positive in almost all aspects and the effectiveness of promoting adherence to a training program is extremely encouraging. With this in mind HIIT should be utilised more as a way of assisting those with MS. Modifications should be made for each individual but the general principle of HIIT has proven itself in this population, and should individuals have similar adherence issues, comparable interventions could be employed. The prescribing individual should however always consider individual needs and comfort in the program prescription.

## Further Information

For further reading Multiple Sclerosis and HIIT training programs, please click the links below:
* Adherence and drop-out in randomized controlled trials of exercise interventions in people with multiple sclerosis
* Exercise for multiple sclerosis: a single-blind randomized trial comparing three exercise intensities
* Maximising Abilities, Negotiating and Generating Exercise options (MANAGE) in people with multiple sclerosis
* Systematic Review of Exercise Studies in Persons with Multiple Sclerosis

## References

* 1 2 3 4 5 6 C. Keytsmana, P. Van Notena, J. Spaasa, I. Niestea, P. Van Asch, B. O.Eijndea. Periodized home-based training: A new strategy to improve high intensity exercise therapy adherence in mildly affected patients with Multiple Sclerosis. Multiple Sclerosis and Related Disorders. 2019, Vol.28, p.91-97.
* ↑ S. Amor, H. Van Noort. Multiple Sclerosis. eBook. Oxford University Press. Published 29/9/2012
* ↑ National Multiple Sclerosis Society. Exercise [Internet]. [Unknown location]: National Multiple Sclerosis Society; [cited 2022 Sept 11]. Available from: https://www.nationalmssociety.org/Living-Well-With-MS/Diet-Exercise-Healthy-Behaviors/Exercise
* ↑ R. Dennett, L. T. Madsen, L. Connolly, J. Hosking, U. Dalgas, J. Freeman. Adherence and drop-out in randomized controlled trials of exercise interventions in people with multiple sclerosis: A systematic review and meta-analyses. Multiple Sclerosis and Related Disorders. 2020, Vol.43
* ↑ C. Keytsmana, P. Van Notena, J. Spaasa, I. Niestea, P. Van Asch, B. O.Eijndea. Periodized home-based training: A new strategy to improve high intensity exercise therapy adherence in mildly affected patients with Multiple Sclerosis. Multiple Sclerosis and Related Disorders. 2019, Vol.28, p.91-97.
* ↑ J. Sauro. 4 Experiment Types for User Research [Internet]. [Unknown Location]: MeasuringU; 2013 Oct. 15 [Cited 2022 Sept. 11]. Available from: https://measuringu.com/experimenting-ux/
* 1 2 A. Orban, B. Garg, M. K. Sammi, D. N. Bourdette, W. D. Rooney, K. Kuehl, R. I. Spain. Effect of High-Intensity Exercise on Multiple Sclerosis Function and 31P MRS Outcomes. Medicine & Science in Sports & Exercise. 2019:1
* ↑ Scopus Preview. Keytsman, Charly - Hasselt University [Internet]. [Unknown location]: Scopus Preview. [Unknown Date] [Cited 2022 Sept 11]. Available from: https://www.scopus.com/authid/detail.uri?authorId=56446932300
* ↑ Scopus Preview. van Noten, Pieter - Maastricht University [Internet]. [Unknown location]: Scopus Preview. [Unknown Date] [Cited 2022 Sept 11]. Available from: https://www.scopus.com/authid/detail.uri?authorId=23480649400
* ↑ Scopus Preview. Spaas, Jan - Hasselt University [Internet]. [Unknown location]: Scopus Preview. [Unknown Date] [Cited 2022 Sept 11]. Available from: https://www.scopus.com/authid/detail.uri?authorId=57205097488
* ↑ Scopus Preview. Nieste, Ine - Hasselt University [Internet]. [Unknown location]: Scopus Preview. [Unknown Date] [Cited 2022 Sept 11]. Available from: https://www.scopus.com/authid/detail.uri?authorId=57205102367
* ↑ Scopus Preview. van Asch, Paul - MovetoSport Foundation [Internet]. [Unknown location]: Scopus Preview. [Unknown Date] [Cited 2022 Sept 11]. Available from: https://www.scopus.com/authid/detail.uri?authorId=57194456638
* ↑ Scopus Preview. Eijnde, Bert Op T. - Hasselt University [Internet]. [Unknown location]: Scopus Preview. [Unknown Date] [Cited 2022 Sept 11]. Available from: https://www.scopus.com/authid/detail.uri?authorId=6602499603
* ↑ G. A. Holleman, I. T. C. Hooge, C. Kemnar, R. S. Hessels. The ‘Real-World Approach’ and Its Problems: A Critique of the Term Ecological Validity. Frontiers in Psychology. 2020; 11: 721
* ↑ W. Walker. The strengths and weaknesses of research designs involving quantitative measures. Journal of Research in Nursing. 2005; 10(5): 571-582
* ↑ D. F. Polit. Getting serious about test–retest reliability: a critique of retest research and some recommendations. Quality of Life Research. 2014; 23: 1713-1720