# Exercise as it relates to Disease/Physical activity treatment in multiple sclerosis

This is a critical analysis on the article from the Multiple Sclerosis Journal, “Randomized controlled trial of a behavioral intervention targeting symptoms and physical activity in multiple sclerosis.”

## What is the background to this research?

Multiple sclerosis (MS) is a disease of the central nervous system, in which the immune system attacks myelin, the protective sheath that covers nerve fibres. This means MS patients are not able to drive active motor units at high firing frequencies, resulting in impaired muscle activation and lower limb strength.
When it comes to using exercise training as a form of therapy for people suffering with multiple sclerosis, there is already a wide range of studies that have found supervised training results in improved fitness, fatigue, depression, mobility, and health-related quality of life in MS patients. Although these are positive findings, it has also been found that people with multiple sclerosis are not simply not participating in sufficient amounts of this style of exercise training, resulting in the recommended physical activity levels not being met by majority of the MS community.
This study addresses the promotion of moving away from structured exercise training and instead encouraging engagement in more lifestyle based physical activity, and applying it to the MS community. Lifestyle physical activity involves the daily accumulation of 30 or more minutes of moderate-to-vigorous intensity self-selected activities. This can include activities that make up every day life such as leisure, household chores, gardening etc.

## Where is the research from?

This research was undertaken in the United States at the University of Illinois. The article was published in the Multiple Sclerosis Journal, a peer reviewed journal which is recognised by the Committee on Publication Ethics, making it a reputable source that focuses on all aspects of multiple sclerosis.
The research was supported by a grant from the National Multiple Sclerosis Society. There is no evidence of bias when considering that this is a national, multi-chapter, non-profit organisation. Furthermore, the lead author, Lara A. Pilutto was the recipient of a Postdoctoral Fellowship from the Multiple Sclerosis Society of Canada and a Du Pré Grant from the Multiple Sclerosis International Federation, the international body that links the National MS societies around the world. All of these reputable sponsorship links show no conflict of interest or bias.
Lead author, Professor Lara A Pilutti has 87 publications that focus on the role of exercise in the management and treatment of disability arising from neurological disorders, particularly multiple sclerosis.

## What kind of research was this?

This study was a randomized control trial, the gold standard in research when it comes to determining whether a cause-effect relation exists between the trial groups ensuring bias does not impact the results of the treatment.
There have been many cross-sectional and cohort studies of daily physical activity and it’s outcomes for people with multiple sclerosis, with evidence showing improved quality of life, fatigue and depression as a result of physical activity. By examining these outcomes using a randomized control trial, these correlations found in previous studies can be supported by stronger evidence.

## What did the research involve?

This study was a 6-month randomized controlled trial using an internet-delivered intervention based on symptomatic, health-related quality of life, and physical activity outcomes in 82 ambulatory persons with multiple sclerosis. The initial aim of this trial was to determine the efficacy of using an internet-based intervention for this particular community, which should be considered more important than ever with the current COVID-19 pandemic often placing sufferers of MS into isolation which is exactly where tools like this can be most useful. Once this had been established, the aim was to replicate previous results from other studies encouraging free-living physical activity instead of a structured structured exercise program.
The intervention included:
* A website with information about becoming more physically active
* Self-monitoring and goal setting using a pedometer and activity logs
* One-on-one web-based video coaching sessions.
Intervention Strengths:
* Gold standard randomized control trial
* Duration of 6 months with regular interventions and one-on-one check ins
* Thorough recruitment, baseline and post-trial testing
* Excellent adherence
Intervention Limitations:
* Relying on participants self-reporting which leaves the potential for personal bias when rating activity levels.

## What were the basic results?

Post-trial data from intervention :
| | Intervention | SD | Control | SD |
| Godin Leisure-Time Exercise Questionnaire | 27.2 | 3.0 | 13.0 | 3.0 |
| Moderate-to-vigorous physical activity (minutes) | 19.5 | 2.3 | 13.8 | 2.2 |
| Fatigue Severity Scale | 4.6 | 0.2 | 5.4 | 0.2 |
| Modified Fatigue Impact Scale Total | 35.7 | 1.8 | 40.5 | 1.8 |
| Modified Fatigue Impact Scale Physical | 16.0 | 0.9 | 19.3 | 0.8 |
| Modified Fatigue Impact Scale Cognitive | 16.7 | 1.9 | 18.0 | 0.9 |
| Hospital Anxiety and Depression Scale - Depression | 5.0 | 0.4 | 6.6 | 0.4 |
| Hospital Anxiety and Depression Scale - Anxiety | 4.1 | 0.4 | 5.6 | 0.4 |
| McGill Pain Questionnaire | 8.1 | 0.7 | 9.8 | 0.6 |
| Pittsburgh Sleep Quality Index | 6.4 | 0.4 | 7.4 | 0.4 |
| Multiple Sclerosis Impact Scale - Physical | 29.1 | 1.5 | 33.2 | 1.5 |
| Multiple Sclerosis Impact Scale - Psychological | 27.6 | 2.4 | 33.1 | 2.3 |
Most statistically significant differences between the two trial groups post-trial were seen in the measures of
* Leisure Time Exercise
* Fatigue severity
* Depression and Anxiety

## What conclusions can we take from this research?

The primary finding was the significant and positive effect of the intervention on fatigue severity and its physical impact, depression, and anxiety, and increase in self-reported physical activity.
One limitation to these findings is that all results that showed significant improvements were taken from data pulled from self-completed questionnaires and self-reported activity from participants which does present the risk of personal bias.
This suggests that interventions targeting lifestyle physical activity can provide the same benefits as an intervention based on a structured exercise program, promoting the engagement in lifestyle physical activity among the MS community.

## Practical advice

People with multiple sclerosis should first consult an allied health professional such as an exercise physiologist and complete and an adult pre-exercise screening before making any changes to their current physical activity regime as individual symptoms for persons with MS can vary substantially.
Some examples of lifestyle activities a person with MS could include in their day-to-day life to increase physical activity levels are: (depending on severity of symptoms and recommendations from an allied health professional)
* Walking to local shops or walking a pet
* Taking the stairs instead of an elevator
* Gardening
* Chores around the house
* Occupational physical activity
* Cooking
For general recommendations on physical activity and exercising with MS, please see the link below under the further information/resources heading for MS Australia’s guidelines.

## Further information/resources

For further information regarding this topic, please see below resources for additional support:
* Information on the disease of Multiple Sclerosis: https://www.msaustralia.org.au/what-ms
* Online community for people affected by Multiple Sclerosis: https://shift.ms/
* Physical activity recommendations for Multiple Sclerosis: https://www.msaustralia.org.au/living-with-ms/expert-blog/exercise-and-ms#:~:text=Choose%20exercise%20that%20you%20enjoy.&text=disabilities%20(4).-,Physical%20Activity%20Guidelines%20for%20adults%20with%20mild%20to%20moderate%20MS,days%20per%20week(5).
* Useful Resources for exercising with Multiple Sclerosis: https://www.nationalmssociety.org/Living-Well-With-MS/Diet-Exercise-Healthy-Behaviors/Exercise
* Articles for the Multiple Sclerosis Community: https://www.gene.com/topics/multiple-sclerosis

## References

* 1 2 Pilutti, L., Dlugonski, D., Sandroff, B., Klaren, R., & Motl, R. (2013). Randomized controlled trial of a behavioral intervention targeting symptoms and physical activity in multiple sclerosis. Multiple Sclerosis Journal, 20(5), 594-601.
* ↑ https://www.mayoclinic.org/diseases-conditions/multiple-sclerosis/symptoms-causes/syc-20350269
* ↑ Fimland, M., Helgerud, J., Gruber, M., Leivseth, G., & Hoff, J. (2010). Enhanced neural drive after maximal strength training in multiple sclerosis patients. European Journal Of Applied Physiology, 110(2), 435-443.
* 1 2 Motl RW and Pilutti LA. The benefits of exercise training in multiple sclerosis. Nat Rev Neurol 2012; 8: 487–497.
* 1 2 Motl RW, McAuley E and Snook EM. Physical activity and multiple sclerosis: A meta-analysis. Mult Scler 2005; 11: 459–463.
* 1 2 Dunn AL, Andersen RE and Jakicic JM. Lifestyle physical activity interventions. History, short-and long-term effects, and recommendations. Am J Prev Med 1998; 15: 398–412.
* 1 2 Motl RW, McAuley E, Wynn D, et al. Lifestyle physical activity and walking impairment over time in relapsing–remitting multiple sclerosis: Results from a panel study. Am J Phys Med Rehabil 2011; 90: 372–379.
* ↑ https://www.nationalmssociety.org/Living-Well-With-MS/Diet-Exercise-Healthy-Behaviors/Exercise
* ↑ Kendall, J. (2003). Designing a research project: randomised controlled trials and their principles. Emergency Medicine Journal, 20(2), 164-168.