# Exercise as it relates to Disease/Regular resistance training improves strength in multiple sclerosis patients

This is a critic (created by u3144356) of the journal article “Improvement in strength following resistance training in MS patients despite varied disability levels” by Mary Filipi (2011). This analysis has been written as a university assignment for the University of Canberra for the unit: Health, Disease and Exercise.

## What is the Background to this Research?

Multiple Sclerosis (MS) is a degenerative disease that negatively affects the central nervous system. Inflammation/ damage occurs around the myelin sheath (fatty insulating tissue) inhibiting nerve impulses. The exact cause is unknown, however it is hypothesised that the neuromuscular junctions are the major sites for plasticity. It is thought that during a period of relapse the damaged areas on the axons stimulate nerve rootlets that are present for only a short period of time. Resistance training could possibly activate this process leading to the formation of new collateral impulse pathways, hence decreasing the severity of further degradation. Current research on exercise and MS is broad and generalised. This is a unique study as no one has incorporated individuals with MS with a higher EDSS score than 5.5. Physical interventions have become popular within many diseased populations; specifically with MS due to its decrease in chronic symptoms such as:
* Loss of balance
* Fatigue
* Depression
* Lower independency and quality of life

## Where is the Research From?

This study was conducted in the following universities and corporations in the corresponding departments:
* University of Nebraska Medical Centre, College of Nursing, Omaha, NE, USA
* Neurology Associates, PC. Lincoln, NE, USA
* Fast Forward Gym, Omaha, NE, USA
* Valmont Industries, Valley, NE, USA
* University of Kanas, KS, USA
** Department of Statistics
* University of Nebraska Medical Centre, Omaha, NE, USA
** Department of Allied Health
The corresponding author: Mary Filipi, is a nurse practitioner specialist in Wahoo NE who cooperates with multiple medical groups, especially Saunders Medical Centre, Multiple Sclerosis Centre Of Nebraska. She has current experience and reputation within the target population inclusive with multiple published journal articles based on MS patients.

## What Kind of Research was this?

This study was a cohort/ prospective observational study being randomized and controlled across a 6-month period. The way this study has been undertaken allowed for a vast range of diversity within the study population, sustaining a parallel improvement in both strength and endurance outcomes. The investigation is a unique representation of all disability levels being analysed, with the effects of regular (≥2 days per week) training as no study has ever incorporated individuals with severe MS on the EDSS score of over 7.5.
| Advantages | Disadvantages |
| Good to establish a supervised supportive environment | Expensive machine adaptation to cater for different disability levels as well as equipment/ space for all 67 participants |
| Randomised controlled trial provides strong evidence | Various disabilities have limitations on certain exercises they can participate in so might not be interchangeable |
| Quantitative and Qualitative data able to be obtained | Restricted by land lock- transportation and patients in one specific area can participate due to the controlled setting |
| Proc GLM in SAS program analysis accounts for variability’s between and within subjects | A full program comparison were unable to be achieved due to the inability for some individuals to participate in |

## What did the Research Involve?

6 individuals initiated the clinical treatment protocols and by “verbal report” significant increase in participant numbers ensued. Data was collected from 67 participants, all of various disability levels (minor: 1-4.5, moderate: 5-7, severe: 7.5+ on EDSS Scale). The participants were issued with a 6 month individualized resistance-training program where data was collected at baseline 3-months and 6-month markers. The training program consisted of 3 phases:
* Strength improvement (most machine bound exercises)
* Balance and Dexterity for security, stabilisation and agility (mixture of machine and free weight)
* Balance and coordination (all free weight exercises) with anaerobic benefits
10 exercises were completed per session with 2 or 3 sets and 10 repetitions. The individual must participate in the program at least 2 days a week in order to be included. The result measurements were collected on 12 different exercises and accounted for variability through Proc GLM program. The used methodology was the optimum choice considering all possible variables, and the attempt at controlling as many as physically possible. There are limitations to it being such an intensely controlled study, yet they are minute. Transportation was an issue, meaning all participants had to be local and bound to one accessible location.

## What were the basic results?

The main hypothesis was proven in this study. Despite disability level, strong evidence of strength improvement was noted in all but one tested exercise (abdominal crunches). A parallel response curve was noticed amongst all participants’ progression, including a shorter recovery time from MS flairs after relapse. Only two individuals had a relapse during the course of the program, this is significantly lower than what as predicted due to an estimation of the average person having 1.6-2.0 per year. Interestingly, the cohort consisted of 18 males and 49 females. This is very unbalanced, however the predominance of MS in females is at a 2/3:1 ratio against males. 95.3% of the partakers were Caucasian, which limits our ethnic variability although MS too is more prevalent in a Caucasian population compared to others.
The researchers interpreted the results as that regular resistance training can strengthen individuals with MS, decreasing physical symptoms associated with the disease. Without looking into it too much, they believe that it could possibly do more than just affect the symptomatic state but also disease itself. A positive psychological impact was verbally reported by the participants, however the study suggests that further exploration into this should be investigated with fatigues and depression scales. No over-emphasis was placed on the findings by this study, it more looked into what could further be done and possibly related implications.

## What conclusions can we take from this research?

This study proves the hypothesis that resistance training is effective in lowering physical symptoms (such as fatigue and weakness) in Multiple Sclerosis patients. Secondarily it has also provided evidence that the training effect was similar amongst different disability levels. With a controlled 6-month program, a tight hold and monitoring system had been developed to produce clear results. Collateral progression was evident amongst participants however, more recent studies have been found to provide evidence that although physiological implications are evident, psychological functioning initiates major changes in depression, mood, quality of life and well-being. Although in the past evidence warned Multiple Sclerosis patients to stay clear of exercise in the case of enhancing levels of fatigue, most recent articles all support exercise decreasing symptoms and enhancing quality of life in the long run.

## Practical advice

This research has real-word benefits for improving the quality of life of MS patients, by marginalising the symptoms and allowing them to be more independent. Before taking on this practical advice, individuals should gain further information on a more specific program so to relate solely to their needs. A strongly monitored and supportive environment is recommended for health and safety implications.

## Further reading

For further information on the benefits of resistance training on multiple sclerosis patients read below; a GP or exercise specialist can also be contacted for further information or queries.
* MS Australia
* MS and exercise: http://www.activemsers.org/exercisesstretches/tipsexercisingwithms.html
* Safe tips for exercising: http://www.webmd.com/multiple-sclerosis/guide/multiple-sclerosis-exercise
* Recommendations and applications of exercise with MS patients: http://msj.sagepub.com/content/early/2007/09/19/1352458507079445.short

##### References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Mary L. Filipi, Darcy L. Kucera, Eric O. Filipi, Alanson C. Ridpath, M. Patricia Leuschen, (2011) Improvement in strength following resistance training in MS patients despite varied disability levels. NeuroRehabilitation 28: 323-382
* ↑ Kimmy G. Su, Gary Banker, Dennis Bourdette, Michael Fort, (2009) Axonal degeneration in multiple sclerosis: The mitochondrial hypothesis. Curr Neurol Neurosci Rep. 9(5): 411-417
* ↑ Dangond F.(2002) Multiple Sclerosis: A Prototypical Human Demyelinating Disease. Disorders of Myelin in the Central and Peripheral Nervous Systems. 103-138.
* ↑ Explaining Pathology, (2013) Multiple Sclerosis. Lab Tests Online AU. [Avalible from: http://www.labtestsonline.org.au/contact/print?classnameparent=lto.condition&classnamechildren=lto.conditiondetail&printpath=/learning/Index-of-Conditions/multiplesclerosis]
* ↑ Vivian Budnik, L. Sian Gramates, (1999) Second messenger systems underlying plasticity the neuromuscular junction. Neuromuscular Junctions in Drosophila. Pg 119
* ↑ Tallner, Waschbisch, Wenny, Schwab, Hentschke, Pfeifer, Maurer, (2011) Multiple sclerosis relapses are not associated with exercise. Multiple Sclerosis Journal. vol 18 no. 2 232-235
* ↑ Ng AV, Kent-Braun JA, (1997) Quantification of lower physical activity in persons with multiple sclerosis. Medicine and Science in Sports and Exercise. 29(4): 517-523
* 1 2 3 Sutherland G, Andersen M B, (2001) Exercise and multiple sclerosis: Physiological, psychological, and quality of life issues. Journal of Sports Medicine and Physical Fitness. Vol 41.4: 421-32
* ↑ Petajan, Gappmaier, White, Spencer, Mino, Hicks, (1996) Impact on aerobic training on fitness and quality of life in multiple sclerosis. Annals of Neurology. 39:432-441