# Exercise as it relates to Disease/The impact of resistance training on balance and gait in Multiple Sclerosis

Article critique: Filipi LM, Leuschen P, Huisinga J, Scmaderer L, Vogel J, Kucera D, Stergiou N. Impact of resistance training on balance and gait in Multiple sclerosis. Int J MS Care. 2010 April 1;12(1):6-12.

## What is the background to this research?

Multiple Sclerosis (MS) is a chronic disease where the immune system damages the covering of nerves (myelin sheath) in the brain and spinal cord. This disrupts the communication between motor and sensory pathways between the brain and body. It can impair walking, balance, vision, thinking, and memory. In Australia, MS is the most common neurological disorder for adults aged 20-40, and it affects women 3 times more than men (see MS website for more information). Current research shows that MS can lower quality of life, which leads to an increase in physical inactivity. This is concerning as there is no cure, and MS can lead to physical disability. Research shows that a common barrier to exercise is the fear that exercise can worsen symptoms. This is supported by the inconclusive evidence related to the safety, adherence, and effectiveness of resistance training, as well as the most appropriate exercises to improve walking and balance. Medication is effective in reducing flare-ups and slowing down disease progression, however, the ability of medication to improve symptoms such as muscle weakness, walking ability and balance is limited. The chosen article investigates the effectiveness of resistance training in adults with MS by exploring its effect on walking, balance, and fatigue, regardless of disability level.

## Where is the research from?

The article was published by the International Journal of MS care, a peer-reviewed database for original research articles exploring clinical rehabilitation in MS. Mary L. Filipi is a nurse practitioner specialist based in Nebraska with more than 20 years of experience, has graduated with honours (1997) and has published several papers. The academic team is well-published. The paper has no conflicts of interest and received funding from 3 non-profitable organisations: the MARS foundation, the National Multiple Sclerosis Society and the NMC clinical research centre.

## What kind of research was this?

The study was a nonrandomised, nonblinded prospective cohort study, this type of study explores the effectiveness of an intervention over time on a particular outcome or population.

## What did the research involve?

Participant information
* Age: 24-54 (38.8 +/- 10.7 years)
* 33 participants: 11 males and 22 females
* Group 1: little to no disability (EDSS 1.0-4.0)*
* Group 2: mild to moderate disability (EDSS 4.5-6.5)*
* Recruitment: provider referral or direct advertisement to the general MS population
*Expanded Disability Status Scale score: a valid scoring system that measures physical impairment from MS*
The resistance training program
* Duration of study: 6 months
* Duration of each training session: 50 minutes; 30 minutes resistance training with 5-10 min warm up/cool down
* Exercises: see the link for a summary of the exercises (page 10)
* Frequency: 2 times a week
* Intensity and volume: sets: 2-3 | repetitions: 10 | rest: 30 seconds
* Progression: final repetition at the end of the last set is completed with the same intensity as the first repetition in the last set
* Time of evaluations: before the study, at 3 months and after the study
* Evaluation Instruments: Modified Fatigue Impact Scale (MFIS), Modified Fall Efficacy Scale (MFES), Berg Balance Scale (BBS), Timed Up and Go (TUG) test, Multiple Sclerosis Functional Composite (MSFC), Neuro-Com Balance Master and 3-dimensional biomechanical gait analysis. These are all applicable to a clinical setting.
There are weaknesses to the method that decreases the paper's ability to communicate that resistance training improves balance and walking, regardless of disability level. The article does not have a control group and the results were not compared to normative data. The recruitment process was small, and the sample size did not account for the 4 different types of MS (relapsing, primary and secondary progressive MS) and focused on a mild disease progression. These issues suggest that the study's findings cannot be generalised to all levels of disability. The paper concluded that a structured resistance training program is associated with improved balance and walking for all disability levels (see results). This is an overstatement as this is not agreed upon in the current research. This is because the clinical goal of resistance training in rehabilitation is specific to suit the functional capabilities of a patient. As one's level of disability increases and in patient with severe disability, the goal for exercise is to help with daily functioning and improving quality of life, not to improve walking and balance.
Additionally, research about the physiological effects of resistance training for MS is emerging. As the study was not randomised, reactivity may have occurred. Reactivity is the unintended change in a participant's behaviour that favours what the researcher is looking for. The paper shows that there is a relationship between resistance training and an improvement in symptoms, but the reason as to why this relationship exists is not clear. It was concluded that exercise and medicine work well together and are necessary for a comprehensive rehabilitation program. This is an overstatement; the study did not investigate the interaction between medication and exercise. General statements are not applicable to MS rehabilitation as the process is highly individualised.

## What were the basic results?

* No participants experienced any negative effects to resistance training
Balance and Cognition
* Memory and concentration improved
* Overall participants felt less tired throughout the day
* Participants were less afraid of falling
Walking
* Strength and power increased in all leg muscles
* Daily movements and walking became less tiring
* Stride length increased
What the results mean
The hypothesis was supported, that resistance training will improve balance and fatigue regardless of disability, but the results are overstated.

## What conclusions can we take from this research?

* It promotes that physical activity is safe for MS and follows the appropriate exercise recommendations for a mild disease progression.
* Resistance training can improve quality of life and daily functioning.
* It would have been beneficial if the study investigated exercise adherence as this is lacking in current research. This would help educate patients and health professionals on the barriers to exercise and how to overcome them.
* Further research is needed to investigate the physiological effects and benefits of resistance training for all types of MS.
* A good reference for clinical assessments used in MS rehabilitation.

## Practical advice

* Appropriate exercise recommendations for a mild disease progression
** 2 days per week
** 40-50 minutes
** 10 repetitions, 2-3 sets per exercise
** 30 seconds rest between sets
* Outlines exercise considerations/complications
** Keeping body temperature stable, an increase in body temperature can be problematic.
** Avoid rapid progressions, it can lead to excessive fatigue, injury and can increase disease progression.
* advocates the importance of physical activity
** Staying active increases independence and levels of physical activity.
** Promotes the importance of allied health professionals to prescribe exercise (i.e., Accredited Exercise Physiologist).

## Further information/resources

MS website: https://www.msaustralia.org.au/?gclid=CjwKCAjwx7GYBhB7EiwA0d8oezY46_WCEmrY9mu62iL8Qt75QfKPKHeg_PNbM5Fizu-c1bmqzF8S1hoCybwQAvD_BwE
Exercise right recommendations: https://exerciseright.com.au/multiple-sclerosis/, https://exerciseright.com.au/staying-active-with-multiple-sclerosis/
MS organisations raising awareness: https://www.nationalmssociety.org/
Finding an Accredited Exercise Physiology in your area: https://www.essa.org.au/find-aep
Free Guide to Exercise from MS Australia: https://www.msaustralia.org.au/modifiable-lifestyle-guide-2020/for-people-with-ms/
National Multiple Sclerosis Document: https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/Clinical_Bulletin_Physical-Therapy-in-MS-Rehabilitation.pdf

## References

Add in the references using this code
* 1 2 3 Filipi LM, Leuschen P, Huisinga J, Scmaderer L, Vogel J, Kucera D, Stergiou N. Impact of resistance training on balance and gait in Multiple Sclerosis. Int J MS Care. 2010 April 1;12(1):6-12
* ↑ Oh J, Jordana VA, Montalban X. Multiple sclerosis: clinical aspects. Curr Opin. 2018 Dec 31;31(6):752-759.
* 1 2 MS Australia. What is Multiple Sclerosis (MS)? [Internet]. Australia: [publisher, date unknown] [cited 2022 Aug 17] Available from: https://www.msaustralia.org.au/what-is-multiple-sclerosis-ms/
* ↑ Dorans KS, Massa J, Chitnis T, Ascherio A, Munger KL. Physical activity and the incidence of multiple sclerosis. J Neurol. 2016 Oct 25;87(17):1770-6.
* ↑ MS Australia. Executive Summary: Health Economic Impact of Multiple Sclerosis in Australia in 2017 [Internet]. Australia: University of Tasmania. Menzies Institute of Medical Research; [date unknown] [cited 2022 Aug 21]. Available from: https://www.msaustralia.org.au/wp-content/uploads/2018/08/executive-summary_health-economic-impact-of-ms-in-australia-in-2017-report_ms-research-australia.pdf
* ↑ Halabchi F, Alizadeh Z, Sahraian MA, Abolhasani M. Exercise prescription for patients with multiple sclerosis, potential benefits, and practical recommendations. BMC Neurol. 2017 Sep 16;17(1):185.
* ↑ Kjølhede T, Vissing K, Dalgas U. Multiple sclerosis and progressive resistance training: a systematic review. Mult Scler. 2012 Sep;18(9):1215-28.
* ↑ Reynolds ER, Ashbaugh AD, Hockenberry BJ, McGrew CA. Multiple sclerosis and exercise: A literature review. Curr Sports Med Rep 2018 Jan;17(1):31-35
* ↑ Hauser SL, Cree BC. Treatment of Multiple sclerosis: A review. Am J Med. 2020 Jul 17;133(12):1380-90.
* ↑ Hart FM, Bainbridge J. Current and emerging treatment of multiple sclerosis. Am J Manag Care. 2016 Jun;22(6):159-70.
* ↑ International Journal of MS Care [Internet]. Cleveland: MJH Life Sciences. [date unknown] [cited 2022 Aug 23]. Available from: https://meridian.allenpress.com/ijmsc/pages/About-IJMSC
* ↑ Journal of Multiple Sclerosis. Biography: Mary L. Filipi [Internet]. Nebraska: International Online Medical Council; [date unknown] [cited 2022 Aug 28]. Available from: https://www.iomcworld.org/editor/mary-l-filipi-16170
* ↑ MARS Foundation. About us: partners & projects [Internet]. [place, publisher, date unknown] [cited 2022 Sep 13]. Available from: http://www.helpuscurems.org/aboutus
* ↑ National Multiple Sclerosis Society. Research directions in MS: strategies and progress [Internet]. [place, publisher, date unknown][cited 2022 Sep 13]. Available from: https://www.nationalmssociety.org/Programs-and-Services/Resources/Research-Directions-in-MS-Progress-Strategies-(-pd
* ↑ University of Nebraska Medical Centre. Research [place, publisher, date unknown]. [cited 2022 Sep 13]. Available from: https://www.unmc.edu/nursing/research/index.html
* ↑ NHRMC. NHRMC Levels of Evidence [Internet]. Australia: Australian Aphasia Rehabilitation Pathway; [date unknown] [cited 2022 Aug 28]. Available from: http://www.aphasiapathway.com.au/?name=NHMRC-Levels-of-Evidence
* ↑ Multiple Sclerosis Trust. Expanded Disability Status Scale (EDSS) [Internet]. Herftfodshire; [publisher, date unknown] [cited 2022 Aug 29]. Available from: https://mstrust.org.uk/a-z/expanded-disability-status-scale-edss
* ↑ Moock SM, Feng YS, Maeurer M, Dippel FW, Kohlmann T. Systematic literature review and validity evaluation of the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC) in patients with multiple sclerosis. BMC Neurol. 2014 Mar 25;14:58.
* ↑ Fisk JD, Ritvo PG, Ross L, Haase DA, Marrie TJ, Schlech WF. Measuring the functional impact of fatigue: initial validation of the fatigue impact scale. Clin Infect Dis. 1994 Jan;18(1):79-83.
* ↑ Hill KD, Schwarz JA, Kalogeropoulos AJ, Gibson SJ. Fear of falling revisited. Arch Phys Med Rehabil. 1996 Oct;77(10):1025-9.
* ↑ Conradsson M, Lundin-Olsson L, Lindelöf N, Littbrand H, Malmqvist L, Gustafson Y, Rosendahl E. Berg balance scale: intrarater test-retest reliability among older people dependent in activities of daily living and living in residential care facilities. Phys Ther. 2007 Sep;87(9):1155-63.
* ↑ Pondal M, Ser DT. Normative data and determinants for the timed "up and go" test in a population-based sample of elderly individuals without gait disturbances. J Geriatr Phys Ther. 2008;31(2):57-63.
* ↑ Hoogervorst EL, Winsen LM, Eikelenboom MJ, Kalkers NF, Uitdehaag BM, Polman CH. Comparisons of patient self-report, neurologic examination, and functional impairment in MS. Neurology. 2001 Apr 10;56(7):934-7.
* ↑ Miller DM, Rudick RA, Cutter G, Baier M, Fischer JS. Clinical significance of the multiple sclerosis functional composite: relationship to patient-reported quality of life. Arch Neurol. 2000 Sep;57(9):1319-24.
* ↑ Goldman MD, Motl RW, Rudick RA. Possible clinical outcome measures for clinical trials in patients with multiple sclerosis. Ther Adv Neurol Disord. 2010 Jul;3(4):229-39.
* ↑ National Multiple Sclerosis Society. Types of MS [Internet] [place, publisher, date unknown [cited 2022 Sep 13]. Available from: nationalmssociety.org/What-is-MS/Types-of-MS
* 1 2 Kalb R, Brown TR, Coote S, Costello K, Dalgas U, Garmon E, et al. Exercise and lifestyle physical activity recommendations for people with multiple sclerosis throughout the disease course. Mult Scler. 2020 Oct;26(12):1459-69
* ↑ Charron S, McKay KA, Tremlett H. Physical activity and disability outcomes in multiple sclerosis: A systematic review (2011–2016). Mult Scler Relat Disord. 2018 Feb 1;20:169-77.
* ↑ Madsen TL, Connolly L, Dennett R, Freeman J, Dalgas U, Hvid LG. Is aerobic or resistance training the most effective exercise modality for improving lower extremity physical function and perceived fatigue in people with Multiple sclerosis? A systematic review and meta-analysis. Arch Phys M. 2021 April 24;102(10):2032-48
* ↑ Wong VL, Holahan MR. A systematic review of aerobic and resistance exercise and inflammatory markers in people with multiple sclerosis. Behav Pharmacol. 2019 Dec;30(8):653-60.
* ↑ Given L. Thousand Oaks, California: SAGE Publications, Inc.; 2008. The SAGE Encyclopedia of Qualitative Research Methods; [modified 2022/09/11; [Reactivity]. Available from: https://methods.sagepub.com/reference/sage-encyc-qualitative-research-methods
* ↑ Rohrig M. A resource for healthcare professionals: Physical Therapy in Multiple Sclerosis [Internet]. National Multiple Sclerosis Society. [date unknown] [cited 2022 Sep 8]. Available from: https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/Clinical_Bulletin_Physical-Therapy-in-MS-Rehabilitation.pdf
* ↑ Behm K, Morgan P. The effect of symptom-controlling medication on gait outcomes in people with multiple sclerosis: a systematic review. Disabil Rehabil. 2018 Jul;40(15):1733-44
* 1 2 Kim Y, Lai B, Mehta T, Thirumalai M, Padalabalanarayanan S, Rimmer JH, et al. Exercise training guidelines for Multiple sclerosis, Stroke, and Parkinson disease: Rapid Review and Synthesis. Am J Phys Med Rehabil. 2019 Jul;98(7):613-21.
* ↑ Halabchi F, Alizadeh Z, Sahraian MA, Abolhasani M. Exercise prescription for patients with multiple sclerosis; potential benefits and practical recommendations. BMC Neurol. 2017 Sep 16;17(1):185.
* ↑ Dennett R, Madsen LT, Connolly L, Hosking J, Dalgas U, Freeman J. Adherence and drop-out in randomized controlled trials of exercise interventions in people with multiple sclerosis: A systematic review and meta-analyses. Mult Scler Relat Disord. 2020 Aug;43:102169.
* ↑ Sangelaji B, Smith CM, Paul L, Sampath KK, Treharne GJ, Hale LA. The effectiveness of behaviour change interventions to increase physical activity participation in people with multiple sclerosis: A systematic review and meta-analysis. Clinical Rehabilitation. 2016;30(6):559-76.
* ↑ Learmonth YC, Motl RW. Exercise training for Multiple sclerosis: A narrative review of history, benefits, safety, guidelines, and promotion. Int J Environ Res Public Health. 2021 Dec 16;18(24):13245
* ↑ Edwards T, Pilutti LA. The effect of exercise training in adults with multiple sclerosis with severe mobility disability: A systematic review and future research directions. Mult Scler Relat Disord. 2017 Aug;16:31-9.
* ↑ Learmonth Y. Staying Active with Multiple Sclerosis [Internet]. Australia: Exercise & Sports Science Australia; 2021 Dec 8 [cited Aug 28]. Available: https://exerciseright.com.au/staying-active-with-multiple-sclerosis/
* 1 2 Hoang PD, Lord S, Gandevia S, Menant J. Exercise and Sports Science Australia (ESSA) position statement on exercise for people with mild to moderate multiple sclerosis. J of Sci and Med Sport. 2022 Feb 1;25(2):146-54.
* ↑ Latimer-Cheung AE, Pilutti LA, Hicks AL, Martin Ginis KA, Fenuta AM, MacKibbon KA, et al. 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 Rehabil. 2013 Sep;94(9):1800-28.e3.
* ↑ Exercise & Sports Science Australia. ESSA Find an Accredited Exercise Professional Search [Internet]. Australia: Exercise & Sports Science Australia; 2021 [cited 2022 Aug 28]. Available from: https://www.essa.org.au/find-aep
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