# Exercise as it relates to Disease/Effectiveness of exercise Interventions in clients with Multiple Sclerosis
### Multiple sclerosis and the effectiveness of exercise interventions

Multiple sclerosis (MS) is an autoimmune degenerative disease that effects more than two million people around the world. MS attacks the central nervous system; particularly its two main components, the spinal cord and the brain. Nerve fibers in the central nervous system are covered in fatty tissue known as myelin. In a person with MS, myelin is lost in many areas causing scar tissue named sclerosis. The symptoms of MS are likely to include fatigue, motor weakness, reduced mobility, abnormal gait and poor balance. These symptoms decrease the physical functional capacity of the individual and tend to result in a sedentary lifestyle. As a result of this predominately sedentary lifestyle patients experience a decrease in exercise capacity which ultimately results in skeletal muscle adaptations. The treatment of MS is therapeutically confined to symptom management, with no pharmaceutical cure as yet known. Contemporary research has shown that physical exercise interventions in MS clients decrease fatigue, improve fitness, quality of life (QOL), walking endurance and speed. The optimal approach to maximise the benefit to clients is the subject of ongoing research.

## Methodology of the current research
### Where was the research conducted

The research was conducted at the Hannover Medical School, Hannover, Germany. The participants were recruited from the MS healthcare center of the Hannover Medical School by practicing neurologists and through a local MS newsletter. Participants were eligible to be included in the study if diagnosed with MS, between the ages of 18–65 years and mobility levels that scored between 0-6 with a maximum disability ranking of 6 on the Expanded Disability Status Scale (EDSS) indicating low to moderate mobility impairment.

### What kind of research was conducted

The research conducted was a randomized controlled trial, the purpose of which was to examine if a short term endurance or a combined resistance/endurance exercise intervention was optimal to improve aerobic capacity and maximal force of adult clients diagnosed with low to moderate (disability) multiple sclerosis.

### What did the research involve

The participants (44 females, 16 males) were randomized into either the combined workout group (CWG) or the endurance workout group (EWG) after an initial assessment of their age, gender, Body Mass Index (BMI) and EDSS ranking. Baseline examinations of spiroegometry, isokinetics, neurology and QOL questionaries were completed prior to and at the completion of the three month intervention. All participants performed an exercise program consisting of two training sessions per week for a duration of 40 minutes each at a moderate intensity. The CWG performed a combined resistance/endurance program (20 minutes on a bicycle ergometer, 20 minutes of resistance training), whilst the EWG performed 40 minutes of endurance training. Workload was expressed as watts, aerobic capacity was measured as peak oxygen capacity (Vo2 Max) and ventilator anaerobic threshold (W). Isokinetic testing measured maximal force of the knee and shoulder flexors and extensors. The Sf-36 questionnaire was used to assess QOL and fatigue was measured using the Modified Fatigue Impact Scale.

## What were the results
### Results in layman terms

The research showed that either exercise intervention improved the participant’s aerobic capacity, maximal force, QOL and decreased their self-reported fatigue levels.

### How did the researchers interpret the results

The initial group of 60 participants was reduced to 37 by the completion of the study due to personal reasons (18) and an exacerbation of their MS symptoms (5), 23 participants or 38% of the original sample size were excluded from the final results. Overall 24/26 exercise sessions or 90% on average were completed by the remaining participants. The EWG and CWG were comparable in age, gender, BMI and EDSS ranking, furthermore there was no significant difference in baseline measures of load (W), Vo2 max (mL/min/kgbw) and Ventilator Anaerobic Threshold (W). Both groups showed a significant reduction in fatigue scores and significantly better scores on the QOL questionnaire at the completion of the study. Aerobic capacity improved significantly in both groups however there was no statistically significant variance between the EWG or CWG conditions. Isokenetics showed significant improvements across both groups after the training period, however there was no significant difference between the groups. .

## Conclusions
### Conclusions from the current research

The results from the current research indicate that a short exercise intervention of 80 minutes per week when performed at a moderate intensity will increase aerobic capacity and maximal force in MS patients with a mild to moderate level of disability. These improvements occur independent of the type of intervention utilized. The research supports the activity guidelines that a combined aerobic and resistance exercise program is preferable for all individuals, specifically in the case of MS patients however an endurance based intervention is a viable alternative in the absence of resistance training. Endurance machines that specifically target the upper and lower limb extremities will increase maximal force in the extremities when resistance training is not possible.

### Practical implications of the research

MS clients have significant deficits in various areas of the physiological profile ideally requiring a multidisciplinary rehabilitation intervention for optimal treatment, exercise intervention is an essential part of the treatment process. Demyelination of motor and sensory tracts within the CNS leads to a loss of balance and coordination, clients experience significant activity limitation as a result. Muscle adaptations associated with a sedentary lifestyle occur as a result of decreased physical activity for the client. These adaptations contribute to a reduction in overall functional capacity and are associated with not only primary but secondary health risks such as type two diabetes, cardiovascular disease and stroke. MS clients are susceptible to an increased level of risk when undertaking any exercise based intervention, trouble balancing, a tendency to overheat and level of spasticity all may contribute to the individual’s inability to perform resistance training in line with standardized activity guidelines. With this in mind the current research showed that an endurance based intervention with low impact movements could increase exercise capacity and maximal force offering an alternative to clients diagnosed with MS. The benefits of low to moderate intensity aerobic exercise are well established throughout contemporary research. An increase of exercise capacity and a progression away from a sedentary lifestyle will have primary and secondary health benefits for the client and this research highlights a functional alternative for clients diagnosed with MS.

### Limitations and future research

The research presented limitations such as a relatively small sample size and a high rate of attrition amongst participants. The absence of a control group and only incorporating two treatment conditions made training specific effects difficult to differentiate from intervention based effects. Participation in the study was also self-motivated, making extrapolation to all MS clients problematic as it could be assumed that individuals with greater motivation and an inclination towards activity would exhibit a greater capacity for physical activity independent of any intervention. Improvements in QOL self-report measures may also be accounted for through social engagement or group effects as opposed to an exercise intervention. In furthering the study of MS interventions research is welcomed to further explore these limitations and the effect separately for relapsing-remitting and progressive MS as limited research is available. Individual differences and various mitigating factors affecting the client whilst accounted for to the greatest extent possible can always effect the outcome of an intervention, as such any outcome needs to reflect the contributing environmental factors that may impact on the results. The ever increasing prevalence of MS and the lack of a pharmacological cure, leads us to symptom management to maintain the QOL of the clients. Collaborative research, standardized measures and a broader understanding of the impacts of exercise on MS will all lead to improvements in techniques and ultimately, in increased benefits to the client.

## Further reading

MS Australia
Healthdirect
MS Research Australia
Recovery-Program & Exercise
Multiple-sclerosis & Exercise

## References

* 1 2 3 4 5 6 7 8 9 <Kerling, A., Keweloh, K., Tegtbur, U., Kück, M., Grams, L., Horstmann, H., & Windhagen, A. (2015). Effects of a Short Physical Exercise Intervention on Patients with Multiple Sclerosis (MS). International Journal of Molecular Sciences, 16(7), 15761–15775. doi:10.3390/ijms160715761>
* 1 2 3 Horton, S., MacDonald, D.J., Erickson, K. (2010). MS, Exercise, and the potential for older adults. European Group for Research into Elderly and Physical Activity, (7), 49-57. Doi: 10.1007/s11556-010-0062-9
* 1 2 3 Detters,C. Sulzmann, M. Ruchay-Plossl, A. Gutler, R.. Vieten, M. (2009). Endurance exercise improves walking distance in MS patients with fatigue. ACTA Neurologica Scandanavia, 120, 251-257. Doi: 1-.1111/j.1600-0404.2008.01151.x
* 1 2 3 Dalgas, U., Stenager, E., Ingemann-Hansen, T. (2008). Multiple Sclerosis and Physical Exercise: Recommendations for the Application of Resistance-, Endurance- and Combined Training. Multiple Sclerosis, 14(1), 35-53. Doi:10.1177/1352458507079445