# Exercise as it relates to Disease/Effects of Physical activity on Multiple Sclerosis

This is an analysis of the journal article "Effects of a Short Physical Exercise Intervention on Patients with Multiple Sclerosis (MS)" by Kerling et. al. (2015)

## What is the background to this research?

Multiple Sclerosis (MS) is a disease of the central nervous system that interferes with the nerve impulses within the brain, spinal cord and optic nerves which effects each individual differently. Being one of the most common diseases of the central nervous system, there are over 23,00 people suffering from the disease in Australia and more than 2 million worldwide. Some of the most common symptoms include fatigue, pain and numbness, bladder and bowel issues, spasticity, vision problems, cognitive fog, changes in emotion, heat sensitivity and headache. While there is no cure for the disease, treatment options include medication to manage acute pain, spasticity, fatigue and bladder difficulties, maintaining physical activity levels and a healthy, well-balanced diet, partaking in physiotherapy to reduce muscle problems and counselling to treat depression or anxiety.
As fatigue is one of the most prevalent symptom in MS sufferers, physical activity has become the most effective method of treatment. Often physical activity prescribed to MS sufferers not only includes resistance training to improve muscular strength and endurance training to improve aerobic capacity, but also includes hydrotherapy, yoga and indirect exercise such as gardening, household chores and cooking. The study by Kerling et. al. investigates whether endurance training on its own or a combination of endurance and resistance training is more beneficial to those with MS.

## Where is the research from?

The study was devised and conducted primarily by Dr. Arno Kerling, a sports medicine doctor from the Hannover Medical School, along with a number of other sports medicine professionals from the Institute of Sports Medicine and the Department of Neurology from the Hannover Medical School, Germany. The study was supported by Sanofi Aventis, a pharmaceutical company, and the authors declared no conflict of interest within the study. The 60 patients who partook in the study were directly recruited from the MS Healthcare Centre of the Hannover Medical School by practising neurologists and through the newsletter of the local MS society. Those who participated in the study had to meet the criteria of being diagnosed with MS, adult age (18–65 years) and have mobility with a maximum value of 6 (ie. low to moderate disability) of the Expanded Disability Status Scale (EDSS).

## What kind of research was this?

This was a quantitative research study, involving the use of physical performance as an indicator of positive or negative effects.

## What did the research involve?

After an initial examination, the patients were randomised by age, sex, BMI,and EDSS into either a combined workout group (CWG) consisting of endurance and resistance training, or an endurance workout group (EWG), consisting of only endurance training. Prior to starting exercise and upon the completion of the training program after 3 months, patients completed a spiroergometry (indicative of cardiology and respiratory health), isokinetic (indicative of muscular strength) and neurological examinations as well as quality of life (QOL) and fatigue questionnaires. The training programs competed by the patients were supervised by a physician and consisted of two training sessions perk week, each of 40 minutes at moderate intensity. The training sessions were held at the Institute of Sports Medicine of the Hannover Medical School. An outline of each training program is outlined below:
| | Combined Program | Endurance Program |
| Phase 1 | 20 min cycle ergometer | 20 min cycle ergometer |
| Phase 2 | 2 sets of 10 - 15 reps of 6 of the 8 exercises: Leg press Hamstring curl Chest press Row Pull down Overhead press Abdominal Back extension | 20 min on choice of: Cross trainer Stepper Arm ergometer Treadmill Recumbent ergometer Rowing ergometer |
The study was approved by the ethics committee of the Hannover Medical School and all participants were informed about possible risks and submitted their written consents before commencing the study.

## What were the basic results?

Kerling et. al found that aerobic capacity was significantly higher in both group after training, however there was no significance between the two training groups. Additionally, there were no significant changes in maximum heart rate, nor were there differences between the two training types, as well as no significant changes in the EDSS in both groups. Isokinetic testing, measuring force of the knee and shoulder flexors and extensors, showed to have significantly increased for both the left and right hand side after completing the training program. once again, there were no significant differences in results between the two training groups. The completion of the QOL questionnaires at the end of the study showed significant improvements in the areas of general health perception, vitality, social functioning and mental health. Finally, using the Modified Fatigue Impact Scale (MFIS), it could be seen that both groups experienced a significant reduction in fatigue after completing the study.

## How did the researchers interpret the results?

Kerling et. al claim that their results suggest that in patients with MS, regular training for 80 min per week at a moderate intensity increases aerobic capacity and maximum force, regardless of the type of training. When analysing the results, the researchers had to take into consideration 23 of the original 60 participants dropped out of the study due to personal reasons or exacerbation of their MS symptoms.

## What are the limitations of this research?

One of the stand out limitations of this study is that there was no control group to obtain normative data from to compare training groups to upon completion of the study. Therefore, training specific effects can't be clearly differentiated from intervention-bound effects. Additionally, patients voluntarily nominated themselves for participation in the study and in effect would have more self-motivation to perform better and therefore show more improved results that may not be applicable to other patients with MS who may not have the same desire to improve their symptoms or interests in sports to maintain motivation. Factors that were shown to benefit from the training programs, such as quality of life and fatigue, were subjective measures. Being open to interpretation by the patient means that some of the results in this area could be misleading. Finally, despite the patients being randomly assigned the training method they would perform, the CWG had significantly better results in the isokinetic testing before stating the training programs. This in turn can also make the results appear misleading.

## What conclusions should be taken away from this research?

The researchers were able to conclude that regular training for 40 minutes twice a week at moderate intensity increases aerobic capacity and maximum force in patients with low to moderate MS, regardless of whether endurance or combination exercise is performed. They have also suggested that if resistance training is not possible for a patient, maximum force of the limbs can be enhanced with the aid of equipment such as a row ergometer, cross trainer or arm ergometer, as they target the upper and lower extremities. Additionally, Kerling et. al has surmised that training improves quality of life and reduces fatigue in MS patients. Similar studies have also shown that regular exercise enhances the aerobic capacity and maximum force in MS patients, and the benefits in quality of life and fatigue have also been echoed among health professionals.

## Practical Advice

This study provides a beneficial insight into what kind of training provides substantial improvements to those with MS. However, as with any medical advice, it should always be taken in consultation with your regular health professional. This study also shows how an exercise program is not only beneficial for a patients exercise capacity but also for their quality of life into their future.

## Additional readings

To find out more on Multiple Sclerosis and exercise, click on the links below:
* Multiple Sclerosis: an introduction
http://www.ms.org.au/attachments/documents/publications/multiple_sclerosis-an_introduction.aspx
* Canadian Physical Activity Guidelines for Adults with Multiple Sclerosis
http://www.csep.ca/CMFiles/Guidelines/specialpops/CSEP_MS_PAGuidelines_adults_en.pdf
* Multiple Sclerois and Exercise
http://www.webmd.com/multiple-sclerosis/guide/multiple-sclerosis-exercise
* Multiple sclerosis and physical exercise: recommendations for the application of resistance-, endurance- and combined training
http://msj.sagepub.com/content/14/1/35

## References

* 1 2 3 4 5 6 7 8 9 Kerling, A. et. al. (2015) 'Effects of a Short Physical Exercise Intervention on Patients with Multiple Sclerois (MS)'. International Journal of Molecular Science. 16 (7): 15761- 15775
* 1 2 3 4 5 Understanding MS [Internet]. Australia: Multiple Sclerosis Australia; 2012 [cited 2016 September 20]. Available from: http://www.ms.org.au/attachments/documents/publications/understanding_ms.aspx
* ↑ Managing fatigue for people living with MS [Internet]. Australia: Multiple Sclerosis Australia; 2011 August [cited 2016 September 20]. Available from: http://www.ms.org.au/attachments/managing_fatigue_for_people_living_with_ms_2011.aspx
* ↑ Sutherland, G; Anderson, M B. Exercise and multiple sclerosis: physiological, psychological and quality of life issues. Journal of Sports Medicine and Physical Fitness. 2001 December [cited 2016 September 20]; 41(4): 421-432
* ↑ Mostert, S; Kesselring, J. Effects of a short-term exercise training program on aerobic fitness, fatigue, health perception and activity level of subjects with multiple sclerosis. Multiple Sclerosis Journal. 2001 April [cited 2016 September 20]; 8(2): 161-168
* ↑ Dalgas, U; Stenager, E. Multiple sclerosis and physical exercise: recommendations for the application of resistance-, endurance- and combined training. Multiple Sclerosis Journal. 2008 January [cited 2016 September 20]; 14(1): 35-53