The Effects of Trunk Stabilization and Aerobic Trainings in Multiple Sclerosis

Study Overview
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Brief Summary
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Balance requires many central nervous system controlled functions, and most or all of these functions can be affected by MS, so balance is very often impaired in patients with MS. Core stability is also decreased in patients with MS. Core stability is among the most important factors that ensure the balance and walking of the participants in different environments and conditions during functional activities. In addition to core muscle activity, lower extremity muscle strength and endurance decrease due to the influence of central nervous system and decrease in physical activity. Functional exercise capacity also decreases due to the influence of the central nervous system and the decrease in physical activity in patients with MS. Despite all these symptoms and the benefits of exercise training, unfortunately, most MS patients are physically inactive, which can initiate a cycle of deconditioning and worsening of symptoms. In the literature, the combined effects of aerobic training and resistance training have been examined, and it has been stated that combining these two trainings will increase the effectiveness on symptoms. In recent years, trunk stabilization training has started to be included in physiotherapy and rehabilitation programs as an alternative method in patients with MS, based on the knowledge that core stability is effective on many functions and symptoms, as well as aerobic and resistance training. Considering that combined training practices are more effective in reducing symptoms, the investigators think that aerobic training and trunk stabilization training may be more effective in reducing symptoms in patients with MS when applied in combination. In addition, when all these studies were examined, the subtypes of MS patients included in the studies were generally not specified. The effects of these trainings on balance, core stability lower extremity muscle strength and endurance, and functional exercise capacity have not been demonstrated in patients with relapsing remitting MS (RR-MS), the most common type of MS disease. Therefore, the aim of this study is to examine the effects of trunk stabilization training combined with aerobic training on balance, core stability, lower extremity muscle strength and endurance, and functional exercise capacity in patients with RR-MS.

Detailed Description
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This study was carried out with the purpose of examining the effects of trunk stabilization training combined with aerobic training on balance, core stability, lower extremity muscle strength and endurance, and functional exercise capacity in patients with RR-MS. A total of 20 patients, 10 in each group, were included in the study. Both the combined exercise group and the control group performed 30 minutes of aerobic training. The combined exercise group also received trunk stabilization training after a 10-minute resting period. Both groups received treatment 2 times a week for 8 weeks (in total 16 sessions). The static and dynamic balance were measured using the posturography (Biodex Balance System SDTM) with Postural Stability Test and Limits of Stability Test. Core stability was assessed by core endurance tests using the McGill protocol. Core endurance tests used are flexion endurance test, extension endurance test, and right and left lateral bridge tests. The lower extremity muscle strength and endurance of the patients were determined by evaluating the strength and endurance of the knee flexor and extensor muscles at angular velocities of 60º/sec and 180º/sec. Evaluations were made using the Biodex System 4 (Biodex Corp, Shirley, NY, USA) isokinetic dynamometer. Functional exercise capacity was assessed using the 6-Minute Walking Test (6-MWT) according to criteria set by the American Thoracic Society.

Official Title
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The Effect of Trunk Stabilization Training Combined With Aerobic Training on Neuromuscular Parameters and Functional Exercise Capacity in Patients With Multiple Sclerosis

Conditions
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Physical Therapy

Intervention / Treatment
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* Other: Combined exercise training
* Other: Aerobic training


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: To be diagnosed with relapsing-remitting multiple sclerosis disease by a specialist physician Not having an MS attack in the last 3 months Having a disability level between 1 and 5 according to the Expanded Disability Status Scale Not being included in the physiotherapy and rehabilitation program in the last 3 months Exclusion Criteria: Using corticosteroids in the past 4 weeks Being pregnant Spinal deformities, spinal disc herniation or other spinal pathologies, orthopedic problems related to hip, knee, ankle

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Combined exercise group<br>Combined training consists of trunk stabilization training and aerobic training. | Other: Combined exercise training<br>* Combined exercise group (CEG) performed 30 minutes of aerobic training and also received trunk stabilization training in about 30 minutes after a 10-minute resting period. CEG received treatment 2 times a week for 8 weeks. During trunk stabilization training, the participants were taught how to contract the transversus abdominis and multifidus muscles. Due to the progression protocol, endurance levels of trunk muscles were increased by holding each posture for longer periods. The training was started with theraband resistance, which could be repeated between 10-12 repetitions, and the repetition time was increased up to 20. Aerobic training (AT) was given using a treadmill. A heart rate monitor (Polar V800™, Finland) was used by each patient to follow heart rates during the AT. During AT, the target heart rate was calculated as 60-80% of maximum heart rates (MHR). Each exercise session consisted of a 5-minutes warm-up, 20 minutes of walking, and 5 minutes cool down on the treadmill.<br>Other: Aerobic training<br>* Control group (CG) performed 30 minutes of aerobic training.CG received treatment 2 times a week for 8 weeks. Aerobic training (AT) was given using a treadmill. A heart rate monitor (Polar V800™, Finland) was used by each patient to follow their heart rates during the AT. During AT, the target heart rate was calculated as 60-80% of maximum heart rates (MHR). Each exercise session consisted of a 5-minutes warm-up, 20 minutes of walking, and 5 minutes cool down on the treadmill.<br>|
| Active Comparator: Control group<br>Aerobic training was given to the control group. | Other: Aerobic training<br>* Control group (CG) performed 30 minutes of aerobic training.CG received treatment 2 times a week for 8 weeks. Aerobic training (AT) was given using a treadmill. A heart rate monitor (Polar V800™, Finland) was used by each patient to follow their heart rates during the AT. During AT, the target heart rate was calculated as 60-80% of maximum heart rates (MHR). Each exercise session consisted of a 5-minutes warm-up, 20 minutes of walking, and 5 minutes cool down on the treadmill.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Static balance | Static balance was evaluated by Biodex Balance System SD™ (Biodex Medical Systems, Shirley, New York, USA). Postural Stability Test (PST) was used for static balance assessment of the participants. PST is assessed, while participants stand on both feet on the firm surface and with eyes open. In the start position, a dot is defined as a symbolic presentation of participants' center of feet pressure positioned in the center of the coordinate axes on the monitor screen. The participants targets on holding the dot at the center. PST provides overall postural stability index score. Lower scores indicated better performance. | 4 weeks | 
| Static balance | Static balance was evaluated by Biodex Balance System SD™ (Biodex Medical Systems, Shirley, New York, USA). Postural Stability Test (PST) was used for static balance assessment of the participants. PST is assessed, while participants stand on both feet on the firm surface and with eyes open. In the start position, a dot is defined as a symbolic presentation of participants' center of feet pressure positioned in the center of the coordinate axes on the monitor screen. The participants targets on holding the dot at the center. PST provides anterior-posterior postural stability index score. Lower scores indicated better performance. | 4 weeks | 
| Static balance | Static balance was evaluated by Biodex Balance System SD™ (Biodex Medical Systems, Shirley, New York, USA). Postural Stability Test (PST) was used for static balance assessment of the participants. PST is assessed, while participants stand on both feet on the firm surface and with eyes open. In the start position, a dot is defined as a symbolic presentation of participants' center of feet pressure positioned in the center of the coordinate axes on the monitor screen. The participants targets on holding the dot at the center. PST provides medial-lateral postural stability index scores. Lower scores indicated better performance. | 4 weeks | 
| Dynamic balance | Dynamic balance was evaluated by Biodex Balance System SD™ (Biodex Medical Systems, Shirley, New York, USA). Limits of Stability (LOS) Test was used for dynamic balance assessment of the participants. LOS Test consists of standing on the platform and leaning in eight directions to make a cursor displayed on the system's screen hit a target. LOS Test provides overall direction control score. Higher scores indicated better performance | 4 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Lower extremity muscle strength | The lower extremity muscle strength of the participants were determined by evaluating the strength of the knee flexor and extensor muscles at angular velocities of 60º/second and 180º/second. Evaluations were made using the Biodex System 4 (Biodex Corp, Shirley, NY, USA) isokinetic instrument. The tests were repeated on both the dominant and nondominant sides. As a result of the evaluations, peak torque value was obtained at angular velocities of 60º/second and 180º/second. | 4 weeks | 
| Lower extremity muscle strength | The lower extremity muscle strength of the participants were determined by evaluating the strength of the knee flexor and extensor muscles at angular velocities of 60º/second and 180º/second. Evaluations were made using the Biodex System 4 (Biodex Corp, Shirley, NY, USA) isokinetic instrument. The tests were repeated on both the dominant and nondominant sides. As a result of the evaluations, peak torque/body weight value was obtained at angular velocities of 60º/second and 180º/second. | 4 weeks | 
| Lower extremity muscle endurance | The lower extremity muscle endurance of the participants were determined by evaluating the endurance of the knee flexor and extensor muscles at angular velocities of 60º/second and 180º/second. Evaluations were made using the Biodex System 4 (Biodex Corp, Shirley, NY, USA) isokinetic instrument. The tests were repeated on both the dominant and nondominant sides. As a result of the evaluations, peak torque value was obtained at angular velocities of 60º/second and 180º/second. | 4 weeks | 
| Lower extremity muscle endurance | The lower extremity muscle endurance of the participants were determined by evaluating the endurance of the knee flexor and extensor muscles at angular velocities of 60º/second and 180º/second. Evaluations were made using the Biodex System 4 (Biodex Corp, Shirley, NY, USA) isokinetic instrument. The tests were repeated on both the dominant and nondominant sides. As a result of the evaluations, peak torque/body weight value was obtained at angular velocities of 60º/second and 180º/second. | 4 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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exercise, balance, strength, endurance, stability