Exercise as it relates to Disease/Improving the quality of life in multiple sclerosis sufferers with exercise

Multiple Sclerosis (MS) is an immune-mediated inflammatory disease of the central nervous system (CNS). Patchy demyelination and infiltration of mononuclear cells in the CNS are characteristics of MS. This disease makes carrying out simple daily activities such as walking and carrying things very difficult. The Expanded Disability Status Scale (EDSS) rates how much a person is effected by disability between 0 (normal) to 10 (death due to MS). The lower portion is obligatorily defined by Functional System (FS) grades. The FS are Pyramidal, Cerebellar, Brain Stem, Sensory, Bowel & Bladder, Visual, Cerebral, and Other; the Sensory and Bowel & Bladder Systems have been revised. A link to the EDSS can be found here [1]

Symptoms of MS

[2]:

What's Affected	How it's Affected
Bladder and Bowel	Frequency and incontinence resulting in a loss of hygiene and ability for social interaction. Problems occur in 70-80% of people with MS. Impairments are due to gut motility or an impairment in the neurology of deification.
Cognitive	Defects in memory, attention span, processing speed, visual-spacial abilities and executive function. Severe impairment is a major predictor of low QOL. Impairments present at the start of the onset of the disease, occurring in 40-60% of patients with MS.
Emotional	Effect due to damage to certain areas of CNS that generate and control emotion. Clinical depression is the most common type of depression. Anger, anxiety, frustration and hopelessness appear frequently, also suicide.
Fatigue	Disturbed sleep, chronic pain, poor nutrition, or even some medications contribute to fatigue. When depression is reduced, fatigue is typically reduced too.
Mobility Restrictions	Restrictions in mobility (walking, transfers, bed mobility etc.) are common in individuals suffering from ms. Impairments act on balance, function and mobility. Within 10 years after the onset of MS one-third of patients reach a score of 6 on the EDSS, requiring a unilateral walking aid. Typical impairments are fatigue, weakness, low exercise tolerance, hypertonicity and impaired balance.
Pain	Affects 63% of people with MS, not one certain group affected more than others (i.e. males or females, high EDSS or low). Pain can be severe and debilitating, having a large effect on QOL and mental health. Most common pain: head aches, dysesthetic limbs, back pain and painful spasms.
Spasticity	Increased stiffness, slowness of limb movement, the development of certain postures, an association with weakness of voluntary muscle power, and with involuntary and sometimes painful spasms of limbs.
Speech	Slurred speech, low tone of voice, decreased talking speed and articulation problems.
Transverse Myelitis [3]	Numbness, weakness, bowel/bladder dysfunction and/or loss of muscle function, typically in the lower half of the body as a result of MS attacking the spinal cord.
Tremor and ataxia	Tremor [4]-Muscle movement consisting of to-and-fro movement (oscillation) of one or more body parts. Ataxia [5] is unsteady and clumsy motion of the limbs or torso due to a failure of the gross coordination of muscle movements.

Aerobic Exercise

The effects of a four week aerobic training program on sufferers of MS was studied, focusing on aerobic fitness, fatigue, health perception and activity level. Participants complete a 30 minute cycle, five times a week for the duration of the study. MS patients showed a 13% increase in their VO2 max, and an 11% increase in their work rate. In their own health perception, there was a 46% increase in vitality and a 36% increase in social interaction. The MS patients also said they experienced less fatigue in their day to day life.

A similar study agrees that aerobic training will improve the quality of life of MS sufferers. A 15 week program consisting of three, 40 minute sessions per week of arm and leg ergonometric exercises was undertaken. MS sufferers doing the exercise program showed significant increase in their VO2 max and also their upper and lower extremity strength. Although disability status didn’t change, bowel and bladder function improved. In the first 10 weeks, fatigue, anger and depression levels decreased. It was also noted that skinfold, triglycerides and very low density lipoproteins (VLDL) decreased. All these factors contributed to an overall increase in QOL, allowing the participants increased social interaction, emotional behavior and home management.

A six month aerobic training program has been shown to have minimal effect on the walking gait abnormalities. Whilst there was an increase in hip range of movement (ROM), total knee extension and flexion range decreased. This study also showed a decrease in walking velocity, cadence and ground generation.

Resistance Exercise

An eight week lower body resistance training program has been shown to improve walking and the functional ability of people suffering from MS. This was done looking at the subjects gait kinematics. The study noticed that following the programs, the gait characteristics of the subjects resembled the gait characteristics of non-sufferers much more closely. The study also showed that not only did isometric strength increase, but also fatigue and self reported disability decreased. The subjects also noted that taking part in the study allowed them to once again take part in activities such as shopping and hiking again. This study had a 100% completion rate by the subjects, suggesting that resistance training is well tolerated by MS patients.

A three month resistance exercise program was used in a study to investigate whether postural disturbances experienced by MS suffers can be limited with resistance exercise. The study was comparing subjects affected by MS and a healthy population, it found significant differences in the two groups before the training, but minimal differences between the two groups after the exercise intervention. The exercise program included a range of exercises to stimulate upper and lower extremities and core strength, using stationary machines, Swiss balls and balance boards.

Recommendations

There is conclusive evidence to suggest that aerobic training and resistance-training programs are effective in increasing the QOL in MS sufferers. These forms have been proved to show improvement in the physical capacity of MS sufferers and also the psychological well being, whilst also decreasing fatigue. Yoga is not an effective method of improving QOL in those affected by MS, physically it doesn’t improve the person, it has minor psychological advantages. Garret et al. compared a yoga program and a Fitness Trainer lead program over 10 weeks, showed yoga didn't improve the Multiple Sclerosis Impact Scale (MSIS) or the 6 Minute Walk Test (6MWT) [6] , where as the fitness trainer group did. People with mild MS should dedicate time to exercise aerobically and with resistance aspects, depending on how MS is affecting the patient.

In future, more research need to be done involving subjects with more server MS. Understandably, adherence in these studies may be low do to the severity of the disease and how limited their functioning is to complete required tasks, but investigation needs to be undertaken in how to improve the QOL of severe MS patients. It is positive that the studies had good adherence indicating that exercise is well tolerated by MS patients and should be encouraged. Perhaps encouraging supervised aquatic fitness programs due to their low impact on the body. These have been show to increase both up and lower extremity strength, and also work values.