Rehabilitation & Exercise in the Treatment of MS
Barbara Giesser, MD
Clinical Director, UCLA MS Program
Multiple sclerosis (MS) is a disease that invariably affects ambulation and mobility in the majority of patients. The ability to move may be affected by many impairments, including weakness, imbalance, fatigue, spasticity and cognitive impairment. Standard physical therapy and other rehabilitative techniques may improve function in these areas to some extent, but are not always successful. A newer therapeutic approach to the treatment of these impairments is exercise. This article will provide a brief review of the effectiveness of rehabilitation and exercise in improving mobility in persons with MS.
The goals of rehabilitation for persons with MS are to improve function, and prevent complications. In the International Classification of Impairments, Activities and Participation, (ICIDH-2),impairment refers to structural injury or dysfunction of a body part or system caused by disease or trauma, activities ( formerly disability) refers to the individual’s ability to perform everyday tasks or activities, and participation (formerly handicap) denotes the individual’s role in a societal context. In persons with MS, there are not yet proven modalities to prevent impairment and rehabilitation strategies cannot reverse impairment; rehabilitation aims to improve the ability to perform activities and maximize participation. Additionally, in persons with progressive MS, successful rehabilitation means that the person’s level of function remains constant, rather than deteriorating.
Rehabilitation for persons with MS is most commonly delivered after an acute relapse, in an in-patient or out-patient setting. Several studies have demonstrated benefit of rehabilitation therapy in patients with relapsing remitting MS in both inpatient and out- patient settings ,( La Rocca, et al,1992, Aisen, et al1996, Liu et al 2003). Positive outcomes have included improvement in disability , and handicap and reduction in severity of certain symptoms, such as fatigue.
On going rehabilitation for patients with progressive MS is less commonly accessed, due to factors such as insurance barriers, or the belief that patients with chronic deficits are unlikely to benefit from therapy. However, studies of rehabilitation intervention in patients with long standing progressive MS have indicated that these patients can benefit from such intervention, as assessed by improvement in indices of functional mobility, fatigue, social interaction and quality of life. An early study reported that 60% of patients with progressive MS who were admitted for acute rehabilitation showed improvement in ambulation and stair climbing at discharge compared to admission (Greenspun et al,1987). In a subsequent study, patients with progressive MS admitted for a 3 week in-patient rehabilitation program showed improvement in indices of disability, handicap and quality of life compared to a wait listed control group, and these improvements persisted for 7 to 10 months (Freeman, et al,1999). Patti et al demonstrated that MS patients with primary and secondary progressive disease of mean duration 17 years showed improvement on a standard index of motor function (FIM) after a 6 week outpatient rehabilitation program, compared to a non- treated control group matched for age, duration of disease and disability.. A trial of outpatient maintenance therapy in patients with progressive MS demonstrated reduced symptom frequency over 1 year in patients receiving the intervention compared to a wait listed control group (Difabio et al,1998). Significant improvements in mobility in patients with chronic MS were demonstrated in a cross- over protocol, with similar benefits seen in both in-patient and out –patient settings. (Wiles et al,2001). Thus, patients with progressive MS can and do benefit from rehabilitative intervention in both in-patient and out-patient venues, and long term benefits have been demonstrated.
Can Persons with Multiple Sclerosis Tolerate Exercise?
Until recently, there was concern that persons with MS might not be able to tolerate aerobic exercise regimens, primarily because of their susceptibility to heat-related worsening of symptoms and neurological impairment. There are now evidence-based data that not only can persons with MS tolerate standard aerobic exercise, but also that they can benefit from it. Most studies of the benefits of rehabilitation in persons with MS have focused primarily on functional outcomes. In contrast, the studies of exercise in the MS population have addressed more specific questions. These include the effects of exercise in ameliorating specific deficits such as muscle weakness, fatigue, improvement in fitness parameters, mood, and quality of life. Studies indicate that persons with MS can show improvement in all of these areas using a variety of training and exercise protocols.
In 1996, the seminal study of Petajan et al. conducted a randomized controlled trial of aerobic exercise in patients with moderately severe MS. The treatment group participated in 15 weeks of supervised aerobic training. Compared with the non-treated control group, they exhibited significant improvements in muscle strength, aerobic capacity, serum lipid profile, bladder and bowel function, and quality of life.
Studies that have examined the effects of exercise and resistance training on improving muscle strength in persons with MS include a study which used a progressive resistance-training regimen and demonstrated improved muscle strength in the upper and lower extremities(Kraft et al, 1996). It was reported that an eight- week progressive lower limb resistance-training protocol improved leg strength and stepping ability(White et al, 2004). A protocol using lower body resistance training in a home-based design found that leg extensor power increased, but there was no change in balance or overall mobility (De Bolt et al. 2004). It was initially reported that six-month aerobic-training regimen had little effect on gait parameters in patients with MS(Rodgers et al.1999).
However, a more recent study examined the effects of a six month exercise training program in persons with mild to moderate MSand found significant improvements in muscle strength and walking speed compared with a control group(Romberg et al. 2004). It was demonstrated that aerobic training on an exer-cycle for three sessions/week for eight weeks improved walking distance and speed, as well as fitness parameters in patients with mild to moderate MS(Rampello et al,2007).
In MS patients with moderate disability, functional improvement as measured on the Guy’s Neurological Disability Scale (GNDS) was demonstrated after a 12-week aerobic exercise program ( Kileff and Ashburn 2005). Importantly, none of these studies found any adverse effects of any of the training regimens, i.e. there were no increases in symptoms of deterioration in usual level of function. A four-week study of aerobic training in persons with MS showed benefit in fitness and fatigue parameters, with only a 6% incidence of symptom exacerbation(Mostert et al 2002).
A meta review of 22 studies which employed differentaerobic and non- aerobic exercise interventions on ambulatory mobility in persons with MS reported a modest but definite of exercise (mean effect size=0.19 Snook &Motl) in improving ambulation.
To date, definitive parameters for optimal exercise regimens for person with MS have not been established.. Recent review articles have suggested that an appropriate regimen might consist of training sessions of up to 30 minutes/session of supervised aerobic or aerobic plus endurance exercise, at 60-80% of maximal heart rate, up to 3X/week with 24-28 hrs in between sessions, and rest periods as needed.(Dalgas, Heesen). For resistance exercises, the authors suggest 8-15 repetitions for 1-3 sets initially, with a goal of 3-4 sets. Training should last at least 12 weeks.
A newer modality which combines principles of training, task specificity and aerobicity is locomotor training. Patients are suspended over a treadmill, and their legs are moved in patterns simulating ambulation. This may be accomplished manually or with a robotic device,e.g. the “lokomat” ( Hocoma) Weight bearing, sensory cues and muscle activity consistent with ambulation are used to provide input to spinal neurons involved in ambulation. Studies have demonstrated that locomotor training improves walking parameters in persons with MS(Giesser et al 2007, Lo et al, 2008, Beer, et al 2008,), although it is not clear that this modality is superior to standard physical therapy or simply walking on a treadmill.
Finally, data are beginning to accumulate that suggest that exercise may have neuroprotective effects in the animal model of MS ( EAE),as well as in other disease states. Numerous reports have shown that exercise induces growth factors such as BDNF in the brain and that these mechanisms are responsible for its protective effects in animal models (see Cotman et al., 2007 for a detailed discussion of the molecular processes). At present, BDNF, IGF-1 and vascular endothelial-derived growth factor (VEGF) are the principal growth factors thought to mediate the effects of exercise on the brain. In addition to increasing potential neuroprotective factors, it has been suggested that long-term exercise may have anti-inflammatory effect (Pedersen & Pedersen, 2006), which would also be of interest in MS. At least one study has reported beneficial effects of exercise in the animal model of MS, Experimental Allergic Encephalomyelitis (Le Page et al). Studies also suggest that exercise may have beneficial effects on memory and cognition. This work has been done with healthy older adults, persons at risk for cognitive impairment , and Alzheimer’s. Our group has received a grant from the NMSS to investigate the effects of exercise in cognition in persons with MS in a currently on going study. This is an exciting area that warrants further investigation.
In summary, standard rehabilitation therapies improve and maintain function in persons with MS, both acutely and chronically, when delivered in either in-patient or out-patient settings. Exercise modalities, including resistance training, aerobic protocols, and locomotor training can improve some impairments as well as function. The most recent information suggests that exercise may have neuroprotective properties as well. Clearly, both rehabilitation and exercise are important components of the comprehensive and optimal management of person with MS.
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