Exercise for Managing the Symptoms of Multiple Sclerosis

Can an exercise program help this patient?

Mr White is a 61-year-old man diagnosed by a neurologist with relapsing-remitting MS at the age of 48 years. Mr White's neurologist provided a medical release for him to participate in a 12-week exercise program with no restrictions on intensity or type of activity. However, the neurologist did recommend supervision during exercise because of balance deficits noted on neurologic examination and a history of falls. On initial contact, Mr White indicated that he enjoys walking and playing golf with the use of a cart. Mr White's goals for participating in the exercise program were to improve his lower-extremity strength and balance.

Prior to the exercise program, Mr White was independent with all basic and instrumental ADL, but he indicated that, at times, fatigue limited his ability to fully participate in desired social activities. Mr White reported 2 falls in the previous 3 months and problems with short-term memory and clarity of speech. He ambulated without an assistive device and had no other musculoskeletal or cardiovascular comorbidities. Several outcome measures were completed upon initial assessment, including the Activities-specific Balance Confidence (ABC) Scale, the Timed “Up & Go” Test (TUG), single-leg stance time, and the Balance Evaluation Systems Test (BESTest). The results of Mr White's assessment are presented in Table 2.

How did the clinician apply the results of the Cochrane review to Mr White?

The physical therapist considered whether Mr White would be a good candidate for participation in a supervised exercise program. Using the PICO (Patient, Intervention, Comparison, Outcome) format, the clinician asked the question: Will an independently ambulatory 61-year-old man with relapse-remitting MS benefit from a supervised exercise program (compared with no exercise program) for improving balance and strength? The clinician determined that the information provided in the systematic review by Rietberg et al²⁰ is relevant and applicable for this patient. Although Mr White is slightly older than the participants involved in the reviewed research studies, his diagnosis of relapsing-remitting MS approximately 13 years earlier and his Expanded Disability Status Scale (EDSS) score of 4.5 are similar to the findings for the research participants. Based on these demographics, the medical referral, and Mr White's previous and routine participation in walking for exercise, the clinician deemed it would be appropriate and tolerable for him to engage in a supervised exercise program.

From an appraisal of the systematic review, the clinician developed an exercise program commensurate with the outlined recommendations. The findings support a multifaceted intervention of exercise 2 to 3 times per week for 30 to 60 minutes per session, as well as the inclusion of both aerobic and strengthening exercises with focused outcomes on balance and strength. As such, Mr White was enrolled in an exercise program consisting of 2 sessions per week for 60 minutes each for 12 weeks. Each session included 5 minutes of warm-up on a stationary recumbent bike, 10 minutes of specific stretching exercises, and the remaining time focused on balance activities and specific muscle group strengthening exercises. Strengthening included calf raises, lunges, wall squats, and core strengthening exercises, such as pelvic lifts. Mr White began with 1 set of 6 to 8 repetitions and progressed to 2 sets of 8 to 10 repetitions, depending on the specific exercise. His balance was challenged by standing with various bases of support, on and off different support surfaces (eg, foam), and with eyes open and eyes closed. In addition, dynamic balance exercises such as standing and reaching to various positions through the limits of stability were included in the intervention. All exercises, weights, and repetitions were monitored and recorded throughout the 12 weeks.

How well do the outcomes of the intervention provided Mr White match those suggested by the systematic review?

Mr White attended all but 1 session during the 12-week intervention. His exercise log revealed increased strength as noted by an increase in weight lifted and total repetitions completed during the strength portion of his exercise program. Postintervention results showed differential benefits (Tab. 2). None of the findings showed a clinically detectable change in Mr White's balance ability, but there also was no significant decline over the course of the 12-week intervention.^36,38 Mr White's ABC Scale score increased from 77.5 to 88 out of 100. This increase indicates a noticeable increase in his balance confidence, which has been shown to lower fall risk.^4,39 Mr White did not report a fall during the 12 weeks of the intervention. Although the intervention program did not specifically address aerobic training, Mr White increased his walking to 2 miles (3.2 km) per day and continued playing golf, although this activity may not have been of sufficient intensity to affect physiological changes in cardiovascular health.

Given these results, Mr White met his goals of increased strength; however, he did not meet his goal to improve balance, as measured by the standardized assessments. These findings are not surprising given the short duration of the intervention and the multidimensional and complex nature of balance impairment.

Subsequent to the intervention, Mr White joined an on-going individualized exercise program for people with MS. Thus, we were able to track his progress for another 1.5 years after the specific intervention reported here. Although there was no formal evaluation of Mr White's balance or mobility after 1.5 years of regular participation, he self-reported walking 2 or more miles each morning and playing golf regularly. He indicated that this self-selected distance was a strategy to proactively manage disease-related fatigue and ensure that he could meet the functional demands and energy requirements of the remainder of his day. His EDSS score has remained stable. These results, as well as Mr White's anecdotal reports of increased mood, lifestyle change to include willingness to participate in activity, and continued balance confidence, are significant when taken in the context of the variable and progressive nature of MS.

Can you apply the results of the systematic review to your patients?

The findings of the Cochrane Review by Rietberg et al²⁰ apply to patients with all types of MS with EDSS scores of 1 to 6.5 who are not experiencing an exacerbation of symptoms. Given that details about the study participants' individual disease progression were unknown and the systematic review did not cite any deleterious effects of exercise, patients with medical clearance to exercise should be able to participate in an exercise program.

What can be advised based on the results of this systematic review?

Patients with MS who are ambulatory and have mild to moderate disability can tolerate exercise and are likely to benefit from a supervised exercise program that includes aerobic, balance, and strengthening exercises applied in an individual or group setting. Exercise has the potential to increase strength, mobility-related ADL, and mood in people with MS if offered for 30 to 60 minutes, 2 to 3 times per week, for a duration of 8 to 12 weeks. The systematic review did not provide any evidence indicating that regular exercise decreases fatigue or perception of disability in people with MS. The conclusions offered by the systematic review are limited by the small number of high-quality RCTs and their low sample sizes. Additionally, the authors acknowledged the great variety of outcome measures used across the studies and emphasized the need for consensus regarding a uniform, core set of outcome measures that examine exercise dose and magnitude of effect to determine optimal benefit from different exercise regimens with this population.

However, for patients like Mr White, the existing evidence supports the benefit of regular exercise to improve strength, mobility, and mood. Based on the ICF model of disability, the dynamic interplay of body function and structure with activity and participation determine a person's health-related quality of life. Through continued strengthening and balance training after the intervention program, Mr White continued participation in community, social, and recreational activities, such as golf, and maintained his quality of life beyond the 12-week program.