Exercise and Multiple Sclerosis

1. Exercise and Multiple Sclerosis

3. Introduction

4. Epidemiology 350,000-400,000 people in US 1 in 750 1 in 40 if a parent has MS High incidence in young adults (20-50) 2.5 times higher in women 74% have a life expectancy of at least 25 yrs after diagnosis Of that 74%, 66% are still ambulatory at the 25 year mark.

5. Pathophysiology Autoimmune disease Destruction of myelin, oliogodendrocytes, and axons Inflammatory cells move into the brain Activation of natural killer cells attack myelin

6. Regenerated myelin is thinner with wider Nodes of Ranvier; slower conduction Myelin is lost and replaced with scare tissue called sclerosis Sometimes the neuron is damaged or broken Pathophysiology

7. Pathophysiology Antigen stimulates an immune response A disruption in the balance between pro-inflammatory T helper 1 cells and anti-inflammatory Th2 cytokines with a shift to Th1. Attack on myelin and myelin generating cells (oliogodendrocytes)

8. Pathophysiology The cause of MS is unknown Genetic, infectious, environmental and/or autoimmune factors Most researchers believe the damage to the myelin results from an abnormal response by the body�s immune system Possible triggers: viruses, trauma, and heavy metals (e.g. mercury, lead, or manganese)

9. Researchers Find New Link Between Epstein-Barr Virus and MS April 12, 2006 � Investigators report that individuals who showed signs of significant exposure to the Epstein-Barr virus, which causes several disorders including infectious mononucleosis, were twice as likely to develop multiple sclerosis up to 20 years later. The study, funded in part by a pilot research grant from the National MS Society, adds to previous evidence linking the virus to the risk of developing MS, but does not prove that EBV actually causes MS. The study, by Drs. Gerald N. DeLorenze (Kaiser Permanente Division of Research), Alberto Ascherio (Harvard School of Public Health) and colleagues, was published online April 10 in the Archives of Neurology. �

10. Pathophysiology Require greater neural drive to obtain a give force production Muscle fatigue CNS Peripheral (deconditioning) Decrease functional capacity and daily activity Increase in risk for heart disease, diabetes, etc.

11. Disease Pattern* Relapsing-remitting Primary progressive Secondary progressive Progressive relapsing

12. Physical symptoms

13. Physical symptoms Ataxia, muscular weakness, general fatigue, spasticity, sensory disturbances, hypersensitivity to both internal and external temperature increases

15. Physical symptoms Decrease speed, strength, endurance and cardiorespiratory fitness. Exercise prescription goal is to minimize their disability Wide variation in physical capacity necessitates testing strength, flexibility, and CV endurance.

16. Fatigue Fatigue unrelated to physical activity 65% affected; 40% report it as the most disabling factor of MS General malaise, tiredness, lassitude, fatigue without exercise Wide range of general (systemic) fatigue among MS patients Cognitive fatigue in some

17. Fatigue Possible causes CNS Systemic Immune Heat Pharmacological treatments

18. Muscle Weakness Decrease isometric, isotonic, and isokinetic strength Slower tension development Mechanisms ? MU firing ? MU recruitment ? Conduction time Muscle atrophy ? Aerobic capacity ? Anaerobic metab. Inactivity

19. Depression

20. Spastic Paresis Exaggerated reflexes, resistance to stretch (spastic), and muscle weakness (paresis) Aggravated by increase in body temperature

21. Poor Balance/Fall Risk Risk of fractures is 2-3.4 times higher. Muscle weakness, Impaired visual, somatosensory and vestibular input. Poor judgement from cognitive deficits Awareness of risk further decreases physical activity

22. Respiratory Ventilatory muscle weakness particular expiratory muscles Ineffective cough leading to increase in respiratory diseases Ventilatory muscle specific training and general aerobic training

23. Elimination Dysfunction Bladder control problems 80% of MS patients Less storage Less emptying Greater risk of urinary tract infections Bowel dysfunction 60% of MS patients Constipation All can lead to exercise anxiety

24. Secondary Diseases Heart disease Obesity Diabetes etc

25. Medical Treatment

26. Medical Management Disease Modifying Drugs Decrease frequency and severity of relapses Decrease brain lesion development Comorbidity drugs Depression, fatigue, bowel and bladder function, etc. Secondary diseases (pulmonary and/or heart) Rehabilitation for spastic paresis

27. Exercise Exercise effects on progression of MS unknown Exercise does not increase MS

28. Exercise Petajan et al (1996) Regular exercise better bladder and bowel control less fatigue and depression more positive attitude reduces risks for other diseases

29. Exercise

30. Training

31. Training Bone health Inactivity Corticosteroids May weaken bone tissue but may also improve able to perform weight baring activities Sarcopenia

32. Training

33. Training Systemic Fatigue Underlying causes: depression, anemia, & medication Options:

34. Fitness Testing

35. Fitness Testing Heart rate Linear increase but blunted Fatigue lowers maximum heart rate Lower age-predicted HRmax Blood pressure Blunted response May result in insufficient perfusion to brain and muscles

36. Fitness Testing

37. Exercise Prescription

38. Cardiovascular Training Peak HR, not maximum HR Modes: cycle, water exercises (treadmill, etc. in high functioning MS patients) Strength exercises may need to precede aerobic to develop adequate muscle endurance

39. Intermittent Exercise Prevent or delay fatigue Minimize increase in body temperature

40. Aquatic Exercise Body temperature Pre-cooling before exercise Buoyancy Pre-cooling

41. Strength Training Individualized Gradual progression Closed-kinetic chain Consideration to ROM Can use various types of resistance Attention to balance

42. Strength Training 2-3 sessions per week 1-3 sets of 8-15 RM per major muscle group Emphasize seated exercises Increases of 2-5% after 15RM Less heat problems than aerobic exercise

43. Flexibility - Goals Improve balance Improve posture Counteract spasticity Increase joint mobility Increase muscle length

44. Flexibility - Goals Avoid overstretching; strain on nerves Repeated short periods of gentle stretching better than one single stretchign session.

45. Flexibility - Guidelines

46. Flexibility Target spastic muscles Passive stretching for immobilized MS patients Other options: progressive muscle relaxation yoga meditation massage

47. Special Considerations Balance Body temperature Bladder function

48. Conclusions