Promoting Health, Creating Hope

1. Promoting Health, Creating Hope IMPACT OF PATHOLOGY ON SAFETY AND ABILITY TO EXERCISE FOR PEOPLE WITH MULTIPLE SCLEROSIS Brian Hutchinson, PT President, The Heuga Center

2. MS Classifications Relapsing-Remitting Primary Progressive Secondary Progressive Progressive-Relapsing Generally, MS is separated into 4 classifications. Some people add a 5th category known as Benign MS so you may see that term. Relapsing Remitting is the most commonly seen type of MS in which the disease course consists of exacerbations and remissions. Primary progressive MS is less common. Primary progressive MS is characterized by a fairly rapid increase in disability but does not consist of relapses. Secondary progressive MS is generally characterized by individuals who initially have a relapsing remitting course but then demonstrate a progressive course but not necessarily a rapid increase in disability. Finally, Progressive-Relapsing is characterized by an steady increase in disability with occasional exacerbations.Generally, MS is separated into 4 classifications. Some people add a 5th category known as Benign MS so you may see that term. Relapsing Remitting is the most commonly seen type of MS in which the disease course consists of exacerbations and remissions. Primary progressive MS is less common. Primary progressive MS is characterized by a fairly rapid increase in disability but does not consist of relapses. Secondary progressive MS is generally characterized by individuals who initially have a relapsing remitting course but then demonstrate a progressive course but not necessarily a rapid increase in disability. Finally, Progressive-Relapsing is characterized by an steady increase in disability with occasional exacerbations.

3. MS Demographics Onset most commonly between ages 20 and 40 Affects women about twice as often as men Greater incidence in northern climates (above 40th parallel) Greater incidence in individual of Northern European descent Statistics courtesy of the National MS Society MS is most commonly diagnosed between the ages of 20-40 and the majority of people are diagnosed with relapsing-remitting MS. MS affects women about twice as often as men. There is a greater incidence in northern climates and is more common in individuals of Northern European descent.MS is most commonly diagnosed between the ages of 20-40 and the majority of people are diagnosed with relapsing-remitting MS. MS affects women about twice as often as men. There is a greater incidence in northern climates and is more common in individuals of Northern European descent.

4. Pathophysiology Blood brain barrier breakdown Autoimmune/inflammatory response Myelin damage Lesion formation Axonal damage and atrophy The pathology of MS involves a number of factors including a breakdown of the blood brain barrier, an autoimmune/inflammatory response, myelin damage, lesion formation and axonal damage and atrophy.The pathology of MS involves a number of factors including a breakdown of the blood brain barrier, an autoimmune/inflammatory response, myelin damage, lesion formation and axonal damage and atrophy.

5. Autoimmune Disorder Immune Response Trigger Blood brain barrier Inflammatory process Myelin damage Lesion formation Axonal damage and atrophy Current Immunomodulating Interferon beta 1a Interferon beta 1b Glatiramer Acetate Mitoxanthrone Plasmaphoresis MS is an autoimmune disorder. The immune response is triggered, most likely by a virus or combination of viruses, this in turn causes a breakdown of the blood brain barrier. This leads to an inflammatory response and demyelination. The damaged area forms a scar or sclerosis. In addition, to damaging the myelin it is now known that there is axonal damage and in turn atrophy. The axonal damage originally was thought to occur after years of damage to the myelin. Now it has been shown to occur early and late in the disease process. Current treatment includes immunomodulating treatments. The treatments approved for relapsing MS have been shown to slow the progression of the disease and decrease the number of exacerbations. Mitoxanthrone and Plasmaphoresis have been primarily used for progressive forms of MS to slow the progression of the disease. MS is an autoimmune disorder. The immune response is triggered, most likely by a virus or combination of viruses, this in turn causes a breakdown of the blood brain barrier. This leads to an inflammatory response and demyelination. The damaged area forms a scar or sclerosis. In addition, to damaging the myelin it is now known that there is axonal damage and in turn atrophy. The axonal damage originally was thought to occur after years of damage to the myelin. Now it has been shown to occur early and late in the disease process. Current treatment includes immunomodulating treatments. The treatments approved for relapsing MS have been shown to slow the progression of the disease and decrease the number of exacerbations. Mitoxanthrone and Plasmaphoresis have been primarily used for progressive forms of MS to slow the progression of the disease.

6. Common Symptoms Fatigue Weakness Spasticity Ataxia/Tremor Parasthesias/Dysethesias Dysarthria/Dysphagia Bowel/Bladder/Sexual Function Cognitive Emotional Visual These are some of the common symptoms people with MS may experience. Symptomatology is dependent upon the location and number of lesions. Symptoms vary in number and severity. Individuals with MS may not experience any of these symptoms and some may experience all of them.These are some of the common symptoms people with MS may experience. Symptomatology is dependent upon the location and number of lesions. Symptoms vary in number and severity. Individuals with MS may not experience any of these symptoms and some may experience all of them.

7. Symptom Management Medications Rehabilitation Surgical In addition, to disease modifying agents, it is important to manage a person�s symptoms. There are a number of different methods for symptom management but most fall into three main categories. Medications. There are a number of medications utilized to manage the symptoms mentioned earlier. Rehabilitation is very often used in symptom management; to lessen the effects of the symptoms or help one learn compensatory strategies to increase independence. Rehabilitation is also used to prevent occurrence of other symptoms and secondary complications. Finally, surgical intervention is sometimes required to manage symptoms. Primarily, secondary complications such as contractures (tendon releases), decubiti (flap repairs), spasticity (intrathecal baclofen) and tremors (deep brain stimulation)In addition, to disease modifying agents, it is important to manage a person�s symptoms. There are a number of different methods for symptom management but most fall into three main categories. Medications. There are a number of medications utilized to manage the symptoms mentioned earlier. Rehabilitation is very often used in symptom management; to lessen the effects of the symptoms or help one learn compensatory strategies to increase independence. Rehabilitation is also used to prevent occurrence of other symptoms and secondary complications. Finally, surgical intervention is sometimes required to manage symptoms. Primarily, secondary complications such as contractures (tendon releases), decubiti (flap repairs), spasticity (intrathecal baclofen) and tremors (deep brain stimulation)

8. Effects of MS on Exercise Primary Secondary Tertiary MS can affect exercise three different ways. Primary, Secondary and TertiaryMS can affect exercise three different ways. Primary, Secondary and Tertiary

9. Primary Effects of MS on Exercise Blunted Blood Pressure Responses Dampened arterial blood pressure response to sustained isometric exercise (Pepin, et.al., 1996 & Ng, et. al., 2000) -Pepin: Impaired autonomically mediated pressor response -Ng: A function of dampened muscle metabolic response May affect ability for one to attain �target� zone if an autonomically mediated response Primary effects include a blunted heart rate response. Pepin in 1996 and Ng in 2000 demonstrated a dampened arterial blood pressure response to sustained isometric exercise. However, they differed on the mechanism for the response. Dr. Pepin felt that the dampened response was due to an impaired autonomically mediated pressor response while Dr. Ng felt it was a muscle metabolic response. If this is an autonomically mediated response, it could certainly affect heart rate, of a person with MS, and affect their ability to attain a �target heart rate�Primary effects include a blunted heart rate response. Pepin in 1996 and Ng in 2000 demonstrated a dampened arterial blood pressure response to sustained isometric exercise. However, they differed on the mechanism for the response. Dr. Pepin felt that the dampened response was due to an impaired autonomically mediated pressor response while Dr. Ng felt it was a muscle metabolic response. If this is an autonomically mediated response, it could certainly affect heart rate, of a person with MS, and affect their ability to attain a �target heart rate�

10. Primary Effects of MS on Exercise Fatigue Central Peripheral Thermosensitivity Other primary effects of MS includes fatigue. Approximately 85% of people with MS have complaints of fatigue. There is evidence of central fatigue, once again lending credence to dysautonomia and conduction block. In addition, there is the �short-circuiting� fatigue commonly seen with MS which leads to weakness. Finally, there is thermosensitivity in which nerve conduction is slowed with increased heat and this produces an increase in symptoms.Other primary effects of MS includes fatigue. Approximately 85% of people with MS have complaints of fatigue. There is evidence of central fatigue, once again lending credence to dysautonomia and conduction block. In addition, there is the �short-circuiting� fatigue commonly seen with MS which leads to weakness. Finally, there is thermosensitivity in which nerve conduction is slowed with increased heat and this produces an increase in symptoms.

11. Secondary Effects of MS on Exercise Impairments ROM Strength/Weakness Sensation Balance/Coordination Fatigue due to Deconditioning Pain Medication Effects Secondary effects of MS on exercise include these impairments. Some of these impairments can be related to nerve conduction problems and therefore might be considered primary effects but as it relates to exercise they are generally more secondary effects. These impairments are often seen in people with MS and can certainly affect one�s ability and motivation to exercise.Secondary effects of MS on exercise include these impairments. Some of these impairments can be related to nerve conduction problems and therefore might be considered primary effects but as it relates to exercise they are generally more secondary effects. These impairments are often seen in people with MS and can certainly affect one�s ability and motivation to exercise.

12. Secondary Effects of MS on Exercise Disability Mobility -Difficulty achieving desired levels of exercise (unable to perform previous activities) Cognitive Additional secondary effects are those related to disability. The most common disability which effects ones� ability to exercise are problems with mobility. Difficulties with mobility creates difficulty achieving desired levels of exercise. Many people feel they must exercise at the level or the exact same way they used to exercise and if they do not, then it just isn�t exercise. Mobility disability can certainly force someone to look at different ways or different types of exercise. Cognitive disability can also create difficulties in initiating or maintaining an exercise program. Additional secondary effects are those related to disability. The most common disability which effects ones� ability to exercise are problems with mobility. Difficulties with mobility creates difficulty achieving desired levels of exercise. Many people feel they must exercise at the level or the exact same way they used to exercise and if they do not, then it just isn�t exercise. Mobility disability can certainly force someone to look at different ways or different types of exercise. Cognitive disability can also create difficulties in initiating or maintaining an exercise program.

13. Tertiary Effects of MS on Exercise Emotional Decreased motivation Family/community support Coping skills Accessibility Equipment Location(s) Expertise Finally, there are the tertiary effects of MS on exercise. Emotional aspects can include decreased motivation, limited family and/or community support making exercise more difficult. Also, a person�s coping skills can have an effect on his/her ability to exercise. As mentioned in the earlier example: �if I can�t do it the way I used to, then it doesn�t pay to do it at all�. Accessibility can also be a barrier to exercise including equipment, location, and expertise of people who understand MS and can help direct and guide someone through their exercise program.Finally, there are the tertiary effects of MS on exercise. Emotional aspects can include decreased motivation, limited family and/or community support making exercise more difficult. Also, a person�s coping skills can have an effect on his/her ability to exercise. As mentioned in the earlier example: �if I can�t do it the way I used to, then it doesn�t pay to do it at all�. Accessibility can also be a barrier to exercise including equipment, location, and expertise of people who understand MS and can help direct and guide someone through their exercise program.

14. Effects of Exercise on People with MS Improvements in Impairments Improvements in Disability Improvements in Quality of Life Improvements in Health Measures However, there are many benefits that exercise has on people with MS. First we can see improvements in impairments, disability, quality of life and health measures.However, there are many benefits that exercise has on people with MS. First we can see improvements in impairments, disability, quality of life and health measures.

15. Effects of Exercise on People with MS Improvements in Impairments Improve range of motion Improve strength Improve endurance/decrease fatigue Decrease pain However, exercise can help improve range of motion (Brar, 1991), strength (Chen, 1987; Gehlsen, 1984; Ponichtera-Mulcare, 1993;) endurance (Gehlsen, 1984; Petajan, 1996; Schapiro, 1988, Svennson, 1994) and pain.However, exercise can help improve range of motion (Brar, 1991), strength (Chen, 1987; Gehlsen, 1984; Ponichtera-Mulcare, 1993;) endurance (Gehlsen, 1984; Petajan, 1996; Schapiro, 1988, Svennson, 1994) and pain.

16. Effects of Exercise on People with MS Improvements in Disability Improved mobility -Improvement with bed mobility -Improvement with transfers -Improvement with ambulation Improvement with activities of daily living (ADL) In addition, prudent, well-rounded exercise can improve mobility including bed mobility, transfers and ambulation (Rodgers, 1999; Wiles, 2001). Also, it can include function with ADL�s (Lexell, 2000)In addition, prudent, well-rounded exercise can improve mobility including bed mobility, transfers and ambulation (Rodgers, 1999; Wiles, 2001). Also, it can include function with ADL�s (Lexell, 2000)

17. Effects of Exercise on People with MS Improvements in Quality of Life Emotional behavior Social interaction Recreation Home management Reduction in depression Reduction in anger Improvements in quality of life include improved emotional behavior, social interaction, recreation and home management as measured on the Sickness Impact Profile. In addition, decreases in depression and anger as measured by the Profile of Mood States.(Petajan, 1996)Improvements in quality of life include improved emotional behavior, social interaction, recreation and home management as measured on the Sickness Impact Profile. In addition, decreases in depression and anger as measured by the Profile of Mood States.(Petajan, 1996)

18. Effects of Exercise on People with MS Improvements in Physical Health Measures VO2 max Percent body fat Blood lipids Finally, the improvements seen with physical health measures include increased VO2 max, decreased percent body fat and improvement in blood lipid levels. (Petajan, 1996)Finally, the improvements seen with physical health measures include increased VO2 max, decreased percent body fat and improvement in blood lipid levels. (Petajan, 1996)

19. Summary MS and accompanying symptoms can cause difficulty with exercise The benefits of exercise outweigh the potential difficulties because of the benefits associated with reducing disability, improving quality of life and improving overall health So we have seen that MS and the accompanying symptoms can cause difficulty with exercise but we also have seen, and will discuss in further detail tomorrow, that the benefits of exercise outweigh the potential difficulties or barriers.So we have seen that MS and the accompanying symptoms can cause difficulty with exercise but we also have seen, and will discuss in further detail tomorrow, that the benefits of exercise outweigh the potential difficulties or barriers.

20. References Brar, et.al., Evaluation of Treatment Protocols on Minimal to Moderate Spasticity in Multiple Sclerosis. Arch Phys Med Rehabil, 1991; 72: 186-189 Chen, et.al, Force Time Measurements of Knee Muscle Fundtions of Subjects with Multiple Sclerosis. Phys. Ther, 1987; 67: 934-940 DeSouza, A Different Approach to Physiotherapy for Multiple Sclerosis Patients. Physiotherapy, 1984; 70: 429-432. Freeman, et.al., The Impact of Inpatient Rehabilitation on Progressive Multiple Sclerosis. Ann Neurol, 1996; 39: 432-441 Freeman, et.al., Inpatient rehabilitation in multiple sclerosis. Neurol, 1999; 52: 50-56 Gehlsen, et.al, Effects of an Aquatic Fitness Program on the Muscular Strength and Endurance of Patients with Multiple Sclerosis. Phys Ther, 1984; 64: 653-657 Kidd, et.al., The benefit of inpatient neurorehabilitation in multiple sclerosis. Clin Rehabil, 1995; 9: 198-203. Lexell, Muscle Structure and Function in Chronic Neurological Disorders: The Potential of Exercise to Improve Activities of Daily Living. Ex Sport Science Rev, 2000; 28: 80-84

21. References National Multiple Sclerosis Society website statistics Ng, et.al., Blunted pressor and intramuscular metabolic responses to voluntary isometric exercise in multiple sclerosis. J Appl Physiol, 2000; 88: 871-880 Pepin, et.al., Pressor response to isometric exercise in patients with multiple sclerosis. Med Sci Sports Exerc, 1996; 28: 656-660 Petajan, et.al., Impact of Aerobic Training on Fitness and Quality of Life in Multiple Sclerosis. Ann Neurol, 1996; 39: 432-441 Ponichtera-Mulcare, Exercise and multiple sclerosis. Med Sci Sports Exerc, 1993; 25: 451-465 Rodgers, et.al., Gait characteristics of individiuals with multiple sclerosis before and after a 6-month aerobic training program. J Rehabil Res Dev, 1999: 36: 183-188 Schapiro, et.al., Role of Cardiovascular Fitness in Multiple Sclerosis: A Pilot Study. J Neuro Rehab, 1988; 2: 43-49

22. References Stephens, et.al., Use of Awareness Through Movement Improves Balance and Balance Confidence in People with Multiple Sclerosis: A Randomized Controlled Study. Neuro Rep, 2001; 25: 39-49 Solari, et.al., Physical rehabilitation has a positive effect on disability in multiple sclerosis patients. Neurol, 1999; 52: 57-62 Svensson, et.al., Endurance Training in Patients with Multiple Sclerosis: Five Case Studies. Phys Ther, 1994; 74: 1017-1026 Wiles, et.al., Physiotherapy Improves Mobility, Subjective Well-Being in Patients with MS. J Neurol Neurosurg Psychiatry 2001; 70: 174-179