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How Can Exercise Help People Who Have Multiple Sclerosis?
Guillermo G. Martinez & Len Kravitz, Ph.D.

Article Reviewed:
As a personal trainer you may be familiar with the following scenario. “Mary,” a fictional 30-year-old woman was diagnosed with multiple sclerosis (MS) soon after her 21st birthday. She is often tired in the morning, even after the rare occasion when she gets a full night's worth of restful sleep. This fatigue is unpredictable, gets worse throughout the day, and tends to be brought on easily. It is difficult for her to walk long distances as she suffers from muscle spasms and weakness in her legs. This has made her less able to do her job, forcing her to quit. She finds it difficult to focus for very long on tasks that require thought and attention, and she suffers from depressive episodes. As she accustoms herself to her condition over time, she may be emotionally and socially healthier, but she may still have problems with her physical health.

Mary is not alone. According to the MS Association of America (2013) an estimated 400,000 persons (twice as many women as men) in the United States have MS with an estimated 2 million plus sufferers world-wide (Manouchehrinia and Constantinescu, 2012). MS is often diagnosed in young adults presents with a wide range of signs and symptoms, such as those described above and depicted in Figure 1. Dalgas et al. (2008) summarize research stating that MS patients have a higher incidence of osteoporosis (due to reduced bone mineral density), more depression and fatigue, and increase risk of death from cardiovascular diseases (as compared to persons without MS). This condition can have a financial impact on patients, as managing these symptoms can cost a patient anywhere from $6,603 to $77,938, depending on the condition's severity (Manouchehrinia 2012). Caretakers have traditionally recommended that patients refrain from physical activity in an effort to preserve energy for functional daily living; however, benefits from exercise have been well documented in the last decade (Dalgas 2008). Thus, the role of exercise specialists in caring for people with MS is becoming more essential.

Mood changes, dizziness, depression, sexual dysfunction, blurred vision, walking issues, slurred speech, low energy, swallowing disorders, blurred vision, weakness in arms and legs, sleep problems, anxiety, reduced coordinator, bladder dysfunction
Figure 1. What are the Signs and Symptoms of MS?

The Physiology of Multiple Sclerosis?
Historically, the recognition of MS goes back to 1868, when neurologist Jean-Martin Charcot initially lectured on this disease (MSAA, 2013). Surrounding and protecting the projecting component of nerve cells, called axons, is a myelin sheath made of fatty tissue. In MS, this fat cell covering is periodically attacked by the body's own immune system. The damage to the myelin results in scar tissue build-up (a condition called sclerosis; thus the name multiple sclerosis), interrupts nerve signals (messaging), and thus leads a host of neurological problems and serious health consequences. Although a precise cause of this disease has yet to be identified, some scientists believe it may be a slow-acting virus with some unknown factor in a person's genetic make-up (which is inactive for many years).

Cardiovascular Exercise Interventions for MS Patients
Fatigue plays a large role in an MS patient's suffering, but it can be reduced with regular exercise. A survey conducted by Stroud and Minahan (2009) indicates that MS patients who were classified as exercisers (that is, at least twice a week for 30 minutes) experienced less fatigue, less depression and a higher quality of life than those who did not exercise as much. It appears that this benefit can come from any kind of common exercise intervention. For example, McCallagh et al. (2007) tested a station-based aerobic regimen involving 40 minutes total of 10-minute sessions of combined walking/running, cycling, stair climbing, volleyball, and outdoor walking at low intensities (11-13 RPE, i.e. fairly light to somewhat hard). McCallagh and colleagues state that reductions in fatigue, as well as improvement in quality of life were evident and remained apparent for 6 months after the intervention (although fitness level did drop as expected with cessation of exercise). Exercise professionals are encouraged to determine which modes of exercise their MS clients may enjoy, as multiple investigations indicate that it is the cardiovascular nature of the activity that provides benefits, not any one type of mode. McCallagh et. al emphasize that adherence to exercise for MS sufferers is difficult, thus suggesting that the exercise professional needs to be careful and cautious with progression of duration and intensity with this population.

Resistance Exercise Interventions for MS Patients
Resistance exercise has been shown to be just as effective as aerobic modalities in its benefits for MS symptoms (Sabapathy 2011). These interventions can range from fairly light to moderate intensities. Dalgas et al (2010) completed a 12-week resistance training progam (Exercise Group=16; Control group=15) with lower body exercises performed twice weekly (Monday and Thursday). After completing a 5-min warm up on a stationary bicycle, patients performed &Mac222;ve exercises; leg press, knee extension, hip &Mac223;exion, hamstring curl and hip extension.
The participants performed all exercises with a fast concentric phase and a slower eccentric
phase. Through the 12-week program the subjects performed a supervised, periodized resistance training program progressing from a 15-repetition maximum (15-RM) to an 8-RM (of 3-4 sets per exercise) by the end of the training. Study results showed significant improvements in fatigue, mood and quality of life.

MS, Exercise and Gain Improvements
Snook and Motl (2009) utilized a meta-analytic statistical technique (which reviews existing studies and then summaries the overall findings) to examine the overall effect of exercise training interventions on walking mobility among persons with multiple sclerosis. Results indicate that exercise training of all types can bring about small, but important improvements in mobility with MS patients (Snook 2009).

Exercise Design Applications for MS patients
Combined exercise is well-tolerated by MS patients, given that they are equal parts of resistance and aerobic exercise (2 days per week of each, with at least one day of rest between similar sessions) (Dalgas 2008). Below are some other suggestions
1) Gait abnormalities may cause a client to have improper form for aerobic exercise. Make sure to monitor for proper form.
2) MS clients are likely to be deconditioned and they may not tolerate moderate-to-hard exercise well. Start them off slowly (fairly light and then progressing to somewhat hard) and build up gradually.
3) MS symptoms may be more pronounced following an exercise bout, but they will most likely return to normal within a half hour after exercise (Dalgas 2008).
4) Listen carefully to client feedback on exercise programming, structure and progression.
5) Be flexible in designing the exercise program! Many different modes of exercise are therapeutic for this population.
6) Focus the resistance exercise on the major muscle groups of the lower body as research shows muscular deficits are more pronounced in the lower body of MS patients (Dalgas, 2008).

Side Bar 1: Six Myths about MS
There exist some preconceived notions about MS that are not necessarily true, or may be true for some patients but not most. The following myths presented have been refuted by the National Multiple Sclerosis Society.
Myth 1) MS is caused by pets, allergies, or heavy metals.
Literature does not support the notion that canine distemper, a virus commonly carried by dogs, plays any role in triggering MS. The same holds true for allergies, and while heavy metals (e.g. mercury, led, etc.) have been known to cause nerve damage, this is not the same as a degenerative disease such as MS.

Myth 2) MS is caused by trauma.
There is no evidence supporting the association between physical trauma and either MS onset or MS exacerbation.

Myth 3) MS is a fatal disease.
Most people with MS have a lifespan as long as people without the condition. Only in late-stage or extreme cases does it have the potential to end a life, and early therapies can help delay the impact.

Myth 4) MS will leave a person immobile.
As discussed above, mobility can be jeopardized, but with the correct therapy and early intervention, patients can maintain their functionality without the use of wheelchairs or other related devices.

Myth 5) Women with MS should not have children.
While genetics may be a factor in getting MS, the actual likelihood of passing the condition to a child felt to be quite low.

Myth 6) MS and muscular dystrophy are the same condition.
MS and muscular dystrophy are often classified together as conditions that physically debilitate the patient, and both are degenerative. However, they affect completely different body systems. MS affects the central nervous system while muscular dystrophy affects the skeletal muscles themselves.

@bio:Guillermo G. Martinez is an undergraduate student at the University of New Mexico majoring in exercise science. He will be pursuing a professional doctor of physical therapy degree after graduation. His potential interests of focus in rehabilitation include pain management, neuromuscular reeducation and orthopedic therapy.
@bio:Len Kravitz, PhD, is the program coordinator of exercise science and a researcher at the University of New Mexico, Albuquerque, where he won the Outstanding Teacher of the Year award. He has received the prestigious Can-Fit-Pro Lifetime Achievement Award and was chosen as the American Council on Exercise 2006 Fitness Educator of the Year.

Dalgas, U., Stenager, E., Ingemann-Hansen, T. (2008). Review: Multiple sclerosis and physical exercise. Multiple Sclerosis, 14(1), 35-53.

Dalgas, U., Stenager, E., Jakobsen, J., Petersen, T., et al. (2010). Fatigue, mood and quality of life improve in ms patients after progressive resistance training. Multiple Sclerosis, 16 (4), 480-490.
Manouchehrinia, A. and Constantinescu, C.S. (2012). Cost-effectiveness of disease-modifying therapies in multiple sclerosis. Curr Neurol Neurosci Reports, 12(5), 592-600.

MSAA. Multiple Sclerosis Association of America. Information for the Newly Diagnosed
Retrieved February 26, 2013

MSAA. Multiple Sclerosis Association of America. Frequently Asked Questions about Multiple Sclerosis
Retrieved February 26, 2013

National Multiple Sclerosis Society
Retrieved February 27, 2013

Sabapathy, N.M., Minahan, C.L., Turner, G.T., and Broadley, S.A. (2011). Comparing endurance- and resistance-exercise training in people with multiple sclerosis: a randomized pilot study. Clinical Rehabilitation, 25(1), 14-24.
Snook, E.M. and Motl, R.W. (2009). Effect of exercise training on walking mobility in multiple sclerosis: a meta-analysis. Neurorehabilitation & Neural Repair, 23(2), 108-116

Stroud, N.M. and Minahan, C.L. (2009). The impact of regular physical activity on fatigue, depression and quality of life in persons with multiple sclerosis. Health and Quality of Life Outcomes, 7:68 doi: 10.1186/1477-7525-7-68.