Exercise and Multiple Sclerosis

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Exercise and Multiple Sclerosis
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Exercise and Multiple Sclerosis White
Dressendorfer Sports Medicine, 34(15), 2004
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Introduction
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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.

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Pathophysiology

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

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Pathophysiology

• 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

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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)

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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 bodys
  immune system
• Possible triggers viruses, trauma, and heavy
  metals (e.g. mercury, lead, or manganese)

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Researchers Find New Link Between Epstein-Barr
Virus and MS

• April 12, 2006
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• 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.  

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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.

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Disease Pattern

• Relapsing-remitting
• Primary progressive
• Secondary progressive
• Progressive relapsing

from less to more disabling
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Physical symptoms
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Physical symptoms

• Ataxia, muscular weakness, general fatigue,
  spasticity, sensory disturbances,
  hypersensitivity to both internal and external
  temperature increases

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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.

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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

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Fatigue

• Possible causes
• CNS
• Systemic
• Immune
• Heat
• Pharmacological treatments

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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

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Depression
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Spastic Paresis

• Exaggerated reflexes, resistance to stretch
  (spastic), and muscle weakness (paresis)
• Aggravated by increase in body temperature

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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

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Respiratory

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

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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

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Secondary Diseases

• Heart disease
• Obesity
• Diabetes
• etc

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Medical Treatment
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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

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Exercise

• Exercise effects on progression of MS unknown
• Exercise does not increase MS

Benefits increase CR fitness, muscle strength
and endurance, reduced fatigue, improved mood,
and enhanced daily living
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Exercise

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

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Exercise
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Training
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Training

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

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Training
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Training

• Systemic Fatigue
• Underlying causes depression, anemia,
  medication
• Options

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Fitness Testing
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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

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Fitness Testing
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Exercise Prescription
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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

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Intermittent Exercise

• Prevent or delay fatigue
• Minimize increase in body temperature

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Aquatic Exercise

• Body temperature
• Pre-cooling before exercise
• Buoyancy
• Pre-cooling

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Strength Training

• Individualized
• Gradual progression
• Closed-kinetic chain
• Consideration to ROM
• Can use various types of resistance
• Attention to balance

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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

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Flexibility - Goals

• Improve balance
• Improve posture
• Counteract spasticity
• Increase joint mobility
• Increase muscle length

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Flexibility - Goals

• Avoid overstretching strain on nerves
• Repeated short periods of gentle stretching
  better than one single stretchign session.

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Flexibility - Guidelines
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Flexibility

• Target spastic muscles
• Passive stretching for immobilized MS patients
• Other options
• progressive muscle relaxation
• yoga
• meditation
• massage

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Special Considerations

• Balance
• Body temperature
• Bladder function

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Conclusions