Special Considerations

The following are special considerations that should be taken into account when prescribing exercise to persons with Multiple Sclerosis.

• In spastic muscles, increase the frequency and time of flexibility exercises. Muscles and joints with significant tightness or contracture may require longer duration (several minutes to several hours), and lower load positional stretching to achieve lasting improvements.
• Whenever possible, incorporate functional activities (e.g. stairs, sit-to-stand) into exercise program to promote optimal carryover.
• Use RPE in addition to HR to evaluate exercise intensity. With individuals who have significant paresis, consider assessing RPE of the extremities separately using 6-20 scale to evaluate effects of local muscle fatigue on exercise tolerance.
• During an acute exacerbation of MS symptoms, decrease the FITT of the exercise prescription to the level of tolerance. If the exacerbation is severe, focus on maintaining functional mobility and/or focus on activities such as aerobic exercises and flexibility.
• Commonly used disease-modifying medications such as Avonex, Betaseron, Rebif, and Copaxone can have transient side effects such as flu-like symptoms and localize irritation at the injection site. Take medication side effects into consideration with exercise testing and scheduling.
• Systemic fatigue is common in MS but tends to improve with increased physical fitness. It is important to help the individual understand the difference between more general centrally mediated MS fatigue and temporary peripheral exercise-related fatigue. Tracking the effects of fatigue may be helpful using an instrument such as the Modified Fatigue Impact Scale.
• Heat sensitivity is common in MS. Use of fans, evaporative cooling garments, and cooling vests can increase exercise tolerance and reduce symptoms of fatigue. 
• HR and BP responses may be blunted because of dysautonomia so that HR may not be a valid indicator of exercise intensity. RPE can be used in addition to HR to evaluate exercise intensity.
• Some individuals may restrict their daily fluid intake because of bladder control problems. They should be counseled to increase fluid intake with increased physical activity levels to prevent dehydration. 
• Many individuals with MS have some level of cognitive deficit that may affect their understanding of testing and training instructions . They may also have short-term memory loss that requires written instructions and frequent verbal cueing and reinforcement.
• Watch your signs and symptoms of the Uhthoff Phenomenon. Uhthoff phenomenon typically involves a transient (<24h) worsening of neurological symptoms, most commonly visual impairment associated with exercise and elevation of body temperature. Symptoms can be minimized by using cooling strategies and adjusting exercise time and intensity as appropriate.

THE BOTTOM LINE

Individuals with MS generally have a lower VO2peak compared to a healthy populations. Fatigue is common in individuals with MS but can be improved with exercise training in individuals who have mile-to-moderate disability. The HR response to exercise may be blunted; RPE can be used in addition to HR to evaluate exercise intensity.

(Sourced from ACSM's Guidelines for Exercise Testing and Prescription Ninth Edition)

FITT Recommendations for Individuals with Multiple Sclerosis

For patients with minimal disability (EDSS score of 0-2.5), the FITT principle of exercise prescription is fairly consistent with those outlined for healthy adults located in Chapter 7 of ACSM's Guidelines for Exercise Testing and Prescription. The following FITT recommendations are for people with increased disability:

Aerobic Exercise

• Frequency - 3-5 days per week.
• Intensity - 40%-70% VO2R or HRR; RPE 11-14.
• Time - Increase exercise time initially to a minimum of 10 min before increasing intensity. Progress to 20-60 min. In individuals with excessive fatigue, begin with lower intensity and discontinuous bouts of exercise.

Resistance Exercise

• Frequency - 2 days per week.
• Intensity - 60%-80% 1-RM.
• Time - 1-2 sets of 8-15 repetitions. When strengthening weaker muscle groups or easily fatigued individuals, increase rest time (i.e. 2-5 min)between sets and exercises as needed to allow for full muscle recovery. Focus on large anti-gravity muscle groups and minimize total number of exercises performed. 

Flexibility Exercise

• Frequency - 5-7 days per week, 1-2 times per day.
• Intensity - Stretch to the point of feeling tightness or mild discomfort.
• Time - Hold static stretch 30-60 sec, 2-4 repetitions.

(Sourced from ACSM's Guidelines for Exercise Testing and Prescription Ninth Edition)

Special Populations: Multiple Sclerosis

What is Multiple Sclerosis?

Multiple Sclerosis (MS) is chronic inflammation or inflammatory demyelinating disease of the central nervous system (CNS) that currently affects an estimated 2.1 million individuals worldwide. The onset of MS usually occurs between 20 and 50 year and affects women at a rate two to three times more than men. Initial symptoms often include transient neurological deficits such as numbness or weakness and blurred or double vision. Although the exact cause of MS is still unknown, most researchers believe it involves an autoimmune response that is influenced by a combination of environmental, infectious, and genetic factors. During an exacerbation, activated T cells cross the blood-brain barrier precipitating an autoimmune attack on myelin in the CNS. Following the initial inflammatory response, damaged myelin forms scarlike plaques that can impair nerve conduction and transmission. This can lead to a wide variety of symptoms; the most common of which include visual disturbances, weakness, sensory loss, fatigue, pain, coordination deficits, bowel or bladder dysfunction, and cognitive and emotional changes.

The disease course of MS is highly variable from individual to individual and within a given individual over time. However, several distinct disease courses are now recognized as well as the relative frequency of each including:

a)Relapsing Remitting MS (RRMS)-periodic exacerbations followed by full or partial recovery of deficits

• 85% of MS cases
• Common to develop a Secondary Progressive MS (SPMS) disease course 10-25 years later
• SPMS is characterized by a slow but steady decline in function

b)Primary Progressive MS (PPMS)-continuous disease progression from onset with little or no plateaus or improvements

• 10% of MS cases

c)Progressive Relapsing MS (PRMS)-progression from onset with distinct relapses superimposed on the steady progression

• 5% of MS cases

The level of disability related to the progression of a particular case of MS is documented using the Kurtzke Expanded Disability Status Scale (EDSS). This scale ranges from 1-10.

• 0 - 2.5 –> Indicates no to minimal disability 
• 3 - 5.5 –> Moderate disability and ambulatory without device
• 7.5 - 9 –> Essentially chair-bound or bed-bound
• 10       –> Death due to MS

Individuals with MS usually have a lower maximum aerobic capacity than age- and sex-matched individuals without MS. In fact, aerobic capacity continues to decrease with increasing levels of disability. Heart rate (HR) and blood pressure (BP) responses to a graded exercise test are linear with respect to work rate but tend to be blunted compared to healthy controls. This attenuation of HR and BP may be a result of cardiovascular dysautonomia, which is a the malfunction of the autonomic nervous system (ANS). Individuals with mild-to-moderate MS, however, have shown to improve VO2 max levels, functional capacity, lung function, and delayed onset of fatigue after 3-6 months of progressive aerobic training.

Decreased muscle performance is also a common impairment associated with MS. Individuals with MS have lower isometric and isokinetic force production as well as total work of the quadriceps muscle when compared to age- and sex-matched norms. Changes in muscle performance are most likely closely associated with the central (neural drive and function) and peripheral (decreased oxidative capacity) factors associated with the disease process as well as the secondary effects of disuse atrophy. There is limited research available, but it has been shown that individuals with MS can improve strength and muscular function with progressive resistance training. Greater gains will be made by those with less disability.

(Sources from ACSM's Guidelines for Exercise Testing and Prescription Ninth Edition)

Multiple Sclerosis: Exercise Testing

When exercise testing with individuals effected by MS you will notice many differences from a typical client and will need to adapt your testing methods.

Specifically:

• Generalized fatigue is common in individuals with MS. It is best to perform exercise testing early in the day because energy levels in those with MS quickly worsens throughout the day. Testing in the morning will yield more accurate and consistent results.
• Avoid exercising during an acute exacerbation of MS symptoms
• Problems with balance and coordination may require use of an upright or recumbent cycle leg ergometer. When using a cycle leg ergometer, the use of foot straps may be needed to prevent the foot from falling off the pedal because of weakness and/or spasticity.
• A recumbent stepping ergometer that allows for the use of upper and lower extremities may be advantageous because it distributes work to all extremities, thus minimizing the potential influence of local muscle fatigue on maximal aerobic testing.
• Depending on the disability and physical fitness level of the individual, use a continuous or discontinuous protocol of 3-5 minute stages increasing work for each stage from 12 to 25 W. 
• Heat sensitivity is common in individuals with MS so it is important to use a fan or other cooling strategies during testing.
• Assessment of joint ROM and flexibility is important because increased tone and spasticity can lead to contracture formation. (MS Spasticity Information)
• Isokinetic dynamometry can be used to accurately evaluate muscle performance. However, use of an 8-10 RM or functional testing (e.g., 30 second sit-to-stand test) can also be used to measure muscular strength and endurance in the clinical or community setting. 
• Use physical performance tests as needed to asses endurance (6-min walk test), strength (5 rep sit-to-stand), gait (walking speed), ad balance (Berg Balance Scale, and Dynamic Gait Index).

(Sourced from ACSM's Guidelines for Exercise Testing and Prescription Ninth Edition)