Kines460 Review Paper

Exercise Therapy for Multiple Sclerosis Patients

A review paper on alternative forms of therapy and their effectiveness on patients with Multiple Sclerosis

Courtney Smeltzer

Introduction

Multiple sclerosis is classified as a nervous system disease that affects the brain

and spinal cord. The disease creates damage to the myelin sheath of a person’s nerve

cells by cauasing them to become inflamed, which ultimately slows down or blocks

messages between the brain and body (PubMed Health, 2013.) The exact cause of

multiple sclerosis is unknown, but recent research has shown that it may be considered an

autoimmune disease. Inflammation is the result of the body’s own immune cells

attacking the nervous system, which is why many researches believe an autoimmune

disorder may be the cause of MS.

The onset of MS typically occurs between the ages of 20 and 40 and it is found to

affect more women than men. Most cases of the disease are mild in comparison to other

neurological disorders, but there have been some cases where people have lost their

ability to speak, write, or walk (MedlinePlus, 2014.) There is also a strong genetic

component to this disease, which shows that a person is 15 times more likely to be

diagnosed with MS if their sibling or parent is affected by MS (Latash, 2014.) It is also

believed that if a person resides in an area where MS is more common (i.e. North

America and Northern Europe), they are more likely to become diagnosed with the

disease (Latash, 2014.)

Signs and Symptoms

There is no single test for MS for healthcare providers to utilize. The diagnosis is a

combination of medical history, physical exam, neurological exam, and MRI

(MedlinePlus, 2014.) Some of the signs and symptoms of MS include:

Muscle weakness

2 Exercise Therapy for Multiple Sclerosis Patients

Difficulty with coordination and balance

Trouble with vision

Sensations such as numbness, prickling, or “pins and needles”

Cognition and memory problems

Treatment of Multiple Sclerosis

Currently, there is no known cure for multiple sclerosis. Most treatment options

available to patients are aimed at slowing the progression of disease and control

symptoms in order to maintain a normal quality of life (PubMed Health, 2013.) The

medications often provided to patients are taken long-term and are often used to control

symptoms like muscle spasms, urinary problems, and fatigue or mood issues.

Steroids have often been used to decrease the severity of attacks of some symptoms.

The Problem with Medication for Multiple Sclerosis

The problem with this long-term medication is that medication and drug

treatments can become quite an expense. The National Multiple Sclerosis Society

(NMSS) claims that “illnesses such as multiple sclerosis were associated with the highest

out-of-pocket expenditures,” which will affect many MS patients when the Affordable

Care Act spending caps go into affect in 2015 (Burtchell, 2013.)

With all of these new changes arising that make it difficult for people with

chronic, degenerative diseases like MS to receive the proper treatment, it is important to

be able to consider alternative forms of treatment that are less costly. Because of this, a

great deal of research is being conducted to test the effectiveness of exercise and aerobic

therapy on reducing symptoms in MS patients.

Exercise Therapy for Multiple Sclerosis Patients 3

Paper #1: Aerobic Exercise in People with Multiple Sclerosis: Its Feasibility and Secondary Benefits

Conducted at: Baylor Institute for Rehabilitation, Dallas, TX, USA; and School of Physical Therapy, Texas Woman’s University, Dallas, TX, USA

Contributors: Chad Swank, PT, PhD, NCS, Mary Thompson, PT, PhD, GCS, and Ann Medley, PT, PhD, CEEAA

From: International Journal of MS Care: The Consortium of Multiple Sclerosis Centers, 2013

It has previously been thought that discouraging exercise for people with MS was

the best option, for fear of increasing fatigue or triggering a disease exacerbation.

However, recent research has found strong evidence for primary benefits from exercise

including improved muscle strength, activity tolerance, and mobility in MS patients.

This study aimed to explore the impact of structured aerobic exercise followed by a

period of unstructured physical activity in order to determine the impact of exercise on

cognition, mood, and quality of life in people with Multiple Sclerosis (MS).

Methods

Instruments

This was a 5-month pilot study divided into two components: a structured aerobic

exercise program lasting 8 weeks, followed by 3 months of unstructured physical activity.

Participants testing was performed on three different occasions, the first was to determine

baseline function (session 1), the second was post intervention attainment (session 18),

and the final was follow-up preservation (session 19) after 3 months of unstructured

exercise.


The tests assessed cardiovascular fitness, cognitive performance, and QOL during

session 1, 18, and 19. The cardiovascular fitness was assessed by monitoring the

participant’s breath via a telemetry metabolic measurement system while they performed

the 6-Minture Walk (6MW). Cognitive performance, which included verbal learning and

working memory domains, was assessed by using selected neuropsychological measures

from the Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS).

Factors such as depression, fatigue, and disability are all considered to be independent

predictors of quality of life in MS patients. Therefore, depression was assessed by the

Beck Depression Inventory-II, which provides item internal consistency for people with

MS. Overall quality of life was measured using the Multiple Sclerosis Quality of Life-54

(MSQOL-54), which measures QOL in MS patients using mental and physical sub

scores.

Participants

In order to be eligible for this study, participants had to be ambulatory with or

without an assistive device and score less than 6.5 on the Kurtzke Expanded Disability

Status Scale (EDSS). 9 participants who were previously diagnosed with relapsing-

remitting MS were recruited from a convenience sample. Certain individuals were

excluded if they had comorbid neurologic disease or other conditions that would prevent

participating in an exercise program, such as cardiac or respiratory disease.

Although 9 participants were recruited and completed the baselines pretest, only 8

participants completed the intervention and post-test. Only 6 participants returned for the

3-month follow up.


Procedures

The intervention sessions (2-17) consisted of a standardized aerobic exercise

program that was tailored to each participant’s fitness level. The session took place two

times per week for 8 weeks. The participants engaged in 30 minutes of exercise that

included 15 minutes on upper and lower extremity ergometer and 15 minutes ambulating

on a treadmill. As the sessions progressed, the resistance of the speed of aerobic training

was adjusted to “somewhat hard” on the Rating of Scale of Perceived Exertion (RPE)

scale. The participants exercise blood pressure and heart rate were closely monitored to

ensure participant safety. After the intervention and post-testing, the participants were

encouraged to be physically active until the follow-up testing (session 19), three months

after the post-test. There were no specific exercise instructions provided. The only

recommendation was to participate in physical activity within the community.

Results

An effective exercise program should aim to minimize anticipated deterioration of

physical condition over time. Therefore, the nonparametric analysis, the Wilcoxon

signed rank test, was used to determine the presence or absence of positive means of all

outcome measures.

The researchers found that neither structured nor unstructured physical activity

created any significant benefits for the dependent variables. However, the MSQOL-54

mental subscale and the BD-II demonstrated improvements after the structured aerobic

exercise and after unstructured physical activity. The table below represents the change

from zero for the dependent variables. It also shows that the total BDI-II score

significantly changed from zero, which indicates a change in improved mood after the


structured intervention, but this change was not sustained with unstructured physical

activity.

Table 3. Effects of the exercise intervention on Cognitive Performance and Quality of Life Variables

Although only one score is commonly reported, the BDI-II has two subscales:

Somato-Affective and Cognitive. Because of this, a post hoc analysis was conducted to

determine which subscale was affected by the intervention. The table below

demonstrates that the significant changes in mood were due to improvement in the BDI-II

Somato-Affective subscale. The Cognitive subscale did not demonstrate any significant

changes throughout the entre intervention.


Table 4. Beck Depression Inventory-II subscale analysis

Conclusions

Although an improvement in overall mood was not reflected in the total BDI-II

score, closer examination demonstrates that structured aerobic exercise affected the

different subscales differently. The cognitive subscale involves features like pessimism,

guilt, self-dislike, self-criticism, and worthlessness, remained unchanged throughout the

structured and unstructured portions of the intervention. The Somato-Affective subscale

involves relevant factors such as fatigue, loss of energy, changes in sleep patterns, and

concentration difficulty. These features improved after the structured intervention and

were maintained with unstructured physical activity.

Fatigue is a large debilitating factor in many patients with MS. It impacts energy

loss, sleepiness, inability to sustain activity, increases cognitive complaints, and is

associated with reduced self-efficacy. Although it is not directly measured in this paper,

fatigue has shown to be reduced with physical activity. Further research on the


relationship between the somato-affective features of depression and aerobic exercise

needs to be examined.

Overall, participation in a structured aerobic exercise program two times per week

for 8 weeks improved mood, with the improvement continuing over a 3-month follow-up

period. The participants’ ability to complete the aerobic testing and their improved mood

and QOL indicate the feasibility and secondary benefits of the intervention. However,

the small sample size creates a lack of statistical power and prevents the ability to draw

conclusions from the results. Future research on this topic should be longer in order to

appropriately monitor cognitive improvements and should include a control group.


Paper #2: Massage Therapy and Exercise Therapy in patients with Multiple Sclerosis: A randomized controlled pilot study

Conducted at: Musculoskeletal Rehabilitation Research Center, AhvazJundishapur University of Medical Sciences, Ahvaz, Iran

Contributors: Hossein Negahban, Solmaz Rezaie, and Shahin Goharpey

From: Sage Publications: Clinical Rehabilitation

Although there is much research being conducted on the effects of exercise

therapy, there is very little known about the effects of massage therapy for patients with

Multiple Sclerosis. There are only two studies known to researchers that have

investigated the effects massage therapy has on the psycho-emotional outcomes

associated with MS. The goal of this study was to examine the effects of massage

therapy and exercise therapy for treating pain, fatigue, spasticity, balance, gait, and

quality of life in MS patients.

Materials and Methods

Participants for this study were recruited via telephone contact after receiving

information provided by the medical records of patients in the local Multiple Sclerosis

Society. A convenient sample of 48 patients was recruited for the study. The

randomization process remained balanced by matching patients based on age and sex and

randomly assigning them to one of the four subgroups in equal sample proportions using

a table of random numbers. The subgroups consisted of the massage therapy (group 1),

exercise therapy (group 2), massage-exercise therapy (group 3), and control group (group

4). Each subgroup was assigned 10 female patients and 2 male patients. Patients

assigned to the massage therapy, exercise therapy, and massage-exercise therapy groups


received three 30-minute sessions of supervised intervention for five weeks, creating a

total of 15 therapeutic sessions with two pre-post evaluative sessions.

Massage Therapy Group: This group received 30 minutes of Swedish massage.

7 minutes were dedicated to the lower limb portions, while the patient was lying

supine, 4 minutes were dedicated to massaging the proneal muscle, and 4 minutes

were dedicated to each calf muscle while the patient was lying prone.

Exercise Therapy Group: This group was given various sets of exercises such as

strength, stretch, endurance, and balance training.

The Massage-Exercise Therapy Group: Patients in this group were instructed to

engage in similar exercises of the exercise therapy group for 15 minutes in

addition to the passive massage performed in the massage therapy group for 15

minutes. The order of exercise and massage was randomized for each patient but

remained the same throughout the course of the study.

Control Group: Patients in this group were instructed to continue to receive their

standard medical care. They were also asked to avoid engaging in any exercise

program.

Outcome Measurements

The outcome measurements for this study included pain, fatigue, spasticity,

balance, gait, and quality of life. These measurements were assessed during the pre-

intervention and immediately after completion of the intervention.

Pain: Pain was assessed using a visual analogue scale. Patients were asked their

pain level on a 0-10 point scale, with zero indicating no pain and 10 indicating

severe pain.


Fatigue: Fatigue was assessed using the Fatigue Severity Scale. Patients are

asked a series of nine questions with choices varying between 1 and 7, where 1

indicates a strong disagreement and 7 indicates a strong agreement. The total

score ranges from 7 to 63, with a higher score indicating higher levels of fatigue

during activity.

Spasticity: Spasticity was measured in the ankle plantarflexors using the

Modified Ashworth Scale. The scale ranges from 0 to 4, with 0 indicating no

increase in muscle tone and 4 indicating that the affected part is rigid in

dorsiflexion.

Balance: Static and dynamic balance were assed using the Berg Balance Scale

and the Timed Up and Go test. The Berg Balance test is composed of 14

questions, each graded on a 5-point Likert scale (0-4) ranging in levels of

difficulty. The scale ranges from 0-56, with higher scores indicating higher levels

of functional balance. The Timed Up and Go required the patient to stand up

from a sitting position, walk 3 meters at their preferred speed, and turn back and

sit in the same chair. The total time (in seconds) required to compete the task was

required using a stopwatch.

Gait: Walking speed and endurance were examined using the 10-meter timed

walk and 2-minute walk tests. The 10-meter walk test requires the patient to walk

10 meters as fast as possible. The 2-minute walk is the distance (in meters) the

patient walked as fast as possible for 2 minutes.


Quality of Life: The patients quality of life was assessed by using the Multiple

Sclerosis Quality of Life-54 questionnaire. The questionnaire is made up 54

questions, with 52 of them being grouped into 12 subscales while the remaining

two questions looked at “Satisfaction with sexual function” and “Change in

Health.” There are also Physical Health Composite Scores and Mental Health

Composite Scores. Scores for each subscale range from 0-100 with 0 indicating

poor health related quality of life and 100 indicating good health related quality of

life.

Results

Overall, the results of between-group differences in change score demonstrate that

there was a significant difference between all four study groups in all outcome measures,

with the exception of the Multiple Sclerosis Quality of Life-54. Patients in the massage

therapy group demonstrated significantly larger changes in scores in all outcome

measures compared to the control group. The scores of all outcome measurements in the

exercise therapy group were also larger than the control group with the exception of the

visual analogue scale. Patients in the massage-exercise therapy group all demonstrated

significantly large change in scores compared to the control group with the exception o

the Modified Ashworth Scale. Comparisons between the massage and exercise therapy

groups showed large changes in scores for the visual analogue scale, Timed Up and Go,

and 10-meter timed walk in the massage therapy group compared to the exercise therapy

group. The massage therapy group also demonstrated a larger change in score in the

visual analogue scale compared to the exercise therapy group. However, no significant


difference in change scores were observed between the massage and exercise therapy

groups.

Conclusions

If the exercise therapy group and massage therapy group are analyzed separately,

both are found to produce significant improvements in the outcome measurements. If a

comparison is done between the two groups, the results show that the massage therapy

group demonstrated larger improvements in pain reduction, dynamic balance, and

walking speed than the exercise therapy group. However, there were no significant

differences found in improvements between the massage therapy group and the combined

exercise-massage therapy group.

The limitations to this study are the small sample size within each experimental

group and lack of long-term assessment and follow-up. If future research is conducted,

large sample sizes should be recruited and the intervention should include long-term

assessment to examine the long-term benefits. Due to these limitations, the evidence

from this study suggests that massage-therapy could be more effective than exercise

therapy for patients with multiple sclerosis. In addition, the combination of massage-

exercise therapy could be more effective than exercise therapy alone.


Paper #3: A Qualitative Study Exploring the Usability of Nintendo Wii Fit among Persons with Multiple Sclerosis

Conducted at: Cleveland Clinic Lerner Research Institute, Department of Biomedical Engineering, Department of Physical Medicine and Rehabilitation. Cleaveland, OH, USADepartment of Occupational Therapy, University of Illinois at Chicago, Chicago, IL, USA.

Contributors: Matthew Plow and Marcia Finlayson

From: Wiley Online Library

There are many environmental barriers that prevent adults with disabling

conditions from engaging in physical activity. Because of this, novel approaches are

needed to promote physical activity in adults. One approach may be exergaming, which

is considered to be playing a videogame while using full body movement to control on-

screen action. The purpose of this study was to longitudinally examine the usability of

the Nintendo Wii and identify reasons for using or not using Wii Fit from the perspective

of adults with Multiple Sclerosis.

Methods

Qualitative data was collected from 30 participants with mild to moderate

symptoms of MS. The data examined the potential benefits of using Wii Fit on a

consistent basis. The video game system was set up in the participants’ homes and they

were instructed to utilize the Wii Fit system 3-times-a-week for 14 weeks. They were

encouraged to participate in all four types of Wii Fit exercises, which included yoga,

balance, strength, and aerobic training, during each of their exercise sessions. In order to

account for participants’ fitness levels, exercise duration was tailored to each participants

based on their perceived exertion when playing the “Basic Run” game.


Interviews were conducted over the phone before and after the 14-week

intervention. All 30 participants competed the pre-test interview and 22 completed the

post-test interview. The interviews were tape recorded over the phone and transcribed

exactly the way the participants stated their testimony. The interviews typically took

about 30 minutes to complete and were structured around the occupational well-being

model. This model allows insight into any factors that may influence participant’s

experience while using the Wii Fit. The model believes that a person’s subjective

experience during physical activity is impacted by the extent to which he or she feels a

sense of accomplishment, agency/control, companionship, affirmation, pleasure, renewal

and coherence (i.e. the connection between past, present, and future.) The interviews

consisted mostly of open-ended questions followed by probes. An example of a probe

used in the study was, “did you feel bored play Wii Fit and if so, why?”

Results

In the pre-interviews conducted with the participants, many of them expressed a

range of attitudes and experiences with videogames. Some participants had not played

videogames since they were children and some considered themselves “videogamers for

life.” However, the general consensus was that the participants had high expectations

that Wii Fit would be fun to play, would increase their overall physical activity levels,

and improve their overall health and function.

The researchers identified five main themes from the interviews with the

participants regarding their experience with Wii Fit.

1. Reflecting on my abilities: Participants felt that Wii Fit provided feedback that

encouraged them to reflect on their health and function.


2. Fitting into one’s narrative: The participants who used the Wii Fit on a

regular basis described themselves as exercisers and felt that Wii Fit met their

needs to engage in exercise.

3. Convenient and Fun to Play: Many participants enjoyed themselves while

using the Wii Fit and found it to be much more convenient than going to the gym.

4. Novel technology, but same old exercise barriers: Many participants felt that

the barriers for using the Wii Fit were similar to those for engaging in a regular

exercise program.

5. Usability Issue: Participants experienced difficulties with learning to use the

Wii Fit and could not customize exercises to the meet their individual functional

levels.

Conclusions

As a whole, Wii Fit helped majority of the participants with MS engage in

exercise. They reported that Wii Fit helped them build confidence in their abilities,

achieve goals related to participating in leisure time activities, and remove barriers

associated with going to the gym for exercise. However, participants also reported that

Wii Fit reminded them of their impairments due to its negative feedback and their own

intimidation and fear of falling.

Participants reported that their symptoms presented barriers to using Wii Fit,

although it can be argued that engaging in physical activity like Wii Fit can help reduce

the symptoms of fatigue. However, researchers also concluded that Wii Fit may also

worsen physical barriers associated with things like sensory impairments such as reacting


to on-screen action and game play moving too fast, cognitive deficits such and learning

and problem solving to use Wii Fit, and balance and coordination.

The limitations of this study were included attrition and sampling bias, the use of

phone interviews, ambiguity in how initial attitudes affected future use of the Wii Fit, and

problems associated with qualitative methodology. There was also a selection bias due to

the fact that people who have negative feelings toward video games did not enroll in the

study. Future research on this topic should focus on removing any usability barriers and

adapt the environment and gaming system to the patient’s needs regarding their

symptoms. The use of face-to-face interviews should also be implemented to observe

body language and they should be conducted more frequently throughout the study.


Conclusions for Alternative forms of Therapy for MS Patients

All three of the studies presented in this paper provide data that shows there are

alternative forms of therapy that are effective for people with Multiple Sclerosis.

Although no definitive conclusions can be drawn, the data shows that there is no harm

associated with alternative forms of therapy. Exercise therapy, massage therapy, and

novel forms of therapy like the Wii Fit all have proven to be beneficial for improving

patient symptoms if the programs are tailored to their individual needs and the patient

receives the proper instruction and guidance.

Multiple sclerosis can be a disabling and chronic disease if symptoms progress.

Because there is no known cure, it is important to be able to offer as many treatment

options as possible to control symptoms and improve the patient’s overall quality of life.

With healthcare reform on the forefront of change and healthcare costs rising, alternative

forms of therapy for people with Multiple Sclerosis will be imperative in helping them

receive the treatment they need.


References

Burtchell, J. (2013). How Will the Obamacare Out-of-Pocket Cap Delay Affect MS Patients? Healthline News. Retrieved April 23, 2014, from http://www.healthline.com/health-news/ms-how-will-out-of-pocket-cap-delay-affect-ms-patients-082813

Latsah, Mark. (2014, February 24) Multiple Sclerosis. Class Lecture.

Multiple Sclerosis. (2014). MedlinePlus. Retrieved April 23, 2014, from http://www.nlm.nih.gov/medlineplus/multip

Multiple Sclerosis. (2013). PubMed Health. Retrieved April 23, 2014, from http://www.ncbi.nlm.nih.gov/pubmedhealth

Negahban, H., Rezaie, S., & Goharpey, S. (2013). Massage Therapy and Exercise Therapy in patients with Multiple Sclerosis: A randomized controlled pilot study. Sage, 27(12), 1126-1136. Retrieved April 23, 2014, from http://cre.sagepub.com/content/27/12/112

Plow, M., & Finlayson, M. (2013). A Qualitative Study Exploring the Usability of Nintendo Wii Fit among Persons with Multiple Sclerosis. Wiley Online Library, 21(2014), 21-32. Retrieved April 23, 2014, from http://onlinelibrary.wiley.com/store/10.1002/oti.1345/asset/oti1345.pdf?v=1&t=hufq7std&s=875c85ffa947b3108c71

Swank, C., Thompson, M., & Medley, A. (2013). Aerobic Exercise in people with Multiple Sclerosis: It's Feasibility and Secondary Benefits. International Journal of MS Care, 15(3), 138-145. Retrieved April 23, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/P


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