6/9/2014
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People with MS Can be Healthier,Despite their MS
Deborah Backus, PT, PhD
Herb Karpatkin, PT, DSc, NCS, MSCS
Jacob Sosnoff, PhD
Disclosures
• Backus, and Sosnoff do not have any disclosures
• Karpatkin is on the Speakers Bureau for Acorda
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Objectives
• Discuss the benefits and barriers to exercise in MS and provide a rationale for why exercise is essential for long term health
• Describe current programs and evidence related to different approaches to delivering exercise in MS
• Identify approaches that are appropriate for their given patient population with MS
• Generate research questions to advance research related to exercise for people with MS
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Our Plan
• Introduction: The Benefits and Barriers to Adequate Exercise in People with MS – People with MS can be Healthy, despite their MS
• Outcomes across the EDSS:– Homebased exercise to prevent falls in people with MS– Increasing Volume and intensity in MS gait training – One Step at a Time: Evidence for Body Weight Supported
Treadmill Training in MS – People with MS who are Wheelchair Dependent Can
Exercise, too
• Discussion: How to apply this evidence, description of programs for people with MS, and research questions to advance research related to exercise for people with MS
BENEFITS AND BARRIERS TO EXERCISE IN PEOPLE WITH MS
Deborah Backus, PT, PhD
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Physical ActivityExercise Training
PathogenesisInflammation
Neurodegeneration
CNS:Axonal
damage/lossNeuronal loss
Cardiovascular: ↓ aerobic power
Mental: fatigue,
depression, cognition
Neuromuscular: ↓ muscle function and strength,spasticity
Sensory: Pain
Impair balance
Activities:↓ Walking performance
↓ Participation:↓ QOL↓ ADL
↓Recreation,leisure, work
Manage SymptomsFatigueSpasticity
Pain
Manage MS
Treat the PathogenesisReduce relapses
IMPROVE HEALTHPhysical, Mental, social
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Disease ModifyingTherapies
Manage SymptomsFatigueSpasticity
Pain
Medication
Diet
Rehab:PT/OT
Manage MS
Alternative Approaches
Treat the PathogenesisReduce relapses
IMPROVE HEALTHPhysical, Mental, social
Disease ModifyingTherapies
Manage SymptomsFatigueSpasticity
Pain
Medication
Diet
Rehab:PT/OT
EXERCISE
Alter the Course of MS
Alternative Approaches
Treat the PathogenesisReduce relapses
IMPROVE HEALTHPhysical, Mental, social
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Physical ActivityExercise Training
Pathogenesis↓ Inflammation
↓Neurodegeneration
CNS:↓ Axonal
damage/loss↓ Neuronal loss
Cardiovascular: ↑ aerobic power
Mental: ↓ fatigue,
↓ depression, ↓ cognition
Neuromuscular:
↑muscle function and strength,
↓spas city
Sensory: ↓ Pain
ImPROVE balance
Activities:↑Walking
performance
↑ Participation:↑ QOL↑ ADL
↑Recreation,leisurework
Some Barriers to Exercise in People with MS
• Fatigue• Cost• Transportation• Effort (starting or continuing)• Availability of preferred exercise machines in gym• Don’t like to exercise• Time• Need for assistance• Distance to travel to facility• Distance to from parking to location for exercise• Exercise is boring• Pain• Too repetitive• Uncertainty regarding what to do• Uncertainty about potential results
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HOME‐BASED EXERCISE TO PREVENT FALLS IN PEOPLE WITH MS
Jacob Sosnoff, PhD
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INCREASING VOLUME AND INTENSITY IN MS GAIT TRAINING
Herb Karpatkin, PT, DSc, NCS, MSCS
Gait in MS
• 87%‐91% of all persons with MS CO gait and mobility issues
• Only a fraction of all persons with MS get referred for PT
• The pathophysiology of MS is unique, and results in unique gait abnormalities
• Successful PT intervention must reflect this
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Fatigue
• One of the most ubiquitous MS Sx
• Multifactorial
• Primary and secondary factors
• Has unique effect on MS gait and gait training.
MS Gait fatigue
• The longer the walk, the greater the accumulation of fatigue
• Gait speed progressively decreases
• Gait deviations progressively increase
• Limits ability to improve gait endurance
• “The harder I work, the worse I get!”
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MS fatigue and Gait (Karpatkin et al 2014)
MS Fatigue and 6MWT (intermittent vs Continuous)
• Gait slows over time in MS
• More deviations and compensations seen
• Not seen on shorter gait evals
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The “Volume” problem
• To increase endurance, endurance training must be performed.
• A certain volume of walking must be done to produce an adaptation in the body
• MS fatigue can significantly limit the ability of the MS patient to perform that necessary amount of work.
The Volume Problem
• How can we improve endurance when endurance training is limited by one of the primary factors of the disease?
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Emile Zatopek
• Could not sustain a pace
• Practiced running at goal pace with full walking recoveries
• “Interval training”
• Allowed for a greater volume of high quality training
• 4 Olympic gold medals
Intermittent training
• Commonly used in athletics
• Evidence of effectiveness in COPD, Cardiac conditions, DM, obesity, CFS
• Allows for greater volumes of work
• “The more you rest, the more work you can do”
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Intermittent Exercise in MS
• Less Fatigue than continuous walking
• Greater distance than continuous walking
• Better at improving gait endurance than continuous training
Less fatiguing(Karpatkin and Rzetelny, 2014)
• 29 patients with MS• Randomized crossover design
• 6MW continuous vs intermittent (2 minutes walk/2 min seated)
• VASF increased less in the intermittent condition (from 37.93 mm to 44.83 mm; difference = 6.90 mm) compared to the continuous condition (from 34.33 mm to 54.43 mm: difference = 20.10 mm; P < .001)
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Greater Distance (Karpatkin et al 2014)
• Distance decreases when walks are continuous
• Increased ,then stabilized when intermittent
Intermittent vs Continuous walking as a training protocol
• 9 ambulatory patients with MS
• 6MWT pretest
• Randomized into 6 min continuous walk or 6 minute intermittent walk
• 6MWT posttest
• 4 week washout
• Crossover
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6MWT after continuous vs intermittent training
1278.48
1219.32
1157.42
1300.44
1000.00
1050.00
1100.00
1150.00
1200.00
1250.00
1300.00
1350.00
Continuous Pre 6MWT Continuous Post 6MWT Intermittent Pre 6MWT Intermittent Post 6MWT
Dis
tan
ce (
ft)
Continuous vs Intermittent Pre & Post 6MWT
Results
• Intermittent training: 6MWT improved 143’
• Continuous walking 6MWT decreased 59’
• F (1,8) = 9.634, p< .015.
• Visual observations: as walk progressed, gait deviations became more evident
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Why is intermittent walking effective?
• One theory: thermosensitivity
• Worsening of physical performance when either internal or external heat elevates
• Sustained exercise results in increases in core temperature
• Rest breaks may allow core temp a chance to lower.
MS thermosensitivity
• Heat buildup during exercise can also be managed by cooling garments
• Cooling during exercise may result in better exercise performance
• Most cooling studies look at pre‐cooling
• Does cooling during exercise improve exercise performance in MS
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Effect of cooling post exercise performance in MS
• 14 patients with MS in a randomized crossover trial
• 10 minutes of biking with or without a cooling vest
• BBS performed before and after biking
• Non significant difference (p<.12) between cooled and uncooled condition
• BBS Sensitivity issues?
Effect of cooling during 6MWT performance in MS
• Subjects will perform 3 separate 6‐minute walk tests in cooled vs uncooled conditions
• Cooling via cooling vest
• Total time as well as 1 minute increments will be recorded
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What else?
• Cooling during recovery breaks to lower core temp more rapidly
• Positioning devices (e.g. nightsplints) to maintain muscle length during recovery
• Medications‐ Ampyra
Summary
• The volume problem‐ to improve in mobility skills, a certain volume of work must be performed. Neurogenic fatigue prevents this in MS
• Intermittent exercise and cooling may allow for a greater volume of work to be performed and
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ONE STEP AT A TIME: EVIDENCE FOR BODY WEIGHT SUPPORTED TREADMILL TRAINING IN MS
Jacob Sosnoff, PhD
Funded in part by NMSS (IL Lot 0011)Collaborators: Drs. Robert W. Motl, Lara Pilutti
PEOPLE WITH MS WHO ARE WHEELCHAIR DEPENDENT CAN EXERCISE, TOO
Deborah Backus, PT, PhD
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People with MS in Wheelchairs
Study
NEED
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FES Cycle
• Uses electrical stimulation so can help weak and paralyzed muscles exercise longer and with resistance
• Does NOT increase inflammatory response
Ratchford, J.N., et al., A pilot study of functional electrical stimulation cycling in progressive multiple sclerosis. NeuroRehabilitation, 2010. 27(121‐128).
FES Cycling in People who are Wheelchair dependent
EDSS > 6.5
• N = 14 (7 male, 7 female)• Ages 31‐70; mean 55• All types of MS and on all types of medication
• Cycled 3X/week for 30 mins– 2 min warm up + 30 mins (active/FES or active/FES +passive) + 2 min cool down
– 40‐50rpm– Estim assist at quads, hams and gluts
• Outcome measures related to safety, fatigue, pain, spasticity, QOL
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Results
• No adverse events
• No worsening of symptoms
• Reports equated to exercise responses and not MS‐related responses
• No change in spasticity
FES Cycling Performance
• 7 started able to cycle full 30 minutes either with estim assist or all estim
– 6 were able to maintain, and also increased resistance (increased resistance p<0.01)
• 7 started below 30 mins
– 6/7 increased time (ranged from approx 2 mins to 22 mins) (p=0.04)
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MFIS
Decreased fatigueTremendous variability
MOS Pain Effects Scale
• **No increase in pain• No significant change• 8/13 decrease in pain
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Cognitive Outcomes
• PASAT p<0.01
• SDMT NS
Par
tici
pa
nt
#
Pre%
Correct
Post%
CorrectChange
1 66.7 93.3 26.6
2 16.7 53.3 36.63 63 68.3 5.34 75 100 255 46.6 78.3 31.76 100 95 -5
7 51.7 83.3 31.6
8 58.3 91.6 33.3
9 85 96.7 11.7
10 15 46 3111 28 51 2312 83 96 1313 80 100 2014 18 81 63
Ave 52.47 75.59 23.12P
value<0.01
MSQLI Outcomes
• Statistically significant improvements in Social subscale of MSQLI (p=0.01)
• Statistically significant change, but not positive, in the Positive Affect Subscale of the Mental Health Inventory (p=0.01)
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Measuring Muscle Metabolism
Using NIRS to Measure Muscle Metabolism
1) Progressive Work Test (PWT): With participant supine, NIRS was employed to measure maximal metabolic rate of the left quadriceps during 6 periods of 15 seconds (s) of electrical stimulation (at varying frequencies 2‐7Hz), followed by a 10s cuff inflation and 60s deflation (Figure 1).
2) FES Cycling Test (FCT): With participant seated in wheelchair at RT300 (Figure 2), 1‐4 intervals of active FES cycling (at 100% stimulation). The number of intervals varied depending on when each individual went into passive cycling. NIRS measurements were taken at 3 minute, 7 minute, and 10 minute intervals.
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Quads Max Muscle Metabolism
• Muscle metabolic rate is lower in people with MS than able bodied and people with SCI
– Looks like a deconditioned muscle
• Muscle metabolic rate during FES cycling tends to be lower than work test rate
Changes in Muscle Metabolism after FES Cycle Training
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Summary
• People with moderate to severe disability due to MS (EDSS >6.5), who are primarily wheelchair dependent, can exercise safely
• The FES cycle offers a viable and accessible option– “MS‐free zone” (Kalb)
• Exercise may improve fatigue and cognitive processing speed, which may improve social interaction and ultimately QOL
• Exercise may improve health in people who are at great risk of secondary conditions due to their sedentary lifestyle
• May help ready them for rehab options they couldn’t consider before
• Requires further investigation
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Deborah Backus Director of MS ResearchRachel Betzler CoordinatorBlake Burdett Exercise SpecialistElizabeth Gonzales Coordinator and AbstractorLaura Hawkins Exercise SpecialistCarlyn Kappy Dietician Dylan Lee PhD StudentChris Manella MS Program ManagerMarina Moldavskiy Exercise Specialist
The Eula C. and Andrew C. Carlos MS Rehabilitation and Wellness Research Program
MS Research
Kevin McCully, PhDMary Ann Reynolds, BSSarah Stoddard, MS ES
PEOPLE WITH MS CAN EXERCISE, DESPITE THEIR MS
Discussion
