Physical exercise in MS / Tallinn Anders Romberg, PhD, Physical Therapist Neuro Society / Masku Neurological Rehabilitation Centre

Transcription

1 Physical exercise in MS / Tallinn Anders Romberg, PhD, Physical Therapist Neuro Society / Masku Neurological Rehabilitation Centre

2 2 Finnish Neuro Society

3 Content; 5 perspectives 1) Historical 2) Safety 3) Evidence-based 4) Psychobehavioral 5) Practical Summary & clinical implications 3 Finnish Neuro Society

4 1) Historical perspective 4 Finnish Neuro Society

5 YESTERDAY ( BEFORE MILLENNIUM) Exercise in MS = a controversial issue Persons with MS were often adviced to avoid exercise. The underlying assumptions: fear of increased fatigue symptom worsening associated with elevated core body temperature fear of increased exacerbation risk 5 Finnish Neuro Society

6 TODAY Exercise recommended for PwMS Induces number of improvements in fitness and physical functioning. May have a favorable influence on mechanisms associated with brain health. A key component of MS rehabilitation to optimise function and maintain health. A cheap and important non-pharmacological tool of self-management. (In background: rapidly expanding evidence base) 6 Finnish Neuro Society

7 The expansion of evidence base PubMed: "Multiple Sclerosis"[Mesh] AND "Exercise Therapy"[Mesh] Publications (n) Finnish Neuro Society Year

8 2) Safety Relapses Adverse events Symptom exacerbation 8 Finnish Neuro Society

9 MS relapses and exercise MS-relapses (physician confirmed & treated with steroids) over 6-month follow-up: exercise group (n=45) 5 relapses control group (n=46, no intervention) 6 relapses Romberg A et al. Neurology 2004 No association between self-reported relapses within last 2 years and physical activity (as quantified by a questionnaire) in 546 patients. The group with highest sport activity showed the lowermost mean values concerning the rate of relapses. Tallner A et al. Mult Scler Finnish Neuro Society

10 Adverse events (AEs) A systematic review: 26 studies. Exercise conditions; n=650, control; n=425 AE risk for exercise training in MS is slightly higher than in control conditions, AEs reported: in 1.2% of control persons In 2.0% of exercisers AEs: illness, infection, trigeminal neuralgia, back/joint pain, HOWEVER: Compared to healthy populations, AE risk for exercise is not higher in pwms. Pilutti L et al. J Neurol Sci Finnish Neuro Society

11 Symptom exacerbation or not? Sensory symptoms may increase immediately after a single exercise session. Within 30 mins of exercise cessation sensory signs equal to preexercise status in most (85%) of the exercisers (n=34). Neither perceived fatigue nor general functioning significantly affected by a single exercise session. Smith R et al. Arch Phys Med Rehabil 2006 Leg cycling 30 min/session; 3x/week; 4 weeks (n=22) A small reduction in perceived spasticity immediately after 4 weeks. Persisted for 1 and 4 weeks after exercise. No changes in spasticity as indicated by a clinical (MAS) or elektrophysiological index (H-reflex) (immediately, 1 and 4 weeks after exercise) Sosnoff J et al. NeuroRehabilitation Finnish Neuro Society

12 3) What s the evidence? 12 Finnish Neuro Society

13 Evidence; physical fitness Persons with MS are able to improve their 1) aerobic endurance capacity; strong evidence (9 + 3 studies) 2) muscle strength; strong evidence (5 + 9 studies) Latimer-Cheung A et al. APMR Neuroliitto

14 Evidence; walking ability Meta-analysis (13 studies): Significant benefits in 1) walking speed (10 meter Walk Test) and 2) walking endurance (2 and 6 minute Walk Tests). Pearson M et al. APMR 2015 Multiple training modalities (arm/leg cycling, treadmill walking, recumbent stepping, resistance training, combined aerobic and resistance training, etc.) seem to improve walking ability. Latimer-Cheung A et al. APMR Neuroliitto

15 Evidence; fatigue Evidence inconsistent; many studies have used nonfatigued study populations. Andreasen A et al. Mult Scler 2011 Interventions including a resistance training component may be most effective. Latimer-Cheung A et al. APMR 2013 Both exercise and educational interventions appear to have a stronger effect on reducing the impact/severity of fatigue compared to the most common fatigue medications (= Amantadine and Modafinil). Asano M & Finlayson M. Mult Scler Int Neuroliitto

16 Evidence; health-related quality of life Measurement inconsistencies make it difficult to draw firm conclusions and make comparisons across studies. Nonetheless, a number of indicators suggest that HRQoL (at least in part) may be improved via exercise training in pwms. Motl RW & Pilutti L. Nat Rev Neurol 2012 / Latimer-Cheung A et al. APMR Finnish Neuro Society

17 Evidence; depression Exercise is recommended as a treatment intervention for mild/moderate depression in general populations. Research so far does not support the use of exercise to reduce depressive symptoms in PwMS. Methodological limitations: Absense of clinical depression diagnosis Depression not the primary outcome Etc. Feinstein A et al. Mult Scler Finnish Neuro Society

18 Exercise a strategy to activate brain repair mechanisms in MS? Given that axonal loss and cerebral atrophy occur early in MS, regular exercise in the acute stage could enhance neuroprotection, neurogeneration and neuroplasticity and thus reduce long-term disability. White L & Castellano V. Sports Med 2008 Preliminary evidence supports a positive link between fitness, exercise training and brain health/cognitive function in pwms. Much more (in particular longitudinal) research is needed to confirm that exercise could serve as a simple neuroprotective therapeutic option in MS.

19 4) Psychobehavioral aspects Exercise is easily understood mainly as a physiological entity. It is also, however, a complex and versatile psychological and behavioral phenomenon! 19 Finnish Neuro Society

20 Psychological effects of exercise Poorly understood (so far) in neurological conditions! Importantly, exercise - at its best - may: provide with flow-experiences strenghten self-esteem reinforce sense of coping improve self-efficacy ameliorate mood increase vitality provide (important) positive emotions 20 Finnish Neuro Society

21 Psychological effects; an example Less is more is a common phrase; even a small amount of exercise provides me with incredibly important resources to cope in everyday life and in work. In the ups and downs of the life exercise gives me selfconfidence as well as mental and physical strength to overcome even difficult challenges one way or another. Vitality from exercise into life as a woman (Avain 3/2007) 21 Finnish Neuro Society

22 A number of factors affect exercise behavior (i.e. participation) in pwms. Identification of these would be important Exercise behavior 22 Situational factors Finnish Neuro Society

23 Potential barriers to exercise participation in MS: INTERNAL FACTORS physical (in)ability symptoms negative attitudes low self-efficacy low outcome expectations lack of motivation EXTERNAL FACTORS availability of support poor accessibility of facilities finances lack of transportation 23 Finnish Neuro Society

24 Factors to facilitate exercise participation in MS: INTERNAL FACTORS past exercise participation perceived health/fitness high exercise self-efficacy high outcome expectations EXTERNAL FACTORS spousal support other social support: e.g. rehabilitation staff feedback and rewards role models peer support 24 Finnish Neuro Society

25 5) Practical issues Optimal exercise / dosage / the role of physical therapist 25 Finnish Neuro Society

26 Optimal exercise? Best exercise = regular exercise Consists of aerobic endurance training and resistance training. These are preferably complemented by balance and flexibility training. Remember: Training practices have to be modified sporadically! 26 Finnish Neuro Society

27 Disability adapted physical exercise in MS (Heesen C, Romberg A, Gold S, Schulz K-H. 2006) Disability Exercise Dosage None (occasional) pre-clinical symptoms Mild Fatiguability, perhaps themosensitivity, minor balance disturbances Moderate Restricted walking, paresis, leg spasticity, ataxia, balance problems Severe disability Loss of daily functioning, walking restricted to few meters Bedridden Fully exertable, exercise predominantly alike in the healthy people, no extreme sports though. Comprehensive strength and endurance training. Supervision to avoid overtraining, longlasting efforts, running, fast ball games and e.g. downhill skiing become restricted. Training programme adapted to the deficit. Nordic Walking, home exercises, ergometer cycling, aquatic exercises. Yoga, Strength and balance training, group exercise. Preservation of basic movements and flexibility, stretching, focused strenghtening, active/passive training using a motor-assisted device. Preservation of joint mobility, predominantly passive, breathing exercises Intensity decreases, duration shortens in parallel with the increase of disability and of symptoms

28 Dosage: How much exercise? How often? Latimer-Cheung A et al. APMR Finnish Neuro Society

29 DOSAGE: European Multiple Sclerosis Platform (EMSP) exercise training recommendations (Dalgas U & Romberg A 2012) ENDURANCE TRAINING: 2x times/week at a moderate intensity (i.e. about 60-80% of maximal heart rate) Duration: min, should be modified according to fitness level/disability/ intensity. RESISTANCE TRAINING: 2 times/week: 8-10 exercises for major muscle groups (particularly for lower limbs). Initial stage: 1-2 sets, regular training phase: 2-3 sets; 8-15 repetitions/set Neuroliitto

30 The role of physical therapist PT:s have the required in-depth understanding of MS-related functional limitations and symptomology to provide appropriate exercise counseling. PT = Personal trainer PT = Motivator PT = Mental supporter PT = Promoter of exercise self-efficacy ( you can, you are able to in spite of MS, in spite of your symptoms ) 30 Finnish Neuro Society

31 SUMMARY 1) Over the last decade, a historical turn, based on cumulation of scientific evidence, has occurred related to exercise in MS. 2) Exercise is safe in MS. 3) Exercise produces numerous benefits on fitness, functioning, symptoms. It may even affect brain health. The findings are, however, so far well generalizable only in mild-moderate MS. 4) Exercise is behavior. Consequently, it is substantial to examine barriers and facilitators of exercise participation in pwms. 5) The importance of the psychological effects of exercise may be underestimated and of unexpected importance in pwms. 31 Finnish Neuro Society

32 FINALLY; CLINICAL IMPLICATIONS Exercise = inexpensive therapeutic option Exercise should be an integral part of (self) management and rehabilitation in pwms (in all stages of disease). An ongoing challenge is to encourage and motivate pwms to engage in exercise on a regular basis. 32 Finnish Neuro Society

33 Thank you for your attention! 33 Finnish Neuro Society