MS Rehabilitation Shifting the Paradigm Jeffrey R Hebert, Ph.D., P.T., M.S.C.S. Assistant Professor Physical Medicine & Rehabilitation Neurology University of Colorado Denver
Disclosures/ Acknowledgements I have received compensation for lectures/courses/ seminars with the National Multiple Sclerosis Society, Rocky Mountain Multiple Sclerosis Center, Nebraska Physical Therapy Association I have received funding from and currently am a grantee of the National MS Society
Overview Physical activity - Brain health - Function & structure Brain reorg in MS Progression and aging Comorbidities & MS Extending beyond the clinic
Physical activity Voelcker-Rehage, et al. Neurosci Biobehav Rev 2013
Brain health across the lifespan: Function: Cognition Voelcker-Rehage, et al. Neurosci Biobehav Rev 2013
Cardio-fitness as a long-term modulator of cognition Hotting, et al. Brain Sci. 2012
Combining physical activity and cognitive task training Holzschneider, et al. Neuroimage 2012
Hotting, et al. Neurosci Biobehav Rev 2013
Hotting, et al. Neurosci Biobehav Rev 2013
Brain health across the lifespan - Structure: Volume Voelcker-Rehage, et al. Neurosci Biobehav Rev 2013
Physical exercise and brain volume Killgore, et al. Sci Rep 2013
Physical exercise and neurotrophins across the lifespan Factors Brain-derived neurotrophic factor (BDNF) Nerve growth factor (NGF) Insulin-like growth factor (IGF) Adolescents Pareja-Galeano, et.al. J Musculoskelet Neuronal Interact 2013, and older adults (cardio-training) Voss, et al. Brain Behav Immun 2013 and elderly women (resistancetraining) Coelho, et al. Arch Gerontol Geriatr 2012
Neuroplasticity in MS Functional reorganization Adaptive change in regional brain function in response to insult Begins early in the disease process CIS and early RRMS functional reorganization more centralized to primary brain regions responsible for initial loss of function (i.e. primary sensorimotor) Pantano, et al. Brain 2002 As MS progresses reorganization becomes increasingly maladaptive and more widespread including bilateral (secondary) brain regions Rocca, et al. Neurology 2002 Spontaneous reorganization is neither consistent nor complete
Physical exercise and brain health in MS White, et al. Sports Med 2008
2006 WHO statement Rehabilitation should start as soon as possible after the diagnosis of a neurological disorder or condition... and should focus on the community rehabilitation perspective it is important to recognize that rehabilitation efforts in the community can be delivered by professionals outside the health sector, ideally in collaboration with rehabilitation professionals. World Health Organization. Neurological Disorders: public health challenges Chapter 2: Global burden of neurological disorders: estimates and projections 2006. http://www.who.int/mental_health/neurology/neurodiso/en/index.html. Accessed April, 2014.
Why proactive? Why ASAP!? Stay ahead of the advancing disability curve Maintain/improve brain health Neural protection Brain plasticity Manage and/or prevent comorbidities
Scalfari, et al. Neurology 2011
Disability as a function of age Physical, cognitive and participation related disability advances with age Giordano Eur J Neurol 2013 Scalfari, et al. Neurology 2011
Why proactive? Why ASAP!? Stay ahead of the advancing disability curve Maintain/improve brain health Neural protection Brain plasticity Manage and/or prevent comorbidities
Cardio-training: neuroplasticity & cognitive Leavitt, et al. Neurocase 2013
Physical exercise and neurotrophic factors Bansi, et al. Mult Scler 2013
Why proactive? Why ASAP!? Stay ahead of the advancing disability curve Maintain/improve brain health Neural protection Brain plasticity Manage and/or prevent comorbidities
Physical activity and comorbidities Chronic pain Sullivan, et al. Curr Pain Headache Rep 2012 Cardiorespiratory fitness Motl, et al. Acta Neurol Scand 2011 Bone health Mojtahedi, et al. J Rehabil Res Dev. 2008
Physical activity and coexistence of CVD Motl, et al. Neuroepidemiology 2011
2006 WHO statement Rehabilitation should start as soon as possible after the diagnosis of a neurological disorder or condition... and should focus on the community rehabilitation perspective it is important to recognize that rehabilitation efforts in the community can be delivered by professionals outside the health sector, ideally in collaboration with rehabilitation professionals.
Extending to the community, how? Goal: to provide long-term follow-up care Partner with recreation and fitness centers exercise specialists Salback, et al. J Phys Act Health 2013 American College of Sports Medicine (ACSM) certifications Health & Fitness Clinical Exercise Specialist Multiple Sclerosis Certified Specialist(s) trained/ coached Telerehabilitation Rogante, et al. J Telemed Telecare 2006
Conclusion MS Rehabilitation needs to shift from reactive and short-term to proactive, early and long-term Primary basis for shift Spontaneous brain recovery inefficient and incomplete Becoming more apparent with progression of disease & age Effects of physical activity and brain health Taking advantage of improving knowledge of brain function & structure: anticipate the subclinical! Comorbidities Consequences of the disease, of the progressing disability (worsened by inactivity) Extending beyond the clinic Partnering with exercise specialists in the community = major enhancement of long-term efforts
Conclusion MS Rehabilitation needs to shift from reactive and short-term to proactive, early and long-term Primary basis for shift Spontaneous brain recovery inefficient and incomplete Becoming more apparent with progression of disease & age Effects of physical activity and brain health Taking advantage of improving knowledge of brain function & structure: anticipate the subclinical! Comorbidities Consequences of the disease, of the progressing disability (worsened by inactivity) Extending beyond the clinic Partnering with exercise specialists in the community = major enhancement of long-term efforts
Conclusion MS Rehabilitation needs to shift from reactive and short-term to proactive, early and long-term Primary basis for shift Spontaneous brain recovery inefficient and incomplete Becoming more apparent with progression of disease & age Effects of physical activity and brain health Taking advantage of improving knowledge of brain function & structure: anticipate the subclinical! Comorbidities Consequences of the disease, of the progressing disability (worsened by inactivity) Extending beyond the clinic Partnering with exercise specialists in the community = major enhancement of long-term efforts
Conclusion MS Rehabilitation needs to shift from reactive and short-term to proactive, early and long-term Primary basis for shift Spontaneous brain recovery inefficient and incomplete Becoming more apparent with progression of disease & age Effects of physical activity and brain health Taking advantage of improving knowledge of brain function & structure: anticipate the subclinical! Comorbidities Consequences of the disease, of the progressing disability (worsened by inactivity) Extending beyond the clinic Partnering with exercise specialists in the community = major enhancement of long-term efforts
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