[Drug & Ther Perspect 15(8):7-9, 2000. © 2000 Adis International Limited]
Multiple sclerosis (MS), an inflammatory demyelinating disease of the CNS, is a chronic illness with an unpredictable course. For many years, patients with MS have been advised to avoid exercise because of excessive fatigue and thermosensitivity. However, with appropriate planning, patients with MS can gain a number of benefits from an exercise programme, at least in the short term. These benefits include:
Thermosensitivity Limits Exercise...
Many patients with MS are thermosensitive, and often experience worsening of symptoms on exposure to heat or during physical exercise. In particular, patients with thermosensitivity can develop neurological symptoms, such as blurring of vision, when they exercise. Temporary clinical worsening can occur in patients with MS as increases of 0.5°C in body temperature can slow and ultimately block nerve impulse conduction in demyelinated fibres. Moreover, patients with MS may be more susceptible to temperature-induced conduction block because of impaired ability to regulate body temperature due to dysautonomia.
...As Can Severe Fatigue
Fatigue in patients with MS frequently interferes with performance of daily activities and, along with motor and sensory symptoms, results in decreased mobility and reduced quality of life. Fatigue can be so severe that, although there is no demonstrable weakness of lower extremities at rest, after walking a short distance the patient may develop a limp. With additional walking, complete paralysis of hip flexion may result and leave the patient unable to walk.
Start with Careful Assessment
Before prescribing a physical activity programme, a patient with MS
should be assessed to determine their specific abilities and limitations.
Assessment allows classification of the patient with MS into a functional
category (see Table 1).
A brief exercise history including usual daily activities should be obtained. The specific effect of MS on physical abilities such as ambulation, balance, coordination and strength must also be assessed. This description places current activities in proper perspective and helps to define patient expectations as well as awareness of loss. An assessment of cardiopulmonary function and a graded exercise test should be performed, and possibly an appraisal of muscular fitness.
Results not Always Clear Cut
Functional assessment of a patient with MS is complicated by weakness, spasticity, ataxia and lack of coordination. Furthermore, a test at rest may indicate normal function, although the individual later exhibits abnormal fatigue, conduction block or other symptoms such as spasticity or lack of coordination after only brief exercise or exposure to heat. An individual with MS may fit into 1 category for upper extremity function and be classified completely differently for lower extremity function.
Individualise the Exercise Prescription
Classification of function is helpful in designing an individualised exercise programme where exercises are selected to coincide with a given functional level (see Table 1). In designing the programme, muscular fitness and physical activity can be considered separately, although the 2 are not necessarily mutually exclusive.
When muscular fitness is considered, patients with considerable disability may be limited to passive range of motion exercises whereas those with little or no motor deficit can participate in an integrated strength training programme (see Table 2). Similarly for physical activity, performance of activities of daily living may be adequate exercise for patients with limited function. At the other end of the scale, highly functioning patients may be able to undergo structured aerobic training (see Table 3).
For individuals who are heat sensitive, exercise should be planned to avoid overheating. Pre-exercise cooling can significantly enhance exercise and reduce subjective feelings of fatigue. Prior to exercise, a tepid bath should be prepared to which cool water is added. Cooling the lower half of the body in gently agitated water for 20 to 30 minutes is effective in preventing core temperature increases above normal throughout 40 minutes of exercise and a subsequent 30-minute recovery period. The same bath can be used after exercise has been completed. The use of commercial cooling garments and evaporative cooling methods during physical activity may minimise the heat-related worsening of MS symptoms.
Allow for Special Needs
Patients with MS may benefit from exercise that improves balance and coordination such as Swiss ball exercises and T'ai Chi, although there is little research in this area. For individuals who are relatively unsteady or lacking in strength for these activities, balance and coordination drills may be done in a pool. In this environment, the patient will not fall or be injured if balance is lost and the support of the water will allow the accomplishment of movements that would be difficult on land. The benefits of water exercise include improved flexibility, posture, muscle tone and coordination.
Caution Needed During Exacerbations
The exercise programme may require modification or be temporarily discontinued during an exacerbation. Exercise should be discontinued if corticosteroid treatment is required.
Medications May Affect Performance
Many of the medications commonly prescribed for patients with MS can interfere with an exercise programme.[1,5] For example, drugs used to treat spasticity (including baclofen, dantrolene† and diazepam) cause muscle weakness at the dosages usually required to reduce symptoms of spasticity.
Individuals with fatigue and disability often lack motivation to exercise. Motivation can be improved by participation in an intensive programme offering rehabilitation, exercise, psychological support and total immersion in a proactive atmosphere in which people with disabilities feel comfortable and exercise is a pleasant experience. Physical activity for the purposes of pleasure should be emphasised.
Table 1. Functional classification of the multiple sclerosis population
|Severe motor disability|
|Motor function is lost so that certain activities of daily living are
no longer possible (e.g. inability to walk or transfer, unable to
dress or feed independently)
|Mild to moderate motor disability|
|Aids may be required for ambulation, a hemiparetic or
paraparetic syndrome may be present or there may be ataxia
|Normal with fatigue (with or without thermal sensitivity)|
|Fatigue may consist only of malaise or include a motor component
with a decrement in strength occurring with continued activity
|No fatigue or thermal sensitivity|
Table 2. Suggested activity to improve muscular fitness in patients
with multiple sclerosis (MS) with differing levels of disability a
|Passive range of motion exercises||Slow stretches applied initially, gradually increasing in rate and extent until maximum range is achieved||Minimise the development of contracture and maintenance of function|
|Active flexibility and resistive exercises||Muscle contraction performed against gravity only or with gravity eliminated, with the number of repetitions tuned to the level of fatigue||Maintenance of the strength necessary to carry out essential daily functions|
|Specific muscle strengthening exercises||Simple exercises that isolate specific areas of weakness. Can be performed with equipment such as stretch bands or sandbag weights||Strength improvement|
|Integrated strength training programme||Training of major muscle groups using weights that allow 10 to 12 repetitions through a full range of motion for 3 sets, with moderate fatigue at the end of the third set||Increased strength in complementary muscle groups and improved ability to integrate more complex movement patterns|
Table 3. Suggested physical activity for patients with multiple sclerosis
(MS) with differing levels of disability a
|Activities of daily living||Completion of motor tasks independently if possible and reasonableb||Avoidance of further functional losses|
|Built-in inefficiencies||Participation in increasingly active leisure activities and building in 'inefficiencies' (e.g. increasing walking activity by parking the car at the periphery of the carpark at the supermarket)||Preservation of function|
|Active recreation||Regular participation in recreational activities of moderate activity (e.g. walking, gardening)||Preservation of function and independence|
|Structured aerobic training programme||Aerobic exercise performed 3 or more times per week for 20 to 30 minutesc||Improved cardiovascular fitness and muscular strength, improved quality of life|
† Dantrolene is not available in Spain.
a Passive range of motion exercises would be suitable for a patient with MS with considerable motor disability; each additional level of physical activity indicates appropriate exercise for patients with progressively less disability.References
b Small increments in performance can result in a significant increase in energy expenditure and fitness.
c Some neurological symptoms may worsen during exercise but these resolve in less than an hour, or more rapidly with cooling.
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