Participant characteristics of existing exercise studies in persons with multiple sclerosis - A systematic review identifying literature gaps

Outdoor walking exercise therapy improves walking capacity and well-being in persons with multiple sclerosis: A randomized controlled trial

BACKGROUND

While outdoor walking exercise therapy could likely elicit multiple beneficial effects in persons with multiple sclerosis (pwMS), little evidence exists.

OBJECTIVE

To evaluate the effects of a 7-week group-based outdoor walking exercise therapy intervention on walking capacity and mental well-being as well as additional outcomes in pwMS.

METHODS

In this randomized controlled trial, n = 62 ambulatory pwMS (49/62, 79% females; 51 years [range, 27-68 years]), patient-determined disease steps 1.7 (range, 0-4) were assigned to either a WALK group (a 'personalized' program suited to the starting level of each participant, including one continuous and one intermittent supervised walking session per week at moderate-to-high intensity) or a CONTROL group (continuation of habitual lifestyle). Tests were carried out at baseline (Pre) and after the intervention (Post). Walking capacity included 6-minute walk test (6MWT; primary outcome), timed 25-foot walk test (T25FWT), and six spot step test (SSST). Walking fatigability indexes were calculated from 6MWT data. Patient-reported outcomes included 12-item MS Walking Scale (MSWS), modified fatigue impact scale (MFIS), 7-item falls efficacy scale-international (FES-I), World Health Organization five well-being index (WHO5; main secondary outcome), and 0-100 visual analogue scale health-related quality of life (HR-QoL).

RESULTS

Across the 7-week intervention period, n = 17 (5/17, 27%) pwMS dropped out. No adverse events were reported. Across all WALK sessions, 78% of the time was spent on forest/gravel trails. Substantial between-group changes were observed (beneficial changes in WALK vs no changes in CONTROL) in 6MWT (mean change [95% CI]; +41 m [22;60]; deemed clinically relevant), T25FWT (+0.27 [0.15;0.39] m/s), SSST (-0.80 [-1.33;-0.27] s), WHO5 (+7.3 [0.1;14.5] points), MSWS (-5.1 [-9.2;-1.0] points), MFIS (-6.7 [-11.7;-1.7] points), FES-I (trend; -0.8 [-1.7;0.1] points), and HR-QoL (trend; +5.3 [-2.3;12.9] points). In contrast, walking fatigability indexes remained unaffected.

CONCLUSIONS

Outdoor walking exercise therapy elicited multiple beneficial effects in pwMS, especially evidenced by improvements in walking capacity and mental well-being.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05415956.

A head-to-head comparison of the effects of aerobic versus resistance training on physical capacity and physical function in people with multiple sclerosis: Results from the MSBOOST trial

BACKGROUND

Exercise is a safe and effective way to improve physical function in people with multiple sclerosis (PWMS).

OBJECTIVES

This study aimed to perform a head-to-head study of the effects of aerobic and resistance training on physical capacity and physical function.

METHODS

A multicentre randomized controlled trial with 150 participants was conducted. Participants were randomized into 12 weeks of either aerobic training (AT; n = 62), resistance training (RT; n = 57), or usual care (UC; n = 31). The primary outcome was physical function (measured as a composite score of the 6-minute walk test and five-time sit-to-stand). Secondary outcomes were aerobic capacity (VO2peak), maximal muscle strength (MVC), and self-reported walking ability.

RESULTS

Participants had a mean age of 45.5 (8.8), an expanded disability status scale (EDSS) of 2.8 (1.5), and 75% were female. Physical function did not increase in AT versus UC 0.08 [-0.16; 0.33] (mean (95% CI)) nor in RT versus UC 0.09 [-0.15; 0.34].VO2peak increased in AT versus UC by 4.1 [2.0; 6.3] mL O2/min/kg and in AT versus RT by 2.7 [1.1; 4.3], but not in RT versus UC 1.4 [-0.6; 3.5]. MVC increased in RT versus UC by 0.25 [0.01; 0.48] Nm/kg, but not in RT versus AT 0.17 [-0.02; 0.36] or AT versus UC 0.08 [-0.16; 0.31]).

CONCLUSION

AT and RT elicited improvements in physical capacity in PWMS. However, these improvements only moderately translated into improvements in physical function.Clinicaltrials.gov (NCT04913012)https://clinicaltrials.gov/study/NCT04913012.

Implications of maximal muscle strength and aerobic capacity for lower extremity physical function in people with multiple sclerosis-a cross-sectional study

Background

Multiple sclerosis (MS) is characterized by impairment of physical function that is often linked to neuromuscular and cardiovascular deficits. However, the specific contributions of muscle strength and aerobic capacity to physical function in MS are not fully understood.

Objective

This study aimed to investigate the independent roles of maximal muscle strength (MVC) and aerobic capacity (VO2peak) on lower extremity physical function, as measured by the 6-minute walk test (6MWT) and five-time sit-to-stand test (5STS) in people with MS (pwMS).

Methods

In a cross-sectional study, 150 pwMS underwent assessment of VO2peak, maximal voluntary contraction (MVC), and physical function (6MWT and 5STS). Regression analyses were conducted to explore the associations between physiological parameters and physical function.

Results

MVC and VO2peak were moderately associated with (i.e., explained) 6MWT (R² = 0.40, p < 0.001), yet with VO2peak (β = 7.9, std. β = 0.45, p < 0.001) having a preferential influence compared to MVC (β = 48.2, std. β = 0.26, p < 0.001). MVC and VO2peak were weakly associated with (i.e., explained) 5STS (R² = 0.14, p < 0.001), yet with MVC (β = 0.06, std. β = 0.28, p = 0.004) having a preferential influence compared to VO2peak (β = 0.00, std. β = 0.16, p = 0.101).

Conclusion

Both maximal muscle strength and aerobic capacity to physical function in pwMS. Maximal muscle strength was preferentially linked to performance in the 5STS test, whereas aerobic capacity was preferentially linked to performance in the 6MWT. These findings support the need for tailored exercise interventions to target specific physiological deficits during MS rehabilitation.

Exercise as a Therapeutic Intervention in Multiple Sclerosis

The role of exercise as a therapeutic intervention in multiple sclerosis (MS) has shifted over time. Early views surrounding exercise in MS advocated for caution against participation. With increasing evidence, perspectives shifted to promote exercise as a therapeutic approach for symptom management. Recent efforts have focused on understanding the potential disease-modifying effects of exercise in MS, although this work is still in its infancy. While efforts continue to optimize exercise prescriptions and unravel underlying mechanisms of exercise effects, current knowledge and implementation gaps limit the accessibility of exercise as therapy for all people living with MS. This topical review is based on an invited presentation on 'Exercise as a Therapeutic Intervention in MS' delivered at the ACTRIMS Forum 2024. The review summarizes current evidence for the role of exercise as a therapeutic intervention in MS from symptomatic to disease-modifying potential. We highlight directions for future research efforts to advance our understanding of potential exercise benefits and translate findings into real-world contexts for people living with MS.

Exercise as medicine in Parkinson's disease

Parkinson's disease (PD) is an incurable and progressive neurological disorder leading to deleterious motor and non-motor consequences. Presently, no pharmacological agents can prevent PD evolution or progression, while pharmacological symptomatic treatments have limited effects in certain domains and cause side effects. Identification of interventions that prevent, slow, halt or mitigate the disease is therefore pivotal. Exercise is safe and represents a cornerstone in PD rehabilitation, but exercise may have even more fundamental benefits that could change clinical practice. In PD, the existing knowledge base supports exercise as (1) a protective lifestyle factor preventing the disease (ie, primary prevention), (2) a potential disease-modifying therapy (ie, secondary prevention) and (3) an effective symptomatic treatment (ie, tertiary prevention). Based on current evidence, a paradigm shift is proposed, stating that exercise should be individually prescribed as medicine to persons with PD at an early disease stage, alongside conventional medical treatment.

Study protocol: effects of exercise booster sessions on preservation of exercise-induced adaptations in persons with multiple sclerosis, a multicentre randomised controlled trial-the MS BOOSTER trial

INTRODUCTION

Multiple sclerosis (MS) causes a broad range of symptoms, with physical function being one of the most disabling consequences according to patients themselves. Exercise effectively improves lower extremity physical function. Nonetheless, it is unknown which exercise modality is most effective and it remains challenging to keep persons with MS adhering to exercise over a longer period. Therefore, the present study aims to investigate how exercise booster sessions (EBS) influence the sustainability of exercise-induced effects on physical function, and furthermore, to investigate which exercise modality (aerobic training or resistance training) is most effective in terms of improving physical function.

MATERIALS AND METHODS

This study is a multi-arm, parallel-group, open-label multicentre randomised controlled trial investigating the effects of EBS. Participants (n=150) are initially randomised to 12 weeks of either resistance training+usual care, aerobic training+usual care or usual care. After 12 weeks of intervention, participants in the exercise groups will again be randomised to either EBS+usual care or usual care during a 40-week follow-up period. The primary outcome is physical function (composite score based on 6-min walk test and five-time sit to stand), and the secondary outcomes are fatigue, cognition, physical activity, symptoms of depression and quality of life.

ETHICS AND DISSEMINATION

The study is approved by the Central Denmark Region Committees on Health Research Ethics (1-10-72-237-21) and is registered at the Danish Data Protection Agency (2016-051-000001) and at Clinicaltrials.gov (NCT04913012). All study findings will be published in scientific peer-reviewed journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04913012.

Physical fitness moderates the association between brain network impairment and both motor function and cognition in progressive multiple sclerosis

BACKGROUND

Neurodegeneration leads to continuous accumulation of disability in progressive Multiple Sclerosis (MS). Exercise is considered to counteract disease progression, but little is known on the interaction between fitness, brain networks and disability in MS.

OBJECTIVE

The aim of this study to explore functional and structural brain connectivity and the interaction between fitness and disability based on motor and cognitive functional outcomes in a secondary analysis of a randomised, 3-month, waiting group controlled arm ergometry intervention in progressive MS.

METHODS

We modelled individual structural and functional brain networks based on magnetic resonance imaging (MRI). We used linear mixed effect models to compare changes in brain networks between the groups and explore the association between fitness, brain connectivity and functional outcomes in the entire cohort.

RESULTS

We recruited 34 persons with advanced progressive MS (pwMS, mean age 53 years, females 71%, mean disease duration 17 years and an average walking restriction of < 100 m without aid). Functional connectivity increased in highly connected brain regions of the exercise group (p = 0.017), but no structural changes (p = 0.817) were observed. Motor and cognitive task performance correlated positively with nodal structural connectivity but not nodal functional connectivity. We also found that the correlation between fitness and functional outcomes was stronger with lower connectivity.

CONCLUSIONS

Functional reorganisation seems to be an early indicator of exercise effects on brain networks. Fitness moderates the relationship between network disruption and both motor and cognitive outcomes, with growing importance in more disrupted brain networks. These findings underline the need and opportunities associated with exercise in advanced MS.