Effects of aerobic, resistance, and combined exercise training on health-related quality of life in multiple sclerosis: Systematic review and meta-analysis

Factors Associated with Physical Activity Among People with Multiple Sclerosis in Jordan: Which Clinical Characteristics are Important?

BackgroundPhysical activity (PA) enhances mental and physical functioning of people with multiple sclerosis (PwMS). Yet, PwMS often do not engage in sufficient PA in the Middle East region.ObjectiveTo explore PA-associated factors according to The International Classification of Functioning, Disability and Health (ICF) framework among PwMS in Jordan.MethodsA cross-sectional study was conducted on 97 PwMS. PA levels were measured using The International Physical Activity Questionnaire (IPAQ). Potential associated factors with PA were determined using the ICF framework. Multiple linear regression was used to identify the factors that explain IPAQ's total score.ResultsThe Mean age of the participants was 36.09 years (SD = 10.9), 71.7% females. IPAQ was negatively associated with disease severity, history of falling, fatigue, family social support, and participation in social activities (P < 0.05). Anxiety levels and participation in instrumental activities of daily living were positively associated with IPAQ (P < 0.05).ConclusionsThe study suggests that factors contributing to PA levels in PwMS in the Middle East are multifactorial. A comprehensive rehabilitation plan that addresses those factors is essential to enhance PA levels in this population. Further research is needed to understand the clinical, personal, and cultural factors associated with PA among PwMS in the Middle East.

Internet-based exercise and physical activity promotion for persons with multiple sclerosis: a randomized controlled trial

BACKGROUND

We evaluated the effects of a 12-week internet-based exercise and physical activity promotion program for persons with multiple sclerosis.

METHODS

We performed a multicenter, randomized, waitlist-controlled study. The intervention group (IG) received the 12-week program, followed by 12 weeks with usual care. The control group (CG) received usual care only. The main components of the 12-week program were: (1) a tailored home-based exercise prescription, (2) e-learning resources, (3) telephone and video meetings with an exercise therapist, (4) the provision of a consumer-based PA monitor. Measurements were taken at baseline, postintervention, and after 24 weeks. The primary outcome was device-measured steps/day. Other outcomes were device-measured moderate-to-vigorous physical activity, subjectively measured leisure-time and transportation physical activity and sport/exercise, physical activity-related health competence, walking ability, quality of life, fatigue, depression, and PA-related self-concordance. We compared changes from baseline to postintervention between groups and analyzed changes in the IG during the follow-up.

RESULTS

Analysis of 56 persons with multiple sclerosis (IG: n = 29, CG: n = 27, age: 45.6 ± 10.9) revealed no significant intervention effect on steps/day. However, significant improvements were observed in moderate-to-vigorous physical activity, sport/exercise, control competence, fatigue, and quality of life (physical). During the follow-up, sport/exercise and quality of life decreased significantly. Leisure-time and transportation physical activity increased significantly.

CONCLUSIONS

Our study provides first evidence that the developed program can increase control competence, aspects of physical activity and health in persons with multiple sclerosis. A trial with a larger sample is recommended to confirm our results and examine intervention mechanisms.

TRIAL REGISTRATION

Registry: Clinicaltrials.gov; registration number: NCT04367389; date of registration: 2020-04-21 (retrospectively registered).

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.

Physical Activity in Multiple Sclerosis: Real-World Data From Saskatchewan, Canada

BACKGROUND

Physical activity guidelines for multiple sclerosis (MS) were first published in 2013. Physical activity is safe and beneficial in MS, yet it is unclear if physical activity levels are changing in real-world settings.

METHODS

The primary objective of this study is to determine if the physical activity levels of people with MS are changing. Between September 1, 2014, and February 22, 2022, when people first accessed a provincial MS drugs program in Saskatchewan, Canada, they were invited to complete the Godin Leisure-Time Exercise Questionnaire by mail. Scatter plots of total physical activity (TPA) and health contribution (HC) scores were generated from each person's questionnaire. Multivariable linear regression explored associations and interactions between disease-modifying treatment (DMT), sex, age, age at MS onset, and disease duration on physical activity level.

RESULTS

The response rate was 50.8% (505 responses from 993 requests). Of the respondents, 69.7% were female; the mean age was 42.8 (± 11.5) years; median MS disease duration was 6.0 years (IQR, 2.0-14.0); and 47.4% had prior DMT exposure. There was no significant change in physical activity levels of new registrants over 7 years (regression slopes TPA: 0.71, P = .26; HC: 0.61, P = .21). Men reported higher physical activity levels than women (TPA: β = 11.95; P < .001; HC: β = 6.65; P < .001). There were interactions between age and disease duration on activity scores (TPA: β = 0.03; P = .003; HC: β = 0.03; P < .001). DMT exposure was not associated with physical activity.

CONCLUSIONS

Physical activity levels of people with MS remained suboptimal for health benefits over a 7-year period. Future research should include how to use physical activity guidelines to impact real-world activity levels.

Advancements and Challenges in Exercise Training for Multiple Sclerosis: Comprehensive Review and Future Directions for Randomized Controlled Trials

Exercise training represents a health behavior for the treatment and management of the multi-faceted manifestations of multiple sclerosis (MS). This paper provides a comprehensive overview of evidence from randomized controlled trials (RCTs) regarding benefits, safety, participation, and guidelines for exercise training in MS, based on systematic reviews and meta-analyses. The paper then provides our opinions based on extensive experience regarding challenges for improving and expanding future RCTs that will advance our understanding of exercise training in MS. The comprehensive review of evidence from RCTs indicates that exercise training yields substantial improvements in aerobic and muscle fitness, mobility, fatigue and depression, quality of life, and participation outcomes. There is a non-significant increase in the risk of adverse events or serious adverse events with exercise training compared with control conditions or healthy populations. Rates of adherence and compliance with exercise training (i.e., participation) approximate 80% and 70%, respectively. The current prescriptive guidelines suggest 2-3 days per week of aerobic and resistance exercise training as the minimal dose for safely benefiting from exercise training in MS. We propose 10 important topics as avenues for expanding the body of research and improving its scope for evidence-based practice in MS. Overall, the research on exercise training in MS is strong, but it can get stronger. The expansion and advancement of evidence are critical for moving exercise training into the clinical armamentarium of MS disease treatment and management.

Non-invasive brain stimulation enhances the effect of physiotherapy for balance and mobility impairment in people with Multiple Sclerosis

BACKGROUND

Impairment of balance and gait is common in Multiple Sclerosis (MS). Non-invasive Brain Stimulation techniques are promising adjuncts to physical therapy to improve disability.

OBJECTIVE

To determine if combining transcranial direct current stimulation (tDCS) with conventional exercise therapy enhances balance and mobility in people with multiple sclerosis (PwMS) compared to exercise alone.

METHODS

In a double-blind randomised controlled trial, PwMS were randomised into a real or sham tDCS group. All patients received individualized exercise treatment. Twelve sessions of real (intensity 2mA, bipolar) or sham tDCS was administered over the primary motor area for 20 minutes followed by one hour of physiotherapy focusing on balance, strength, and mobility, twice a week for six weeks. Outcome measures included balance (Berg Balance Score), mobility (10m Walk Test), fatigue (Fatigue Severity Scale) and quality of life (Multiple Sclerosis Quality of Life - 54) performed 1 week before intervention, at week 7 (1-week post-intervention), and at six months post-intervention. Falls questionnaire was completed 1 week before intervention and at 6 months post-intervention. Generalised linear mixed model analysis was used to compare outcomes at different time points within groups (before and after exercise treatment) and between groups (sham vs real stimulation groups).

RESULTS

Forty participants (mean age 54 and mean EDSS 3.5) were randomly allocated to receive real (n=19) or sham (n=21) stimulation, with 36 completing the post-intervention (real 17, sham 19) and 32 completing the 6-month assessments (real 15, sham 17). All participants had significantly improved balance and mobility scores post exercise treatment (within groups comparison, p<0.05). Between groups comparison found a small but significant improvement in the Berg Balance Score (mean improvement 1.9 and 2 points, p <0.05) and 10-metre Walk Test (mean improvement of 0.09 and 0.11m/s, p <0.05) in the real tDCS group compared to the sham group after six weeks of training and at six months follow-up, respectively. There was no benefit in fatigue, falls and QOL scores in the real stimulation group compared to the control group.

CONCLUSION

Our results suggest that the addition of tDCS prior to exercise treatment provides a significant improvement in walking speed and balance in people with MS which lasts longer, compared to exercise alone. Further study is needed to optimize the use of this relatively inexpensive and well tolerated device for rehabilitation.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trial Registry (ACTRN12628001836224).

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.

Identifying Preferences for Exercise and Sport in Australians With Mild Multiple Sclerosis: Looking Beyond Clinical Characteristics when Implementing Exercise Interventions

OBJECTIVE

Exercise is a salient component in delaying disability progression in multiple sclerosis (MS). This study considers personal preferences regarding exercise program prescription and the resources needed to facilitate exercise.

DESIGN

Cross-sectional study.

SETTING

Community online, Australia.

PARTICIPANTS

Adults with MS.

INDEPENDENT VARIABLES

Participants completed online questionnaires on current exercise and sport, and preferences toward exercise prescription variables, facilitative resource needs, and delivery method.

MAIN OUTCOMES

We established preference responses for the entire sample, and separately, we used logistic regression and analysis of variance to compare preferences between participants stratified according to (1) geographical rurality (ie, metro vs rural and remote) and (2) current exercise engagement (ie, active, moderately active, and insufficiently active).

RESULTS

Fifty people with a diagnosis of MS completed the survey. Participants had mild disability; most were metro-dwelling (74%) and physically active (58%). Preferences included a program of at least 6 months (70%), where exercise sessions are performed 5 d/wk (38%) at a moderate intensity (50%). Half (50%) of responders wanted to participate in sports for exercise. There was a significant difference in the preference toward higher-intensity exercise in active persons compared with inactive persons. Facilitative resources selected included a behavioral exercise coach (80%) who provides MS-specific information (46%) and behavioral change strategies (41%).

CONCLUSIONS

Persons with mild MS are interested in participating in various exercises and sports. Encouraging participation will have long-term benefits. We recommend that HCPs and researchers consider individual social factors, in addition to patient symptoms and disability, when designing exercise programs for an Australian MS population.

The meaning of health to persons aging with longstanding multiple sclerosis

Understanding how persons aging with a chronic condition view their health is essential for planning and delivering person-centered care. The purpose of this study was to explore how persons aging with the chronic and disabling condition multiple sclerosis (MS) describe their health and how this has changed over time using data from Years 1 to 26 of an ongoing longitudinal survey study of health promotion and quality of life for persons with MS. The survey included measures of perceived meaning of health, self-rated health, health behaviors and quality of life outcomes. The sample included 168 persons with MS who returned the survey at Time 1 (1996) and again at Time 26 (2022). In 2022, participants had a mean age of 70.13 (SD = 8.19) and had been diagnosed with MS for an average of 34.47 years (SD = 6.27). Sixty percent of participants rated their overall health as good or excellent. Decreases in health self-ratings over time were not significant. Participants consistently agreed more strongly with items reflecting a wellness-oriented view of health than those reflecting a more clinical/biomedical model. At both time points, clinical definitions of health were negatively related and wellness definitions were positively related to reported frequency of health behaviors. Findings suggest that persons aging with the chronic condition of MS may be more responsive to health messages that emphasize function in daily living, carrying out normal responsibilities, and adjusting to changes in environment and demands. Patient or Public Contribution: Persons with MS provided study data, input on design, and construct measurement.

Predictors of six-month change in health-related quality of life in people with multiple sclerosis: A secondary data analysis of a randomized controlled trial

BACKGROUND

Symptomatic treatment in people with multiple sclerosis (pwMS) requires multidisciplinary rehabilitation to alleviate disease progression and increasing health-related quality of life (HRQoL). However, the participant- and disease-specific factors that predict sustained improvement in HRQoL in pwMS undergoing inpatient rehabilitation remain unclear. Identifying these factors can help individually tailor inpatient rehabilitation programmes. Therefore, the aim of this study was to identify factors of pwMS at clinic entry for a three-week multidisciplinary inpatient rehabilitation that predict the change in physical and mental HRQoL over six months.

METHODS

This is a secondary data analysis of a randomized controlled trial (NCT04356248) conducted at the Valens Rehabilitation Centre, Switzerland. HRQoL was assessed with the Medical Outcome Study 36-item Short Form Health Survey (SF-36) at clinic entry (T0; baseline) and six months after (T3; six-month follow-up). Data for 99 pwMS (mean age in years: 49.60 ± 10.17 SD, mean Expanded Disability Status Scale (EDSS) score: 4.62 ± 1.33 SD, 68.7 % female) were analysed using multiple linear regression. Outcome variables were six-month change in SF-36 Physical (ΔPCS) and Mental Component Scale (ΔMCS) scores. Predictor variables included baseline scores of PCS or MCS, fatigue, anxiety, depressive mood, cardiorespiratory fitness (V̇O2peak/kg), self-efficacy, smoking status, education level, age, EDSS, sex, time since diagnosis and MS phenotype.

RESULTS

The regression model with ΔPCS as outcome variable explained 18.6 % of the variance of the ΔPCS score (p = .003). Lower PCS score (p < .001) and lower depressive mood (p = .032) at baseline predicted higher ΔPCS score. The regression model with ΔMCS as outcome variable explained 26.8 % of the variance of the ΔMCS score (p < .001). Lower MCS score (p < .001) and longer time since diagnosis (p = .048) at baseline predicted higher ΔMCS score.

CONCLUSION

PwMS with lower physical HRQoL and better mood at clinic entry improved most in physical HRQoL over six months. PwMS with lower mental HRQoL and longer time since diagnosis at clinic entry improved most in mental HRQoL over six months. The results of this study contribute to the development of individualized rehabilitation programmes with the aim of maintaining and/or improving HRQoL of pwMS beyond the inpatient rehabilitation stay.

Impact of dance classes on motor and cognitive functions and gut microbiota composition in multiple sclerosis patients: Randomized controlled trial

Evidence suggests that multiple sclerosis (MS) induces a decline in motor and cognitive function and provokes a shift in gut microbiome composition in patients. Therefore, the aim of the study was to explore the effect of dance classes on the motor and cognitive functions and gut microbiota composition of MS patients. In this randomized controlled trial, 36 patients were randomly divided into two groups: the experimental group (n = 18) and the passive control group (n = 18). Supervised rock and roll and sports dance classes were performed for 12 weeks at a frequency of two times a week. Before and after the intervention, fecal samples were taken and the motor and cognitive function assessments were completed. Fecal microbiota were categorized using primers targeting the V3-V4 region of 16S rDNA. Our results revealed significant differences in mobility performance (T25-FWT), attention and working memory (TMT B), and finger dexterity (9-HPT) within the experimental group. Furthermore, we reported favorable shifts in gut microbial communities (an increase in Blautia stercoris and a decrease in Ruminococcus torques) within the experimental group. In conclusion, our randomized control trial on the effects of 12-week dance classes in MS patients found significant improvements in motor and cognitive functions, with further moderate influence on gut microbiota composition.

No immediate change in systemic cytokines following an eccentric muscle training session in people with multiple sclerosis

Background

Eccentric muscle contractions elicit distinct physiological responses, including modulation of the cytokine profile. Although relevant for rehabilitation, the effect of eccentric muscle training on the immune system has never been investigated in multiple sclerosis (MS).

Objectives

Examine the immediate cytokine response of interleukin-4 (IL-4), IL-6, IL-10, IL-17a, interferon-gamma, and tumor necrosis factor-alpha after a moderate eccentric training session in individuals with MS. Additionally, further investigate the association between systemic cytokine levels at rest and clinical measures of mobility and lower limb functional strength.

Design

Observational study.

Methods

The first session included blood sampling for baseline cytokine measures. Subsequently, the participant completed a battery of clinical assessments related to mobility and lower limb strength, that is, the Timed-Up-and-Go Test, Five-Repetition-Sit-to-Stand-Test (5STS), Four-Square-Step-Test, and Two-Minute-Walk-Test. The second session included the eccentric exercise training session, followed by a second blood sampling to assess the acute cytokine response to the eccentric training bout. This session comprised 10 exercises concentrating on the strength of the trunk and lower extremities.

Results

Twenty-seven people with MS (pwMS), with a mean age of 40.1 years, participated in the study. No difference was demonstrated in the cytokine concentration values between baseline and immediately after the eccentric training session. The 5STS explained 30.3% of the variance associated with interferon-gamma, 14.8% with IL-4, and 13.8% with IL-10.

Conclusion

An eccentric training bout does not impact cytokine concentration in the blood and, consequently, does not boost a pro-inflammatory response, thus, it can be performed on pwMS in a rehabilitation setting.

Effects of the powerball® system on muscle strength, coordination, fatigue, functionality and quality of life in people with multiple sclerosis. A randomized clinical trial

INTRODUCTION

Although clinical and functional impairments in the lower limbs have been extensively studied in patients with MS, the upper limb (UL) are also frequently affected. Clinical impairment of the UL in patients with MS is very common with muscle strength and hand dexterity as critical factors in maintaining functional activities that are the basis for independence and quality of life in people with MS.

OBJECTIVE

To investigate the effects of a training protocol using the Powerball® system in combination with conventional physiotherapy on muscle strength, coordination, fatigue, functionality, and quality of life in persons with MS over an 8-week period.

MATERIALS AND METHODS

A double-blind randomized controlled trial was conducted. The control group received conventional treatment, while the experimental group received additional UL training using the Powerball® system. Both groups received the same number of sessions and weeks of intervention. The following outcome measures were used: isometric grip and pinch strength, Box and Block Test (BBT), Nine Hole Peg Test (NHPT), Abilhand scale, Fatigue Severity Scale (FSS), Multiple Sclerosis Impact Scale (MSIS-29), and Likert satisfaction questionnaire for the experimental group. All measures were administered at baseline, after the treatment, and during a 3-week follow-up period.

RESULTS

25 patients completed the study (12 in the experimental and 13 in the control group). The experimental group showed significant improvements in coordination and manual dexterity of the more affected UL as measured by the BBT comparing pre- to post-treatment (p = 0.048) and pre-treatment to follow-up (p = 0.001), and on the less affected UP comparing pre-treatment to follow-up (p < 0.001) and post-treatment to follow-up (p = 0.034). The Likert-type satisfaction questionnaire obtained a mean score of 89.10 (± 8.54) out of 100 points.

CONCLUSIONS

Upper limb treatment protocol using the Powerball® system, in combination with conventional physiotherapy for 8 weeks resulted in significant improvements in the intra-group analysis for UL coordination and manual dexterity in favor of the experimental group. The experimental group showed excellent satisfaction to the treatment.

Effects of a Remote Multimodal Intervention Involving Diet, Walking Program, and Breathing Exercise on Quality of Life Among Newly Diagnosed People with Multiple Sclerosis: A Quasi-Experimental Non-Inferiority Pilot Study

Background

Interventions involving diet, physical activity, and breathing exercises are shown to be beneficial in managing both fatigue and quality of life (QoL) related to MS; however, the impact of such interventions among people newly diagnosed with clinically isolated syndrome (CIS) or relapsing-remitting multiple sclerosis (RRMS) who decline disease-modifying therapies (DMTs) is unknown.

Methods

A 12-month prospective quasi-experimental non-inferiority trial recruited people newly diagnosed with CIS or RRMS who voluntarily declined DMTs (health behavior group; HB, n = 29) or followed standard of care (SOC, n = 15). Participants in the HB group were remotely coached on the study diet, moderate-intensity walking, and breathing exercises. All participants completed questionnaires validated to assess MS symptoms, including perceived mental and physical QoL (MSQOL54); fatigue (Fatigue Severity Scale, FSS; and Modified Fatigue Impact Scale, MFIS); mood (Hospital Anxiety and Depression Scale, HADS); and cognitive function (Perceived Deficits Questionnaire, PDQ).

Results

During the 12 months, the HB group experienced improvement in scores for mental QoL (MSQOL54 - Mental, 0.24, 95% CI 0.01, 0.47; p = 0.04), fatigue (Total MFIS, -7.26, 95% CI -13.3,-1.18; p = 0.02), and perceived cognitive function (Total PDQ, PDQ-Attention, PDQ-Promemory, and PDQ-Planning, p ≤ 0.03 for all). A between-group difference was observed only for PDQ-Planning (p = 0.048). Non-inferiority analysis revealed that the 12-month changes in means for the HB group were not worse than those for the SOC group with respect to fatigue (FSS, p = 0.02), mood (HDS-Anxiety, p = 0.02; HADS-Depression, p < 0.0001), physical QoL (MSQOL54 - Physical, p = 0.02), or cognitive dysfunction (Total PDQ, p = 0.01).

Conclusion

The multimodal lifestyle intervention for individuals newly diagnosed with CIS or RRMS, who voluntarily decline DMTs, did not yield patient-reported outcomes worse than those observed in the SOC group regarding perceived mental quality of life, mood, fatigue, and cognitive function.

Trial Registration

clinicaltrials.gov identifier: NCT04009005.