Respiratory function in multiple sclerosis. Utility of clinical assessment of respiratory muscle function

Reliability and Minimal Detectable Change for Respiratory Muscle Strength Measures in Individuals With Multiple Sclerosis

BACKGROUND AND PURPOSE

The test-retest reliability and minimal detectable changes (MDCs) for respiratory muscle strength measures have not been determined in individuals with multiple sclerosis (MS). This study determined the test-retest reliability and MDCs for specific respiratory muscle strength measures, as well as their associations with health-related quality of life (HRQoL), disability, dyspnea, and physical activity level measures in this population. In addition, the study examined differences in respiratory muscle strength between different degrees of disability.

METHODS

Sixty-one individuals with MS attended 2 appointments separated by 7 to 10 days. Respiratory muscle strength was evaluated by maximal inspiratory and expiratory pressures (MIP/MEP), HRQoL by EuroQol-5D-5L (index and visual analog scale [EQ-VAS]), disability by the Expanded Disability Status Scale, dyspnea by the Medical Research Council scale, and physical activity levels by the International Physical Activity Questionnaire.

RESULTS

Respiratory muscle strength measures had excellent test-retest reliability (ICC ≥ 0.92). The MDC for MIP is 15.42 cmH 2 O and for MEP is 17.84 cmH 2 O. Participants with higher respiratory muscle strength (MIP/MEP cmH 2 O and percentage of predicted values) had higher HRQoL ( r = 0.54-0.62, P < 0.01, EQ-5D-5L index; r = 0.30-0.42, P < 0.05, EQ-VAS); those with higher expiratory muscle strength (cmH 2 O and percentage of predicted values) had lower levels of disability ( r ≤ -0.66) and dyspnea ( r ≤ -0.61). There were differences in respiratory muscle strength between different degrees of disability ( P < 0.01; d ≥ 0.73).

DISCUSSION AND CONCLUSION

Respiratory muscle strength measures provide excellent test-retest reliability in individuals with MS. MDCs can be interpreted and applied in the clinical setting. Low respiratory muscle strength can contribute to a poor HRQoL; specifically, expiratory muscle strength appears to have the strongest influence on disability status and dyspnea.

Anaesthetic management of people with multiple sclerosis

There is a lack of published guidelines on the management of patients with multiple sclerosis (MS) undergoing procedures that require anaesthesia and respective advice is largely based on retrospective studies or case reports. The aim of this paper is to provide recommendations for anaesthetists and neurologists for the management of patients with MS requiring anaesthesia. This review covers issues related to the anaesthetic management of patients with MS, with a focus on preoperative assessment, choice of anaesthetic techniques and agents, side-effects of drugs used during anaesthesia and their potential impact on the disease evolution, drug interactions that may occur, and the need to use monitoring devices. A systematic PubMed research was performed to retrieve relevant articles.

Impaired lung function in multiple sclerosis: a single-center observational study in 371 persons

INTRODUCTION

Abnormal lung function in people with multiple sclerosis (PwMS) could be considered as the result of muscle weakness or MS-specific structural central nervous system (CNS) abnormalities as a precipitant factor for the worsening of motor impairment or cognitive symptoms.

METHODS

This is a cross-sectional observational study in PwMS. Forced spirometry was conducted, and normative metrics of forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and the relation FEV1/FVC were calculated. Qualitative and quantitative brain magnetic resonance imaging (MRI) examinations were carried out.

RESULTS

A total of 371 PwMS were included in the study. Of those, 196 (53%) had RRMS, 92 (25%) SPMS, and 83 (22%) PPMS. Low FVC and FEV1 was present in 16 (8%), 16 (19%), and 23 (25%) of the patients in the RRMS, PPMS, and SPMS, respectively. PwMS with T2-FLAIR lesions involving the corpus callosum (CC) had a significantly higher frequency of abnormally low FVC and FEV1 (OR 3.62; 95% CI 1.33-9.83; p = 0.012) than patients without lesions in that region. This association remained significant in the RRMS group (OR 10.1; 95% CI 1.3-67.8; p 0.031) when the model excluded PPMS and SPMS. According to our study, for every increase of 1 z score of FVC, we observed an increase of 0.25 cm3 of hippocampal volume (β 0.25; 95% CI 0.03-0.47; p 0.023) and 0.43 cm3 of left hippocampus volume (β 0.43; 95% CI 0.16-0.71; p 0.002).

CONCLUSIONS

We observed an incremental prevalence of abnormally low pulmonary function tests that parallels a sequence from more early relapsing courses to long-standing progressive courses (RRMS to PPMS or SPMS).

Cardiopulmonary exercise testing in people with minimally impaired multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic demyelinating inflammatory disorder of the central nervous system that may affect respiratory system at the later stages of the disease. The aim of our study was to evaluate respiratory function and cardiopulmonary exercise testing in ambulatory without aid people with MS (pwMS), and to investigate quality of life parameters and fatigue in this population.

METHODS

25 pwMS and 16 healthy controls were included in this study. Pulmonary function tests were performed and were followed by proper cardiopulmonary exercise testing with the use of treadmill. Quality of life assessment was done with SF-36 questionnaire.

RESULTS

The mean age of the patient group was 38.4 ± 8.2 years. Spirometric values were within normal limits, and so did lung diffusion capacity, while maximal voluntary ventilation was reduced. In cardiopulmonary exercise testing the patient group showed impairment compared to control group. The statistically significant lower parameters were V'O2 peak, V'CO2 peak, RER, V'O2/kg peak, V'CO2/kg peak, oxygen pulse peak and V'E/V'CO2 slope. Moreover, there was a negative and statistically significant correlation between CPET values and BMI and MFIS, while there was a positive and statistically significant correlation with quality of life, evaluated by SF-36.

CONCLUSION

Our study showed that the main cardiopulmonary exercise testing parameters were affected in ambulatory pwMS, even without evidence of respiratory symptoms. Therefore, these people should be evaluated for pulmonary function compromise.

Respiratory issues in patients with multiple sclerosis as a risk factor during SARS-CoV-2 infection: a potential role for exercise

Coronavirus disease-2019 (COVID-19) is associated with cytokine storm and is characterized by acute respiratory distress syndrome (ARDS) and pneumonia problems. The respiratory system is a place of inappropriate activation of the immune system in people with multiple sclerosis (MS), and this may cause damage to the lung and worsen both MS and infections.The concerns for patients with multiple sclerosis are because of an enhance risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The MS patients pose challenges in this pandemic situation, because of the regulatory defect of autoreactivity of the immune system and neurological and respiratory tract symptoms. In this review, we first indicate respiratory issues associated with both diseases. Then, the main mechanisms inducing lung damages and also impairing the respiratory muscles in individuals with both diseases is discussed. At the end, the leading role of physical exercise on mitigating respiratory issues inducing mechanisms is meticulously evaluated.

Expiratory Muscle Strength Training in Multiple System Atrophy: A Pilot Study

Background

The effects of expiratory muscle strength training (EMST) has not yet been investigated in MSA patients.

Objective

The primary objective was to test the effects of EMST on expiratory muscle strength and voluntary peak cough flow (vPCF) in patients with multiple system atrophy (MSA). The secondary objective was to assess the suitability of the pulmonary dysfunction index as a tool for identifying MSA patients with expiratory muscle weakness and reduced voluntary peak cough flow.

Methods

This was an open label, non-controlled study, with an 8-week intensive home-based EMST protocol. The outcome measures included: maximal expiratory pressure (MEP) and vPCF. The sensitivity and specificity of the index of pulmonary dysfunction in the respiratory diagnostic process were assessed using receiver operating characteristic (ROC) analysis.

Results

Fifteen MSA patients were enrolled in the study. Twelve MSA patients completed the training period. After the training period, MEP significantly increased (P = 0.006). Differences in vPCF were not significant (P = 0.845). ROC analysis indicated that the overall respiratory diagnostic accuracy of the index of pulmonary dysfunction had an outstanding capability to detect patients at risk of less effective coughing and an acceptable capability of detecting patients with decreased expiratory muscle strength.

Conclusions

These findings indicate non-significant differences in vPCF after 8 weeks of EMST. The index of pulmonary dysfunction appears to be a promising prognostic screening tool for identifying altered cough efficacy in MSA patients. Test cut-offs may be used to select an appropriate respiratory physiotherapy technique.

Effect of eight weeks respiratory muscle training on respiratory capacity, functional capacity and quality of life on subjects with mild to moderate relapsing-remitting multiple sclerosis: A single-blinded randomized controlled trial

BACKGROUND

Multiple Sclerosis (MS) is a chronic inflammatory disease of the nervous system leading to muscle weakness, including the respiratory muscles that cause pulmonary complications, impair functional capacity, increased fatigue, and as a result decreases the quality of life.

AIM

The purpose of the present study is to examine the influence of 8 weeks of respiratory muscle training (RMT) on pulmonary function and respiratory muscle strength in MS patients.

METHODS

The present study was a single-blind, randomized controlled trial that was conducted on 36 (27 Female, 9 Male) relapsing-remitting MS patients who were definitively diagnosed by a neurologist and randomly were divided into intervention and control groups. Both groups were educated on lifestyle modification with an emphasis on regular physical activity. In addition, the intervention group was prescribed eight weeks of respiratory muscle training with a threshold resistance device, daily, twice a day for three sets of 15 repetitions per set. Maximal expiratory pressure (PImax), maximal expiratory pressure (PEmax), spirometric indices, functional tests (six-minute walk test, timed up and go test), fatigue questionnaire, and questionnaire of quality of life were assessed before and after trials.

RESULTS

A total of 36 patients (75% female; mean age 38.00(8.86) years; BMI 26.56(2.64) kg/m²) were included in the study. The strength of inspiratory and expiratory muscles, respiratory function, fatigue, and quality of life were significantly improved in the intervention group (p<0.005). In addition, there was a significant improvement in the rate of fatigue and quality of life in all their dimensions (p<0.005). Only in the six-minute walk test, no significant improvement was seen in the intervention group compared to the control group (p = 0.262).

CONCLUSION

Findings could help therapists to provide MS patients with more effective respiratory muscle training protocols to maximize the benefits of rehabilitation.

A Narrative Review of Respiratory Impairment, Assessment, and Rehabilitation in Multiple Sclerosis

<b><i>Background:</i></b> Respiratory impairment is a problem seen in people with multiple sclerosis (pwMS) from the early stages of the disease but not frequently recognized by clinicians until the later stages. It is seen in different ways, such as respiratory muscle weakness, change in pulmonary volumes, and decrease in cough efficiency. This situation has consequences affecting individuals’ physical fitness, participation in daily life, and quality of life. <b><i>Summary:</i></b> This review explains possible respiratory impairment mechanisms, related problems, assessment, and rehabilitation approaches in pwMS. <b><i>Key Messages:</i></b> It is recommended a comprehensive assessment of respiratory functions in pwMS regardless of the disease severity and stage. In addition, pulmonary rehabilitation and other exercises can have positive effects on the respiratory functions of pwMS. In future studies, specific training parameters should be determined for pwMS to achieve optimal benefits. There is also a need for studies that apply respiratory muscle training in pwMS who have a high disease severity and limited participation in the activities of daily living.

Pulmonary function testing in neuromuscular disease

Neuromuscular disorders frequently compromize pulmonary function and effective ventilation, and a thorough respiratory evaluation often can assist in diagnosis, risk assessment, and prognostication. Since many of these disorders can be progressive, serial assessments may be necessary to best define a trajectory of impairment or improvement with therapy. Patients with neuromuscular diseases may have few respiratory symptoms and limited signs of skeletal muscle weakness, but can have significant respiratory muscle weakness. A single testing modality may fail to elucidate true respiratory compromise, and often a combination of tests is recommended to fully evaluate these patients. Common tests performed in this population include measurement of flow rates, lung volumes, maximal pressures, and airways resistance. This review covers the major respiratory testing modalities available in the evaluation of these patients, emphasizing both the benefits and shortcomings of each approach. The majority of parameters are available in a standard pulmonary laboratory (flows, volumes, static pressures), although referral to a specialized center may be necessary to conclusively evaluate a given patient.

Urinary incontinence and impaired physical function are associated with expiratory muscle weakness in patients with multiple sclerosis

PURPOSE

Patients with multiple sclerosis (MS) with respiratory muscle weakness could have physical function impairments, given the functional/biomechanical link of the trunk stabilising system. Thus, clinicians could employ new treatment strategies targeting respiratory muscles to improve their physical function. This study pretends to evaluate the relationship between respiratory muscle strength, pulmonary function and pelvic floor function, and also to correlate these variables with physical function (gait function, disability and quality of life) in patients with MS.

METHODS

41 patients participated in this descriptive cross-sectional study. Respiratory muscle strength [maximal respiratory pressures (MIP/MEP)], pulmonary function (forced spirometry), pelvic floor function [urinary incontinence (UI)], physical function [Timed Up & Go (TUG) test, Barthel index and health status questionnaire (SF-12)] were evaluated.

RESULTS

Respiratory muscle strength and pulmonary function were moderately related to UI (MIP: rho = -0.312; MEP: rho = -0.559). MEP was moderately related to physical function (TUG: rho = -0.508; Barthel index: rho = 0.418). Patients with and without expiratory muscle weakness showed differences in UI, pulmonary and physical function.

CONCLUSION

Patients with MS with greater deterioration in pulmonary function and respiratory muscle strength, especially expiratory muscles, showed greater deterioration in UI and physical function. Expiratory muscle weakness had a negative impact on urinary, physical and pulmonary function.Implications for rehabilitationPulmonary function is associated with urinary incontinence and gait functionality in patients with multiple sclerosis (MS).Expiratory muscle weakness is associated with impaired urinary and physical function in patients with MS.The inclusion of respiratory muscle training to the rehabilitation programs of patients with MS could improve their pelvic floor disorders and physical function.

Effects of 12-week inspiratory muscle training with low resistance in patients with multiple sclerosis: A non-randomised, double-blind, controlled trial

BACKGROUND

Patients with multiple sclerosis (MS) have respiratory limitations like fatigue or muscle weakness. The aim of the study was to evaluate the effectiveness of a low-intensity protocol with inspiratory muscle training (IMT) to improve respiratory strength, spirometric parameters and dyspnea in patients with MS.

METHODS

This study was a controlled, non-randomised, double-blind trial on 67 patients with MS distributed in 2 groups, intervention group (IG) (n = 36) and respiratory exercise group (REG) (n = 31). Over 12 weeks, 5 days/week, 15 min/day all subjects followed a respiratory training program. IG trained with IMT with low resistance (20% maximum inspiratory pressure (MIP) during the first two weeks, 30% MIP after the second week). REG followed a program involving nasal breathing and maximum exhalation. Main outcome measured was inspiratory strength (MIP); secondary outcomes were maximum expiratory pressure (MEP), spirometry, dyspnea and health-related quality of life.

RESULTS

After respiratory training, the intervention group improved MIP, MEP, MVV, peak expiratory flow (PEF), tidal volume (TV) and dyspnea, 51%, 36%, 21%,11%, 51% and 19% respectively (p < .001, p < .001, p < .001, p < .05, p < .05, p < .05). The control group improved MIP, MEP, MVV and PEF, 24%, 27%, 28% and 12% respectively (p < .001, p < .001, p < .001, p < .05). Improvements achieved on MIP and dyspnea were significantly higher in IG patients (p=.002, p=.046, respectively).

CONCLUSION

12-week inspiratory muscle training with low resistance was more effective than conventional respiratory exercises to improve respiratory strength, spirometric parameters and dyspnea in patients with multiple sclerosis.

Evaluation of respiratory functions and quality of life in multiple sclerosis patients

The aim of this study was to evaluate respiratory muscle strength, respiratory functions and quality of life in multiple sclerosis (MS) patients and compare the results with the healthy volunteers. The study included a group of 24 patients diagnosed with MS (16 women, 8 men) with an EDSS score of ≤ 5, who were without clinical respiratory impairment. MS patients were compared with the healthy volunteer group (16 women, 8 men). Respiratory muscle strength and respiratory functions were evaluated with specific devices. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) parameters were measured for the muscle strength. Forced vital capacity (FVC), forced expiratory volume (FEV1), FEV1/FVC, peak expiratory flow, and forced expiratory flow (FEF_25-75) parameters were measured for the respiratory functions. Questionnaire SF-36 was applied to evaluate health-related quality of life. A total of 24 MS patients' respiratory function test results were compared with healthy volunteers and significant changes were found at MIP, MEP, and FEV1 parameters. Quality of life was compared between the groups and there was a significant difference in parameters related with physical performance and physical-health-related role limitations. There is an early involvement of the respiratory muscles in patients with MS, yet clinical symptoms appear in later stages. Respiratory functions should be evaluated at the earlier stage of the disease so that rehabilitation can be planned in order to reduce respiratory complications and improve the quality of life in patients.

Self-Reported Changes in Cognition, Communication and Swallowing in Multiple Sclerosis: Data from the Swedish Multiple Sclerosis Registry and from a National Survey

PURPOSE

The aim of this study was to investigate self-reported cognition, speech, communication and swallowing changes in a large sample of individuals with multiple sclerosis (MS) in Sweden. A second aim was to update information about speech and language pathology (SLP) services received by people with MS (pwMS).

METHOD

Self-ratings of cognition, speech/communication and swallowing registered by pwMS between 2012 and 2018 were retrieved from the Swedish MS Registry. In addition, more detailed information about speech, communication, swallowing and provision of SLP services was collected using an online survey distributed via a national patient organization.

RESULTS

In total, entries from 5,289 pwMS were retrieved from the MS Registry. Nearly two thirds of the respondents reported that cognition was affected to some degree, whereas approximately one third perceived some difficulties with speech/communication. A smaller group reported swallowing problems. The majority of those who reported problems with speech/communication also reported problems with cognition. Among the 440 individuals who responded to the MS survey, word-finding difficulties were the most frequently self-reported problem related to communication, and the second most common problem was getting off topic. In all, close to four out of five respondents experienced at least one symptom related to speech and communication, such as speech-related fatigue or imprecise articulation. Swallowing difficulties were reported by one out of four respondents in the MS survey. As a result of their speech difficulties, up to one in three experienced changes in professional or social roles and participation. A limited number of respondents had received SLP services, the most common intervention being voice training.

CONCLUSIONS

In MS, changes associated with cognition as well as speech/communication are frequent, cognitive-linguistic symptoms being the most common. Swallowing difficulties are also relatively prevalent. Access to SLP services seems to be insufficient compared to prevalence of perceived symptoms. Considering that the majority of pwMS are part of the working-age population, access to SLP services must be more highly prioritized and must address cognitive-linguistic problems as well as voice, speech and swallowing dysfunction.

Respiratory repercussions of neurological diseases and how best to manage them

Introduction: The high incidence of respiratory impairments in patients with neurological diseases is recognized, but the design, dosage, and effectiveness of interventions to manage them are seen as an ongoing challenge.Areas covered: This article summarizes the evidence regarding the respiratory impairments in major neurological diseases, and how to best manage them.Expert opinion: On the balance of available evidence, respiratory impairments are part of the clinical profile of neurological diseases including Multiple Sclerosis, Stroke, and Parkinson's Disease, acquiring more importance as the pathologies progress. It is recognized that knowledge gaps remain in some areas of relevance related to respiratory function and further research is required. When considering the therapeutic options, the respiratory training emerges as the approach with most evidence. However, important questions remain unsolved: what kind, how much, and how to best include respiratory interventions is uncertain. At present, respiratory programs also fail to include clinically relevant factors such as ambulation and trunk stability.

Pulmonary Function Testing in Neuromuscular and Chest Wall Disorders

Neuromuscular and chest wall disorders frequently compromise pulmonary function, and thorough respiratory evaluation often can assist in diagnosis, risk assessment, and prognosis. Because many of these disorders can be progressive, serial assessments are necessary to best define a trajectory of impairment (or improvement with therapy). This article covers the major respiratory testing modalities available in the evaluation of these patients, emphasizing both the benefits and shortcomings of each approach. Most parameters are available in a standard pulmonary laboratory (flows, volumes, static pressures), although referral to a specialized center may be necessary to conclusively evaluate a given patient.

Effects of multiple sclerosis on respiratory functions

Objectives: To measure respiratory functions of ambulatory patients with multiple sclerosis and compare the results with expected values from healthy general population data. Further, to study the correlation of respiratory function impairment with the multiple sclerosis-induced disability level.

Subjects: Thirty-eight patients with definite diagnosis of multiple sclerosis from the multiple sclerosis outpatient clinic.

Methods: The Expanded Disability Status Scale (EDSS) scores (mean 4.34±1.39) were evaluated to measure disability level. Respiratory functions tested in the laboratory included spirometric (FVC, FEV1, FEV1/FVC), maximal inspiratory (MIP) and expiratory (MEP) mouth pressure measurements. Patients were clinically assessed using a pulmonary dysfunction index (PDI) and dyspnoea index; various breathing features were also recorded.

Results: With respect to expected values from healthy general population, important decreases were found in mouth pressures with MIP (77%±23%, p ≃ 0) and MEP (60%±13%, p ≃ 0) while spirometric measures were significantly but less affected (FVC 94%±12%, p < 0.01, FEV191%±16%, p < 0.001). FEV1/FVC ratios were normal. Notable increases in PDI (5.58±0.68, p ≃ 0) and dyspnoea index (0.32±0.47, p ≃ 0) were observed. Significant relationships (p < 0.01) between respiratory function impairment and the multiple sclerosis disability level could be detected for FVC, MEP and PDI.

Conclusions: Multiple sclerosis clearly impairs respiratory functions; maximal mouth pressures are more severely reduced. This impairment increases with multiple sclerosis-induced disability level but is found to be independent from duration of disease.

Breathing-enhanced upper extremity exercises for patients with multiple sclerosis

Objective: To explore the effectiveness of breathing-enhanced upper extremity exercises on the respiratory function of patients with multiple sclerosis.

Design: Randomized controlled study of six-week duration.

Subjects: Forty patients with multiple sclerosis (age 39.2 ± 7 years; Kurtzke Expanded Disability Status Scale scores: 4.51 ± 1.55) randomly divided into two groups.

Methods: The training group followed a six-week home training programme designed to strengthen accessory respiratory muscles. Controls performed no exercises. All subjects submitted to baseline and post-training tests of spirometry, respiratory muscle strength and 6-minute walking. They were also assessed with pulmonary dysfunction and exertion fatigue indices.

Results: Spirometry revealed clear improvement in forced expiratory volume in 1 second (FEV1) (+13%, P = 0.003) resulting in higher FEV1/FVC (forced vital capacity) (+8.5%, P = 0.03). Maximal inspiratory pressure ( PImax) increased by +7.1% but not significantly. Maximal expiratory pressure ( PEmax) and FVC were significantly higher (by +7.1%, P = 0.0066 and +4.8%, P = 0.036 respectively) with respect to baseline measures. Pulmonary dysfunction was reduced (—9%, P = 0.002) while 6-minute walking distance was longer (+16%, P = 0.029) at equal exertion fatigue level.

Conclusions: The programme improved most pulmonary performance measures and had clinical significance. Its sustained application may prevent respiratory complications frequently observed in the later stages of multiple sclerosis.

T-cell activation and HLA-regulated response to smoking in the deep airways of patients with multiple sclerosis

Cigarette smoking is a risk factor for multiple sclerosis (MS), and the risk is further multiplied for HLA-DRB1*15(+) smokers. To define the smoke-induced immune responses in the lung we performed bronchoscopy with bronchoalveolar lavage (BAL) on smokers and non-smokers, both MS-patients and healthy volunteers. In the BAL, non-smokers with MS showed an increased preformed CD40L expression in CD4(+) T-cells while smokers displayed an increase in proliferating (Ki-67(+)) T-cells. In addition, our results confirm that smoking induces an increase of alveolar macrophages in BAL, and further defined a significant attenuation of this response in carriers of the HLA-DRB1*15 allele, in both MS patients and healthy controls. This first systematic investigation of the immune response in the lungs of smokers and non-smokers diagnosed with MS, thus suggests an MS-associated lung T-cell phenotype, involvement of a specific T-cell response to smoke, and a genetic regulation of the macrophage response.

Respiratory dysfunction in multiple sclerosis

Respiratory dysfunction frequently occurs in patients with advanced multiple sclerosis (MS), and may manifest as acute or chronic respiratory failure, disordered control of breathing, respiratory muscle weakness, sleep disordered breathing, or neurogenic pulmonary edema. The underlying pathophysiology is related to demyelinating plaques involving the brain stem or spinal cord. Respiratory complications such as aspiration, lung infections and respiratory failure are typically seen in patients with long-standing MS. Acute respiratory failure is uncommon and due to newly appearing demyelinating plaques extensively involving areas of the brain stem or spinal cord. Early recognition of MS patients at risk for respiratory complications allows for the timely implementation of care and measures to decrease disease associated morbidity and mortality.

Anesthetic management of a patient with multiple sclerosis undergoing cesarean section with low dose epidural bupivacaine

A 32-year-old Indian female 38 weeks pregnant, with a history of multiple sclerosis since 2008 was admitted in obstetric ward for safe confinement. She had a history of diminution of vision in both eyes and limb weakness, relapsing – remitting type with movement-induced muscle spasms, in all the four limbs. Her symptoms were usually diplopia, difficulty in vision and ataxic gait. Sh was then treated with methylprednisolone. She was on oral dimethyl fumarate trial, which was stopped at the beginning of pregnancy. Presently, she was completely asymptomatic. Epidural anesthesia with an indwelling catheter was administered with 15 ml of 0.25% bupivacaine in 5 ml increments. A total of 3 mg of epidural morphine was given for post-operative analgesia. The surgery evolved without any intercurrences and patient was discharged from the hospital 72 h after surgery without worsening of her symptoms. We report a safe anesthetic management of a patient with MS undergoing cesarean section with low dose epidural bupivacaine with the addition of morphine for post-operative analgesia.

Acute and chronic respiratory failure

Respiratory failure (RF) can be attributed to a plethora of neuromuscular diseases (NMDs) and manifests clinically in a multitude of overt or more subtle ways. The basic principles of pathophysiology, diagnosis and treatment of neurologic diseases and of RF apply concomitantly to this subset of patients. Various entities should be approached according to the latest evidence-based recommendations. Treatment follows the natural disease progression, from minimal respiratory assistance to mechanical ventilation (MV). A comprehensive treatment plan has to be formulated that takes into consideration the patient's wishes.

Pulmonary issues in patients with chronic neuromuscular disease

Patients with chronic neuromuscular diseases such as spinal cord injury, amyotrophic lateral sclerosis, and muscular dystrophies experience respiratory complications that are cared for by the respiratory practitioner. An organized anatomical approach for evaluation and treatment is helpful to provide appropriate clinical care. Effective noninvasive strategies for management of hypoventilation, sleep-disordered breathing, and cough insufficiency are available for these patients.

Early respiratory evaluation should be carried out systematically in patients with multiple sclerosis

The present study aimed at evaluating respiratory parameters in multiple sclerosis (MS). The sample comprised 30 patients with MS diagnosis and 30 healthy subjects, matched by gender and age. Neurological assessment, expanded disability status scale (EDSS), manovacuometry, and peak flow (PEF) were performed. Patients with MS had lower values of maximum inspiratory (MIP) and expiratory (MEP) pressures and PEF compared to healthy controls. It was shown that respiratory impairment may be present in MS patients with low functional disability by EDSS. The data suggest that manovacuometry and PEF determination should be carried out systematically in patients with MS, and may be a reliable tool for the early detection of respiratory impairment allowing early respiratory rehabilitation.

Lung volume recruitment in multiple sclerosis

Introduction

Pulmonary function abnormalities have been described in multiple sclerosis including reductions in forced vital capacity (FVC) and cough but the time course of this impairment is unknown. Peak cough flow (PCF) is an important parameter for patients with respiratory muscle weakness and a reduced PCF has a direct impact on airway clearance and may therefore increase the risk of respiratory tract infections. Lung volume recruitment is a technique that improves PCF by inflating the lungs to their maximal insufflation capacity.

Objectives

Our goals were to describe the rate of decline of pulmonary function and PCF in patients with multiple sclerosis and describe the use of lung volume recruitment in this population.

Methods

We reviewed all patients with multiple sclerosis referred to a respiratory neuromuscular rehabilitation clinic from February 1999 until December 2010. Lung volume recruitment was attempted in patients with FVC <80% predicted. Regular twice daily lung volume recruitment was prescribed if it resulted in a significant improvement in the laboratory.

Results

There were 79 patients included, 35 of whom were seen more than once. A baseline FVC <80% predicted was present in 82% of patients and 80% of patients had a PCF insufficient for airway clearance. There was a significant decline in FVC (122.6 mL/y, 95% CI 54.9–190.3) and PCF (192 mL/s/y, 95% 72–311) over a median follow-up time of 13.4 months. Lung volume recruitment was associated with a slower decline in FVC (p<0.0001) and PCF (p = 0.042).

Conclusion

Pulmonary function and cough decline significantly over time in selected patients with multiple sclerosis and lung volume recruitment is associated with a slower rate of decline in lung function and peak cough flow. Given design limitations, additional studies are needed to assess the role of lung volume recruitment in patients with multiple sclerosis.

The respiratory muscle capabilities of Jordanian patients with multiple sclerosis

The aim of this study was to evaluate the maximum expiratory pressure (MEP) and maximum inspiratory pressure (MIP) of Jordanian patients (19 females and 20 males) with multiple sclerosis (MS). A control group of 28 females and 26 males was included for the purposes of comparison. For the MS group, MIP results were as follows: female = 53.5 ± 36, male = 88.6 ± 40.9. MEP results were: female = 37.7 ± 13, male = 8.94 ± 30.3. The control group results were as follows: MIP female = 56.2 ± 43.8, male = 109.2 ± 49.8; MEP results were female = 70.9 ± 16.7, male = 115 ± 44.8). The control group results were as follows: MIP female = 56.2 ± 43.8, male = 109.2 ± 49.8; MEP results were female = 70.9 ± 16.7, male = 115 ± 44.8). In the patient group, there were significant differences between the two genders' MIP and MEP values (P=0.00). Significant differences were also found between the MS group and control group in MEP values (P=0.00) but not in MIP values (P=0.208). Possible psychosocial consequences of MS on Jordanian patients were measured using the Voice Handicap Index (VHI)-Arab with the following results for female patients: functional=7.3±6.9, physical=6.7±7.1, emotional=5±6.8, and total=19±19.7 and for male patients: functional=8.4±8.5, physical=9.8±9.3, emotional=9.6±11.4, and total=27.7±19.7. The VHI-Arab scores for female controls were as follows: functional = 5.1 ± 3.6, physical = 4.4 ± 2.9, emotional = 1.9 ± 2, and total = 11.4 ± 6.3). Male controls VHI-Arab scores were as follows: functional = 3.8 ± 3.4, physical = 5 ± 3.6, emotional = 1.2 ± 1.4, and total = 10.1 ± 6.2. Significant differences were found between the MS group and control group in the VHI-Arab functional domain (VHIF) (P=0.006), physical domain (VHIP) (P=0.006), emotional domain (VHIE) (P=0.00), and total score (VHIT) (P=0.00) values. In conclusion, MS can limit effective communication and may cause higher perception of voice handicap.

Voice-related quality of life in patients with multiple sclerosis

Objective. To investigate the voice-related quality of life in a group of patients with multiple sclerosis. Participants. A total of 87 subjects (59 MS subjects and 28 controls) participated in this study. Main Outcome Measures. Variables included presence or absence of phonatory symptoms, duration of the disease, the expanded disability status scale (EDSS), the severity of fatigue, and depression. All patients were asked to fill the Voice Handicap Index. Results. The average age was 35.47 years + 10.92 with 39% being males. The average duration of the disease was 77.93 months. The EDSS score was 1.94 + 1.84, the FSS score was 4.07 + 2.09, and the HRSD was 7.28 + 7.70. Only 7 subjects out of the 59 had vocal symptoms compared to 3 in the control group. There was no significant difference in the VHI total score between cases (5.9 + 15.5) and controls (5.4 + 8.2). There was a positive correlation between VHI total score, FSS score, and HRSD (P values of 0.011 and <0.01. Conclusion. The voice-related quality of life in MS is within normal with no disability.

Puzzling dyspnea caused by respiratory muscle weakness

Dyspnea is common in advanced stages of neuromuscular disorders, but it is infrequently the presenting symptom. However, dyspnea is a frequent complaint in a primary care setting but is rarely caused by a respiratory muscle weakness. Consequently, the diagnosis of respiratory muscle weakness often is delayed. First symptoms may occur when respiratory muscles are under increased load, such as when standing in the water higher than the chest, swimming, or in the supine position. We describe a patient in whom dyspnea was the first symptom of amyotrophic lateral sclerosis to remind clinicians of clinical features of respiratory muscle weakness and to help avoid the delay in diagnosis.

Six-minute walk test for persons with mild or moderate disability from multiple sclerosis: performance and explanatory factors

PURPOSE

The primary purpose of this study was to determine the extent to which health factors, functional measures, and pulmonary impairment explain performance on 6-Minute Walk Test (6MWT) distance in ambulatory persons with multiple sclerosis (MS). Another purpose was to determine the effect of disability and age on 6MWT performance and explanatory factors.

METHODS

A cross-sectional study design was used to evaluate factors that explain performance on the 6MWT in 64 community-dwelling persons with MS-related disability (Expanded Disability Status Scale [EDSS] 3.8±1.6). Of the 64 participants, 43 (67.2%) exhibited mild disability (EDSS <4.0) and 21 (32.8%) had moderate disability (EDSS 4.0-6.5). A regression analysis compared 6MWT performance to measures of health factors (EDSS, number of medications, number of comorbidities, resting HR, systolic and diastolic blood pressure [BP]); physical performance (functional stair test [FST], sit-to-stand test [SST], static standing balance [BAL], Fatigue Severity Scale [FSS], Activities-specific Balance Confidence [ABC] Scale); and pulmonary function (forced expiratory volume in 1 second [FEV(1)], forced vital capacity [FVC], maximal voluntary ventilation [MVV], maximal inspiratory pressure [MIP], maximal expiratory pressure [MEP]).

RESULTS

EDSS, ABC, FST, SST, BAL, MVV, MIP, and MEP were significantly associated with 6MWT distance after adjusting for age. Multiple step-wise linear regression analysis revealed that ABC, FST, and BAL were significant and independent explanatory factors of 6MWT distance. ABC and FST explained 75% of the variance in 6MWT performance (R(2)=0.75). Curvilinear regression analysis revealed that the FST is the most significant explanatory factor for 6MWT distance, explaining 79% of the variance (R(2)=0.79).

CONCLUSIONS

6MWT performance in persons with MS was explained by balance confidence (ABC) and stair-climbing ability (FST). The ABC and FST may be practical clinical measures for explaining walking ability and determining risk for disablement in persons with MS.

Effects of a 10-week inspiratory muscle training program on lower-extremity mobility in people with multiple sclerosis: a randomized controlled trial

Pulmonary muscle weakness is common in ambulatory people with multiple sclerosis (MS) and may lead to deficits in mobility function. The purpose of this study was to examine the effect of a 10-week home-based exercise program using an inspiratory muscle threshold trainer (IMT) on the results of four lower-extremity physical performance tests in people with MS. The study design was a two-group (experimental-control), pretest-posttest study. Outcome measures consisted of pulmonary function measures including maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and maximal voluntary ventilation (MVV), and the following lower-extremity physical performance measures: the 6-Minute Walk (6MW) distance, gait velocity (GV), the Sit-to-Stand Test (SST), the Functional Stair Test (FST), and a balance test (BAL). A total of 46 ambulatory participants (Expanded Disability Status Scale [EDSS] score, 2.0-6.5) with MS were randomly assigned to an intervention group (mean EDSS score, 4.1) that received 10 weeks of home-based inspiratory muscle training or a nontreatment control group (mean EDSS score, 3.2). Of the original 46 participants, 20 intervention group participants and 19 control group participants completed the study. Compared with the control group, the intervention group made significantly greater gains in inspiratory muscle strength (P = .003) and timed balance scores (P = .008). A nonsignificant improvement in 6MW distance (P = .086) was also noted in the IMT-trained group as compared with the control group. This is the first study directly linking improvement in respiratory function to improvement in physical performance function in people with mild-to-moderate disability due to MS.

Lower motor neuron loss in multiple sclerosis and experimental autoimmune encephalomyelitis

OBJECTIVE

Multiple sclerosis (MS) is considered a chronic inflammatory and demyelinating disease of the central nervous system. Evidence that axonal and neuronal pathology contributes to the disease is accumulating, however, the distribution of neuronal injury as well as the underlying mechanisms have not yet been fully clarified. Here, we investigated the role of neuronal cell loss in MS and its animal model, experimental autoimmune encephalomyelitis (EAE).

METHODS

We performed electrophysiological investigations in MS patients, including assessment of compound muscle action potentials and motor unit numbers and quantified neuronal cell loss in human MS samples and different EAE models by high-precision stereology.

RESULTS

Both electrophysiological and morphological analyses indicated a massive loss of lower motor neurons in MS patients. We regularly found dying spinal motor neurons surrounded by CD3+ (CD4+ as well as CD8+) T cells expressing tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). We observed a similar degree of damage and immune attack in different variants of EAE; the lower motor neurons were preserved in adoptive transfer EAE induced with TRAIL-deficient T lymphocytes.

INTERPRETATION

Our study indicates that damage to lower motor neurons and TRAIL-mediated inflammatory neurodegeneration in the spinal cord contribute to MS pathology.

Randomized control trial of effects of a 10-week inspiratory muscle training program on measures of pulmonary function in persons with multiple sclerosis

Pulmonary impairments have long been recognized as major causes of morbidity and mortality in individuals with advanced multiple sclerosis (MS). This study was designed to determine if a 10-week home exercise inspiratory training program in community-dwelling persons with MS improves pulmonary muscle strength and endurance. Forty-six ambulatory individuals with clinically diagnosed MS [Expanded Disability Status Scale (EDSS) 2.0-6.5, intervention group mean = 3.96 and control group mean = 3.36] were randomly assigned to an intervention group that received 10 weeks of inspiratory muscle strength training (IMT) or a nontreatment control group. Twenty-one subjects in the control group and 20 subjects in the intervention group completed the study. The intervention group demonstrated significantly greater improvement than the control group in maximal inspiratory pressure (P < 0.001). When compared to the control group, no significant differences were noted for maximal expiratory pressure or maximal ventilation volume after training in the intervention group. Baseline and postexercise training comparison of secondary pulmonary expiratory outcomes were significant in the intervention group for forced expiratory volume at one second (FEV1) (P = 0.014), forced vital capacity (FVC) (P = 0.041), and midexpiratory flow rate(FEF(25-75%)) (P = 0.011). No significant changes were noted for the control group. Thus, IMT significantly increased inspiratory muscle strength and resulted in generalized improvements in expiratory pulmonary function in persons with MS who have minimal to moderate disability. Future studies are needed that focus on the long-term effects of IMT with increased resistance and the impact it has on increasing pulmonary function and functional performance.

Perioperative care of patients with neuromuscular disease and dysfunction

A variety of different pathologies result in disease phenotypes that are summarized as neuromuscular diseases because they share commonalty in their clinical consequences for the patient: a progressive weakening of the skeletal muscles. Distinct caution and appropriate changes to the anesthetic plan are advised when care is provided during the perioperative period. The choice of anesthetic technique, anesthetic drugs, and neuromuscular blockade always depends on the type of neuromuscular disease and the surgical procedure planned. A clear diagnosis of the underlying disease and sufficient knowledge and understanding of the pathophysiology are of paramount importance to the practitioner and guide optimal perioperative management of affected patients.

Rééducation fonctionnelle et sclérose en plaques : une vue d’ensemble

Multiple sclerosis (MS) is a chronic progressive disease which is the leading cause, after road traffic accidents, of handicap in young subjects. The large range of symptoms associated with MS lead to continuing decline in mood and quality of life. Despite therapeutic advances, functional impairments have significant consequences. Neurorehabilitation can be highly contributive in this disease with the goals of increasing independence and quality-of-life and improving functional capacities. Individualized programs elaborated by a multidisciplinary team of experts are the key to success of rehabilitation. Assessment is difficult because of the underlying conflict between the philosophies of rehabilitation and evidence-based medicine. The aim of this paper is to provide an overview of MS rehabilitation. Physical exercise is safe and should be encouraged for people with MS. Some studies have shown that supervised exercises have a beneficial effect on MS disability and quality of life. Inpatient rehabilitation for MS yields short-term benefits in function, mobility and quality of life; periodic hospitalization may be needed. In the future, rehabilitation professionals will have to learn how to anticipate patient needs and lay the groundwork for services and equipment in advance. Rehabilitation is one of the treatments of MS patients and should be viewed as an ongoing process to maintain and restore maximum function and quality of life.

Pulmonary function in multiple sclerosis without any respiratory complaints

OBJECTIVES

Pulmonary complications in severe multiple sclerosis (MS) are often seen secondary to respiratory muscle dysfunction. The development of respiratory muscle dysfunction and its association with disability during the course of MS is unknown. In our study, we investigated the predictive value of respiratory muscle functions and the change in forced vital capacity (Delta forced vital capacity [FVC]; FVC upright-FVC supine) to detect deterioration of respiratory muscle functions in the early phase of MS.

PATIENTS AND METHODS

Twenty-one MS patients with a median age of 34.5+/-9.45 years were enrolled. Fourteen cases were relapsing-remitting, six were secondary progressive, one was primary progressive type. The mean duration of disease was 10.76+/-6.6 years. Seventeen healthy subjects with a median age of 40.7+/-7.6 years were chosen as a control group. Smoking habit was similar in both groups. Pulmonary function tests (PFT), lung volumes, diffusion, respiratory muscle function ( P(Imax) , P(Emax)), mouth occlusion pressure, and indirect sign of respiratory center function (P(0.1)) tests were performed. PFT were repeated in supine and upright positions.

RESULTS

Our results in the MS group and the control group, respectively, were: diffusion (DL(CO): 18.8+/-4.2 vs. 26.4+/-7.3 mL/mmHg/min), P(I(max) (82.1+/-26.3 vs. 109.1+/-23.3 cm H(2)O), P(E(max) (119.2+/-42 vs. 171.8+/-50.2 cm H(2)O), P(0.1) (2.6+/-0.7 vs. 4.2+/-0.7). All parameters were lower in the MS group compared with the control group (p<0.05). In the MS group, FVC values in the upright position were higher than FVC values in the supine position. The difference in FVC values in MS patients between the upright and supine positions (Delta FVC) was also found to be significantly higher than in the control group (Delta FVC 262.3+/-247.6 (MS), 98.8+/-179.1 mL (CONTROL)) (p<0.01).

CONCLUSION

Our results indicate the presence of pulmonary dysfunction in MS even in the absence of any respiratory symptoms.

Cardiopulmonary and metabolic functions, aerobic capacity, fatigue and quality of life in patients with multiple sclerosis

OBJECTIVES

The objectives of this study were to evaluate cardiopulmonary and metabolic functions in patients with multiple sclerosis (MS) and to clarify the relationship between these functions and neurological deficits, respiratory involvement, fatigue and quality of life.

MATERIALS AND METHODS

Twenty-five patients with MS and 15 healthy controls were included in the study. Cardiopulmonary and metabolic responses to maximum exercise were investigated with an electronically braked arm crank ergometer. A computerized gas analysis system collected and analysed expired gases during exercise.

RESULTS

In the present study, significant respiratory muscle weakness, and decreased aerobic performance and cardiopulmonary and metabolic responses to maximum exercise were determined in patients with MS.

CONCLUSIONS

As respiratory muscle function plays a strong role in aerobic capacity and in most of the cardiopulmonary and metabolic responses to exercise, measurement of respiratory muscle strength and endurance should also be carried out in the MS population.

Six-minute walk distance as a measure of functional exercise capacity in multiple sclerosis

PURPOSE

We hypothesised that six-minute walk (6MWT) distance of patients with ambulatory multiple sclerosis (MS)would differ from age-matched healthy control subjects. We also investigated the contribution of demographic, physical and physiological factors to impaired functional capacity in MS.

METHOD

Thirty MS patients and 30 healthy subjects participated in this study. Respiratory muscle strength was measured. Pulmonary function test and 6MWT were performed. The Barthel Index (BI) was used to assess activities of daily living, and the Modified Ashworth Scale was used to determine spasticity. Symptomatic fatigue was measured using the Fatigue Severity Scale (FSS).

RESULTS

Pulmonary function and respiratory muscle strength of ambulatory MS patients were significantly lower, and baseline heart rate and fatigue perception were significantly higher than were healthy controls (p < 0.05). MS patients reached a significantly higher exercise heart rate, and walked significantly shorter distance than did healthy subjects (p < 0.05). The BI score, baseline heart rate and FSS score together accounted for 81 percent variance in 6MWT distance of MS patients (p < 0.05).

CONCLUSION

The shorter distance covered during a 6MWT is determined by the limitations in activities of daily living,resting heart rate and subjective symptomatic fatigue in ambulatory patients with MS. Respiratory muscle weakness, lung function and level of neurological impairment do not contribute to impaired functional exercise capacity in these patients.

Spiroergometric and spirometric parameters in patients with multiple sclerosis: are there any links between these parameters and fatigue, depression, neurological impairment, disability, handicap and quality of life in multiple sclerosis?

One-hundred and twelve patients with multiple sclerosis were selected as population-based sample and examined on impairment (Expanded Disability Status Scale), disability (Barthel Index), handicap (Environment Status Scale), the quality of life (Multiple Sclerosis Quality of Life), fatigue (Modified Fatigue Impact Scale), depression (Beck Depression Inventory Score), respiratory function (spirometric parameters on spirometry) and physical fitness (spiroergometric parameters on a bicycle ergometer). The aim of the study was to examine and analyse (descriptive statistics) spiroergometric and spirometric parameters in patients with multiple sclerosis. Firstly, we tested the hypothesis whether spiroergometric and spirometric parameters are decreased and whether there are any correlations between these parameters and measures of impairment, depression, disability, handicap and quality of life. Secondly, we tested the hypothesis whether there is any correlation between a possible deconditioning and fatigue, and between a possible respiratory dysfunction and fatigue in multiple sclerosis. It results from this study that many spiroergometric parameters in patients with multiple sclerosis are significantly lowered in comparison to the population norm. A link can be found between some spiroergometric parameters and neurological impairment, disability, handicap and quality of life. It is not possible to prove any correlation between spiroergometric parameters and depression. From the spirometric parameters, these are expiratory flows that are significantly lowered in MS patients. It is not possible to prove any correlation between spirometric parameters and fatigue, depression, neurological impairment, duration of the disease, disability, handicap and quality of life in multiple sclerosis.

Disorders of the respiratory muscles

The act of breathing depends on coordinated activity of the respiratory muscles to generate subatmospheric pressure. This action is compromised by disease states affecting anatomical sites ranging from the cerebral cortex to the alveolar sac. Weakness of the respiratory muscles can dominate the clinical manifestations in the later stages of several primary neurologic and neuromuscular disorders in a manner unique to each disease state. Structural abnormalities of the thoracic cage, such as scoliosis or flail chest, interfere with the action of the respiratory muscles-again in a manner unique to each disease state. The hyperinflation that accompanies diseases of the airways interferes with the ability of the respiratory muscles to generate subatmospheric pressure and it increases the load on the respiratory muscles. Impaired respiratory muscle function is the most severe consequence of several newly described syndromes affecting critically ill patients. Research on the respiratory muscles embraces techniques of molecular biology, integrative physiology, and controlled clinical trials. A detailed understanding of disease states affecting the respiratory muscles is necessary for every physician who practices pulmonary medicine or critical care medicine.

Multiple sclerosis and anesthetic implications

PURPOSE OF REVIEW

Multiple sclerosis remains prevalent among young women in the United States of America. It is a disease of the central nervous system that possesses many anesthetic implications. Anesthesia providers need to understand this disorder and its multiple anesthetic ramifications.

RECENT FINDINGS

Recent work has provided more insight into the etiology of multiple sclerosis, its pathogenesis, diagnosis and natural history. A number of new medications have also been added to the therapeutic armamentarium. Optimal anesthetic care entails a thorough preoperative evaluation, medication history and neurologic examination, intraoperative awareness of conditions that may precipitate attacks and lead to potentially life-threatening complications, as well as postoperative attention to respiratory and other risks. Recommendations for management are based on information from small retrospective studies and anecdotal reports.

SUMMARY

In summary, our aim is to provide an updated view of multiple sclerosis from the perspective of perioperative care, emphasizing interactions between the disease, surgery and anesthesia.

Effects of a short-term exercise training program on aerobic fitness, fatigue, health perception and activity level of subjects with multiple sclerosis

Multiple sclerosis (MS) patients of an inpatient rehabilitation program have been randomly assigned to an exercise training (MS-ET) or nontraining group (MS-NI). Before and after 4 weeks of aerobic exercise training, a graded maximal exercise test with measurement of gas exchange and a lung function test was administered to all 26 patients fulfilling the inclusion criteria. Activity level, fatigue and health perception were measured by means of questionnaires. Twenty-six healthy persons served as control group and were matched in respect of age, gender and activity level. Training intervention consisted of 5x30 min sessions per week of bicycle exercise with individualised intensity. Compared with baseline, the MS training group demonstrated a significant rightward placement of the aerobic threshold (AT) (VO2+13%; work rate [WR])+11%), an improvement of health perception (vitality+46%; social interaction+36%), an increase of activity level (+17%) and a tendency to less fatigue. No changes were observed for the MS-NI group and the control groups. Maximal aerobic capacity and lung function were not changed by either training or nontraining in all four groups. Overall compliance to the training program was quite low (65%), whereas incidence of symptom exacerbation by physical activity has been lower than expected (6%).