Multiple+Sclerosis+Prognosis


 * For a patient with Multiple Sclerosis, how does therapeutic exercise affect their functional outcomes? **

Multiple Sclerosis Systematic Review Multiple Sclerosis Progression Physical Activity Exercise Therapy Multiple Sclerosis AND physical therapy What is Multiple Sclerosis (MS)?
 * Search Terms: **
 * Background **
 * Pathophysiology (1,3)
 * MS is a chronic, neurological disorder characterized by the progressive demyelination of neurons in the spinal cord and cranial nerves
 * Demyelination can interfere with conduction of motor, sensory, and autonomic fibers
 * Etiology unknown -genetic and environmental factors
 * Early - lesions develop on the nerves and demyelination occurs in the white matter of the CNS
 * Later - plaques form with larger areas of demyelination
 * Risk Factors (1, 13)
 * Females twice as likely than males
 * Age 20-40
 * Family history
 * Infections (Epstein-Barr)
 * Race (Caucasian, Northern European descent most common)
 * Location: more common in the US, Canada, New Zealand, Southeastern Australia, and Europe
 * Thyroid disease, Type 1 Diabetes, Inflammatory Bowel Disease
 * Smoking

Diagnosis / Signs & Symptoms (5,9,3)
 * Visual (typically presents first)
 * Optic Neuritis-painful, single eye vision loss
 * Diplopia -double vision
 * Amblyopia - vision loss in one eye b/c of disturbance between the brain and the eye, also commonly known as lazy eye
 * Motor
 * Trunk / limb weakness
 * Spasticity
 * Hyperreflexia
 * Gait Disturbance
 * Balance Problems
 * Sensory
 * Lhermitte’s Sign - electric shock like pain that runs down arms and legs
 * “MS Hug” - constant feeling of tightness around chest and ribs
 * Proprioception deficits
 * Heat intolerance
 * Cerebellar
 * Tremor
 * Ataxia
 * Uncoordinated movement
 * Genitourinary
 * Urgency
 * Incontinence
 * Impotence
 * Neuropsychiatric
 * Impairments with memory, cognition, attention
 * Anxiety
 * Other
 * Vertigo
 * Fatigue
 * The disease process has exacerbations and remissions (3) and varies in effects, severity, and progression. (1)
 * Radiographic imaging
 * MRI’s can detect lesions on neurons [[image:kumc-ptrs-ebp/a50979777ca8e3_new-enhancing-lesions.jpg width="346" height="214" align="right"]]
 * Cerebrospinal Fluid (14)
 * Immunoglobulin G (IgG) elevated - reflect the autoimmune activation
 * Oligoclonal bands - segments of the myelin damage

McDonald Diagnostic Criteria for Multiple Sclerosis (9)

Prognosis and Progression of MS (14,6) media type="youtube" key="9vIBFDpj4wk" width="560" height="315"
 * Seldom fatal and life expectancy is shortened by only a few months.
 * 15 years after onset of MS
 * 20% patients are bedridden or institutionalized
 * 20% require an assistive device for ambulation (wheelchair, crutches, cane)
 * 60% ambulatory without assistance and with little deficit
 * ⅓ of all patients with MS go through life without any persistent disability, and suffer only intermittent, transient episodes of symptoms
 * Relapses are the most detrimental of the complications that come with MS

Inclusion/Exclusion Criteria (2):
 * Effects of Therapeutic Exercise **
 * Had to include at least 1 of the following:
 * Fitness, mobility, fatigue, or health related quality of life (HRQOL)
 * Both randomized and nonrandomized controlled designs were included

__ Fitness (2) __ For more exercise ideas, see: __ [] __
 * Physical capacity
 * Aerobic capacity
 * Defined as maximal oxygen consumption (VO2max)
 * Pertinent for cardiovascular health, functional independence, fatigue resistance, brain health, and quality of life.
 * Moderate-intensity physical activity is effective at improving the aerobic capacity in patients with MS.
 * Power output
 * Defined as peak power output
 * Impacts the ability to effectively perform daily functions. (ex: walking and climbing stairs)
 * Muscular strength
 * Improvements in strength can impact mobility, balance, ADLs, and reduce fatigue.
 * Increased bone health and metabolism result from gains in lean muscle mass.
 * Resistance training:
 * Weight machines, free weights, resistance bands
 * Resistance bands have been shown to be effective in increasing upper body strength, but not lower body strength. However, resistance bands do increase lower extremity fatigue resistance.

__ Mobility (2) __ media type="youtube" key="SemXuZkUW-U" width="560" height="315"
 * One of the most common impairments in MS is gait impairments. Gait is also used to track disease progression over time.
 * Measured by:
 * 6-minute walk test, Timed 25-Foot Walk, Timed Up and Go
 * Test walking endurance, speed, and agility.
 * Gains in aerobic capacity and muscular strength can translate into improved gait.
 * Leg extensor power was found to be a significant predictor of mobility problems in seniors (11)

__ Fatigue __
 * Most common and disabling symptom (4) (2)
 * Significantly impacts daily function.
 * Measured by self-reporting questionnaires:
 * Fatigue Severity Scale, Fatigue Impact Scale, Modified Fatigue Index Scale, Short-Form Health Survey-36 vitality subscale, Profile of Mood States energy and fatigue subscales, Multiple Sclerosis Quality of Life-54 energy subscale.
 * Resistance training interventions may be most effective for fatigue reduction. Although, more research is needed to determine the optimal dose.

__ Health-related quality of life __
 * Compatible with World Health Organization definition of health, “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (4) (2)
 * Health-related quality of life is compromised in patients with MS compared to patients with other chronic diseases along with the general population.
 * Due to:
 * Age of diagnosis
 * Unpredictable and unstable nature of disease
 * Absence of disease-modifying therapy.
 * Improving the following may improve quality of life in patients with MS:
 * Fatigue, depression, self-efficacy, social support, and disability status.
 * Motivation is a big factor for these pt’s because they are nervous they are going to have harmful side effects from the exercise (8)
 * Measured by self-reporting measures:
 * Short-form Health Survey-36, Multiple Sclerosis Quality of Life-54, Multiple Sclerosis Impact Scale, Hamburg Quality of Life Questionnaire in Multiple Sclerosis, and the Multiple Sclerosis Quality of Life Inventory


 * Therapeutic exercise for positive functional outcomes **
 * Training characteristics (2)
 * Historically, MS patients have been advised to avoid physical activity due to thermosensibility and elevated body temperature. (7)
 * Supervised training vs. Home-based exercise programs:
 * Greater improvements are seen with supervised training compared to a single home-based training program.
 * Individuals less likely to modify training programs to ensure adequate workload progression. This is essential for adaptation.
 * We now know that several bouts of training per week can be tolerated by adults with MS.
 * Focus of training programs should be on ongoing participation.
 * Training Dosage (2,10)
 * Aerobic exercise:
 * 2-3 x/week for 30-60 minutes of moderate intensity
 * Reported significant increases in aerobic capacity (VO2max) after 5 weeks of training.
 * 3 x/week for 45 minutes of moderate intensity cycling (10)
 * Reported significant short term and long term improvements in fatigue, quality of life, and exercise capacity at 3 months of training (ST) and at 6 months (LT)
 * Power output:
 * Studies have reported improved power output from:
 * Cycle ergometry (leg or combined leg/arm) on 2+ days/week for 30-60 minutes at moderate intensity.
 * Combination training with cycle ergometry and plyometrics for 60 minutes at moderate intensity 2x/week
 * Resistance training:
 * 20 weeks, 2-3 x/week, intensity of 10-12 RM
 * Weight machines, free weights, and resistance bands

** References: ** 1. Smirnova, Irina. (2016). Neurologic Disorders. [PowerPoint slides 64-70]. Retrieved from [].

2. Latimer-Cheung, A. E., Pilutti, L. A., Hicks, A. L., Ginis, K. A., Fenuta, A. M., Mackibbon, K. A., & Motl, R. W. (2013). Effects of Exercise Training on Fitness, Mobility, Fatigue, and Health-Related Quality of Life Among Adults With Multiple Sclerosis: A Systematic Review to Inform Guideline Development. Archives of Physical Medicine and Rehabilitation,94(9), 1-32. doi:10.1016/j.apmr.2013.04.020

3. Baker, N. A., & Tickle-Degnen, L. (2001). The Effectiveness of Physical, Psychological, and Functional Interventions in Treating Clients With Multiple Sclerosis: A Meta-Analysis. American Journal of Occupational Therapy,55(3), 324-331. doi:10.5014/ajot.55.3.324

4. Benito-León, J., Morales, J. M., Rivera-Navarro, J., & Mitchell, A. J. (2003). A review about the impact of multiple sclerosis on health-related quality of life. Disability and Rehabilitation,25(23), 1291-1303. doi:10.1080/09638280310001608591

5. Signs and Symptoms Consistent with Demyelinating Disease. (n.d.). Retrieved April 10, 2017, from [|http://www.nationalmssociety.org/For-Professionals/Clinical-Care/Diagnosing-MS/Signs-and-Symptoms-Consistent-with-Demyelinating-D#section-0]

6. Brown, Murray G., Mark Asbridge, Vern Hicks, Sarah Kirby, Thomas J. Murray, Pantelis Andreou, and Dong Lin. "Estimating Typical Multiple Sclerosis Disability Progression Speed from Clinical Observations." PLOS ONE. Public Library of Science, n.d. Web. 10 Apr. 2017.

7. Mostert S, Kesselring J. Effects of a short-term exercise training program on aerobic fitness, fatigue, health perception and activity level of subjects with multiple sclerosis. Mult Scler 2002;8:161-8.

8. Bjarnadottir OH, Konradsdottir AD, Reynisdottir K, Olafsson E. Multiple sclerosis and brief moderate exercise. A randomised study. Mult Scler 2007;13:776-82.

9. Olek, M. J. (2005). Differential Diagnosis, Clinical Features, and Prognosis of Multiple Sclerosis. Multiple Sclerosis, 15-53. doi:10.1385/1-59259-855-2:015

10. McCullagh R, Fitzgerald AP, Murphy RP, Cooke G. Long-term benefits of exercising on quality of life and fatigue in multiple sclerosis patients with mild disability: a pilot study. Clin Rehabil 2008;22:206-14.

11. DeBolt LS, McCubbin JA. The effects of home-based resistance exercise on balance, power, and mobility in adults with multiple sclerosis. Arch Phys Med Rehabil 2004;85:290-7.

12. Dalgas U, Stenager E, Jakobsen J, et al. Fatigue, mood and quality of life improve in MS patients after progressive resistance training. Mult Scler 2010;16:480-90.15

13. Alberto Ascherio, MD, DrPH, and Kassandra L Munger, MSc. Environmental Risk Factors for Multiple Sclerosis. Part I: The Role of Infection. Annual of Neurology Vol 61 No 4 April 2007.

14. Rolak, L. A. (2003). Multiple Sclerosis: It’s Not The Disease You Thought It Was. Clinical Medicine and Research, 1(1), 57–60.

MRI image came from http://www.radiologyassistant.nl/en/p4556dea65db62/multiple-sclerosis.html