Healthy Aging

Resistance Training In Multiple Sclerosis Patients To Restore Functional Capacity
by Lindsay Federko

Struggling to stand up, unable to walk to the park with a loved one, or simply not having the energy to get out of bed in the morning are all daily scenarios encountered by those battling the symptoms of the degenerative disease Multiple Sclerosis (MS). With no concrete cure for MS in place, it was previously accepted that the degenerative process would continue and functional capacity would decrease to negatively affect daily activity outcomes, progressively. The most debilitating symptom of the disease, fatigue, greatly influences abnormal walking mechanics, poor balance, muscle weakness, and mood. If the level of fatigue can be reduced, the following symptoms associated with MS will be reduces to restore functional capacity of daily living. Vast research now demonstrates the solution is to incorporate exercise training programs to promote gains in muscular strength, slowing the degenerative disease process: to improve the individual’s functional capacity and quality of life. (White et al, 2004)

Diagnosed as a chronic disease of the central nervous system, at times MS possess an unpredictable course of action affecting each individual slightly different in the severity and progression of the symptoms associated with the disease. It is very important to actively preserve and improve muscular strength and cardiovascular health in order to increase the functional reserve in MS patients to improve daily living capabilities. (White, 2001) MS is typically characterized by a remitting-relapsing course of symptomatic actions being triggered into an intensified state. It is at this time the patient is incapacitated and left in a permanently worse state with an accumulation of disabilities from the sporadic exacerbations. The rate of exacerbations declines from as often as 3 incidences each year to less than once annually, 5 years after diagnosis. If these incidences can be reduces within the first 5 years to limit the chronic damage and disabilities left, the progression of the disease is slowed and the patient is left in a more functional, comfortable position to live. Recent research has proven that improvements in physical fitness increases this functional reserve within the muscles to assist in fighting the negative symptoms associated with MS.

Although MS is a serious debilitating disease, it is not typically the cause of death in those diagnosed with the chronic condition; in fact, this population tends to contract the same illnesses that effect the general population: circulatory conditions such as heart disease, stroke, along with cancer and obesity. The main objective when treating MS is to slow the progression of the disease to diminish the symptoms which greatly interfere with daily activities and overall quality of life; aim to maintain skeletal muscle strength and mobility with optimal cardiorespiratory functioning to reduce the risk of developing such secondary disorders. (Kileff & Ashburn, 2005)

Exercise is known to assist immensely in the prevention of painful circulatory conditions and fatal cancer developments, but the thought of beginning a physically active regime to ward off these potential secondary developments is painful and intolerable for many MS sufferers. The impairments associated with the disease, fatigue, muscle weakness, motor weakness, muscle spasms, poor balance, heat sensitivity, and mental depression are the chief culprits. Past research recommendations, now considered outdated and inaccurate, did not advise physical activity. Rest was viewed as the solution to assist in symptom treatment. Today, even with proven research evidence demonstrating the inaccuracy of previous recommendations to remain sedentary, many MS sufferers hold the fear that physical activity will increase the pain and fatigue and such therapeutic results are unattainable. (Petajan & White, 1999) Reductions in functional capacity accelerate respectively with the severity of the disease. Therefore, if muscle strength can be preserved or partially restored to improve balance and strength to minimize daily fatigue, the quality of life is restored. The effect MS has on the activities of daily living is greatly influenced by the patient’s functional activity level, the progression of the disease and the stage of the disease, being measured by the number of years since diagnosis, and the management of the symptoms through medication and therapy – specific exercise techniques, physiotherapy, acupuncture, and others. Improving fitness in MS patients should result in minimizing disability. (White & Dressendorfer, 2004)

Most bothersome, debilitating, and severe when compared to other symptoms, affecting approximately 85% of MS patients, is the symptom fatigue. Fatigue is found to negatively impact the functional lives of individuals. (Petajan & White, 1999) This multifaceted, overwhelming sense of tiredness, exhaustion, or lack of energy greatly triggers other aspects associated with MS: mood, balance, muscle spasms, muscle strength, functional ability to carry out daily tasks, and overall physical activity and movement. It is very upsetting to many individuals to be limited in daily activities and not being able to fulfill tasks once capable of doing due to disease limitations, specifically fatigue. With MS patients having a 12-18% greater rate of daily fatigue compared to healthy individuals, it displays that fatigue is a genuine consequence of MS due to nervous tissue damage, rather than being a psychological influence. (Surakka et al, 2004)(Comi et al, 2001) When fatigue is present, patients typically attempt to regain energy and strength by minimizing physical movement and daily activities. But when reported, this sedentary action seldom improved fatigue levels. It has become obvious that more proactive measures need to be implemented to counteract MS induced fatigue; the most recent beneficial method is the implementation of specific physical exercise programs. (Comi et al, 2001)

Treatment methods being prescribed to MS patients, regarding exercise, have evolved due to research advancements. The beneficial effects physical activity has on improving the functional capacity of MS patients is through diminishing the symptoms. Strong evidence for reduced fatigue and improved muscular strength and movement are the basis of the physical activity prescription; inactivity contributes to muscle deconditioning and therefore motility is lost causing the disease to advance. When an exercise program is being constructed, specific considerations are taken into account to ensure symptoms are not amplified, injuries are not obtained, and optimal results are acquired. (Surakka et al, 2004)

Resistance training, also identified as strength training, focuses on muscle strength and functional movements while aerobic training focuses on cardiorespiratory health and weight management. These are the two beneficial areas of physical exercise for MS patients. An overall improvement in such fitness boosts energy levels and mood state. With both vital contributors to overall health improvements, beginning with a resistance training program is optimal for MS patients. The addition or preservation of strength within the muscles as the goal for the resistance training program will enhance balance and confidence to encourage walking and improvements in functional living with daily tasks. Once adequate strength is obtained and progress achieved, aerobic training may be incorporated into training programs at a later date. (Surakka et al, 2004)

The reduction in muscle strength is a major factor impairing daily living, and contributing to this weakness is fatigue. Because of the low energy levels recognized in MS patients, the overall use of the muscles is reduced which causes the muscles to diminish in size, known as muscle atrophy. Consequently, smaller muscles produce smaller amounts of energy because of the reduced structural size and functional processes occurring within the muscle. This results in a “vicious circle” to aggravates the symptoms of the disease – increasing fatigue when opposite intentions were intended. (White & Dressendorfer, 2004) A study was conducted with MS patients, participating in a 6-month resistance-training exercise program, to measure the effects of fatigue. It was recorded that fatigue significantly decreased by 24% following the 6-month resistance training program. Contributing to this success was the improved muscular strength which enhanced the functional reserves within the muscles to make daily activities less fatiguing, therefore, more productive and enjoyable. This proves that increasing the strength and functional capacity of the major muscles will assist in decreasing fatigue rates in MS patients, improving daily living. (White et al, 2004)

Prior to beginning a resistance training program, the health status of the patient needs to be assessed and cleared by a physician to ensure no preexisting health risk may be amplified. Upon clearance, the functional capacity and strength of the patient is to be measured by a certified fitness professional. This will ensure appropriate, beneficial exercises are prescribed with appropriate alterations in place. It can be ensured the appropriate exercises and resistance weights are consumed to escape additional pain and injuries. Contributing to the program’s success is the setting of personal goals to be achieved. When a desired, realistic outcome is recorded to work towards, adherence and motivation are increased to improved outcomes, also increasing the enjoyment of the program by noticing progress. An overall goal for MS patients participating in a resistance training program is to reduce the level of fatigue associated with the disease to improve the symptoms decreasing the functional capacity so daily activities can be continued. Personal goals can become more detailed and individualistic: to be able to walk up the stairs without stopping or assistance, to walk without a cane, to have the energy to prepare lunch, to go for a short shopping trip, or to spend quality time with grandchildren. (Howley & Franks, 2003)

Different forms of resistance training exist to enhance muscular strength. Beginning to build strength within the muscles through stationary weight machines is advantageous for MS patients for increased stability and safety. Weight machines are designed to strengthen the major muscle groups which are essential contributors to daily activities. Being relatively easy to use, weight machines promote controlled, safe movements of the limbs. Free weights are also another form of resistance training but require additional experience, stability, and technique for optimal outcomes while escaping injury. Free weights are an optimal start point for MS patients but a possible are to progress to. (Howley & Franks, 2003)

To ensure comfort, reduction in MS symptoms, and prevention of exacerbations, appropriate preparation is needed. Because increases in core body temperature, by as little as 0.5 degrees Celsius, can trigger MS symptoms, ensuring the attending facility has optimal ventilation and temperature control with mobile fans available is vital. Choosing to exercise during cooler times of the day, such as the early morning, assists to reduce environmental heat. (White, 2001) Self preparation includes wearing the proper attire: cool, comfortable, clothing, headbands, and cooling vests, along with comfortable athletic shoes. To ensure hydration and to keep a cool body temperature, a water bottle is necessary. Participation of the resistance training program is most advantageous when the participant enjoys the time spent fulfilling the exercises. Having another person or group to work with and motivate the MS patient is optimal, whether it is an MS support group, or if the MS patient has a friend or family member to go to the facility with. It allows for this time to be a social outing as well as a health building event. (Howley & Franks, 2003)

A fundamental to keep in mind upon commencing the resistance program is the primary goal to decrease fatigue and the symptoms associated with MS. All exercises should be completed in a full range of motion (ROM) to the capacity of the individual, not increasing pain. If an MS exacerbation occurs at any point during the program, ceasing activity until symptoms subside is necessary. Optimal results will be achieved if dedication, consistency, and a positive attitude are contributed to the constructed program. The strength building program is designed to be a gradual process to attain strength to regain functional movement by preventing injury while working against the degenerative nature of MS. Patience are essential to obtain results. (Howley & Franks, 2003)

A general program prescription regarding the frequency, intensity, and the amount of time required for the strength building type exercises is best suited for MS patients. Completion of the training program should occur 2 to 3 times each week, allowing 48 to 72 hours of rest from similar activities between sessions. (Howley & Franks, 2003) This allows for the muscles to recover and gain strength. If adequate rest is not allowed, the process will be reversed causing the fibers which formulate the muscle to breakdown, atrophy, and lose strength. Fatigue would not be improved for the MS patients and the risk of injury would be greatly increased. Such factors can be easily avoided if a proper training schedule is adhered to. (DeBolt & McCubbin, 2004) The intensity of the strength program will vary between individuals, but progression in weight used in each exercise will be reviewed at the 4-week program point, to ensure no problems are occurring, and again at the 8-week program point, to consider program alterations. Keeping the weight consistent for the initial 8 weeks has been proven beneficial in gaining muscular strength in MS patients. This time allows the connective tissue and muscles to adapt slowly, escaping pain and injury while achieving success. (DeBolt & McCubbin, 2004) Resistance training programs consist of sets which are made up of repetitions. A repetition is one complete movement of an exercise and a group of consecutive repetitions, performed without stopping, make up a set. For this program targeted towards MS patients, it will consist of 1 set of 10-15 repetitions. (Howley & Franks, 2003) When considering the optimal time of day to complete the program, research shows MS patients hold highest amounts of energy at the beginning of the day, therefore, exercising in the morning is most beneficial to minimize the debilitating effects of fatigue which can increase as the day progresses. (Comi et al, 2001)

All exercise regimes, particularly resistance training programs, must begin with a 5 to 10 minute warm-up period, consisting of low intensity aerobic exercise on a stationary machine (Howley & Franks, 2003). This activity increases the blood flow to the muscles to prevent injury and optimize training outcomes (DeBolt & McCubbin, 2004). An optimal machine for MS patients to perform the warm-up on is the recumbent bike. This machine has a back rest to provide low back support and the structural design of the machine reduces the stress placed on the stabilizing muscles: compared to treadmill walking, stationary cycling, or elliptical cross-training. This is beneficial to MS patients to increase stability while performing the cycling motion, preventing pain, falls, and injuries. Ensuring the bike is properly adjusted, so that the seat is positioned 2 to 3 degrees before the knees will lock when put into extension, is the correct set up. (Pinchas, 2005) Once an adequate warm-up has been completed, ensuring the core temperature of the MS patient is not elevated, the participant is now prepared to begin the resistance program. (Howley & Franks, 2003)

Having an individual resistance training program constructed for each MS patient ensures accurate prescription to target the necessary muscles to reduce fatigue and regain functional capacity. Each patient is affected slightly differently in the degree of strength lost in the different muscles. The fitness professional will choose appropriate resistance exercises to benefit each patient specifically to restore and preserve muscular strength. Similar exercises will be noticed between programs due to the general benefits achieved by the strength exercises, but variations may occur. It is at this time that personal goals are addressed and focused on, to ensure the patient will receive his or her desired outcomes. (Howley & Franks, 2003) Located in Appendix B are a series of recommended strength building exercises that may be incorporated into a resistance training program for MS patients.

After the resistance training workout, it is necessary to complete a cool-down period, similar to the warm-up session. A cool-down assists in relaxing the body and reducing the chance of muscle stiffness and soreness from occurring. Resistance-free aerobic exercise is most beneficial, such as the recumbent bike again, followed by static stretching exercises with the fitness professional to complete the workout. (Howley & Franks, 2003)

In spite of the precautionary views regarding exercise recommendations for MS patients, regular activity has been repeatedly shown to have important health benefits in MS patients. With an appropriately constructed program to incorporate beneficial strength building exercises and with a fitness professional’s guidance, resistance training demonstrates to be a safe, well tolerated intervention to restore functional capacity while reducing MS triggered fatigue. (White et al, 2004) The gain in muscular strength which is obtained from such a program slows the progression of the debilitating disease allowing daily activities to be completed as once enjoyed (White & Dressendorfer, 2004). Attention to environmental conditions, modifications of activity intensity and duration, and selection of appropriate strength building exercises can safely maximize the benefits of exercise in MS patients not only to make the strength building program beneficial to the patient’s health, but socially enjoyable to improve quality of life, also contributing to improve MS symptoms (Howley & Franks, 2003). Although MS degenerates the body physiologically and a cure is not in place, research has been found that mechanisms exist to delay the progression of this debilitating disease. This mechanism is exercise and gaining muscular strength restores daily activities and functional living so MS patients can enjoy additional content years of life. (White et al, 2004)

References

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DeBolt, L. S., & McCubbin, J. A. (2004). The effects of home-based resistance exercise on balance, power, and mobility in adults with multiple sclerosis. American Academy of Physical Medicine and Rehabilitation, 85, 290-297.

Howley, E. T., & Franks, D. B. (2003). Health Fitness Instructor’s Handbook. (4 th ed.) Champaign, IL: Human Kinetics.

Kileff, J., & Ashburn, A. (2005). A pilot study of the effect of aerobic exercise on people with moderate disability multiple sclerosis. Clinical Rehabilitation, 19, 165-169.

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Pinchas, Y. (2005). The Complete Holistic Guide to Working Out in the Gym in Calgary : Sport Technology Research Lab.

Surakkam, J., Romberg, A., Ruutiainen, J., Aunola, S., Virtanen, A., Karppi, S., & Maentaka, K. (2004). Effects of aerobic and strength exercise on motor fatigue in men and women with multiple sclerosis: a randomized controlled trial. Clinical Rehabilitation, 18, 737-746.

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Walter, G. A., & Vandenborne, K. (2004). Resistance training improves strength and functional capacity in persons with multiple sclerosis. Multiple Sclerosis, 10, 668-674.