How can exercise help

people with MS?

John M Saxton Department of Sport, Exercise & Rehabilitation Northumbria University

As early as the ninth century B.C., the ancient Indian system of medicine (Ayurveda) recommended exercise and massage for the treatment of rheumatism

Greek philosopher Hippocrates (‘the father of medicine’) acknowledged the virtues of exercise for physical and mental health in the 4th century B.C.

Health-

related

Quality of life

&

Disease-free

survival

Morphological

(Body

composition)

Cardio-respiratory

Metabolic

Motor

Immunological

Molecular

Muscular

Depression

Anxiety

Stress

Self-esteem

Cognitive

function

Mood states

Sense of control

Perceived

fatigue

Perceived

ability to cope

Perceived

Physical

attractiveness

Social

integration

Enjoyment

of life

Physiological Psychosocial

Exercise rehabilitation Aims to reduce the impact of the long-term condition and promote quality of life through active rehabilitation – exercise as an adjunctive treatment (assists primary treatment)

• How can exercise therapy be optimised (frequency, intensity, time type) to bring the greatest health or therapeutic benefits?

• What is the role of exercise therapy in disease modification?

• How does exercise therapy interact with drug treatments?

• Why do some people respond/adapt differently to exercise therapy?

• What are the contra-indications to exercise therapy?

Research questions

EXIMS – EXercise Intervention for people with MS A practical approach to providing accessible exercise training for people with MS

Purpose of EXIMS

• Long-term supervised (facility-based) exercise programmes are likely to prove difficult due to time barriers, transport issues and health constraints (e.g. fatigue) in PwMS.

• A major challenge is to develop pragmatic and cost-effective interventions that can safely engage PwMS in their preferred modes of exercise and provide robust evidence of a long-lasting impact on important health outcomes, such as quality of life and fatigue.

Randomised Controlled Trial Research Questions

• Can a practically-designed exercise intervention evoke long-term improvements in physical activity behaviour and important health outcomes, including quality of life and fatigue?

• Is this a cost effective treatment strategy?

RANDOMISED CONTROLLED

TRIAL

Frequency • 2 supervised exercise + 1 home exercise (wks 1-6)

• 1 supervised exercise + 2 home exercise (wks 7-12)

Intensity • Low to moderate

Time • Short bouts of exercise

• e.g. 5 x 2 min, 2 min rest periods

Type • Range of aerobic exercises e.g. cycle, treadmill, rowing, arm-bike

ergometers

• Balance control, mobility, core stability resistance exercises

Exercise intervention

Aerobic exercise

Resistance Exercise

Consistent evidence of fatigue-reducing effects in PwMS (2 x weekly training)

Can easily be transferred to the home environment (sustainability, adherence)

Wk 1 – 2 (Cognitive) • Review of session and programme: How did you find it? was it to hard or

to easy? Did you enjoy it? Education: Warm up/cool down, fluid intake, benefits of exercise

Wk 3 - 4 (Cognitive) • Self re-evaluation: What have I learnt? What benefits have I noticed? What

do I prefer? Education: Training principles, when and when not to exercise

Wk 5 – 6 (Cognitive) • Self re-evaluation: How do I feel about exercise? What do I enjoy?

• Opportunities to exercise, finding social support

• Goal Setting introduction

Wk 7 – 12 (Behavioural) • Goal setting, moving on: Home programme, exercise options

• High risk situations and strategies

• Review achievements, social support

• Future exercise options, action plan for home

Cognitive behavioural strategies

Transtheoretical Model of behaviour change Prochaska & DiClemente (1983)

Outcomes

Primary outcome

Physical activity behaviour

• Godin Leisure Time Exercise Questionnaire

• 7-day accelerometry

Secondary outcomes

Function • EDSS • MSFC • 6MWT

Fatigue • Modified Fatigue Impact Scale

Quality of life • MSQoL-54 • EQ5D

Focus groups and interviews

Results

89.9

81.1

91.7 84.8 82.3

66.7

0

10

20

30

40

50

60

70

80

90

100

Adherence to exercise

ED

SS

≤ 5

ED

SS

≥ 5

AL

L

ED

SS

≤ 5

ED

SS

≥ 5

ALL

Supervised exercise Home exercise

38

.9 -

10

0 %

50

.0 -

10

0 %

38

.9 -

10

0 %

11

.1 -

10

0 %

44

.4 -

10

0 %

11

.1 –

94

.4 %

Perc

enta

ge a

tten

dan

ce

Minutes of aerobic exercise achieved

Low

inte

nsi

ty

(RP

E<1

2)

Mo

de

rate

inte

nsi

ty

(RP

E 1

2-1

4)

Vig

oro

us

inte

nsi

ty

(RP

E >

14

)

Gra

nd

ave

rage

Min

ute

s o

f ex

erc

ise

212

527

50

789

0

100

200

300

400

500

600

700

800

40%

18%

19%

15%

5%

3%

1.0-2.5 (low) Walk

Home

Public Facilities

Swim/Aqua

Daily Living

Yoga/Pilates

Other

40%

18%

13%

21%

6%

2%

3.0-4.5 (medium)

52%

27%

2%

3% 11%

2% 3%

5.0-6.5 (higher)

Home exercise preferences

9.6

6.9

-2

0

2

4

6

8

10

12

14

16

18

688.5

-18

-600

-450

-300

-150

0

150

300

450

600

750

900

1050

1200

Adjusted* mean difference in self-reported physical activity questionnaire score

Adjusted* mean difference in average daily step count

3 m

on

ths

9 m

on

ths

3 m

on

ths

9 m

on

ths

* Adjusted for baseline, gender and EDSS

Ave

rage

GLT

EQ s

core

Ave

rage

dai

ly s

tep

co

un

t

Physical health

Role limitations – physical

Role limitations – emotional

Pain

Emotional well-being

Energy

Health perceptions

Social function

Cognitive function

Health distress

Sexual function

Change in health

Satisfaction with sexual function

Overall QoL

Physical health component

Mental health component

EQ-5D

Effect size

(95% confidence

intervals)

Follow-up 3 months 9 months

Health-related QoL

Function

6MWT

25’ Walk

9 hole pin test DH

9 hole pin test NDH

PASAT

Effect size

(95% confidence

intervals)

Follow-up 3 months 9 months

Would you say fatigue is one of your 3 main symptoms?

MSIF fatigue survey involving 10,090 PwMS from 101 countries

Exercise group Control group

Pre Post Pre Post

% of PwMS experiencing clinically significant symptoms of fatigue in the two groups (N=120)

71.7 66.7

49.1

61.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

% M

FIS

>3

8

Focus Groups & Structured Interviews

Participant quotes

“When I was diagnosed I asked specifically if there was anything I could do to help myself, diet wise and exercise and I was told there was nothing you could whatsoever”

“I don't recall any professionals mentioning anything about exercise at all and I don't believe I asked”

“You have no advice

really. So you were

scared about doing

the wrong thing ...”

Experience of MS exercise-related advice and support

Variable experiences, usually non-existent advice or non-specific to MS

“I did enjoy coming and I am the kind of person that will stick to an arrangement I've made. I will stick to a commitment”

“... Just everything about it, I just enjoyed coming so much. I looked forward to it”

“ Very good. I

needed it”

Participant's views of taking part in the EXIMS study

Generally grateful to have had the opportunity to take part in the exercise programme

“I think when you've got MS you put, your world becomes smaller, you think "I can't do that, I might feel tired before I get far", and then you realise that you can”

“I feel as though I'm less fatigued. I don't have as many floppy days. I still get the odd one but nowhere near like it was”

“I do find simple things

like turning over in bed

which isn’t a very easy

task and picking things

up of the floor without

collapsing; things of that

nature are a lot easier”

Perceived benefits of exercise participation Commitment and discipline needed but a worthwhile investment

FATIGUE PHYSICAL BENEFITS

OUTLOOK

“For me I think it was taking the mystery out of exercise and giving the confidence that it’s safe to do this and you’ll get benefit from it...and I think guided exercise in the initial stages was the key”

“My little boy will be surprised when I say "Yeah, alright I'll go swimming" or "yeah OK let's go for a walk", and he'll think "Oh, that doesn't sound quite right".

“I really enjoyed the social

aspect of meeting people

and talking because you

don't always get that when

you have MS. You tend to

be at home a lot on your

own so I enjoyed coming

and I miss not coming”

FAMILY IMPACT

CONFIDENCE

SOCIAL IMPACT

Perceived benefits of exercise participation

Low EDSS (1.0 - 2.5)

more confident, more motivated, stronger, fitter, less tired, feel more alive and positive, walking more

Medium EDSS (3.0 - 4.5)

fitter, more energy and enthusiasm, less fatigued, improved stamina, walking further, better balance

Higher EDSS (5.0 - 6.5)

more confident, better mobility, fitter, stronger legs, functional improvements (standing, sitting, stairs, getting up off floor), feel better, healthier, more energy

Participant perceptions by EDSS score

Conclusions Physical activity and health outcomes

• EXIMS had a positive impact on self-reported physical activity and objectively assessed movement counts at 3 months (non-significant increase in self-reported physical activity at 9 months).

• EXIMS reduced physical, cognitive and psychosocial fatigue symptoms at 3 months.

• EXIMS improved most HRQoL dimensions at 3 months, with sustained enhancements in emotional wellbeing, social function and overall QoL score at 9 months.

• The improvements in fatigue and other HRQoL dimensions observed in the EXIMS group at 3 months were not maintained to 9 months.

Acknowledgements MS Society

Research staff •Anouska Carter •Liam Humphreys •Robert Scaife •Nicky Snowdon

Co-investigators and Trial Steering Committee members •Amanda Daley •Basil Sharrack •Nicola Woodroofe •Jane Petty & Liz Whilde •Andrea Roalfe •Jon Tosh & Simon Dixon •Rachel Milner & Amber Sheridan

•Howard Capelin & James Bramel

Consultant Neurologists involved in recruitment •Sian Price

•Stephen Howell

Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.

Plato 428-347 B.C.

The End