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Courtney Smeltzer

2 Exercise Therapy for Multiple Sclerosis Patients

Introduction

Multiple sclerosis is classified as a nervous system disease that affects the brain
and spinal cord. The disease creates damage to the myelin sheath of a persons nerve
cells by cauasing them to become inflamed, which ultimately slows down or blocks
messages between the brain and body (PubMed Health, 2013.) The exact cause of
multiple sclerosis is unknown, but recent research has shown that it may be considered an
autoimmune disease. Inflammation is the result of the bodys own immune cells
attacking the nervous system, which is why many researches believe an autoimmune
disorder may be the cause of MS.
The onset of MS typically occurs between the ages of 20 and 40 and it is found to
affect more women than men. Most cases of the disease are mild in comparison to other
neurological disorders, but there have been some cases where people have lost their
ability to speak, write, or walk (MedlinePlus, 2014.) There is also a strong genetic
component to this disease, which shows that a person is 15 times more likely to be
diagnosed with MS if their sibling or parent is affected by MS (Latash, 2014.) It is also
believed that if a person resides in an area where MS is more common (i.e. North
America and Northern Europe), they are more likely to become diagnosed with the
disease (Latash, 2014.)
Signs and Symptoms
There is no single test for MS for healthcare providers to utilize. The diagnosis is a
combination of medical history, physical exam, neurological exam, and MRI
(MedlinePlus, 2014.) Some of the signs and symptoms of MS include:
Muscle weakness
Exercise Therapy for Multiple Sclerosis Patients 3

Difficulty with coordination and balance
Trouble with vision
Sensations such as numbness, prickling, or pins and needles
Cognition and memory problems
Treatment of Multiple Sclerosis
Currently, there is no known cure for multiple sclerosis. Most treatment options
available to patients are aimed at slowing the progression of disease and control
symptoms in order to maintain a normal quality of life (PubMed Health, 2013.) The
medications often provided to patients are taken long-term and are often used to control
symptoms like muscle spasms, urinary problems, and fatigue or mood issues.
Steroids have often been used to decrease the severity of attacks of some symptoms.
The Problem with Medication for Multiple Sclerosis
The problem with this long-term medication is that medication and drug
treatments can become quite an expense. The National Multiple Sclerosis Society
(NMSS) claims that illnesses such as multiple sclerosis were associated with the highest
out-of-pocket expenditures, which will affect many MS patients when the Affordable
Care Act spending caps go into affect in 2015 (Burtchell, 2013.)
With all of these new changes arising that make it difficult for people with
chronic, degenerative diseases like MS to receive the proper treatment, it is important to
be able to consider alternative forms of treatment that are less costly. Because of this, a
great deal of research is being conducted to test the effectiveness of exercise and aerobic
therapy on reducing symptoms in MS patients.
4 Exercise Therapy for Multiple Sclerosis Patients

Paper #1: Aerobic Exercise in People with Multiple Sclerosis: Its
Feasibility and Secondary Benefits

Conducted at: Baylor Institute for Rehabilitation, Dallas, TX, USA; and School of
Physical Therapy, Texas Womans University, Dallas, TX, USA

Contributors: Chad Swank, PT, PhD, NCS, Mary Thompson, PT, PhD, GCS, and Ann
Medley, PT, PhD, CEEAA

From: International Journal of MS Care: The Consortium of Multiple Sclerosis Centers,
2013

It has previously been thought that discouraging exercise for people with MS was
the best option, for fear of increasing fatigue or triggering a disease exacerbation.
However, recent research has found strong evidence for primary benefits from exercise
including improved muscle strength, activity tolerance, and mobility in MS patients.
This study aimed to explore the impact of structured aerobic exercise followed by a
period of unstructured physical activity in order to determine the impact of exercise on
cognition, mood, and quality of life in people with Multiple Sclerosis (MS).
Methods
Instruments
This was a 5-month pilot study divided into two components: a structured aerobic
exercise program lasting 8 weeks, followed by 3 months of unstructured physical activity.
Participants testing was performed on three different occasions, the first was to determine
baseline function (session 1), the second was post intervention attainment (session 18),
and the final was follow-up preservation (session 19) after 3 months of unstructured
exercise.

Exercise Therapy for Multiple Sclerosis Patients 5

The tests assessed cardiovascular fitness, cognitive performance, and QOL during
session 1, 18, and 19. The cardiovascular fitness was assessed by monitoring the
participants breath via a telemetry metabolic measurement system while they performed
the 6-Minture Walk (6MW). Cognitive performance, which included verbal learning and
working memory domains, was assessed by using selected neuropsychological measures
from the Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS).
Factors such as depression, fatigue, and disability are all considered to be independent
predictors of quality of life in MS patients. Therefore, depression was assessed by the
Beck Depression Inventory-II, which provides item internal consistency for people with
MS. Overall quality of life was measured using the Multiple Sclerosis Quality of Life-54
(MSQOL-54), which measures QOL in MS patients using mental and physical sub
scores.
Participants
In order to be eligible for this study, participants had to be ambulatory with or
without an assistive device and score less than 6.5 on the Kurtzke Expanded Disability
Status Scale (EDSS). 9 participants who were previously diagnosed with relapsing-
remitting MS were recruited from a convenience sample. Certain individuals were
excluded if they had comorbid neurologic disease or other conditions that would prevent
participating in an exercise program, such as cardiac or respiratory disease.
Although 9 participants were recruited and completed the baselines pretest, only 8
participants completed the intervention and post-test. Only 6 participants returned for the
3-month follow up.

6 Exercise Therapy for Multiple Sclerosis Patients

Procedures
The intervention sessions (2-17) consisted of a standardized aerobic exercise
program that was tailored to each participants fitness level. The session took place two
times per week for 8 weeks. The participants engaged in 30 minutes of exercise that
included 15 minutes on upper and lower extremity ergometer and 15 minutes ambulating
on a treadmill. As the sessions progressed, the resistance of the speed of aerobic training
was adjusted to somewhat hard on the Rating of Scale of Perceived Exertion (RPE)
scale. The participants exercise blood pressure and heart rate were closely monitored to
ensure participant safety. After the intervention and post-testing, the participants were
encouraged to be physically active until the follow-up testing (session 19), three months
after the post-test. There were no specific exercise instructions provided. The only
recommendation was to participate in physical activity within the community.
Results
An effective exercise program should aim to minimize anticipated deterioration of
physical condition over time. Therefore, the nonparametric analysis, the Wilcoxon
signed rank test, was used to determine the presence or absence of positive means of all
outcome measures.
The researchers found that neither structured nor unstructured physical activity
created any significant benefits for the dependent variables. However, the MSQOL-54
mental subscale and the BD-II demonstrated improvements after the structured aerobic
exercise and after unstructured physical activity. The table below represents the change
from zero for the dependent variables. It also shows that the total BDI-II score
significantly changed from zero, which indicates a change in improved mood after the
Exercise Therapy for Multiple Sclerosis Patients 7

structured intervention, but this change was not sustained with unstructured physical
activity.
Table 3. Effects of the exercise intervention on Cognitive Performance and Quality
of Life Variables


Although only one score is commonly reported, the BDI-II has two subscales:
Somato-Affective and Cognitive. Because of this, a post hoc analysis was conducted to
determine which subscale was affected by the intervention. The table below
demonstrates that the significant changes in mood were due to improvement in the BDI-II
Somato-Affective subscale. The Cognitive subscale did not demonstrate any significant
changes throughout the entre intervention.


8 Exercise Therapy for Multiple Sclerosis Patients

Table 4. Beck Depression Inventory-II subscale analysis


Conclusions
Although an improvement in overall mood was not reflected in the total BDI-II
score, closer examination demonstrates that structured aerobic exercise affected the
different subscales differently. The cognitive subscale involves features like pessimism,
guilt, self-dislike, self-criticism, and worthlessness, remained unchanged throughout the
structured and unstructured portions of the intervention. The Somato-Affective subscale
involves relevant factors such as fatigue, loss of energy, changes in sleep patterns, and
concentration difficulty. These features improved after the structured intervention and
were maintained with unstructured physical activity.
Fatigue is a large debilitating factor in many patients with MS. It impacts energy
loss, sleepiness, inability to sustain activity, increases cognitive complaints, and is
associated with reduced self-efficacy. Although it is not directly measured in this paper,
fatigue has shown to be reduced with physical activity. Further research on the
Exercise Therapy for Multiple Sclerosis Patients 9

relationship between the somato-affective features of depression and aerobic exercise
needs to be examined.
Overall, participation in a structured aerobic exercise program two times per week
for 8 weeks improved mood, with the improvement continuing over a 3-month follow-up
period. The participants ability to complete the aerobic testing and their improved mood
and QOL indicate the feasibility and secondary benefits of the intervention. However,
the small sample size creates a lack of statistical power and prevents the ability to draw
conclusions from the results. Future research on this topic should be longer in order to
appropriately monitor cognitive improvements and should include a control group.
10 Exercise Therapy for Multiple Sclerosis Patients

Paper #2: Massage Therapy and Exercise Therapy in patients
with Multiple Sclerosis: A randomized controlled pilot study

Conducted at: Musculoskeletal Rehabilitation Research Center, Ahvaz
Jundishapur University of Medical Sciences, Ahvaz, Iran

Contributors: Hossein Negahban, Solmaz Rezaie, and Shahin Goharpey

From: Sage Publications: Clinical Rehabilitation

Although there is much research being conducted on the effects of exercise
therapy, there is very little known about the effects of massage therapy for patients with
Multiple Sclerosis. There are only two studies known to researchers that have
investigated the effects massage therapy has on the psycho-emotional outcomes
associated with MS. The goal of this study was to examine the effects of massage
therapy and exercise therapy for treating pain, fatigue, spasticity, balance, gait, and
quality of life in MS patients.
Materials and Methods
Participants for this study were recruited via telephone contact after receiving
information provided by the medical records of patients in the local Multiple Sclerosis
Society. A convenient sample of 48 patients was recruited for the study. The
randomization process remained balanced by matching patients based on age and sex and
randomly assigning them to one of the four subgroups in equal sample proportions using
a table of random numbers. The subgroups consisted of the massage therapy (group 1),
exercise therapy (group 2), massage-exercise therapy (group 3), and control group (group
4). Each subgroup was assigned 10 female patients and 2 male patients. Patients
assigned to the massage therapy, exercise therapy, and massage-exercise therapy groups
Exercise Therapy for Multiple Sclerosis Patients 1
1

received three 30-minute sessions of supervised intervention for five weeks, creating a
total of 15 therapeutic sessions with two pre-post evaluative sessions.
Massage Therapy Group: This group received 30 minutes of Swedish massage.
7 minutes were dedicated to the lower limb portions, while the patient was lying
supine, 4 minutes were dedicated to massaging the proneal muscle, and 4 minutes
were dedicated to each calf muscle while the patient was lying prone.
Exercise Therapy Group: This group was given various sets of exercises such as
strength, stretch, endurance, and balance training.
The Massage-Exercise Therapy Group: Patients in this group were instructed to
engage in similar exercises of the exercise therapy group for 15 minutes in
addition to the passive massage performed in the massage therapy group for 15
minutes. The order of exercise and massage was randomized for each patient but
remained the same throughout the course of the study.
Control Group: Patients in this group were instructed to continue to receive their
standard medical care. They were also asked to avoid engaging in any exercise
program.
Outcome Measurements
The outcome measurements for this study included pain, fatigue, spasticity,
balance, gait, and quality of life. These measurements were assessed during the pre-
intervention and immediately after completion of the intervention.
Pain: Pain was assessed using a visual analogue scale. Patients were asked their
pain level on a 0-10 point scale, with zero indicating no pain and 10 indicating
severe pain.
12 Exercise Therapy for Multiple Sclerosis Patients

Fatigue: Fatigue was assessed using the Fatigue Severity Scale. Patients are
asked a series of nine questions with choices varying between 1 and 7, where 1
indicates a strong disagreement and 7 indicates a strong agreement. The total
score ranges from 7 to 63, with a higher score indicating higher levels of fatigue
during activity.
Spasticity: Spasticity was measured in the ankle plantarflexors using the
Modified Ashworth Scale. The scale ranges from 0 to 4, with 0 indicating no
increase in muscle tone and 4 indicating that the affected part is rigid in
dorsiflexion.
Balance: Static and dynamic balance were assed using the Berg Balance Scale
and the Timed Up and Go test. The Berg Balance test is composed of 14
questions, each graded on a 5-point Likert scale (0-4) ranging in levels of
difficulty. The scale ranges from 0-56, with higher scores indicating higher levels
of functional balance. The Timed Up and Go required the patient to stand up
from a sitting position, walk 3 meters at their preferred speed, and turn back and
sit in the same chair. The total time (in seconds) required to compete the task was
required using a stopwatch.
Gait: Walking speed and endurance were examined using the 10-meter timed
walk and 2-minute walk tests. The 10-meter walk test requires the patient to walk
10 meters as fast as possible. The 2-minute walk is the distance (in meters) the
patient walked as fast as possible for 2 minutes.

Exercise Therapy for Multiple Sclerosis Patients 1
3

Quality of Life: The patients quality of life was assessed by using the Multiple
Sclerosis Quality of Life-54 questionnaire. The questionnaire is made up 54
questions, with 52 of them being grouped into 12 subscales while the remaining
two questions looked at Satisfaction with sexual function and Change in
Health. There are also Physical Health Composite Scores and Mental Health
Composite Scores. Scores for each subscale range from 0-100 with 0 indicating
poor health related quality of life and 100 indicating good health related quality of
life.
Results
Overall, the results of between-group differences in change score demonstrate that
there was a significant difference between all four study groups in all outcome measures,
with the exception of the Multiple Sclerosis Quality of Life-54. Patients in the massage
therapy group demonstrated significantly larger changes in scores in all outcome
measures compared to the control group. The scores of all outcome measurements in the
exercise therapy group were also larger than the control group with the exception of the
visual analogue scale. Patients in the massage-exercise therapy group all demonstrated
significantly large change in scores compared to the control group with the exception o
the Modified Ashworth Scale. Comparisons between the massage and exercise therapy
groups showed large changes in scores for the visual analogue scale, Timed Up and Go,
and 10-meter timed walk in the massage therapy group compared to the exercise therapy
group. The massage therapy group also demonstrated a larger change in score in the
visual analogue scale compared to the exercise therapy group. However, no significant
14 Exercise Therapy for Multiple Sclerosis Patients

difference in change scores were observed between the massage and exercise therapy
groups.
Conclusions
If the exercise therapy group and massage therapy group are analyzed separately,
both are found to produce significant improvements in the outcome measurements. If a
comparison is done between the two groups, the results show that the massage therapy
group demonstrated larger improvements in pain reduction, dynamic balance, and
walking speed than the exercise therapy group. However, there were no significant
differences found in improvements between the massage therapy group and the combined
exercise-massage therapy group.
The limitations to this study are the small sample size within each experimental
group and lack of long-term assessment and follow-up. If future research is conducted,
large sample sizes should be recruited and the intervention should include long-term
assessment to examine the long-term benefits. Due to these limitations, the evidence
from this study suggests that massage-therapy could be more effective than exercise
therapy for patients with multiple sclerosis. In addition, the combination of massage-
exercise therapy could be more effective than exercise therapy alone.
Exercise Therapy for Multiple Sclerosis Patients 1
5

Paper #3: A Qualitative Study Exploring the Usability of Nintendo
Wii Fit among Persons with Multiple Sclerosis

Conducted at: Cleveland Clinic Lerner Research Institute, Department of Biomedical
Engineering, Department of Physical Medicine and Rehabilitation. Cleaveland, OH, USA
Department of Occupational Therapy, University of Illinois at Chicago, Chicago, IL,
USA.

Contributors: Matthew Plow and Marcia Finlayson

From: Wiley Online Library

There are many environmental barriers that prevent adults with disabling
conditions from engaging in physical activity. Because of this, novel approaches are
needed to promote physical activity in adults. One approach may be exergaming, which
is considered to be playing a videogame while using full body movement to control on-
screen action. The purpose of this study was to longitudinally examine the usability of
the Nintendo Wii and identify reasons for using or not using Wii Fit from the perspective
of adults with Multiple Sclerosis.
Methods
Qualitative data was collected from 30 participants with mild to moderate
symptoms of MS. The data examined the potential benefits of using Wii Fit on a
consistent basis. The video game system was set up in the participants homes and they
were instructed to utilize the Wii Fit system 3-times-a-week for 14 weeks. They were
encouraged to participate in all four types of Wii Fit exercises, which included yoga,
balance, strength, and aerobic training, during each of their exercise sessions. In order to
account for participants fitness levels, exercise duration was tailored to each participants
based on their perceived exertion when playing the Basic Run game.
16 Exercise Therapy for Multiple Sclerosis Patients

Interviews were conducted over the phone before and after the 14-week
intervention. All 30 participants competed the pre-test interview and 22 completed the
post-test interview. The interviews were tape recorded over the phone and transcribed
exactly the way the participants stated their testimony. The interviews typically took
about 30 minutes to complete and were structured around the occupational well-being
model. This model allows insight into any factors that may influence participants
experience while using the Wii Fit. The model believes that a persons subjective
experience during physical activity is impacted by the extent to which he or she feels a
sense of accomplishment, agency/control, companionship, affirmation, pleasure, renewal
and coherence (i.e. the connection between past, present, and future.) The interviews
consisted mostly of open-ended questions followed by probes. An example of a probe
used in the study was, did you feel bored play Wii Fit and if so, why?
Results
In the pre-interviews conducted with the participants, many of them expressed a
range of attitudes and experiences with videogames. Some participants had not played
videogames since they were children and some considered themselves videogamers for
life. However, the general consensus was that the participants had high expectations
that Wii Fit would be fun to play, would increase their overall physical activity levels,
and improve their overall health and function.
The researchers identified five main themes from the interviews with the
participants regarding their experience with Wii Fit.
1. Reflecting on my abilities: Participants felt that Wii Fit provided feedback that
encouraged them to reflect on their health and function.
Exercise Therapy for Multiple Sclerosis Patients 1
7

2. Fitting into ones narrative: The participants who used the Wii Fit on a
regular basis described themselves as exercisers and felt that Wii Fit met their
needs to engage in exercise.
3. Convenient and Fun to Play: Many participants enjoyed themselves while
using the Wii Fit and found it to be much more convenient than going to the gym.
4. Novel technology, but same old exercise barriers: Many participants felt that
the barriers for using the Wii Fit were similar to those for engaging in a regular
exercise program.
5. Usability Issue: Participants experienced difficulties with learning to use the
Wii Fit and could not customize exercises to the meet their individual functional
levels.
Conclusions
As a whole, Wii Fit helped majority of the participants with MS engage in
exercise. They reported that Wii Fit helped them build confidence in their abilities,
achieve goals related to participating in leisure time activities, and remove barriers
associated with going to the gym for exercise. However, participants also reported that
Wii Fit reminded them of their impairments due to its negative feedback and their own
intimidation and fear of falling.
Participants reported that their symptoms presented barriers to using Wii Fit,
although it can be argued that engaging in physical activity like Wii Fit can help reduce
the symptoms of fatigue. However, researchers also concluded that Wii Fit may also
worsen physical barriers associated with things like sensory impairments such as reacting
18 Exercise Therapy for Multiple Sclerosis Patients

to on-screen action and game play moving too fast, cognitive deficits such and learning
and problem solving to use Wii Fit, and balance and coordination.
The limitations of this study were included attrition and sampling bias, the use of
phone interviews, ambiguity in how initial attitudes affected future use of the Wii Fit, and
problems associated with qualitative methodology. There was also a selection bias due to
the fact that people who have negative feelings toward video games did not enroll in the
study. Future research on this topic should focus on removing any usability barriers and
adapt the environment and gaming system to the patients needs regarding their
symptoms. The use of face-to-face interviews should also be implemented to observe
body language and they should be conducted more frequently throughout the study.
Exercise Therapy for Multiple Sclerosis Patients 1
9

Conclusions for Alternative forms of Therapy for MS Patients
All three of the studies presented in this paper provide data that shows there are
alternative forms of therapy that are effective for people with Multiple Sclerosis.
Although no definitive conclusions can be drawn, the data shows that there is no harm
associated with alternative forms of therapy. Exercise therapy, massage therapy, and
novel forms of therapy like the Wii Fit all have proven to be beneficial for improving
patient symptoms if the programs are tailored to their individual needs and the patient
receives the proper instruction and guidance.
Multiple sclerosis can be a disabling and chronic disease if symptoms progress.
Because there is no known cure, it is important to be able to offer as many treatment
options as possible to control symptoms and improve the patients overall quality of life.
With healthcare reform on the forefront of change and healthcare costs rising, alternative
forms of therapy for people with Multiple Sclerosis will be imperative in helping them
receive the treatment they need.
20 Exercise Therapy for Multiple Sclerosis Patients

References
Burtchell, J. (2013). How Will the Obamacare Out-of-Pocket Cap Delay Affect MS
Patients? Healthline News. Retrieved April 23, 2014, from
http://www.healthline.com/health-news/ms-how-will-out-of-pocket-cap-delay-
affect-ms-patients-082813

Latsah, Mark. (2014, February 24) Multiple Sclerosis. Class Lecture.

Multiple Sclerosis. (2014). MedlinePlus. Retrieved April 23, 2014, from
http://www.nlm.nih.gov/medlineplus/multip

Multiple Sclerosis. (2013). PubMed Health. Retrieved April 23, 2014, from
http://www.ncbi.nlm.nih.gov/pubmedhealth

Negahban, H., Rezaie, S., & Goharpey, S. (2013). Massage Therapy and Exercise
Therapy in patients with Multiple Sclerosis: A randomized controlled pilot
study. Sage, 27(12), 1126-1136. Retrieved April 23, 2014, from
http://cre.sagepub.com/content/27/12/112

Plow, M., & Finlayson, M. (2013). A Qualitative Study Exploring the Usability of
Nintendo Wii Fit among Persons with Multiple Sclerosis. Wiley Online Library,
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ufq7std&s=875c85ffa947b3108c71


Swank, C., Thompson, M., & Medley, A. (2013). Aerobic Exercise in people with
Multiple Sclerosis: It's Feasibility and Secondary Benefits. International Journal
of MS Care, 15(3), 138-145. Retrieved April 23, 2014, from
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