Exercise as it relates to Disease/The impact of resistance training on balance and gait in Multiple Sclerosis

Article critique: Filipi LM, Leuschen P, Huisinga J, Scmaderer L, Vogel J, Kucera D, Stergiou N. Impact of resistance training on balance and gait in Multiple sclerosis. Int J MS Care. 2010 April 1;12(1):6-12.

What is the background to this research?
Multiple Sclerosis (MS) is a chronic disease where the immune system damages the covering of nerves (myelin sheath) in the brain and spinal cord. This disrupts the communication between motor and sensory pathways between the brain and body. It can impair walking, balance, vision, thinking, and memory. In Australia, MS is the most common neurological disorder for adults aged 20-40, and it affects women 3 times more than men (see MS website for more information). Current research shows that MS can lower quality of life, which leads to an increase in physical inactivity. This is concerning as there is no cure, and MS can lead to physical disability. Research shows that a common barrier to exercise is the fear that exercise can worsen symptoms. This is supported by the inconclusive evidence related to the safety, adherence, and effectiveness of resistance training, as well as the most appropriate exercises to improve walking and balance. Medication is effective in reducing flare-ups and slowing down disease progression, however, the ability of medication to improve symptoms such as muscle weakness, walking ability and balance is limited. The chosen article investigates the effectiveness of resistance training in adults with MS by exploring its effect on walking, balance, and fatigue, regardless of disability level.

Where is the research from?
The article was published by the International Journal of MS care, a peer-reviewed database for original research articles exploring clinical rehabilitation in MS. Mary L. Filipi is a nurse practitioner specialist based in Nebraska with more than 20 years of experience, has graduated with honours (1997) and has published several papers. The academic team is well-published. The paper has no conflicts of interest and received funding from 3 non-profitable organisations: the MARS foundation, the National Multiple Sclerosis Society and the NMC clinical research centre.

What kind of research was this?
The study was a nonrandomised, nonblinded prospective cohort study, this type of study explores the effectiveness of an intervention over time on a particular outcome or population.

What did the research involve?
Participant information


 * Age: 24-54 (38.8 +/- 10.7 years)
 * 33 participants: 11 males and 22 females
 * Group 1: little to no disability (EDSS 1.0-4.0)*
 * Group 2: mild to moderate disability (EDSS 4.5-6.5)*
 * Recruitment: provider referral or direct advertisement to the general MS population

*Expanded Disability Status Scale score: a valid scoring system that measures physical impairment from MS*

The resistance training program

There are weaknesses to the method that decreases the paper's ability to communicate that resistance training improves balance and walking, regardless of disability level. The article does not have a control group and the results were not compared to normative data. The recruitment process was small, and the sample size did not account for the 4 different types of MS (relapsing, primary and secondary progressive MS) and focused on a mild disease progression. These issues suggest that the study's findings cannot be generalised to all levels of disability. The paper concluded that a structured resistance training program is associated with improved balance and walking for all disability levels (see results). This is an overstatement as this is not agreed upon in the current research. This is because the clinical goal of resistance training in rehabilitation is specific to suit the functional capabilities of a patient. As one's level of disability increases and in patient with severe disability, the goal for exercise is to help with daily functioning and improving quality of life, not to improve walking and balance.
 * Duration of study: 6 months
 * Duration of each training session: 50 minutes; 30 minutes resistance training with 5-10 min warm up/cool down
 * Exercises: see the link for a summary of the exercises (page 10)
 * Frequency: 2 times a week
 * Intensity and volume: sets: 2-3 | repetitions: 10 | rest: 30 seconds
 * Progression: final repetition at the end of the last set is completed with the same intensity as the first repetition in the last set
 * Time of evaluations: before the study, at 3 months and after the study
 * Evaluation Instruments: Modified Fatigue Impact Scale (MFIS), Modified Fall Efficacy Scale (MFES), Berg Balance Scale (BBS), Timed Up and Go (TUG) test, Multiple Sclerosis Functional Composite (MSFC), Neuro-Com Balance Master and 3-dimensional biomechanical gait analysis. These are all applicable to a clinical setting.

Additionally, research about the physiological effects of resistance training for MS is emerging. As the study was not randomised, reactivity may have occurred. Reactivity is the unintended change in a participant's behaviour that favours what the researcher is looking for. The paper shows that there is a relationship between resistance training and an improvement in symptoms, but the reason as to why this relationship exists is not clear. It was concluded that exercise and medicine work well together and are necessary for a comprehensive rehabilitation program. This is an overstatement; the study did not investigate the interaction between medication and exercise. General statements are not applicable to MS rehabilitation as the process is highly individualised.

What were the basic results?

 * No participants experienced any negative effects to resistance training

Balance and Cognition


 * Memory and concentration improved
 * Overall participants felt less tired throughout the day
 * Participants were less afraid of falling

Walking


 * Strength and power increased in all leg muscles
 * Daily movements and walking became less tiring
 * Stride length increased

What the results mean

The hypothesis was supported, that resistance training will improve balance and fatigue regardless of disability, but the results are overstated.

What conclusions can we take from this research?

 * It promotes that physical activity is safe for MS and follows the appropriate exercise recommendations for a mild disease progression.


 * Resistance training can improve quality of life and daily functioning.


 * It would have been beneficial if the study investigated exercise adherence as this is lacking in current research . This would help educate patients and health professionals on the barriers to exercise and how to overcome them.
 * Further research is needed to investigate the physiological effects and benefits of resistance training for all types of MS.
 * A good reference for clinical assessments used in MS rehabilitation.

Practical advice

 * 1) Appropriate exercise recommendations for a mild disease progression
 * 2) * 2 days per week
 * 3) * 40-50 minutes
 * 4) * 10 repetitions, 2-3 sets per exercise
 * 5) * 30 seconds rest between sets
 * 6) Outlines exercise considerations/complications
 * 7) * Keeping body temperature stable, an increase in body temperature can be problematic.
 * 8) * Avoid rapid progressions, it can lead to excessive fatigue, injury and can increase disease progression.
 * 9) advocates the importance of physical activity
 * 10) * Staying active increases independence and levels of physical activity.
 * 11) * Promotes the importance of allied health professionals to prescribe exercise (i.e., Accredited Exercise Physiologist).

Further information/resources
MS website: https://www.msaustralia.org.au/?gclid=CjwKCAjwx7GYBhB7EiwA0d8oezY46_WCEmrY9mu62iL8Qt75QfKPKHeg_PNbM5Fizu-c1bmqzF8S1hoCybwQAvD_BwE

Exercise right recommendations: https://exerciseright.com.au/multiple-sclerosis/, https://exerciseright.com.au/staying-active-with-multiple-sclerosis/

MS organisations raising awareness: https://www.nationalmssociety.org/

Finding an Accredited Exercise Physiology in your area: https://www.essa.org.au/find-aep

Free Guide to Exercise from MS Australia: https://www.msaustralia.org.au/modifiable-lifestyle-guide-2020/for-people-with-ms/

National Multiple Sclerosis Document: https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/Clinical_Bulletin_Physical-Therapy-in-MS-Rehabilitation.pdf