Exercise Benefits for Multiple Sclerosis Participant: Case Study Matthew S. Wiggins, EdD; Emily Rader, MS; Jeremy B. Erdmann, MA, ATC The purpose of this case study was to determine whether an exercise program could increase physical strength, endurance, balance, and flexibility in a multiple sclerosis (MS) participant while improving the individual’s psychological well-being. The activity sessions were designed around a whole-body experience, with 10–12 exercise/weight-training stations two times per week for 6 months. Several initial baseline assessments were taken for physical strength (leg press, handgrip dynamometer), upperbody endurance (chest press), flexibility/range of motion (sit-and-reach test, shoulder-stick test), balance (stork stand), and body-fat analysis. Increases in these functional tests were recorded at 3, 6, 9, and 12 months. Psychological well-being measures were taken at baseline, 6, and 12 months, with social physique anxiety and quality-of-life measures showing overall improvement and self-efficacy related to exercise barriers showing a slight improvement. The importance of this case study is discussed in relation to other MS survivors and the maintenance of their functional capacities. Int J MS Care. 2007;9:126–130.
M
ultiple sclerosis (MS) is an autoimmune disease that has no known cure. Individuals with MS have an abnormal immune system response that causes T cells to attack myelin. This process is called demyelination, whereby the fatty substance that surrounds and insulates nerve fibers and facilitates the conduction of nerve impulse transmissions is rendered ineffective, scarring and hardening the nerve fibers (ie, sclerosis).1 Thus, coordinated movement is compromised by the loss of neural pathways, with specific effects on the body dependent on the level of impairment. Various symptoms may include spasticity, impaired balance, muscle weakness, fatigue, partial or full-body paralysis, and sensory loss.2,3 Based on the disease’s effect on the body, Mulcare2 has stated that exercise will have no overall effect on an individual’s MS prognosis or progression of the disease. More specifically, exercise cannot stop the eventual demyelination process. Mulcare did point out, however, that exercise may improve the short-term physical fitness and functional capacity of MS individuals. Studies have shown short-term results regarding quality of life (QOL) and physical changes. In one study, MS patients completed 4 weeks of 30-minute aerobic activity, 5 days per week.4 Results indicated an increase in From the Department of Wellness and Therapeutic Sciences, Murray State University, Murray, KY, USA.
health perception for the training group. No differences were found between the training and nontraining groups for maximal aerobic capacity and lung function. A more recent study found that increases in peak oxygen uptake and maximum work rate were significantly higher in a group after 8 weeks of aerobic training compared with a neurological rehabilitation-only group.5 No significant differences were found concerning fatigue effects or QOL perceptions. Positive physical and psychological results have also been shown in studies lasting 6 months. For instance, Romberg et al.6 studied health-related QOL in MS subjects by comparing those on a resistance-training program with a control group. Although no significant increase in QOL was seen, the experimental/resistancetraining group did show significantly (P < .05) higher ratings than the subjects receiving no intervention after 6 months. Another study by Romberg and colleagues7 was designed to assess walking and physical functioning in MS patients within a 6-month exercise program. Significant changes occurred between the groups, with the experimental group walking faster than the control group over 500 meters. The authors also reported upper-body endurance increases in the physically active group, although no changes were found concerning lower-body strength or balance increases. Based on these and other studies, White and Dressendorfer3 stated that exercise can provide physical
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and psychological benefits to MS patients involved in physical activity, and the benefits should outweigh any potential adverse effects from participation in an exercise program. The authors further stated that exercise programs should be designed to increase QOL, cardiorespiratory fitness, muscle strength, and mobility. Thus, even though exercise cannot stop the deterioration process, short-term physical fitness improvements may offset some of the disease progression or provide a higher functional capacity that would help individuals extend their current QOL. Based on this conjecture, the purpose of this case study was to determine whether an exercise program could increase physical strength, endurance, balance, and flexibility in an MS participant while improving psychological well-being.
Methods Participant The subject was a 60-year-old woman, ~5 feet 6.5 inches tall, with a baseline blood pressure of 94/64, and a resting heart rate of ~74. At age 11 years, she experienced her first physical problems associated with MS, including loss of balance and weakening in the leg muscles. Within a few weeks, she gradually became paralyzed on the right side of the body. The paralysis then remitted, and she led a fairly active life. The actual MS diagnosis did not occur until age 19 years, when she was diagnosed with a relapsing-remitting clinical course of the disease.1 In subsequent years, the MS prognosis developed into secondary progressive MS, where she experienced an initial period of relapsingremitting MS, followed by a steadily worsening disease course.1 Most recently, the subject was in a period of minor remission or plateau. Her balance and leg strength have been affected the most, necessitating the use a cane for walking ~2 years ago.
Measures To measure functional capacity and physical fitness changes over time, several assessments were taken for physical strength (leg press, handgrip dynamometer), upper-body endurance (YMCA bench press), flexibility/ range of motion (sit-and-reach test, shoulder-stick test), balance (stork stand), and body-fat estimates (bioelectrical impedance analysis and body mass index). These assessments are standard protocols used by exercise science and wellness practitioners. These tests were chosen to demonstrate the possible loss, maintenance, or increase in functional capacity by the subject concerning her exercise program. Reliability for the previously
mentioned tests has been demonstrated in various fields and settings of exercise, with coefficients ranging from 0.90 to 0.93 for each test.8 Initially, a cardiorespiratory test was not included because the participant was unable to walk safely on a treadmill. In the following months, that scenario changed, although she was still unable to perform a standardized protocol test. Three inventories were used to address chronic changes in psychological well-being. QOL was assessed by the Functional Assessment of Cancer Therapy– General (FACT-G) scale.9 Although designed for a cancer population, the FACT-G uses general non–diseasespecific statements to determine subscale scores for physical, functional, social, and emotional well-being and total QOL. Sample items include “I have a lack of energy,” “I am losing hope in the fight against my illness,” and “I get emotional support from my family.” Thus, the general nature of FACT-G appears to enable investigators to measure QOL in relation to other chronic diseases. Cella et al.9 used a five-phase validation process showing high coefficients for validity and reliability, whereas 15 cancer specialists provided content validity for the survey. The Barriers Efficacy Scale (BES) was used to measure the subject’s perceived ability to exercise in the face of possible barriers (eg, bad weather, vacation, lack of interest in the activity, boredom with the program, exercising alone).10 Total scores range from 12 to 120, with higher numbers indicating more confidence (selfefficacy) to overcome barriers. Internal consistency with studies using BES range between 0.82 and 0.96. The Social Physique Anxiety Scale (SPAS) was the third inventory used in this study.11 SPAS is a 12-item survey directed toward assessing an individual’s perception of physique in social situations, with overall summed scores ranging from 12 to 60. Cronbach α internal reliability was reported at .90, with an 8-week test-retest reliability coefficient of .82. Scale validation was provided through construct and criterion-related validity in two separate studies.
Procedures Contact was made with the participant through a friend the first author had been working with in an exercise and cancer recovery (ECR) research program. During an interview session, background information concerning her medical and exercise history was obtained. Agreement to be in a supervised exercise program was reached, and a consent form was filled out. Safety precautions and emergency procedures of the
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exercise facility, along with any risks involved in the program, were discussed with the subject. Once she understood the possible risks associated with exercising, she filled out a participant safety briefing form. Physical and psychological baseline measures were conducted the following week for all of the tests, with follow-up assessments taken at 3, 6, 9, and 12 months. Baseline information was used to write an exercise prescription for activity sessions under the direction of the investigators, with all workouts taking place in the ECR lab in the Carr Health Building on the campus of Murray State University (Murray, KY, USA). The subject participated 2 days per week in a 6month structured exercise program consisting of a warmup, main exercise activity (aerobic and weight training), and cooldown. The warmup included ~5 minutes of flexibility/stretching techniques, followed by 3–5 minutes of light aerobic exercise (bicycle ergometer, elliptical machine) to increase blood flow and prepare the body for the sessions. Aerobic activity varied throughout the 6-month program, starting with a bicycle ergometer, then elliptical machine, treadmill, and treadmill and recumbent bicycle. The duration was ~10 minutes for the first 6-week cycle (including warmup/cooldown time), increasing to ~20 minutes the last 6 weeks. Intensity was limited by walking ability, so the subject would maintain as fast a leg cadence as possible for the duration of the aerobic exercise. Concerning muscular strength and endurance, the amount of weight lifted stayed approximately the same for the first 3 weeks, with a gradual increase in repetitions from 10 to 15 over the first 4 weeks. In subsequent weeks, the number of sets was increased to 2, and the repetitions were increased to 20. Weight was increased after a few weeks to continue the overload progression. Stations were used during the workout time, with the subject alternating between upper- and lower-body exercises. Upper-body exercises included the upright seated bench, shoulder press, lat pulldown, triceps, and biceps, in that order. Lower-body exercises were leg press, leg extension, outer thigh, inner thigh, and situps. The cooldown portion of the session involved 3–5 minutes of light aerobic exercise (bicycle mostly) to bring the heart rate back to normal, followed by light flexibility/stretching. After the subject gained an increase in balance and stability in her lower extremities, several exercises with resistance tubing were prescribed. Having been in the program for ~3 months, the subject began using the
resistance tubing to perform hip flexion, hip extension, hip adduction, and hip abduction exercises in a standing position, with the idea of attaining better balance and further increases in leg strength. She was instructed to maintain balance on the opposite lower extremity while performing the exercises. With each session, she performed two bilateral sets of 10 repetitions for each direction with a 1-minute rest.
Results Initial testing resulted in the following deficiencies or weaknesses: 1. Subject was unable to balance on one foot (stork stand) for any length of time. 2. Although overall strength was above average, legpress results indicated that improvement in leg endurance would help with walking. 3. Flexibility in the shoulder area was rated poor to fair and needed to be improved for activities of daily living. 4. Back/hamstring flexibility was rated good for the sit-and-reach test. Exercise goals were then based on the aforementioned weaknesses: 1. Maintain upper-body endurance and strength, and, if possible, use strength/endurance exercises to increase balance and functional capacity. 2. Improve shoulder range of motion, along with maintaining overall flexibility. 3. Increase strength in the lower body enough to be able to walk on the treadmill. As can be seen in Table 1, the participant was able to increase most of her physiological measures from baseline to 12 months. The subject’s ability to perform a Naughton graded walking test without assistance was noteworthy at 9 months. The subject was able to make it to the 3rd stage of the protocol (time 8:45), with a speed of 2.0 mph and a grade of 7%. The subject also showed considerable improvement in upper-body endurance, a slight to moderate increase in lower-body strength where she was most affected by the disease, and a small but important improvement in balance over the course of the program. Regarding the three psychological well-being measures, the subject’s social physique anxiety ratings showed an overall improvement (ie, decrease) from baseline to 12 months (Table 2). More important, an increase in her QOL rating was demonstrated through the 12-month program, which mirrored her continued
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Table 1. Physical assessments over time Assessment Treadmill, min (mph) Body fat, % Body mass index, kg/m
2
Weight, lb
Baseline
3 Months
6 Months
9 Months
12 Months
0
11 (1.5)
10 (2.2–2.4)
Naughton
10 (2.2)
28.2
26.8
25.3
27.5
26.4
20.1
20.1
19.7
20.5
20.5
126.5
127.5
122.0
128.0
127.0
Handgrip, kg force Left
29
30
30
NA
NA
Right
32
34
35
NA
NA
9
17
31
41
46
Bench repetitions (35 lb)
90
90
Sit and reach, inches
Leg press, lb (1 repetition)
12.50
13.25
Shoulder range of motion, inches
35.0 0
Stork stand (left/right leg), s
110
110
120
13.75
13.00
13.00
28.5
28.5
21.0
19.0
0
3 (both legs)
5/6
4/7
physiological increases. Self-efficacy related to exercise barriers went down slightly at 6 months but increased above the baseline rating when recorded at 12 months.
Discussion This case study is important for both this MS survivor and similar individuals in regard to the maintenance of functional capacities. As mentioned above, the subject’s ability to perform a walking test without assistance was significant. When she first entered the program, one of her goals was to simply walk on the treadmill. During the initial weeks, she used a cane to get from one station to the next, and she was unable to walk on the treadmill even at its slowest speed (1.0 mph). As she became stronger in her lower body, she began to carry her cane from station to station. After 2 months, she began to walk to all the stations without even holding the cane. Moreover, as her confidence, strength, and balance improved, the subject was able to move from using the bicycle ergometer, to the elliptical trainer, to walking on the treadmill at 1.2 mph, with help from an investigator to maintain a rhythm. By the end of the program, she had increased her treadmill speed to a comfortable pace of 2.2 mph. In addition, the subject was able to complete a standardized treadmill protocol at 9
months that required her to not only walk at 2.0 mph but increase the elevation of the treadmill up to 7%. Because the subject wore out more quickly with the increased elevation, the final test only assessed length of time on the treadmill with no elevation. The participant was pleased to have met her initial goal of just being able to walk on the treadmill for any length of time. Furthermore, she remarked how she was able to personally show her dogs at competitions after not being able to do so for several years because of her anxiety about walking without a cane. Psychologically, the subject initially did not appear to have changed much over the course of the first 6 months, with only slight improvement in QOL and SPAS measures. However, the following email sent to one of the investigators in 2006 shows how sometimes inventories may not capture all of a patient’s psychological or emotional health: It is very hard to say exactly what the program means to me or has done for me. I can do more without getting so tired in all aspects of my life. For example, I did more Christmas shopping this year than I have done in ages and was not worn out by it. I have gotten back in the show ring sort of. I
Table 2. Psychological well-being assessments over time Assessment Social Physique Anxiety Scale
Baseline
6 Months
12 Months
Possible score
44
38
32
12–60
Barriers Efficacy Scale
77
75
81
12–120
Quality of life
70
75
80
0–104
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do not avoid going places like I used to. But it is much more than a physical thing. I was sitting home letting life sort of slip by as an observer. This program gets me up and out and doing and interacting with some very special people. The small successes have been real ego boosters. I still have some issues. The world, as I said, is not flat and carpeted, but I am making small strides in improving myself mentally and physically, and that is great. These changes in psychological well-being became even more apparent once the subject had been tested at 12 months. The subject’s long-term involvement in the exercise program could explain some previous research with regard to findings and QOL. Specifically, perhaps previous studies have been unable to show QOL changes because the exercise programs were too short.6 Changes in self-concept may therefore be better facilitated with programs structured to last longer than the traditional 12-week to 6-month study. One troubling aspect with the subject’s psychological well-being was her perceived self-efficacy related to exercise barrier ratings. Although she improved overall in the ratings from baseline to 12 months, the increase in self-efficacy was small. The subject may have still seen her disease as a limiting factor with regard to her ability to exercise, even though she had been successful at maintaining a consistent workout routine for a year. This point can also be illustrated in a study by Wiggins,12 who found that the highest self-efficacy perceptions are not always associated with the most physically fit individuals. More specifically, physical increases in strength and endurance cannot be assumed to naturally increase psychological well-being in all areas. In some cases, psychological interventions to build confidence, enhance body image, etc., will need to be part of a comprehensive exercise recovery program. The purpose of this case study was to determine whether an exercise program could increase certain physical capacities and psychological well-being in an MS patient. According to the data collected, the exercise program was a success by improving functional capacity (walking time and speed on the treadmill, balance), increasing muscular strength and endurance, lowering social physique anxiety, and increasing perceived QOL. According to these findings and those concerning exercise interventions with MS patients,
individuals with a similar disease progression (ie, with a mild to moderate form of MS progression) may benefit physically and psychologically from being involved in an exercise management program. According to Mulcare,2 individuals who want to work with an MS patient should consider several factors related to exercise tolerance before prescribing physical activity as a means to increase functional capacity. For instance, general and exercise-related fatigue can reduce exercise tolerance, so daily subjective feelings will need to be monitored. Heat intolerance may affect intensity, duration, and mode of the exercise program for the participant, whereas sensory loss might affect upright activities such as treadmill and bicycle ergometer use. As was the case for the current participant, careful planning and execution of an individualized exercise prescription that takes into account the patient’s current disease status and progression and any physical setbacks and triumphs is crucial. References 1. About MS. Available at: www.nationalmssociety.org/about%20ms. asp. Accessed 3 January 2007. 2. Mulcare JA. Multiple sclerosis. In: Durstine JL, Moore GE, eds. ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities. 2nd ed. Champaign, IL: Human Kinetics; 2003:267–272. 3. White LJ, Dressendorfer RH. Exercise and multiple sclerosis. Sports Med. 2004;34(15):1077–1100. 4. 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(2):161–168. 5. Rampello A, Franceschini M, Piepoli M, et al. Effect of aerobic training on walking capacity and maximal exercise tolerance in patients with multiple sclerosis: a randomized crossover controlled study. Phys Ther. 2007;87(5):545–555. 6. Romberg A, Virtanen A, Ruutiainen J. Long-term exercise improves functional impairment but not quality of life in multiple sclerosis. J Neurol. 2005;252(7):839–845. 7. Romberg A, Virtanen A, Ruutiainen J, et al. Effects of a 6-month exercise program on patients with multiple sclerosis: a randomized study. Neurology. 2004;63(11):2034–2038. 8. Morrow JR, Jackson AW, Disch JG, Mood DP. Measurement and Evaluation in Human Performance. 3rd ed. Champaign, IL: Human Kinetics; 2005. 9. Cella DF, Tulsky DS, Gray G, et al. The Functional Assessment of Cancer Therapy (FACT) scale: development and validation of the general measure. J Clin Oncol. 1993;11:570–579. 10. McAuley E, Mihalko SL. Measuring exercise-related self-efficacy. In: Duda, JD, ed. Advances in Sport and Exercise Psychology Measurement. Morgantown, WV: Fitness Information Technology; 1998: 371–390. 11. Hart EA, Leary MR, Rejeski WJ. The measurement of social physique anxiety. J Sport Exerc Psychol. 1989;11:94–104. 12. Wiggins MS. Psychophysiological comparison of self-efficacy and resting heart rate. Percept Motor Skills. 2002;94:720–722.
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