Original Research

The effect of a combined exercise programme for people with Multiple Sclerosis: a case series Leigh Hale, PhD, MSc Physio(WITS), BSc Physio (UCT), School of Physiotherapy *Elaine Schou, BPhty (Otago), Private Practice Jan Piggot, MHSc, GradDipHSc (Curtin), DipPhty (AIT), School of Physiotherapy Andy Littmann, BSc (Wisconsin), MA (Iowa), School of Physiotherapy Steve Tumilty, GradDipPhys(Newcastle), School of Physiotherapy * This author was, at the time this study was undertaken, a summer scholarship student in the School of Physiotherapy at the University of Otago.

ABSTRACT The purpose of this study was to pilot an eight-week programme of aerobic, stretching, strengthening and balancing exercises in four people with MS. The programme was initiated in a clinical setting under physiotherapy supervision for four weeks and then continued in the home environment for a further four weeks. The programme was assessed for its impact on participants’ fitness and function, and for its appropriateness for use in a private home. Participants reported that the exercise programme was enjoyable and beneficial, and these positive results were substantiated in improvements in muscle strength, Berg Balance scores, mobility and ability to cycle. This confirms recent evidence that, contrary to earlier opinions, people with mild to moderate MS disability can exercise at an appropriate intensity and duration to achieve positive results without noticeably increasing fatigue symptoms or exacerbating the disease process. However three participants felt that it was difficult to keep up the motivation to exercise at home indicating that long-term compliance may be an issue in maintaining exercise programmes. Two participants demonstrated abnormal cardiovascular responses to aerobic exercise which may have been associated with autonomic dysfunction, emphasising that exercise programmes for people with MS must be carefully prescribed and monitored. Leigh Hale, *Elaine Schou, Jan Piggot, Andy Littmann, Steve Tumilty. The effect of a combined exercise programme for people with Multiple Sclerosis: a case series. New Zealand Journal of Physiotherapy 31 (3): 130-138. Key Words: Multiple Sclerosis, exercise programmes, physiotherapy, aerobic exercise

INTRODUCTION Multiple Sclerosis (MS) is an incurable chronic demyelinating neurological disease that usually affects people from early adulthood (Petajan & White, 1999). The symptoms are numerous, commonly including fatigue, muscle weakness, and psychosocial problems (Petajan & White, 1999; Ponichtera-Mulcare, 1993; Sutherland &Anderson, 2001). Fatigue is one of the major debilitating symptoms of MS (Vaz Fragoso et al., 1995) and is thought to be due to a combination of central and peripheral changes. Centrally slowed axonal electrical conduction along motor pathways is thought to result in fatigue symptoms (Sheean et al., 1997). Peripheral changes include muscle fibre alterations and reduction in muscle cross sectional area (De Haan et al., 2000), altered enzyme (Kent-

Braun et al., 1997) and metabolic activity (KentBraun et al., 1994). These peripheral changes may be further exacerbated by chronically reduced physical activity (De Haan et al., 2000). People with MS participate in significantly less physical exercise compared to sedentary individuals (Ng & KentBraun, 1997). Reduced activity in people with MS may cause muscle fibres to atrophy resulting in a reduction in type I fibres (Kent-Braun et al., 1997). Physical inactivity exposes people with MS to other conditions such as heart disease and osteoporosis (Pate et al., 1995), and has been correlated with less social interaction, a depressed mood and diminished well being (Rudick et al., 1992). In the past, physiotherapy management of MS focussed on rest and passive treatment to avoid exacerbating fatigue or the disease process (Russel,

NZ Journal of Physiotherapy – November 2003. Vol. 31, NZ 3 Journal of Physiotherapy – November 2003. Vol. 31,130 3 130

1967). Current research is demonstrating overwhelming benefits when people with Multiple Sclerosis exercise. Aerobic exercise and strengthening programmes improve maximal aerobic capacity (Petajan et al., 1996) and muscular force production, power, work and endurance (Gehlsen et al., 1984; Svensson et al., 1994). Further benefits of exercise for people with MS include improved fatigue, cognitive ability and energy. (Sutherland et al., 2001). Published exercise programmes have shown the benefits of specific strengthening regimens (Harvey et al., 1999; Svensson et al., 1994), aquatic (Gehlsen et al., 1984) and aerobic programmes (Kirsch & Myslinski, 2000; Petajan et al., 1996). The duration of these programmes vary from four to fifteen weeks, with most participants attending three times a week. In a single case study of a person with MS Van Sint Annaland & Lord (1999) showed that a combined programme of aerobic, strengthening and balance exercises was beneficial but again the participant attended the programme three times a week over a five-month period. Although combined exercise programmes have not otherwise been investigated in an MS population, such programmes have been shown to be beneficial in preventing falls and improving general well being in elderly people (Brown, 1999; Campbell et al., 1997; Munro et al., 1997). As MS is a chronic disease, on-going exercise programmes are required (Kirsch & Myslinski, 2000). However, attending lengthy physiotherapysupervised exercise programmes could prove expensive (Kirsch & Myslinski, 2000). A more costef fective approach may be to attend a physiotherapy-supervised programme for four weeks to ensure safety and familiarisation with exercises followed by independent continuation of the exercise programme at home; four weeks being the minimum period so far shown to provide benefits from a specifically described exercise programme in an MS population (Svensson et al., 1994). To ensure compliance and cost effectiveness the exercise equipment needs to be easily bought and stored in a private home. Aerobic equipment such as treadmills (Van Sint Annaland & Lord, 1999) and arm and leg ergometers (Petajan et al., 1996) may not be suitable due to the cost and size of this equipment. A stationary cycle to enhance aerobic fitness may be feasible from a cost-effective and storage point of view and has been shown to improve aerobic function in individuals with other neurological deficits (Holt et al., 2001). It is important to investigate exercise programmes for people with MS that demonstrate efficacy and cost effectiveness, and that can be easily carried out in the home (Solari et al., 1999). This paper reports on the effects of a combined exercise programme (including strengthening, aerobic, balancing and stretching components) that was established over four weeks in a clinical setting and then transferred into the home for a further

four weeks. The programme was piloted with four people with MS and its benefits relating to function, fitness and home-use evaluated.

METHOD Recruitment of Participants Otago Ethics Committee approved this study. Information regarding the study was sent to the Multiple Sclerosis Society Otago Inc for distribution to their members. People interested in participating were asked to contact the researchers and informed written consent was then obtained from those who fulfilled the inclusion criteria. Inclusion Criteria Participants had to meet the following criteria: 1) confirmed diagnosis of clinically definite MS (Poser et al., 1983); 2) Kurtze Expanded Disability Status Scale (EDSS) score of 6.5 or less (a score of 6.5 indicating that participants are ambulant with assistive devices over 20m; a lower score indicating better independent ambulation) (Kurtze, 1983); 3) no history of any medical condition that would preclude participation in the prescribed training programme, such as cardiac conditions or in a relapse-stage of their disease process; 4) independently mobile, with or without walking aids. Participants agreed that the researchers could contact their general practitioners, who confirmed the inclusion criteria and that the participants were medically safe to be involved in the research. In addition participants completed a pre-exercise health questionnaire to ensure they were safe to exercise (American College of Sports Medicine, 2000). Outcome Measures Fitness was evaluated by muscle strength testing and the heart rate response to aerobic exercise. Maximal isometric peak force output was evaluated using a mechanical dynamometer, a method for testing muscle strength that has been validated for people with MS (Svensson et al., 1994). Maximal oxygen uptake (VO2max) is recognised as the criterion measure in evaluating the efficiency of the cardiovascular system to supply working muscles with oxygen (Nieman, 1990; Russo, 1990) and is usually measured with indirect calorimetry during maximal exercise in MS research (Kirsch & Myslinski, 1999; Petajan et al., 1996; PonichteraMulcare, 1997). However, the test requires expensive equipment and expertise. VO2max can be predicted using submaximal exercise protocols and recording resting and steady-state heart rates to increased workload, and such a procedure was used in a single case study of a person with stroke (Holt et al., 2001). Balance and walking were evaluated as indicators of improved function. Balance was assessed using the Timed “Up and Go” Test (TUG test) (Podsiadlo & Richardson, 1991) and the Berg Balance Scale (Berg et al., 1992), and walking

131 NZ Journal of Physiotherapy – November 2003. Vol. 31, NZ 3 Journal of Physiotherapy – November 2003. Vol. 31,131 3

assessed with the Ten-Metre walk test (Wade, 1996). All three tests have been used extensively in neurorehabilitation, and have been shown to be reliable and valid (Cole et al., 1994). Two tests for balance were included as each test assesses different components of balance function. In addition to the above measures, the Multiple Sclerosis Self-Efficacy Scale (MSSE) (Schwartz et al., 1996) and the Performance Scale (Schwartz et al., 1999) were included as self-reported measures of impairment and ability in MS. Both scales have been shown to be reliable and valid for people with MS (Schwartz et al., 1996; Schwartz et al., 1999). On the Performance Scale respondents are asked to rate their present ability on eight domains of function, whereas the MSSE Scale asks respondents to rate how certain they are able to perform specific behaviours related to functional independence and psychological management of the disease. Although similar, the two scales rate different functional components. Testing Procedure Participants were tested three times: prior to commencement of the exercise programme, after completion of the four week physiotherapy supervised programme within the School of Physiotherapy and a third time on completion of the four week home programme. The questionnaires were only administered before and after eight weeks. Each testing session was performed over two days with a rest day between test days. On day one the functional tests and questionnaires were completed, and on day two the fitness testing. Physiotherapists who were not involved in the exercise prescription or data analysis per for med the tests. One physiotherapist did all the dynamometry testing and another physiotherapist did all other tests at each of the three sessions. Dynamometry: the maximal output for the hamstrings and the quadriceps muscle groups were

tested isometrically for 5 seconds once each at an angle of 40˚ knee flexion using the KinKom TM as described by Bever et al (1995). In a test-retest reliability study of isometric testing with a cohort of people with MS, Bever et al (1995) found no significant differences between three repeats tests. Thus in the present study participants only perfor med one test for each muscle group. Cardiovascular Fitness Assessment: A Polar™ Heart rate monitor was used to monitor heart rate continuously at rest, during five minutes of cycling on a Monark™ stationary cycle and after cessation of cycling for three minutes. Heart rate was recorded very 60 seconds. The resistance of the cycle was set so the participants worked at a moderately hard level of perceived exertion (13/20 on the Borg scale) (Borg, 1982). Case Histories None of the participants was, at the time of the study, attending physiotherapy or any form of organised physical activities. Information relating to each participant’s age, level of mobility and time since diagnosis are detailed in Table 1. Training Programmes The training programmes for all participants included strengthening exercises, aerobic fitness (stationary cycling) and balance exercises, and were done three times a week for four weeks under the supervision of one physiotherapist. Each session finished with a stretching programme for the lower limb. The details of these programmes are shown in Table 2. The participants then continued the same exercise programme at home, unsupervised, for a further four weeks. The physiotherapist ensured that participants were familiar with what they had to do and each participant received a folder in which each exercise was described along with a diagram. Participants were asked to perform each

Table 1. Participant Information Age (years)

Time since Diagnosis (years)

Participant 1

72

20

Participant 2

59

27

Participant 3

56

12

Participant 4

45

7

Mobility

4-wheeled walking frame approximately 250m. Fall 3 years ago, resulted in a fractured right neck of femur 4-wheeled walking frame and a right anklefoot-orthosis for approximately 25 metres. Usually uses a wheelchair at home. Fractured her right distal tibia and fibula in a fall a year ago. Can mobilise 100m outdoors with two elbow crutches, but requires a single crutch when indoors. Independently mobile without aid and able to walk approximately 900m before fatiguing. Can manage stairs independently. Poor balance made it difficult for her to walk over uneven surfaces.

NZ3Journal of Physiotherapy – November 2003. Vol. 31,132 3 132 NZ Journal of Physiotherapy – November 2003. Vol. 31,

Table 2. Exercice Programme Aerobic Exercises Balance Exercises

Strengthening Exercises

Independent cycling against progressively increasing resistance and duration. Balancing exercises, depending on the individual participant’s ability, included: sit to stand, squats, side to side walking, semi tandem and tandem standing and walking, stair climbing, single leg balancing, walking changing direction, beam walking, walking uneven surfaces, fast stepping, walking and dual tasking, walking up and down an incline, walking unaided and with assistive devices. Position of exercising depended on strength of muscles, as to whether gravity was eliminated or not. Resistance was applied where possible in the form of a cuff weight or by the use of body weight. In some cases where muscles were particularly weak, a polish board was used to reduce friction. A mixture of open- and closed-chained exercises where used. Exercises included (depending on the individual): squats, calf raises, hip abduction (standing/supine), knee extension (side lying/sitting), knee flexion (side lying/prone), bridging, lunges. Sets of 10 repetitions were used for each exercise performed, and the number of sets increased as strength improved.

exercise three times a week. Participants were instructed as to whom they should contact if they required advice and a research physiotherapist maintained weekly telephone contact. Exercises were not progressed during the home programme. The home programmes were similar to those shown in the Table 2 however due to logistical and size constraints one of the participants used a converted arm to leg ergometer rather than a stationary cycle (Participant 1). Participant 2 was unable to cycle for two weeks during the home period as her carer was away on leave and it was considered unsafe for her to cycle unsupervised. The resistance used in the strengthening exercises was progressed by increasing the number of repetitions performed. Participants kept training diaries for both the School and home programmes, in which they commented on their exercise sessions and how they felt as a result of the exercises. During the home programme they marked off on a calendar what exercises they had performed each day.

RESULTS Tables 3 - 6 show results from the initial, week four and week eight test sessions, and indicate, in percentages, the changes that occurred over the exercise periods. A negative sign before the percentage change indicates a worse result. All participants could perform the TUG Test quicker, had higher Berg Balance scores, and all but one participant could walk the test distance of 10m faster. The scores of the MSSE Scale and the Performance Scale had improved. Participants could cycle for longer and against a greater resistance, although their resting heart rate remained unchanged. Generally, all participants demonstrated strength gains. Much of this improvement was maintained at the eight-week test or had declined slightly but not back to the initial test level. During the cycle testing, heart rate was monitored continuously, and two participants were noted to have an abnormally steady baseline heart rate, a delayed heart rate response to aerobic exercise and an extended recovery period back to

baseline resting rate at the cessation of exercise. For example, in one participant it took three minutes for the heart rate to begin to increase at the commencement of cycling, the response was attenuated (the heart rate reached 95 beats per minute from a resting heart rate of 63 beats per minute after 7 minutes cycling at a moderatelyhigh level of perceived exertion) and a lengthy recovery (9 minutes) of heart rate back to resting state at the end of exercise. No participant missed a session at the School and the home exercise calendars indicated that participants had continued with the exercise programme three times a week at home. Although participant diaries indicated daily fluctuations in fatigue as well as some initial muscle soreness and tightness, the general response was one of feeling “good” and increased energy to do other activities, such as gardening. All participants enjoyed the exercise programme: “feel so much fitter” and “able to do more”. On the whole participants said that they enjoyed coming into the School to do the programme as they felt that they worked harder under supervision. At home they would feel “lazy” or be distracted and not be inclined to exercise. Three participants admitted that they had complied well with the home programme because they knew it was part of a research study. One participant said that she would not like to come into the School on a long-term basis and she felt happy with being shown exercises to do at home and to come in periodically for a check-up.

DISCUSSION The four participants in this study found the prescribed exercise programme to be beneficial. On the whole this positive subjective evaluation was borne out by the results of the outcome measures used, especially those at the four-week test. There were some notable exceptions, which cannot be explained, for example, Participant 1’s TUGT and Berg Balance scores continued to improve over the eight weeks whilst her 10m-walk time became slower. Participant 3’s 10m walk was remarkably improved at eight-weeks concurrently with a decrease in Berg Balance score.

133 NZ Journal of Physiotherapy – November 2003. Vol. 31, NZ 3 Journal of Physiotherapy – November 2003. Vol. 31,133 3

Table 3. Results of Functional Outcome Measures and Questionnaires Initial test

4 week test

% change from initial test

8 week test

% change from initial test

Timed Get Up and Go (decrease in time indicates improvement) Participant 1 21.8s 15.1s 11%

15.3s

29.5%

Participant 2

26.0s

17.0s

35%

20.8s

20 %

Participant 3

29.3s

18.5s

37%

18.9s

35 %

Participant 4

8.6s

7.7s

11%

7.4s

15 %

Mean group % improvement (n = 4)

24%

25%

Berg Balance Assessment (Total = 56; increase in score indicates improvement) Participant 1

31

46

48 %

49

58 %

Participant 2

26

29

11.5%

29

11.5 %

Participant 3

36

41

14 %

32

-11 %

Participant 4

54

55

2%

55

2%

Mean group % improvement (n = 4)

43 %

15 %

Time taken to walk 10 m (decrease in time indicates improvement in speed of walking) Participant 1

31.0s

46.0s

- 48%

49.0s

- 58%

Participant 2

30.3s

22.0s

27%

16.2s

47%

Participant 3

36.0s

41.0s

- 14%

17.6s

51 %

Participant 4

8.6s

8.3s

4%

7.5s

13%

Mean group % i Improvement (n = 4)

- 8%

13 %

MS Self efficacy scale – Control (Total = 100; increase in score indicates improvement) Participant 1

76

84

11%

100

32%

Participant 2

42.5

42.5

0%

41

- 4%

Participant 3

81

87

7%

88

9%

Participant 4

32

58

81%

59

84 %

Mean group % improvement (n = 4)

25 %

30 %

MS Self Efficacy Scale – Function (Total = 100; increase in score indicates improvement) Participant 1

66

78

18 %

84

27 %

Participant 2

49

60

22 %

38

-22 %

Participant 3

80

88

10%

88

10 %

Participant 4

63

78

24 %

74

17.5 %

Mean group % improvement (n = 4)

18.5 %

8%

Performance Scale (Total Score = 41; decrease in score indicates improvement) Participant 1

17

-

-

9

20 %

Participant 2

26.5

-

-

23

9%

Participant 3

13

-

-

9

10 %

Participant 4

30

-

-

29.5

Mean group % improvement (n = 4)

Although the results indicate that the exercise programme was beneficial, it must be noted that, due to time constraints, participants were only tested once for each outcome measure prior to the

-

1% 10 %

intervention programme and therefore the stability of baseline data was not established. The clinical significance of a change in score using the Berg Balance Scale or the TUG Test

NZ Journal of Physiotherapy – November 2003. Vol. 31, NZ 3 Journal of Physiotherapy – November 2003. Vol. 31,134 3 134

Table 4. Results of the Fitness Tests Initial test

4 week test

% change from initial test

8 week test

% change from initial test

Resting Heart Rate Participant 1

60

68

13 %

76

- 27 %

Participant 2

100

102

2 %

103

-3 %

Participant 3

82

85

4 %

67

18 %

Participant 4

86

85

-1 %

79

8 %

Heart rate at 4 minutes after the start of cycling Participant 1

60

68

13 %

100

-6%

Participant 2

105

106

1%

116

- 11 %

Participant 3

105

101

-4%

71

32 %

Participant 4

141

145

3%

126

11 %

Participant 1

1N

10 N

900 %

10 N

900 %

Participant 2

1N

5N

400 %

10 N

400 %

Participant 3

1N

10 N

900 %

10 N

900 %

Participant 4

5N

15 N

200 %

10 N

100 %

-

Resistance Level on Bicycle

Time spent on cycling at each session in minutes Participant 1

5

10

-

14

Participant 2

5

10

-

8

-

Participant 3

5

10

-

9

-

Participant 4

5

13

-

15

-

Table 5. Peak Isometric Force in Newtons: Knee Extension at 40˚ Extension Initial test test Participant 1 Participant 2 Participant 3 Participant 4

Right Left Right Left Right Left Right Left

4 week

% change from initial

8 week test

242 243 48 180 180 264 246 258

14 % 4% 433 % 18 % - 18 % 56 % -8% 30 %

152 205 60 131 129 244 253 282

212 234 9 153 220 169 269 198

% change from initial - 28 % 12 % 567 % - 14.3 % - 41 % 44 % -6% 42 %

Table 6. Peak Isometric Force in Newtons: Hamstrings at 40˚ Flexion

Participant 1 Participant 2 Participant 3 Participant 4

Right Left Right Left Right Left Right Left

Initial test

4 week test

115 124 40 89 102 135 109 90

110 143 44 60 128 163 150 185

have not been established in MS. Stevenson (2001) established in a cohort of 48 patients with acute stroke that approximately 6 Berg Balance points are necessary to be 90% confident of

% change from initial test -4% 15 % 10 % - 32 % 25 % 21 % 38 % 106 %

8 week test

% change from initial test

140 190 59 89 127 135 143 149

37 % 41 % 48% 0% 25 % 0% 31 % 66 %

genuine change. Based on this, only one participant in this study showed any genuine change, and she was able to subsequently walk without a stick.

135 NZ Journal of Physiotherapy – November 2003. Vol. 31, 3 NZ Journal of Physiotherapy – November 2003. Vol. 31, 1353

A velocity of 2.4m/s, which is 30% of the normal population average velocity (Bohannon, 1997), is thought to be the threshold value required to walk effectively in the community (Perry et al., 1995). At initial testing three of the participants walking velocity fell below this threshold and subjectively they found it difficult to walk in the community. The walking velocity of all participants improved with the programme and resulted in two participants meeting the criteria to ambulate effectively in the community and another doubling her walking velocity. Shwid et al (2002) demonstrated that a 20% improvement in the 25 Foot walk, a test similar to the 10-m walk test (Cohen et al., 2001), is a significant change in Multiple Sclerosis suggesting that the results seen in this case series may have been clinically significant. Generally most participants had improved their peak isometric force output production in both quadriceps and hamstrings muscles groups. In the Beaver et al study (1995) the intersession coefficient of variability was found to be 7.81 +/6.97% for the hamstrings and 5.97 +/- 4.03% for the quadriceps. Based on these figures participants in this study had isometric strength gains that were generally above those expected due to variability. The physiological reasons for the improvement in strength observed in this programme were most likely due to neural changes. In the normal population it has been suggested that short-term training programmes, similar to that in the current study, have lead to more efficient muscle recruitment, increased neural activation and motor unit synchronization and a decrease in golgi tendon organ inhibition (Enoka, 1988; Keen et al., 1994). Harvey et al (1999) suggested that people with MS undergo neuromuscular adaptations during strengthening programmes. A further reason for observed changes in muscle strength in people with MS may be due to increased willingness and confidence of participants to participate in physical activity (Svensson et al., 1994). All participants particularly enjoyed cycling. Although participants’ resting heart rates, on the whole, were not shown to decrease, as had been anticipated, participants showed improvement in the length of time they could maintain cycling and the resistance at which they cycled against increased. One participant, at the initial test had to be assisted to turn the pedals and to balance on the cycle but by the end of four weeks she was able to cycle independently at a resistance of 5N for ten minutes. Participants in this study were unable to achieve steady state heart rates before becoming too tired to cycle further, and this made it difficult to accurately measure any improvements in cardiovascular function. Although participants were able to cycle for longer against increased resistance indicating improvement, this improvement could have been due to improved efficiency of the legs to cycle and not indicative of improved cardiovascular function. The delayed heart rate response to the cycle test demonstrated by two participants may indicate

involvement of the autonomic system. Approximately one third of people with MS are reported to have autonomic involvement that can affect the cardiovascular system’s response to exercise (Pepin et al., 1996; Ponichtera-Mulcare et al., 1993; Senaratne et al., 1984). Research has demonstrated moderate abnormalities in resting heart rate and blood pressure in people with MS (Monge-Argiles et al., 1998), and blunted cardiovascular responses to routine autonomic testing (Pepin et al., 1996). Pepin cautioned that a potential consequence of inadequate pressor response to exercise is reduced cerebral blood flow, resulting in dizziness or syncope. Autonomic dysfunction may not be the only cause of an attenuated cardiovascular response to exercise in MS. Ng et al. (2000) monitored heart rate, mean arterial blood pressure and intramuscular metabolic responses using phosphorus magnetic resonance spectroscopy during isometric dorsiflexion exercise and concluded that the dampened pressor responses to exercise can be explained by a blunted muscle metabolic response. The four-week school-based combined exercise programme appeared to be effective; participants showed noticeable improvement and were enthusiastic about the programme. There was good compliance with the programme, although two participants indicated that they persisted with the home programme as they knew they were part of a study. They considered coming to the School for exercises a better option as these two participants did not feel they had the self-discipline or drive to exercise appropriately at home unsupervised. Another participant found she enjoyed exercising at home more, and that she would only like to come back to the School for “top-ups” or changes to her programme.

CONCLUSION This paper reported on the effects of a combined exercise programme (including strengthening, aerobic, balancing and stretching components) for people with MS that could be initiated in a clinic and transferred into the home. This programme was explored with four people with MS and found to be feasible, enjoyable and beneficial. Participants reported a feeling of improvement and this subjective evaluation was substantiated by improvements in both impairment and functional measurements. Although the home programme was feasible, equipment size and compliance would probably be the two main deterring factors. A stationary cycle is relatively inexpensive but can take up a lot of space in a small home. Long-term compliance with the home programme would probably depend on the individual and would require constant support and encouragement from a physiotherapist. Two participants demonstrated abnormal heart rate responses to aerobic exercise and all participants expressed difficulty with their balance whilst walking, thus it is recommended that exercise programmes should be set up and monitored under professional supervision before

NZ Journal of Physiotherapy – November 2003. Vol. 31, NZ 3 Journal of Physiotherapy – November 2003. Vol. 31,136 3 136

being continued as a home or community programme to ensure that the programme can be performed safely, both from a falls and from a cardiovascular perspective.

ACKNOWLEDGEMENTS We would like to acknowledge with thanks the four people with MS who volunteered to take part in this case series, the MS Society Otago Inc for their support of the project, the School of Physiotherapy, University of Otago for the use of their equipment, academic and technical support, and the organisations that provided funding.

SOURCE OF FUNDING Funding for this project was provided by the New Zealand Society of Physiotherapy, Deloitte Touche Tohmatsu for a summer student scholarship and the School of Physiotherapy, University of Otago.

REFERENCES American College of Sports Medicine (1995): Guidelines for Exercise Testing and Prescription. (5th ed.) Philadelphia: Lea & Febiger. Bever Jr CT, Anderson PA, Smith GV, Panitch HS and Johnson KP (1995): Isometric Measurement of Hamstrings and Quadriceps Strength in Multiple sclerosis patients: Sensitivity and Variability. Jour nal of Neurological Rehabilitation, 9, 4: 221-227. Berg KO, Maki BE and Williams J (1992): Clinical and laboratory measures of postural balance in an elderly population. Archives of Physical Medicine & Rehabilitation, 73: 1073-1089. Bohannon RW (1997): Comfortable and maximum walking speed of adults aged 20 – 79 years: reference values and determinants. Age Ageing, 26: 15-19. Borg GAV (1982): Psychological bases of perceived exertion. Medicine and Science in Sports Exercise, 14, 5: 377. Brown AP (1999): Reducing falls in elderly people: a review of exercise interventions. Physiotherapy Theory and Practice, 15: 59-68. Campbell AJ, Roberston MC, Gardner MM, Norton RN, Tilyard MW and Buchner DM (1997): Randomised controlled trial of a general practice programme of home based exercises to prevent falls in elderly women. British Medical Journal, 315: 1065-1069. Cohen JA, Cutter GR, Fischer JS, Goodman AD, Heidenreich FR, Jak JR and Kniker JE (2001): Use of the Multiple Sclerosis Functional Composite as an outcome measure. Archives of Neurology, 58: 961-967. Cole B, Finch E, Gowland C and Mayo N (1994): Physical Rehabilitation Outcome Measures. Canadian Physiotherapy Association. De Haan A, De Ruiter C, Van der Woude L and Jongen P (2000): Contractile properties and fatigue of quadriceps muscle in Multiple Sclerosis. Muscle & Nerve, 23: 1534-1541. Enoka RM (1988): Muscle strength and its development: new perspectives. Sports Medicine, 6: 146-168. Gehlsen GM, Grigsby SA and Winant DM (1984): Effects of an aquatic exercise programme on muscular strength and endurance of patients with Multiple Sclerosis. Physical Therapy, 64: 635-637. Harvey L, Davies-Smith A and Jones R (1999): The effect of weighted leg raises on quadriceps strength, EMG parameters and functional activities in people with Multiple Sclerosis. Physiotherapy, 85, 3: 154-161. Holt R, Kendrick C, McGlasshan K, Kirker S and Jenner J (2001): Static bicycle training for functional mobility in chronic stroke – a case report. Physiotherapy, 5: 257-260. Keen D, Yue G and Enoka R. 1994. T raining related enhancements in the control of motor output in elderly humans. Journal of Applied Physiology, 77, 2648-2658. Kent-Braun JA, Ng AV, Castro M, Weiner MW, Gelinas A, Dudley GA and Miller RG (1997): Strength, skeletal muscle composition and enzyme activity in Multiple Sclerosis. Journal of Applied Physiology, 83, 6: 1998-2004. Kent-Braun JA, Scharma KR, Weiner MW and Miller RG (1994): Effects of exercise on muscle activation and metabolism in Multiple Sclerosis. Muscle & Nerve, 17: 1162-1169.

Kirsch NR and Myslinski MJ (2000): The effect of a personally designed fitness program on the aerobic capacity and function for two individuals with Multiple sclerosis. Physical Therapy Case Reports, 2, 1: 19-27. Kurtzke JF (1983): Rating neurological impairment in multiple sclerosis: an expanded disability status scale (EDSS). Neurology, 33: 1444-1452. Monge-Argiles JA, Palacios-Ortega F, Vila-Sobrino JA and Matias-Guiu J (1998)º: Heart rate variability in multiple sclerosis during a stable phase. Acta Neurological Scandinavia, 97: 86-92. Munro J, Brazier J, Davey R and Nicholl J (1997): Physical activity for the over-65s: could it be a cost-effective exercise for the NHS? Journal of Public Health Medicine, 19, 4: 397-402. Ng AV and Kent-Braun JA (1997): Quantitation of lower physical activity in persons with multiple sclerosis. Medicine and Science in Sports and Exercise, 29, 4: 517-523. Ng AV, Dao RG, Miller DF, Gelinas DF and Kent-Braun JA (2000): Blunted pressor and intramuscular metabolic responses to voluntary isometric exercise in multiple sclerosis. Journal of Applied Physiology, 88: 871-880. Nieman DC (1990). Fitness and Sports Medicine: an Introduction. California: Bull Publishing Company. Pate RR, Pratt M and Blair SN (1995): Physical activity and public health. JAMA, 273: 402-407. Pepin EB, Hicks RW, Spencer MK, Zund VT and Jackson CGR (1996): Pressor response to isometric exercise in patients with Multiple Sclerosis. Medicine and Science in Exercise and Sport, 28, 6: 656-660. Perry J, Garrerett M, Gronley JK and Mulroy SJ (1995): Classification of walking handicap in the stroke population. Stroke, 26: 982-989. Petajan JH, Gappmaier E, White AT, Spencer MK, Mine L and Hicks RW (1996): Impact of aerobic training on fitness and quality of life in Multiple Sclerosis. Annuals of Neurology, 39: 432-441. Petajan JH and White AT (1999): Recommendations for physical activity in patients with Multiple Sclerosis. Sports Medicine, 27, 3: 179-191. Podsiadlo D and Richardson S (1991): The “Timed up and Go”: a test of basic functional mobility for frail elderly persons. The Journal of American Geriatric Society, 39: 142-148. Ponichtera-Mulcare J (1993): Exercise and multiple sclerosis. Medicine & Science in Sports & Exercise, 25, 4: 451–165. Ponichtera-Mulcare JA, Glaser RM, Mathews T and Camaione DN (1993): Maximal aerobic exercise in persons with multiple sclerosis. Clinical Kinesiology, 46: 12-21. Ponichtera-Mulcare JA, Mathews T, Barrett PJ, and Grupta SC (1997): Change in aerobic fitness of patients with multiple sclerosis during 6-month training program. Sports Medicine Training and Rehabilitation, 7: 265-272. Poser CM, Paty DW, Scheinberg L, McDonald WI, Davis FA, Eberts GC, et al. (1983): New diagnostic criteria for multiple sclerosis: guidelines for research protocols. Annuals of Neurology, 13, 3: 227–231. Rudick RA, Miller D, Clough JD, Gragg LA and Farmer RG (1992): Quality of life in Multiple Sclerosis. Comparison with inflammatory bowel disease and rheumatoid arthritis. Archives of Neurology, 49: 1237–1242. Russel R (1967): Diseminated Multiple Sclerosis: rest exercise therapy – a progress report. Physiotherapy: 66-77. Russo C (1990) In Ada L and Canning C (Ed.): Key Issues in Neurological Physiotherapy. Oxford: Butterworth Heinemann, pp 127-154. Schwartz CE, Coulthard-Morri L, Zeng Q and Retzlaff P (1996): Measuring self-efficacy in people with multiple sclerosis: a validation study. Archives of Physical Medicine and Rehabilitation, 77: 394-398. Schwartz CE, Vollmer T and Lee H (1999) Reliability and validity of two self-report measures of impairment and disability for MS. Neurology, 52: 63-70. Schwid SR, Goodman AD, McDermott MP, Bever CF and Cook SD (2002): Quantitative functional measures in MS: what is a reliable change? Neurology, 58, 8: 1294-1296. Seraratne MPJ, Carroll D, Warren KG and Kappagoda T (1984): Evidence for cardiovascular autonomic nerve dysfunction in multiple sclerosis. Journal of Neurology, Neurosurgery and Psychiatry, 47: 947-952.

NZ Journal of Physiotherapy – November 2003. Vol. 31, NZ 3 Journal of Physiotherapy – November 2003. Vol. 31,137 3 137

Sheean GL, Murray NMF, Rothwell JC, Miller DH and Thompson AJ (1997): An electrophysiological study of the mechanism of fatigue in Multiple Sclerosis. Brain, 120: 299-315. Solari A, Filippini G, Gasco P, Colla L, Salmaggi A, la Mantia L, Farinotti M, Eoli M and Mendozzi L (1999): Physical rehabilitation has a positive effect on disability in Multiple Sclerosis. Neurology, 52: 57-62. Stevenson TJ (2001): Detecting change in patients with stroke using the Berg Balance Scale. Australian Journal of Physiotherapy, 47,1: 29-38. Sutherland G, Anderson MB and Stoove MA (2001): Can aerobic exercise training affect health-related quality of life for people with Multiple Sclerosis. Journal of Sports & Exercise Psychology, 23: 122-135. Sutherland G and Anderson M B (2001): Exercise and Multiple Sclerosis: physiological, psychological, and quality of life issues. The Journal of Sports Med & Phys Fitness, 41, 4: 421-432. Svensson B, Gerdle B and Elert J (1994): Endurance training in patients with Multiple Sclerosis: five case studies. Physical Therapy, 74, 11: 1017-1026. Vaz Fragoso CA, Wirz D and Mashman J (1995): Establishing a physiological basis to Multiple Sclerosis related fatigue: a case report. Archives of Physical Medicine and Rehabilitation, 76: 583-586. Wade DT (1996): Measurement in Neurological Rehabilitation. Oxford: Oxford University Press. Van Sint Annaland E and Lord S (1999): Vigorous exercise for Multiple Sclerosis: a case report. New Zealand Journal of Physiotherapy, December: 42-44.

Plane View Services Advert

ADDRESS FOR CORRESPONDENCE. Dr LA Hale, School of Physiotherapy, University of Otago, PO Box 56, Dunedin, New Zealand. [email protected]

200 years ago they sent us away, now they’re begging us to come back!

We can’t promise to find you accommodation in a castle but we do have some fantastic offers for Allied Health Professionals who can work in the UK through Medic International. So what are you waiting for? Physiotherapists for locum and permanent employment in a variety of settings. Join Medic International and come to the UK in 2003 and we’ll: • Pay your return flight to New Zealand (when you’re ready to go home)* • Pay your HPC registration fee - worth approx $550* • Assist you with your visas • Help you set up a UK bank account • Negotiate the best rates of pay on your behalf • Help you find accommodation

In fact they’re doing more than that, they’re paying us to come back!

Then call the Medic International Consultant at WHE.

0800 935 935

Freecall Email [email protected]

www.whe.co.uk

Established for over 30 years, Medic International is one of the leading suppliers of Allied Health Professionals in the UK. *conditions apply MELBOURNE

•

EDINBURGH

•

LONDON

•

AUCKL AND

NZ Journal of Physiotherapy – November 2003. Vol. 31, NZ 3 Journal of Physiotherapy – November 2003. Vol. 31,138 3 138