Though once regarded with suspicion, exercise as a therapy for multiple sclerosis (MS) has gained traction in recent years, and has the potential to counter the physical effects often seen among patients, as well as reduce risk of progression.
That was the key message of a talk given by Ulrik Dalgas, PhD, professor of exercise biology at Aarhus University in Denmark, who spoke at the annual meeting of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS).
Rethinking the Role of Exercise
It used to be thought that exercise could worsen disease, but case studies in the 1960s suggested some beneficial effects. The first interventional studies were published in the 1990s. A 2008 special issue of Multiple Sclerosis Journal declared exercise safe for people with MS. Research has continued to evolve, “and now we are actually at a stage where some of us have started to believe that exercise is a medicine in multiple sclerosis,” said Dalgas, who outlined that view in a 2019 review paper.
In the early phase of MS, before the onset of a significant decline in brain volume or increase in disability, there are already measurable physical deficits. Dalgas showed data from an unpublished study from his group, which looked at 48 patients who had been diagnosed in the previous 2 years, at an average 10 months after diagnosis. “Already at this very early stage of the disease, we can actually observe impairments or deficits in walking, different walking outcome measures here between 10 and up to more than 30%, depending on the walking outcome,” said Dalgas. Similar deficits appeared in physical activity and maximum rate of oxygen consumption (VO2 max).
Animal studies suggest that exercise could improve matters at this stage. In a model of experimental autoimmune encephalomyelitis, animals allowed the opportunity to exercise had lower levels of clinical disability throughout the model disease course. That has led some to examine a “prehabilitation” approach to early MS – a term borrowed from orthopedics. “We try to prevent rather than to treat symptoms, or build reserve capacity rather than restore capacity,” said Dalgas.
Some work in this area has been done in human patients, but a review found that none of more than 70 published studies looked at patients within 5 years of onset. “That left kind of an unstudied early phase,” said Dalgas.
In the mid-phase of MS, when brain volume loss increases and mobility and other problems increase, exercise has proved to counteract some of these issues. “What we are now trying to do is figure out what are the best exercise modalities for treating different symptoms,” said Dalgas.
Resistance and aerobic training have predictable, positive effects on strength and VO2 max, but one study showed that the two modes of exercise had similar positive impacts on short and long walks, as well as fatigue, despite the fact that they have very different physiological effects.
Other studies have looked at the impact of exercise on the diseases itself. One recent study examined aerobic exercise versus a wait-list group. Gray matter volume remained stable in the exercise group, but dropped in the wait-list group, suggesting a possible protective effect .
In the later, more severe phase of MS, more specialized equipment is needed to ensure safety during exercise. A pilot study by Dalgas’ group in individuals with Expanded Disability Status Scores (EDSS) scores between 6.5 and 8 found that upper body exercise improved VO2 peak score in five out of six patients. “Even at this later stage of the disease, it seems that people can still have important improvements in health and performance markers,” said Dalgas.
A review of numerous studies found that exercise had a positive effect on quality of life, and the gains were not affected by baseline disability, disease duration, or exercise type. The study shows that “it’s never too late to improve your life through exercise,” said Dalgas.
Next Steps
Challenges remain for the field. “We still need to figure out how long-term adherence is best secured in these patients, and then we really need to look further into how to provide exercise in the best possible way in severe and elderly patients,” said Dalgas.
During the Q&A session following the presentation, Dalgas was asked for advice on how to get a patient with MS started with exercise. “We normally recommend that people should find a physical therapist or sports scientist who has expertise in this field to help with getting started. If you start out wrong you can get into problems, so having the right expertise at hand is a good way to start. Then shortly afterward they will be more independent to do the exercise,” said Dalgas.
Alan Thompson, MD, who moderated the session, brought up the concept of cognitive reserve in MS, which posits that positive life experience builds up the capacity and efficiency of neural networks, which in turn act as a sort of buffer against later cognitive decline due to aging and illness. “Can you build up your exercises in a way that has a meaningful impact in delaying the onset of confirmed disability or progression?” asked Thompson, professor of clinical neurology and neurorehabilitation at University College London.
Dalgas said that there are studies that suggest this may be true, with MS diagnoses occurring later in patients who are physically active. “You can interpret that as some kind of delayed onset of the disease.”
For more information, Dalgas suggested recently published recommendations for exercise in MS patients.
Dalgas disclosed ties with Biogen Idec, Merck Serono, Sanofi Aventis, Almirall, Novartis, Bayer Schering, and Sanofi Genzyme. Thompson has no relevant financial disclosures.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
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