Cognitive impairment is a major debilitating feature of multiple sclerosis, and is estimated to occur in more than 50% of people living with MS at some point during the disease. These cognitive impairments can appear as difficulties with learning and memory, and deterioration of executive functions, such as planning or decision-making, focusing attention, multi-tasking, and problem-solving. People living with cognitive deficits can experience greatly diminished quality of life and loss of independence while facing the realization that treatment options are few-and-far-between. There are currently no drug therapies available that can specifically treat cognitive impairments in people living with MS, and cognitive rehabilitation studies have shown mixed success to date.
One approach that is emerging as a promising strategy for treating cognitive dysfunction in MS is exercise training. There is compelling experimental evidence showing that specific types of exercise training can improve cognition in both the general population and in people with certain neurological conditions like stroke, traumatic brain injury, and schizophrenia. For people living with MS, there have been three controlled clinical trials that have examined the effects of exercise on some aspects of cognition, although the results so far have been mixed. Part of the reason for these inconclusive findings is that the types and intensities of exercise have yet to be standardized, making comparisons across studies difficult.
A study published in the Journal of Clinical and Experimental Neuropsychology by Dr. Robert Motl and colleagues examined the short-term effects of several types of aerobic and non-aerobic exercise training on cognitive performance in people living with relapsing-remitting MS.
The study was performed on 24 individuals with relapsing-remitting MS. The participants underwent assessment of disability status using the Expanded Disability Status Scale (EDSS); eligible participants needed to be able to walk with or without minimal assistance (e.g. cane or crutch) in order to be able to participate in the exercise routines.
The researchers used the modified-flanker test to assess each subject’s reaction time and accuracy in identifying a randomly-presented object while blocking out either helpful or distracting information on either side of the object. In other words, the test allowed the researchers to measure the participants’ attention and executive functions (i.e. ability to suppress information that is either related or unrelated to the task).
The procedure consisted of five sessions (one per week); the first session established the baseline for exercise endurance fitness and trained the participants in the modified-flanker test, and was followed by four testing sessions. For each testing session, participants took the modified-flanker test, followed by one of three exercises (treadmill walking, stationary bicycle, or guided yoga) or quiet rest. After completion of the exercise and a cool-down period, participants took the modified-flanker test again to determine whether the exercise training affected performance on the test. For each session, participants performed a different exercise, so that by the end of the experiment each participant performed every exercise in a random order.
The researchers measured the effects of each type of exercise on participants’ performance in the modified-flanker test, and compared that to their performance after quiet rest. They found that treadmill walking improved reaction time on the test with no improvement in accuracy compared to quiet rest; the reaction time was particularly improved in trials where the target object was surrounded by distracting information.
Both stationary bicycling and guided yoga also improved test reaction time without improving accuracy compared to quiet rest, although the reaction time improvements were not seen in trials where the target object was surrounded by distracting information.
The results of this study show that several types of exercise can improve cognitive performance and executive functions in people with relapsing-remitting MS. Treadmill walking in particular appeared to have the strongest effect on improving selective attention and blocking distracting information in this study; although the reason for this is unclear, the authors suggested that since impaired ambulation is so common in people with MS, treadmill walking perhaps stimulates those parts of the brain involved in attention to a greater degree than stationary cycling or yoga. The improvements in test performance were only seen in reaction time and not accuracy, although accuracy scores at baseline were already quite high, so there was very little room for improvement. A limitation of this study was that overall, the participants were not cognitively impaired, and it remains to be seen how people affected by MS with cognitive impairment could benefit from exercise training, as well as how to adapt exercise training in those with severe physical disability who cannot carry out these exercises.
The findings from this study contribute to a growing body of literature linking physical activity to neuroplasticity in the brain, both in the general population and in people living with MS. While the bulk of this research has looked at ways of harnessing neuroplasticity for promoting physical rehabilitation, an emerging area of study is the application of exercise interventions to improving cognitive impairment. Visit the research blog to learn more about neuroplasticity in MS.
Sandroff BM et al. (2015) Acute effects of walking, cycling, and yoga exercise on cognition in persons with relapsing-remitting multiple sclerosis without impaired cognitive processing speed. J Clin Exp Neuropsychol. 37(2):209-19
Source: MS Society of Canada © 2015 MS Society of Canada (25/03/15)
Exercise bike pedals hope(09/03/15)
Researchers from the University of Sydney have designed an innovative exercise system that allows people with multiple sclerosis to workout their paralysed leg muscles in the hope of improving symptoms and slowing the disease progression.
The specially-designed exercise bike uses electrical stimulation to activate contractions in the major leg muscles, which forces the pedals to rotate.
Lead researcher Dr Ché Fornusek, an expert in biomedical engineering from the Faculty of Health Sciences, said people with multiple sclerosis benefit from regular exercise, but the progression of the disease meant many people gradually lose their ability to walk and stay active.
"Inactivity isn't good for any of us, but for people with MS it exacerbates health problems and can put them at greater risk of conditions like diabetes and cardiovascular disease," Dr Fornusek said.
The research team has a long history in world-leading research in electrical stimulation exercise and for this study adapted a bike they previously developed for people with spinal cord injuries. They are now undertaking testing to assess the benefits that can be gained for those with advanced multiple sclerosis.
Dr Fornusek said early trials show a lot of promise and the researchers were eager to see just how effective the exercise treatment could be.
"I'm confident we can improve the condition of people's legs and make tasks like transitioning to and from a wheelchair easier which is great. But I'm also keen to know if this exercise can improve the immune function and ultimately slow the progression of MS," he said.
The study is funded by a grant from MS Research Australia. Chief Executive Officer Dr Matthew Miles said the project highlights the importance of researchers continuing to seek new and innovative treatments for people in the advanced stages of the disease.
"This study has the potential to make a real difference to the quality of life for many people currently living with severe multiple sclerosis," Dr Miles said.
Source: HealthCanal (09/03/15)
While yoga seems to be effective in a number of neuropsychiatric disorders, the evidence of efficacy in multiple sclerosis remains unclear.
The aim of this review was to systematically assess and meta-analyze the available data on efficacy and safety of yoga in patients with multiple sclerosis.
Medline/PubMed, Scopus, the Cochrane Central Register of Controlled Trials, PsycINFO, CAM-Quest, CAMbase, and IndMED were searched through March 2014.
Randomized controlled trials (RCTs) of yoga for patients with multiple sclerosis were included if they assessed health-related quality of life, fatigue, and/or mobility. Mood, cognitive function, and safety were defined as secondary outcome measures.
Risk of bias was assessed using the Cochrane tool. Seven RCTs with a total of 670 patients were included.
Evidence for short-term effects of yoga compared to usual care were found for fatigue (standardized mean difference [SMD] = −0.52; 95% confidence intervals (CI) = −1.02 to −0.02; p = 0.04; heterogeneity: I2 = 60%; Chi2 = 7.43; p = 0.06) and mood (SMD = −0.55; 95%CI = −0.96 to −0.13; p = 0.01; heterogeneity: I2 = 0%; Chi2 = 1.25; p = 0.53), but not for health-related quality of life, muscle function, or cognitive function.
The effects on fatigue and mood were not robust against bias. No short-term or longer term effects of yoga compared to exercise were found. Yoga was not associated with serious adverse events. In conclusion, since no methodological sound evidence was found, no recommendation can be made regarding yoga as a routine intervention for patients with multiple sclerosis.
Yoga might be considered a treatment option for patients who are not adherent to recommended exercise regimens.
Source: PLOS | One (13/11/14)
A new study has found that people with multiple sclerosis may reduce perceived fatigue and increase mobility through a series of combined strength training and fitness exercises.
The research from the Miguel Hernández University of Elche, supervised by Professor Raúl Reina, aimed to analyze the effects of strength training on the fatigue that MS patients suffer. A total of 19 participants (5 men and 14 women) were split into two groups. Most took part in a 12-week training program, whilst others were included in a control group. The research was conducted in collaboration with the Neurology Department of Elche General Hospital.
A first phase of general fitness was followed by a personalized intervention program based on each patient’s maximum force. The scientists assessed the effects of training and found that the experiment group gained "a fair amount" of functionality while the control group remained stable.
One patient, who was diagnosed the illness in 2007, says she has noticed improvements in her daily routine: “I was used to a life with limitations and now I can pick up my son and go with him to the park on foot."
The training and data collection process took place on campus, both at the sports facilities and the university’s Sport Research Centre. Meanwhile, perceived fatigue was registered daily, weekly and monthly through specific questionnaires. Each patient’s muscle strength was assessed by isokinetic dynamometry and functional tests.
The study also includes an analysis of motivational aspects and an interview on the perception of the effects of sport. This part is especially interesting as it shows an improvement of the participants’ quality of life, although the University will continue working with the MS patients to see the long term effects.
Source: Science 2.0 © 2014 ION Publications LLC (01/10/14)
Specialised programme improved quality of life, decreased pain and fatigue.
Paula Meltzer was only 38 when out of nowhere everything she looked at was blurry. For the single mother, who had a lucrative career as a gemologist and spent hours examining valuable pieces of jewelry, it seemed as if – in a split second – her life changed.
At first doctors thought Meltzer had a brain tumor. What they determined after further tests, however, was that she had multiple sclerosis, an autoimmune disease that affects the brain and central nervous system and was causing optic neuritis, an inflammation of the optic nerve that can cause a partial or complete loss of vision.
“I was living independently, doing my job, taking care of my child and then I had to look to my parents to take care of me,” Meltzer said.
Almost two decades later, Meltzer, out of a wheelchair and walking without a cane, was one of 14 women with moderate disability due to MS who participated in a pilot trial conducted by the Rutgers School of Health Related Professions. A specially-designed yoga program for these MS patients not only improved their physical and mental well-being but also enhanced their overall quality of life.
“I felt like I became steadier and stronger in my core,” Meltzer said. Prior to yoga, she described herself as a “wall walker,” someone who felt safer holding onto the wall in order to get around. “To be able to stand on one leg and feel balanced is amazing.”
Susan Gould Fogerite, director of research for the Institute for Complementary and Alternative Medicine in the School of Health Related Professions, said that although there is widespread evidence that yoga is being used as a form of exercise by those with MS, much of the feedback has been anecdotal and there isn’t much empirical data regarding its safety and efficacy.
This is why she and her colleagues, Evan Cohen and David Kietrys, physical therapists and associate professors in the School of Health Related Professions at Stratford, decided to undertake the small pilot study, believing that a specialized yoga program for MS patients – which incorporates mind, body and spirit – would be beneficial to everyday living.
What they discovered at the end of the eight-week trial was that those who participated were better able to walk for short distances and longer periods of time, had better balance while reaching backwards, fine motor coordination, and were better able to go from sitting to standing. Their quality of life also improved in perceived mental health, concentration, bladder control, walking, and vision, with a decrease in pain and fatigue.
“Yoga is not just exercise, it is a whole system of living,” said Fogerite, an associate professor, who, along with Kietrys, will present the results on September 26 at the Symposium on Yoga Research at the Kripalu Institute in Massachusetts. “The panel of experts who advised us on the trial wanted to make sure that we provided a fully integrated program that included philosophy, breathing practices, postures, relaxation and meditation.”
The yoga pilot trial was held at Still Point Yoga Center in Laurel Springs, a southern New Jersey town close to Philadelphia. Of the 72 individuals who were interested in participating, only 16 were eligible based on medical and other criteria and availability. Of those, 15 were enrolled and 14 completed the program after one person had to withdraw because of an unrelated health problem.
Meltzer and the other women who participated in the trial ranged in age from 34 to 64. Some had been diagnosed with MS within the last two years while others had been living with the illness for up to 26 years. For 90 minutes, twice a week for two months, they practiced techniques and exercises that would improve their posture, help to increase stamina, and teach them how to relax and focus.
“This study, I hope, is one of many that will give us the clinical information we need,” said Fogerite. “Yoga is not currently being widely prescribed for people with MS, although it might turn out to be a very helpful treatment.”
The yoga practices were done by the women in the study sitting, standing, or lying on yoga mats, and using metal folding chairs situated close to the wall to provide them with more support.
“What was so nice about this experience was that although everyone was at a different level of the disease, we felt like we were all together, so I think the comraderie helped,” said Meltzer. “And it wasn’t just about gaining more mobility and balance in our legs but our arms and necks felt stronger as well.”
Fogerite said a larger randomized controlled trial would be needed to determine whether yoga could be used as a prescribed treatment for individuals with moderate disability due to MS. More than 2.3 million people – two to three times more women than men – throughout the world are diagnosed with this disease which can cause poor coordination, loss of balance, slurred speech, tremors, numbness, extreme fatigue and problems with memory and concentration.
“When I was first diagnosed I no longer felt safe in my own body,” Meltzer said. "I didn’t trust my body at all. What the program did was really bring that trust back.”
Source: Rutgers Copyright 2014, Rutgers, The State University of New Jersey (02/09/14)
Multiple sclerosis (MS) patients who would benefit the most from an increase in physical activity were, unfortunately, those for whom an intervention designed to boost it was least effective, a researcher said here.
In a secondary analysis of data from an earlier, overall successful trial of an Internet-based exercise intervention, factors associated with the strongest responses included mild versus moderate disability, body weight in the normal range versus obesity, and relapsing-remitting versus progressive MS, according to Robert Motl, PhD, of the University of Illinois in Urbana-Champaign.
There is "value in modifying and refining interventions" to improve their chances of success in difficult populations, he suggested at the joint meeting of the Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis.
Separately, another analysis of the same trial data indicated that, in the overall study sample, the improvements seen in measures of physical activity were accompanied by reductions in time spent sitting.
Rachel Klaren, a graduate student in Motl's laboratory, reported that mean sitting time among all study participants (including dropouts) was lower by 1.6 hours per day compared with a wait-listed control group; and among those completing the study per protocol, the difference was 2.1 hours per day.
The results confirmed that participants did indeed get up out of their chairs to achieve the increased step counts seen in the primary study results, reported at the CMSC-ACTRIMS meeting in 2013.
Motl and colleagues had developed a 6-month intervention geared to increasing physical activity in MS patients. It included a website providing information on how MS patients can become more physically active using social cognitive therapy techniques, as well as one-on-one live video coaching conducted over the Internet. Participants wore pedometers and had goals for the number of steps, recording their actual step counts in a diary.
At the 2014 meeting, Motl explained that physical activity is known to be beneficial in preserving mobility for MS patients, which typically diminishes over time even in those who remain in the relapsing-remitting phase.
The trial randomized 82 patients either to the intervention or to a wait-listed control. While on the wait-list, participants received no encouragement or coaching; they then entered the program at the trial's conclusion.
Who Responds, Who Doesn't
Overall, mean step counts increased from baseline by nearly 40% in the intervention group. But Motl said that the investigators noted that not every participant showed such an increase. In fact, some had marked decreases.
Relative to the wait-listed controls, only those in the intervention group with mild disability on the basis of Expanded Disability Status Scale scores showed increases in step counts, whereas the intervention had no effect for those classified with moderate disability (P<0.01 for the effect of disability status).
Similarly, the intervention was effective only in those with relapsing-remitting disease, not in those with progressive forms of MS (P<0.01 for the effect of clinical course) -- and it was effective only for those with body mass index values of 25 kg/m2 or less, not for those with higher values (P<0.05 for the effect of obesity status).
As it happens, the subgroups not benefiting from the intervention were those at the greatest risk for continued or accelerated disability progression, and therefore those for whom an increase in physical activity would have the greatest health benefit. Motl concluded that his, or other interventions, may need to be tailored more specifically to these patients to increase the chances of success.
Other factors, including whether patients were taking disease-modifying drugs or medications for specific MS symptoms, did not affect the intervention's impact, Motl indicated.
Effect on Sedentarism
Klaren noted that time spent sitting "has been described as 'the new smoking'" because of its adverse effects on a host of health outcomes.
Although the increase in step counts seen in the trial's primary results might logically entail a commensurate decrease in sitting times, it can't be assumed. Consequently, Klaren analyzed data on sitting time specifically collected in the trial.
As part of the baseline and 6-month follow-up evaluations, participants were asked to estimate their average daily time spent sitting down over the past 7 days. The analysis covered 70 participants who had provided baseline data (intent-to-treat sample), of whom 13 did not complete the intervention.
In the overall group and after adjusting for baseline differences, the mean daily sitting time in the intervention group at follow-up was 7.2 hours (SE 3.3), compared with 8.8 (SE 3.3, P<0.05) for the wait-listed controls.
For the per-protocol group, mean daily sitting time at follow-up was 6.8 hours (SE 3.5) with the intervention versus 8.9 (SE 3.5, P<0.05) for controls, Klaren reported.
She said these were the first data specifically addressing the effect on sitting time of an exercise intervention in MS patients.
Next steps, she added, would be to examine whether reductions in sitting time really do lead to demonstrable health benefits, and to identify factors associated with sedentarism in MS patients.
The study was supported by the National Multiple Sclerosis Society.
Motl reported relationships with Biogen Idec and Acorda. Klaren declared she had no relevant financial interests.
Primary source: Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis
Source reference: Motl R, et al, "Does the effect of a physical activity behavior intervention vary by clinical characteristics of people with multiple sclerosis?" CMSC-ACTRIMS 2014; Abstract RH05.
Additional source: Consortium of Multiple Sclerosis Centers and the Americas Committee for Treatment and Research in Multiple Sclerosis
Source reference:Klaren R, et al "Efficacy of a behavioral intervention for reducing sedentary behavior in people with multiple sclerosis" CMSC-ACTRIMS 2014; Abstract RH04.
Source: MedPage Today © 2014 MedPage Today, LLC (04/06/14)