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Exercise & Multiple Sclerosis
Tuesday, March 13, 2007
Multiple sclerosis (MS) is an inflammatory demyelinating disease involving the brain and spinal cord. It is estimated that about 400,000 people in the US have MS. In this condition, there is damage to a substance known as myelin. Myelin forms a protective coating around nerves, and it also helps the nerves to function properly. Nerves in the body can be likened to electrical wire, which has a conducting center (that transmits electrical impulses) and a peripheral wrapping or insulation. The insulation or sheath found around the nerves is called myelin. The nerves conduct electrical signals from the brain to other parts of the body, including muscles and other organs. Besides surrounding peripheral nerves, myelin is also found in the brain, especially in portions of the brain referred to as "white matter".
In MS, myelin is lost at multiple sites, leaving scar tissue, or sclerosis, behind. The name of the disease reflects the fact that there are typically multiple sites of demyelination or sclerosis. These areas of damage are often referred to as "plaques" by physicians. Although the cause of the MS is not fully understood, it appears that the body's own immune system is partly responsible for the damage that occurs with this condition. Genetic and environmental factors may also play a role.
The immune system is designed to fight off foreign invaders, such as bacteria and viruses. With autoimmune diseases, the body's immune system attacks itself. In the case of multiple sclerosis, this means injury to the myelin of the brain and spinal cord. When the myelin is damaged, the nerves and the brain do not function as well.
Symptoms vary depending on the extent and locations of myelin injury. Symptoms can include unusual fatigue, visual problems, weakness, numbness, pain, imbalance, bowel and bladder problems, emotional changes, speech difficulties, as well as memory and thinking impairment. Multiple sclerosis affects women more commonly than men; in fact, it is twice as common in women. MS often presents in females between the ages of 25 and 50 years. MS is more common in Caucasians and in people of northern European ancestry. Within the United States, it is more common in latitudes that are farther away from the equator.
Multiple sclerosis may go undetected for months or even years. This is because many of the symptoms it produces are nonspecific. Also, MS has a tendency to come and go; its clinical course has often been referred to as "remitting and relapsing." During a phase of remittance, symptoms improve. During a relapse or exacerbation, symptoms worsen. New symptoms can appear, as new portions of the central nervous system (the brain and spinal cord) are affected. Most people affected by MS initially demonstrate a relapsing-remitting pattern of disease; 85% of patients fall into this category. In later stages, progressive worsening of symptoms may develop.
In the past, many physicians felt that it was unwise for people with MS to engage in an exercise program. There were fears that exercise would not be tolerated or that physical activity could make MS worse. In particular, doctors were concerned about the possibility that the increase in core body temperature that occurs with exercise could be detrimental to patients with MS. Studies have now shown that, instead, exercise can be beneficial for individuals with multiple sclerosis. A properly performed program of physical activity can increase muscle strength, improve exercise tolerance, elevate mood, and improve mobility. There is no cure for MS, but exercise does help to improve quality of life in individuals with this disease.
In a study of 54 individuals with multiple sclerosis conducted at the University of Utah, persons who exercised were shown to have better cardiovascular fitness, less fatigue and depression, more positive attitude, and better bowel and bladder function than those who did not exercise. Also, exercise participants appeared to enjoy a better quality of life, with increased involvement in social activities.The National Multiple Sclerosis Society has outlined the following seven objectives for an effective exercise program:
- Improve socialization, decrease isolation
- Promote well-being and improve self-esteem
- Provide an atmosphere to exercise that minimizes or prevents a rise in body temperature
- Prevent symptoms secondary to MS (muscle atrophy, joint contractures, pressure sores)
- Maintain or improve range of motion and flexibility of joints
- Maintain or increase endurance potential
- Maximize muscle strength
MS patients should take special precautions when exercising. To avoid triggering a flare of symptoms, individuals with MS should exercise in a cool environment and at low to moderate intensity. Lightweight clothing is advised. If indoors, the use of fans or air conditioning is suggested. When performing physical activity outdoors, it should be done when the temperature is mild; exercising outdoors during the heat of the day should be avoided.
Increased body temperature can slow conduction velocity in nerves, delaying messages traveling from the brain to other parts of the body. Because nerve conduction is already slowed from loss of myelin in patients with MS, increase in body temperature can produce a pseudoexacerbation of symptoms, and could lead to temporary blurred vision, tingling, and numbness. This is why extra care should be taken by MS patients to exercise in a cool environment and to avoid overheating. Drinking fluids to stay well-hydrated is also important.
Exercise programs should be individualized. Symptoms of MS can vary considerably from person to person. Exercises appropriate for the patient's abilities and fitness level should be utilized. A certified personal trainer can assist in individualizing exercise programs for MS patients who are new to exercise.
Persons with MS should listen to their bodies. Fatigue secondary to MS is common. On days that the individual may be experiencing an extra level of fatigue, it may be advisable to engage in lower intensity physical activity or to even skip an exercise session. Physical activity can be performed in short 10 minute bouts, rather than all at once, and this may be better tolerated. If a pseudoexacerbation of symptoms develops during exercise, the symptoms will usually resolve within 30-60 minutes following exercise.
Many patients with MS can safely and effectively engage in an exercise regimen that includes both strength training -- to improve muscular strength and bone health-- and cardiovascular conditioning -- to improve circulation, heart health, and lung capacity. If you have MS, speak with your physician before beginning an exercise program.
In patients with mild MS, strength training can be done in a circuit fashion with one or more sets of 8-12 repetitions for the major muscle groups of the body. Such a program must be individualized. If an individual has weakness in one or more muscle groups, care must be taken in selecting the right exercises and the appropriate level of resistance. Again, a certified personal trainer can help in this process.
Yoga and tai chi may be good overall exercise choices for those with multiple sclerosis. Both yoga and tai chi are nonimpact activities. They may be well tolerated by MS patients. Yoga will modestly elevate heart rate; it will improve flexibility and aid in muscular tone. Practicing yoga has been associated with reduction in stress levels and reduction in blood pressure, and it also improves balance. Tai chi is a Chinese martial art and is also a gentle form of exercise. It modestly elevates heart rate and can improve muscle tone and balance.
For MS patients who are capable and motivated, a structured cardiovascular training program can be performed with aerobic exercise being done for 20-30 minutes at approximately 50 to 70% of the maximal heart rate. The maximal heart rate is calculated by subtracting the person's age in years from the number 220. If tolerated, such exercise can be done on most days of the week. Indoor cycling may be a good form of aerobic exercise to consider initially. Elliptical trainers or stairsteppers, depending upon the clinical status of the patient, may be good choices. Aquatic exercise (both swimming and group aqua aerobics classes) can be an ideal form of aerobic activity, since it can improve cardiovascular fitness while limiting the rise in body temperature that can accompany exercise, because it is performed in a cool environment (the pool).
For persons with more advanced MS, exercises in a weight-bearing position should focus on gait-training with an assistive device such as a cane or walker, and are best done under supervision. Gait training can improve balance and coordination.
If you have MS, you should choose an activity that you enjoy and that matches your abilities. Consider doing physical activity in smaller 10 minute bouts, if longer sessions leave you drained. Stay hydrated and cool, and listen to your body. Always consult with your physician, if you have any questions.More information:
- The National Multiple Sclerosis Society (2004). Part A: Physical activity for people with multiple sclerosis: An education manual for health and wellness professionals
- Petajan, J. & White, A. (1999). Recommendations for physical activity in patients with multiple sclerosis. Sports Medicine , 27, 3, 179-191.
- Rietberg et al. (2004). Exercise therapy for multiple sclerosis. The Cochrane Database of Systematic Reviews, Issue 5. Art. No.:CD003980.pub2. DOI:10.1002 / 14651858.CD003980.pub.2