Moderators of Exercise Effects on Depressive Symptoms in Multiple Sclerosis: A Meta-regression

Advancements and Challenges in Exercise Training for Multiple Sclerosis: Comprehensive Review and Future Directions for Randomized Controlled Trials

Exercise training represents a health behavior for the treatment and management of the multi-faceted manifestations of multiple sclerosis (MS). This paper provides a comprehensive overview of evidence from randomized controlled trials (RCTs) regarding benefits, safety, participation, and guidelines for exercise training in MS, based on systematic reviews and meta-analyses. The paper then provides our opinions based on extensive experience regarding challenges for improving and expanding future RCTs that will advance our understanding of exercise training in MS. The comprehensive review of evidence from RCTs indicates that exercise training yields substantial improvements in aerobic and muscle fitness, mobility, fatigue and depression, quality of life, and participation outcomes. There is a non-significant increase in the risk of adverse events or serious adverse events with exercise training compared with control conditions or healthy populations. Rates of adherence and compliance with exercise training (i.e., participation) approximate 80% and 70%, respectively. The current prescriptive guidelines suggest 2-3 days per week of aerobic and resistance exercise training as the minimal dose for safely benefiting from exercise training in MS. We propose 10 important topics as avenues for expanding the body of research and improving its scope for evidence-based practice in MS. Overall, the research on exercise training in MS is strong, but it can get stronger. The expansion and advancement of evidence are critical for moving exercise training into the clinical armamentarium of MS disease treatment and management.

Best practice exercise for emerging depression in multiple sclerosis: A systematic review and meta-analysis

OBJECTIVE

To examine the effects of instructor-led exercise on depression symptoms in adults with multiple sclerosis, with a focus on moderating factors to treatment response.

DATA SOURCES

Cochrane Library, Embase, PEDro, PsycINFO and PubMed databases were searched until 21 April 2024.

REVIEW METHODS

The reporting quality of included studies assessed (PEDro and TESTEX scales). Hedges' g effect sizes were calculated and pooled using random and mixed-effects modelling.

RESULTS

Twenty-two independent studies (k), representing 785 participants with relapsing remitting or progressive MS, were included. Individual studies varied in their reporting quality (PEDro range: 3-8) and did not routinely detail exercise parameters (TESTEX range: 5-13). Nonetheless, exercise reduced core symptoms of depression (gw = .52, CI: .30-.73, P < .01). Treatment effects were, however, not maintained once training had ceased (gw = -.53, CI: -.80 to .24, P ≤ .01, k = 5). Both aerobic and non-aerobic exercise groups experienced a significant (P < .01) reduction in depression scores. Larger gains were noted by those with better ambulation at baseline (P = .03).

CONCLUSION

Regular exercise can help to stabilise mood for people living with multiple sclerosis, regardless of session frequency or duration. Treatment efficacy could be maximised by addressing potential barriers for those with limited mobility, including exercise type, delivery and intensity. Protocol registered on Open Science Framework [https://osf.io/zfymq/].

Individualized activity recommendation based on a physical fitness assessment increases short- and long-term regular physical activity in people with multiple sclerosis in a retrospective cohort study

Background

Despite the evidence of beneficial effects of physical activity (PA), people with multiple sclerosis (pwMS) are less physically active than the general population. To increase PA in pwMS, we developed a structured individually tailored PA promotion program which is conducted within clinical practice in a university-based outpatient clinic since 2016. This study serves as retrospective quality control of this program.

Objective

In a retrospective cohort study, we assessed the physical fitness of pwMS and the impact of the program on short- and long-term PA changes and behavioral determinants.

Methods

The program consisted of four appointments each 2-4 weeks apart. Spiroergometric test results of female pwMS were compared to female non-MS controls who underwent a voluntary physical fitness analysis. The short version of the Freiburger questionnaire, self-developed questions and the modified Physical activity screening questionnaire (PASQ) were sent to all participants assessing the PA levels before the program, 3 months after the program (short-term), and at the time of the survey (long-term). Additionally, established questionnaires assessed behavioral determinants before the program and long-term.

Results

A total of 166 participants [mean age 38.32 (± 10.61 SD), mean EDSS 2.30 (±1.29 SD)] and mostly females (63.3%, n = 105) were included in the study and started the program. A total of 136 participants completed the program. Out of these 63.9% (n = 87) answered the questionnaires in 12.38 (±11.34 SD) months after finishing the program. At baseline female pwMS (n = 100) showed a lower physical fitness in comparison to non-MS controls (n = 26) (maximal workload (Watts): 138.86 ± 37.85 vs. 191.73 ± 45.25, p < 0.001; peak oxygen consumption (ml min-1 kg-1): 26.40 ± 7.23 vs. 31.56 ± 10.10, p = 0.020). pwMS were more regularly active in short- (62.1%) and long-term (55.2%) compared to baseline (24.2%, p < 0.001). Among the activated participants, we observed improved internal motivation (p = 0.002) and decreased perception of barriers (p = 0.006) compared to baseline.

Conclusion

PwMS showed a lower physical fitness in comparison to non-MS controls. An individually tailored PA promotion program might improve behavioral determinants and thereby increase short- and long-term PA levels of pwMS.

Reinventing the wheel for a manual wheelchair

PURPOSE

Standard manual wheelchairs (MWCs) are inefficient and pushrim propulsion may cause progressive damage and pain to the user's arms. We describe a wheel for a MWC with a novel propulsion mechanism.

METHODS

The wheel has two modes of operation called "Standard" mode and "Run" mode. In Run mode, the wheelchair is propelled forward by pushing a compliant handle forward and then pulling it back, both strokes contributing to forward propulsion. We report the propulsive force and preliminary testing on a rough outdoor circuit by three able-bodied participants.

RESULTS

In Run mode, the peak applied force is reduced to 30% and the maximum force gradient is reduced to 10% of that for standard pushrim propulsion, for the same work output. The travel time for the 1.06 km outdoor circuit is about 60% of that for a brisk walk and about 40% of that for pushrim propulsion. At a propulsion speed of 1 m/s, the cardiovascular effort in Run mode is 56% of that for pushrim propulsion. Automatic hill-hold in Run mode improves safety when ascending slopes. The mechanism has three gears so that it can be used by people with widely varying strength and fitness. Folding the handle away converts the operation to Standard mode with the conventional pushrim propulsion, supplemented by three gears.

CONCLUSIONS

Despite the increased weight, width and friction, the bimodal geared wheels facilitate wheelchair travel on challenging paths. This may bring significant improvement to the quality of life of MWC users.

Study protocol: exercise training for treating major depressive disorder in multiple sclerosis

BACKGROUND

Major depressive disorder (MDD) is prevalent, yet sub-optimally treated among persons with multiple sclerosis (MS). We propose that exercise training may be a promising approach for treating depression in persons with MS who have MDD. Our primary hypothesis predicts a reduction in depression severity immediately after an exercise training intervention compared with minimal change in an attention control condition, and the reduction will be maintained during a follow-up period.

METHODS

This study involves a parallel-group, assessor-blinded RCT that examines the effect of a 4-month home-based exercise training intervention on depression severity in a sample of persons with MS who have MDD based on the MINI International Neuropsychiatric Interview. The primary outcomes of depression severity are the Patient Health Questionnaire-9 and Hamilton Depression Rating Scale. Participants (N = 146) will be recruited from within 200 miles of the University of Illinois at Chicago and randomized (1:1) into either a home-based exercise training condition or control condition with concealed allocation. The exercise training and social-contact, attention control (i.e., stretching) conditions will be delivered remotely over a 4-month period and supported through eight, 1:1 Zoom-based behavioral coaching sessions guided by social-cognitive theory and conducted by persons who are uninvolved in screening, recruitment, random assignment, and outcome assessment. We will collect outcome data at 0, 4 and 8 months using treatment-blinded assessors, and data analyses will involve intent-to-treat principles.

DISCUSSION

If successful, the proposed study will provide the first Class I evidence supporting a home-based exercise training program for treating MDD in persons with MS. This is critical as exercise training would likely have positive secondary effects on symptoms, cognition, and quality of life, and provide a powerful, behavioral approach for managing the many negative outcomes of MDD in MS. The program in the proposed research is accessible and scalable for broad treatment of depression in MS, and provides the potential for integration in the clinical management of MS.

TRIAL REGISTRATION

The trial was registered on September 10, 2021 at clinicaltrials.gov with the identifier NCT05051618. The registration occurred before we initiated recruitment on June 2, 2023.

Exploring the Major Barriers to Physical Activity in Persons With Multiple Sclerosis: Observational Longitudinal Study

BACKGROUND

Physical activity (PA) represents a low-cost and readily available means of mitigating multiple sclerosis (MS) symptoms and alleviating the disease course. Nevertheless, persons with MS engage in lower levels of PA than the general population.

OBJECTIVE

This study aims to enhance the understanding of the barriers to PA engagement in persons with MS and to evaluate the applicability of the Barriers to Health Promoting Activities for Disabled Persons (BHADP) scale for assessing barriers to PA in persons with MS, by comparing the BHADP score with self-reported outcomes of fatigue, depression, self-efficacy, and health-related quality of life, as well as sensor-measured PA.

METHODS

Study participants (n=45; median age 46, IQR 40-51 years; median Expanded Disability Status Scale score 4.5, IQR 3.5-6) were recruited among persons with MS attending inpatient neurorehabilitation. They wore a Fitbit Inspire HR (Fitbit Inc) throughout their stay at the rehabilitation clinic (phase 1; 2-4 wk) and for the 4 following weeks at home (phase 2; 4 wk). Sensor-based step counts and cumulative minutes in moderate to vigorous PA were computed for the last 7 days at the clinic and at home. On the basis of PA during the last 7 end-of-study days, we grouped the study participants as active (≥10,000 steps/d) and less active (<10,000 steps/d) to explore PA barriers compared with PA level. PA barriers were repeatedly assessed through the BHADP scale. We described the relevance of the 18 barriers of the BHADP scale assessed at the end of the study and quantified their correlations with the Spearman correlation test. We evaluated the associations of the BHADP score with end-of-study reported outcomes of fatigue, depression, self-efficacy, and health-related quality of life with multivariable regression models. We performed separate regression analyses to examine the association of the BHADP score with different sensor-measured outcomes of PA.

RESULTS

The less active group reported higher scores for the BHADP items Feeling what I do doesn't help, No one to help me, and Lack of support from family/friends. The BHADP items Not interested in PA and Impairment were positively correlated. The BHADP score was positively associated with measures of fatigue and depression and negatively associated with self-efficacy and health-related quality of life. The BHADP score showed an inverse relationship with the level of PA measured but not when dichotomized according to the recommended PA level thresholds.

CONCLUSIONS

The BHADP scale is a valid and well-adapted tool for persons with MS because it reflects common MS symptoms such as fatigue and depression, as well as self-efficacy and health-related quality of life. Moreover, decreases in PA levels are often related to increases in specific barriers in the lives of persons with MS and should hence be addressed jointly in health care management.

Effectiveness of physical activity interventions for improving depression, anxiety and distress: an overview of systematic reviews

OBJECTIVE

To synthesise the evidence on the effects of physical activity on symptoms of depression, anxiety and psychological distress in adult populations.

DESIGN

Umbrella review.

DATA SOURCES

Twelve electronic databases were searched for eligible studies published from inception to 1 January 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Systematic reviews with meta-analyses of randomised controlled trials designed to increase physical activity in an adult population and that assessed depression, anxiety or psychological distress were eligible. Study selection was undertaken in duplicate by two independent reviewers.

RESULTS

Ninety-seven reviews (1039 trials and 128 119 participants) were included. Populations included healthy adults, people with mental health disorders and people with various chronic diseases. Most reviews (n=77) had a critically low A MeaSurement Tool to Assess systematic Reviews score. Physical activity had medium effects on depression (median effect size=-0.43, IQR=-0.66 to -0.27), anxiety (median effect size=-0.42, IQR=-0.66 to -0.26) and psychological distress (effect size=-0.60, 95% CI -0.78 to -0.42), compared with usual care across all populations. The largest benefits were seen in people with depression, HIV and kidney disease, in pregnant and postpartum women, and in healthy individuals. Higher intensity physical activity was associated with greater improvements in symptoms. Effectiveness of physical activity interventions diminished with longer duration interventions.

CONCLUSION AND RELEVANCE

Physical activity is highly beneficial for improving symptoms of depression, anxiety and distress across a wide range of adult populations, including the general population, people with diagnosed mental health disorders and people with chronic disease. Physical activity should be a mainstay approach in the management of depression, anxiety and psychological distress.

PROSPERO REGISTRATION NUMBER

CRD42021292710.

The strategies of exercise intervention for adolescent depression: A meta-analysis of randomized controlled trials

Purpose

This study aimed to investigate the effect of exercise intervention, and analyze exercise intervention strategies for adolescent depression through a meta-analysis of RCTs.

Methods

Accordance to PRISMA guidelines, PubMed, Medline, EBSCO, Web of Science, SPORTDiscus, PsycINFO, ProQuest, and CNKI were searched for eligible records. Peer-reviewed studies were included if they met the following criteria: population (mean age of 10-18 years), intervention (physical activity, sport, or exercise), and outcomes (depression, adherence, ITT, dropout, adverse events, follow-up report). The protocol of this systematic review was registered in PROSPERO (CRD42022321683). Effect sizes calculations and methodological quality of exercise intervention (TESTEX scale) were carried out. The certainty of evidence was assessed by GRADE framework.

Results

Thirteen randomized controlled trials were eligible for this review, which comprised a total of 433 adolescents. Compared with the control treatment, the effect of exercise on adolescent depression was moderate (SMD = -0.65, 95%CI: -1.03 to -0.27, p < 0.01). Heterogeneity was substantial (T 2 = 0.30, I 2 = 67%, p < 0.01). The moderating effect analysis showed that exercise intervention characteristics (organization form, exercise frequency, exercise intensity, exercise type, and single exercise session duration) of included studies varied greatly revealing multiple factors that may impact the antidepressant effect of exercise on adolescent depression (I 2 > 50%, p < 0.05). Three studies show that the positive effect of exercise on reducing depression in adolescents remained 40 weeks after the intervention. Moreover, owing to the included studies contained methodological limitations, the certainty of evidence was reduced to moderate level.

Conclusion

This study shows that exercise intervention has a moderate and sustained positive effect on adolescent depression. Our results recommended that adolescents with depression undertake moderate to high intensity group mixed exercise for more than 12 weeks, 20 to 60 min/time, more than 3 times/week. Additionally, our study also shows that the antidepressant effects remained for a long time after the end of exercise interventions. However, following the GRADE framework, we rated the certainty of evidence the primary meta-analysis as moderate evidence due to some limitations of included studies. Therefore, rigorous studies are still needed to verify the results.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=321683], identifier [CRD42022321683].

Functional correlates of self-reported energy levels in the Health, Aging and Body Composition Study

BACKGROUND

Effects of fatigue on health in older age are well studied, yet little is known about the clinical relevance of energy perception.

AIMS

To explore cross-sectional associations of self-reported energy with physical and mental health metrics in the Health, Aging, and Body Composition Study.

METHODS

Participants rated their energy from 0 to 10; the outcome was energy dichotomized at the median (≥ 7 = higher energy). Four domains were assessed: depressive symptoms (Center for Epidemiologic Studies Depression Scale); physical performance (function: usual and rapid gait speed; fitness: 400-m walk time); physical activity (casual walking, walking for exercise, and intense exercise); and cognitive function (Modified Mini-Mental State Examination and Digit Symbol Substitution Test). Covariates bivariately associated with energy entered a multivariable logistic regression model, adjusted for demographics, chronic conditions, and strength.

RESULTS

Depressive symptoms, physical performance and activity, but not cognition, were bivariately associated with energy (p < 0.0005). Younger age, male sex, greater strength, and absence of chronic conditions predicted higher energy (p < 0.001). In a multivariable model, depressive symptoms [adjusted odds ratio (aOR) 95% CI 0.69 (0.62, 0.76)] and 400-m walk times [aOR = 0.81 (0.72, 0.91)] were inversely associated with energy; usual and rapid gait speed [aOR = 1.3 (1.2, 1.4); aOR = 1.2 (1.1-1.4)], and time spent in intense exercise [aOR = 1.4 (1.1-1.7)] were positively associated with energy.

DISCUSSION

In this cohort with a range of chronic conditions and fatigue, perceiving higher energy levels may reflect better emotional and physical health.

CONCLUSION

Energy should be considered in multidimensional clinical assessments of older age.

Distinguishing between Fatigue and Fatigability in Multiple Sclerosis

Fatigue is one of the most common debilitating symptoms reported by persons with multiple sclerosis (MS). It reflects feelings of tiredness, lack of energy, low motivation, and difficulty in concentrating. It can be measured at a specific instant in time as a perception that arises from interoceptive networks involved in the regulation of homeostasis. Such ratings indicate the state level of fatigue and likely reflect an inability to correct deviations from a balanced homeostatic state. In contrast, the trait level of fatigue is quantified in terms of work capacity (fatigability), which can be either estimated (perceived fatigability) or measured (objective fatigability). Clinically, fatigue is most often quantified with questionnaires that require respondents to estimate their past capacity to perform several cognitive, physical, and psychosocial tasks. These retrospective estimates provide a measure of perceived fatigability. In contrast, the change in an outcome variable during the actual performance of a task provides an objective measure of fatigability. Perceived and objective fatigability do not assess the same underlying construct. Persons with MS who report elevated trait levels of fatigue exhibit deficits in interoceptive networks (insula and dorsal anterior cingulate cortex), including increased functional connectivity during challenging tasks. The state and trait levels of fatigue reported by an individual can be modulated by reward and pain pathways. Understanding the distinction between fatigue and fatigability is critical for the development of effective strategies to reduce the burden of the symptom for individuals with MS.

Health Promotion and Wellness in Neurologic Physical Therapy: Strategies to Advance Practice

BACKGROUND AND PURPOSE

Neurologic physical therapy (PT) can assist people with neurologic conditions and injuries to optimize their health and well-being by addressing barriers at the individual, relationship, community, and societal levels. The purpose of this special interest article is to provide consensus-driven strategies to address barriers to implementing health promotion and wellness (HPW)-related neurologic PT practice.

SUMMARY OF KEY POINTS

Environmental scan, literature review, and expert input were used to determine barriers and develop strategies. Barriers include lack of time; low knowledge, self-efficacy, and awareness; client complexity; and lack of HPW resources; as well as concerns regarding payment and scope of practice. Four key strategies emerged: (1) develop and disseminate a consensus-based scope of practice for HPW in neurologic PT; (2) increase knowledge of resources related to HPW; (3) promote delivery models for HPW-related neurologic PT; and (4) encourage advocacy, community building and partnership along the continuum of care.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Clinicians should practice to their full scope of HPW-related PT practice. This includes optimizing movement, including physical activity and fitness, as well as reinforcing the importance of healthy sleep, nutrition, stress, and smoking cessation. These activities address primary, secondary, and tertiary prevention. Clinicians are encouraged to report their experiences with HPW-focused delivery models and outcomes. Additional research is needed to understand the full impact of HPW on PT practice (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A364).

A short-term exercise program in patients with multiple sclerosis: is body mass index important?

Obesity is a health problem that can exacerbate the symptoms of multiple sclerosis (MS). In the current study, we aimed to investigate the effectiveness of a short-term exercise program on fatigue, depression, anxiety, and walking performance in normal-weight and overweight patients with MS (PwMS). Sixty-two PwMS were divided into groups according to their BMI (BMI normal/BMI high). Also, they were all included in the exercise program. The participants took a moderate-intensity walking program 5 days a week for 4 weeks, including 30 min between 5 min of warm-up and 5 min of cooling periods. Also, patients underwent breathing, posture, flexibility, and stretching exercises for 4 weeks. Fatigue, depression, anxiety, 6-minute walking test (6MWT), and BMI were measured before and after the 4 weeks. After the exercise program, there were statistically significant improvements in fatigue, depression, anxiety, and the 6MWT. However, no relation could be detected between the examined variables and BMI. All patients participated effectively in the exercise program, regardless of BMI. The results obtained from this study support that a short-term exercise program is an effective therapeutic intervention, unrelated to BMI, in improving fatigue, depression, anxiety, and walking performance in PwMS.

Participant experiences of eight weeks of supervised or home-based Pilates among people with multiple sclerosis: a qualitative analysis

PURPOSE

An exploratory qualitative study investigating participants' experiences of a feasibility study of supervised and home-based Pilates.

METHODS

All 10 females who participated in an eight-week supervised (n = 4) or home-based Pilates (n = 6) program were invited and agreed to be interviewed. Data were collected via semi-structured interviews and researcher observations of participant experiences. Data were analysed using codebook thematic analysis framework.

RESULTS

Two domain summaries emerged: (1) the suitability of home-based Pilates in particular for this population. Participants indicated that supervised and home-based Pilates was a safe, intensity-appropriate, and implementable exercise method to improve mental health outcomes among persons with multiple sclerosis (PwMS), and (2) the benefits experienced by PwMS while participating in Pilates. Home-based Pilates reduced both exercise participation and accessibility barriers commonly experienced by PwMS. Furthermore, PwMS reported improvements in mental health outcomes following Pilates, in both exercise environments.

CONCLUSIONS

PwMS reported experiencing improved mood following regular Pilates training and indicated that home-based in particular reduced barriers regularly experienced by this population. Results support Pilates as a feasible exercise modality providing potential mood improvements among PwMS. Future appropriately powered home-based randomised controlled trials to further explore the effects of Pilates training on mental health among PwMS with minimal-to-mild mobility disability are warranted.Implications for RehabilitationParticipants in this study described the mental health benefits experienced from engaging in Pilates, a non-traditional exercise modality.Home-based Pilates overcame participatory and accessibility barriers to exercise among people with multiple sclerosis (MS).Participants valued that Pilates was low intensity and did not exacerbate fatigue.Home-based Pilates is a feasible exercise method for people with MS with minimal-to-mild mobility disability.

Home-based Pilates for symptoms of anxiety, depression and fatigue among persons with multiple sclerosis: An 8-week randomized controlled trial

BACKGROUND

Symptoms of anxiety, depression and fatigue are common comorbidities among persons with multiple sclerosis (PwMS). A previous pilot study supported Pilates as a feasible exercise modality that may improve these outcomes among PwMS.

OBJECTIVE

To quantify the effects of 8 weeks of home-based Pilates on symptoms of anxiety, depression and fatigue among PwMS.

METHODS

A total of 80 PwMS (69 female) were randomized to twice-weekly home-based Pilates guided by a DVD) or wait-list control. Validated questionnaires assessed anxiety, depressive and fatigue symptoms at baseline, weeks 2, 4, 6 and 8. Using intention to treat, repeated measures analysis of covariance (RM-ANCOVA) adjusted for baseline physical activity examined between-group differences across time. Hedges' d quantified the magnitude of differences in outcome change. Sensitivity analyses examined female-only samples.

RESULTS

Group × time interactions were statistically significant for all outcomes (all p ⩽ 0.005). Pilates significantly reduced (all p ⩽ 0.03) depressive symptoms (Quick Inventory of Depressive Symptomatology, d = 0.70; Hospital Anxiety and Depression Scale-Depression, d = 0.74), anxiety (State-Trait Anxiety Inventory, d = 0.30; Hospital Anxiety and Depression Scale-Anxiety, d = 0.49), cognitive (d = 0.44), physical (d = 0.78), psychosocial (d = 0.56) and total fatigue (d = 0.76). Female-only results were materially the same.

CONCLUSION

Home-based Pilates significantly improved anxiety, depressive and fatigue symptoms among PwMS with minimal-to-mild mobility disability, including moderate-to-large, clinically meaningful improvements in depressive and fatigue symptoms.Trial Registration: ClinicalTrials.gov (NCT04120207).

Depression in multiple sclerosis: Is one approach for its management enough?

BACKGROUND

Major depression disorder (MDD) and severe depression symptoms are highly prevalent in multiple sclerosis (MS). Depression can worsen symptoms of MS and is associated with significantly reduced quality of life and increased risk of suicide. Currently, there is no gold-standard, single treatment available for depression in MS. Pharmacotherapy, cognitive behavior therapy (CBT), and exercise training individually are moderately, yet incompletely, efficacious for managing depression in the general population and MS.

PURPOSE

This review provides an overview of evidence from meta-analyses and systematic reviews for current treatments of depression in persons with MS. This review further develops the rationale for using a combinatory treatment approach in persons with MS.

METHODS

We performed a narrative review of meta-analyses and systematic reviews regarding the current state of evidence for the three most common treatments of depression in persons with MS (i.e., antidepressant medication, cognitive-behavior therapy, and exercise training). We provide a concise assessment of the overall effect of these treatments on depression in the general population and then persons with MS. We further note short-comings of research on these treatments for depression.

CONCLUSION

There is no single, gold-standard treatment for depression in MS, and we proposed that combinatory treatments should be considered for the management of depression in MS. However, there is a paucity of evidence for the use of combinatory therapy on depression and its outcomes in persons with MS, and this supports direct examination of the feasibility and efficacy of such combinatory approaches for MDD in MS.

Exercise and Multiple Sclerosis

Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system (CNS) with an estimated prevalence approaching 1 million adults in the United States. The disease pathogenesis and resulting damage express as dysfunction (e.g., walking and cognitive impairment) and symptoms (e.g., fatigue and depression) that compromise quality of life (QOL) and full participation. There has been a steadily increasing body of research on the outcomes of exercise among persons with MS, and this has accelerated sharply over the past decade. The current chapter provides a review of exercise and its outcomes, safety, and prescription in MS. This chapter initially reviews the evidence for benefits of exercise based principally on meta-analyses and literature reviews. The chapter then reviews evidence on the safety of exercise in MS and lastly provides guidelines for exercise prescription in MS. Collectively, this chapter serves as an overview and reference for researchers and clinicians interested in the benefits, safety, and prescription of exercise in MS.

Serum Histidine is Lower in Fatigued Women with Multiple Sclerosis

BACKGROUND

Disabling persistent perceived fatigue occurs in 50% of people with multiple sclerosis (MS), but mechanisms are poorly understood. Low histidine could contribute to fatigue since it is the neurotransmitter histamine precursor and low serum levels are reported in other diseases where fatigue is common (e.g., breast cancer, kidney disease, diabetes). Serum histidine is also inversely correlated with proinflammatory cytokines (e.g., TNF, IFN-y), which have been linked to MS fatigue.

PURPOSE

To determine if serum histidine is low in fatigued women with MS, and if histidine is related to differences in proinflammatory cytokines.

METHODS

Participants were classified as having elevated (n = 19) or normal (n = 18) perceived fatigue based on a median sample split using Profile of Mood States fatigue scale scores, with the elevated fatigue group having scores >7. Histidine and gene-expression of TNF, IFN-y, and leptin were assayed from a serum sample.

RESULTS

After adjustment for depression, serum histidine was significantly lower in women with MS with elevated fatigue, compared to normal fatigue (64.57 vs. 70.48 nmol/ml, p = .048, g = 0.75). There were no differences between groups in cytokine expression (all p > .24). Gene expression of TNF correlated with histidine only in people with normal fatigue (r = .51, p = .034), while no other cytokines related to histidine levels.

CONCLUSIONS

These results provide evidence that serum histidine is lower in fatigued women with MS, but the study did not find a relationship between histidine and TNF, IFN-y, or leptin gene expression.

Effect of Short-Term Interval Exercise Training on Fatigue, Depression, and Fitness in Normal Weight vs. Overweight Person With Multiple Sclerosis

CONTEXT

Excessive weight is a health problem that can exacerbate multiple sclerosis (MS) symptoms and its associated comorbidities such as depression and fatigue. In addition, weight may be a moderator of exercise effects on depression and fatigue symptoms.

OBJECTIVE

This study aimed to investigate the effects of exercise training on fatigue and depression in normal and overweight individuals with MS.

METHODS

Sixty-six persons with MS were randomly assigned into an exercise or control condition based on body weight status (overweight vs. normal weight). The exercise conditions involved 8-weeks of interval exercise at 60%-75% Watt_peak, while the control condition did not involve any exercise. Fatigue, depression, aerobic capacity, time up and go (TUG) and body mass index were measured before and following the 8-week period.

RESULTS

There were no significant relationship's revealed for weight status interactions for any of the variables examined. There were significant condition main effects for fatigue, depression, aerobic capacity and TUG, and significant improvements were noted for the exercise conditions, but not in the non-exercising control group.

CONCLUSION

The results from this study confirm that exercise is an effective therapeutic intervention for improving fatigue, depression and functional parameters, independent of initial weight status, in persons with MS.

Effects of exercise training on cytokines and adipokines in multiple Sclerosis: A systematic review

BACKGROUND

Physical activity, particularly exercise training, is an evidence-based approach for managing symptoms, restoring function and improving overall wellness in people with multiple sclerosis (MS). Several recent studies have argued for a potential disease modifying effect of exercise in people with MS, and among the potential mediating mechanisms are exercise training effects on both cytokines and adipokines. The objectives of this study were to perform a systematic review of exercise training effects on cytokine and adipokine profiles in persons with MS.

METHODS

We conducted open-dated searches of PubMed, Cochrane Library, EMBASE and PEDro using the terms 'Multiple sclerosis' or 'MS' AND 'exercise' OR 'training' OR 'physical activity' AND 'cytokine' OR 'inflammatory' OR 'immune' OR 'adipokine'. Included studies were written in English; comprised of humans with MS, and evaluated the effects of regular physical activity or exercise on pro-inflammatory, anti-inflammatory cytokines or adipokines. Two authors independently scanned titles and abstracts, and read the studies included. All studies were rated on the PEDro scale and further classified based on American Academy of Neurology criteria.

RESULTS

Twelve studies were included of which 10 studies focused on cytokines, 1 study focused on adipokines, and 1 study included both cytokines and adipokines. The selected studies included 3 Class I studies, 7 Class II studies, and 2 Class IV studies and had average PEDro scores of 6.9 ± 1.6. Studies included endurance (n = 5), resistance (n = 3), combined (n = 3), and vibration (n = 1) training. Overall, there is a general lack of standardization of procedures across studies and inconsistent evidence for the effects of physical activity and exercise on cytokine and adipokine profiles in MS, with a general pattern indicating a lack of effect.

CONCLUSION

Research regarding the effects of exercise training on cytokines and adipokines in MS is in its infancy, but exercise represents an adjuvant therapy in MS, and future studies are essential for clarifying the role of exercise on cytokines and adipokines in MS.

Perceived fatigue and energy are independent unipolar states: Supporting evidence

Persistent fatigue is a common problem (∼20-45% of U.S. population), with higher prevalence and severity in people with medical conditions such as cancer, depression, fibromyalgia, heart failure, sleep apnea and multiple sclerosis. There are few FDA-approved treatments for fatigue and great disagreement on how to measure fatigue, with over 250 instruments used in research. Many instruments define fatigue as "a lack of energy", thus viewing energy and fatigue states as opposites on a single bipolar continuum. In this paper, we hypothesize that energy and fatigue are distinct perceptual states, should be measured using separate unipolar scales, have different mechanisms, and deficits should be treated using tailored therapies. Energy and fatigue independence has been found in both exploratory and confirmatory factor analysis studies. Experiments in various fields, including behavioral pharmacology and exercise science, often find changes in energy and not fatigue, or vice versa. If the hypothesis that energy and fatigue are independent is correct, there are likely different mechanisms that drive energy and fatigue changes. Energy could be increased by elevated dopamine and norepinephrine transmission and binding. Fatigue could be increased by elevated brain serotonin and inflammatory cytokines and reduced histamine binding. The hypothesis could be tested by an experiment that attempts to produce simultaneously high ratings of energy and fatigue (such as with two drugs using a randomized, double-blind, placebo-controlled design), which would offer strong evidence against the common viewpoint of a bipolar continuum. If the hypothesis is correct, prior literature using bipolar instruments will be limited, and research on the prevalence, mechanisms, and treatment of low energy and elevated fatigue as separate conditions will be needed. In the immediate future, measuring both energy and fatigue using unipolar measurement tools may improve our understanding of these states and improve therapeutic outcomes.

Effect of exercising at minimum recommendations of the multiple sclerosis exercise guideline combined with structured education or attention control education - secondary results of the step it up randomised controlled trial

BACKGROUND

Recent exercise guidelines for people with multiple sclerosis (MS) recommend a minimum of 30 min moderate intensity aerobic exercise and resistance exercise twice per week. This trial compared the secondary outcomes of a combined 10-week guideline based intervention and a Social Cognitive Theory (SCT) education programme with the same exercise intervention involving an attention control education.

METHODS

Physically inactive people with MS, scoring 0-3 on Patient Determined Disease Steps Scale, with no MS relapse or change in MS medication, were randomised to 10-week exercise plus SCT education or exercise plus attention control education conditions. Outcomes included fatigue, depression, anxiety, strength, physical activity, SCT constructs and impact of MS and were measured by a blinded assessor pre and post-intervention and 3 and 6 month follow up.

RESULTS

One hundred and seventy-four expressed interest, 92 were eligible and 65 enrolled. Using linear mixed effects models, the differences between groups on all secondary measures post-intervention and at follow-up were not significant. Post-hoc, exploratory, within group analysis identified improvements in both groups post intervention in fatigue (mean ∆(95% CI) SCT -4.99(-9.87, -0.21), p = 0.04, Control -7.68(-12.13, -3.23), p = 0.00), strength (SCT -1.51(-2.41, -0.60), p < 0.01, Control -1.55(-2.30, -0.79), p < 0.01), physical activity (SCT 9.85(5.45, 14.23), p < 0.01, Control 12.92(4.69, 20.89), goal setting (SCT 7.30(4.19, 10.4), p < 0.01, Control 5.96(2.92, 9.01), p < 0.01) and exercise planning (SCT 5.88(3.37, 8.39), p < 0.01, Control 3.76(1.27, 6.25), p < 0.01) that were maintained above baseline at 3 and 6 month follow up (all p < 0.05). Only the SCT group improved at 3 and 6 month follow up in physical impact of MS(-4.45(-8.68, -0.22), -4.12(-8.25, 0.01), anxiety(-1.76(-3.20, -0.31), -1.99(-3.28, -0.71), depression(-1.51(-2.89, -0.13), -1.02(-2.05, 0.01)) and cognition(5.04(2.51, 7.57), 3.05(0.81, 5.28), with a medium effect for cognition and fitness (Hedges' g 0.75(0.24, 1.25), 0.51(0.01, 1.00) at 3 month follow up.

CONCLUSIONS

There were no statistically significant differences between groups for the secondary outcomes once age, gender, time since diagnosis and type of MS were accounted for. However, within the SCT group only there were improvements in anxiety, depression, cognition and physical impact of MS. Exercising at the minimum guideline amount has a positive effect on fatigue, strength and PA that is sustained at 3 and 6 months following the cessation of the program.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02301442 , retrospectively registered on November 13th 2014.