Effects of exercise training on multiple sclerosis biomarkers of central nervous system and disease status: a systematic review of intervention studies

Response of Central Nervous System Biomolecules and Systemic Biomarkers to Aerobic Exercise Following Concussion: A Scoping Review of Human and Animal Research

The purpose of this study was to identify the response of biomolecules and biomarkers that are associated with the central nervous system to aerobic exercise in human and pre-clinical models of concussion or mild traumatic brain injury (TBI), and to highlight the knowledge gaps in the literature. A systematic scoping review was conducted following a search of EMBASE, MEDLINE, SCOPUS, BIOSIS, and Cochrane Libraries performed on September 8, 2023 (from data base inception). The scoping review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. Duplicates were removed and article screening was performed using an online systematic review management system. The search resulted in a total of 2,449 articles being identified, with 14 articles meeting the inclusion/exclusion criteria and having their data extracted. One study was conducted in humans, while the remainder of identified studies utilized murine models. The current literature is limited and evaluated many different biomolecules and biomarkers with brain-derived neurotrophic factor being the most researched. Further studies on this topic are needed to better understand the biomarker response to exercise after concussion and mild TBI, especially in the human population.

Empowering Minds and Bodies: The Impact of Exercise on Multiple Sclerosis and Cognitive Health

Multiple sclerosis (MS) is a global health concern affecting around 2.6 million people. It is characterised by neural inflammation, myelin breakdown and cognitive decline. Cognitive impairment, especially reduced cognitive processing speed (CPS), which affects up to 67% of MS patients and frequently manifests before mobility concerns, is one of the disease's most serious side effects. Effective adaptation and the application of cognitive rehabilitation treatments depend on the early diagnosis of cognitive impairment. Although pharmaceutical therapies have some drawbacks, endurance training has become a promising alternative. Intensity-controlled endurance exercise has the ability to delay the onset of MS symptoms and enhance cognitive function. Exercise has also been shown to have neuroprotective effects in a number of neurological disorders, including MS, Parkinson's disease and stroke. This includes both aerobic and resistance training. A mix of aerobic exercise and weight training has shown promise, especially for people with mild cognitive impairment, but according to recent studies any amount of physical activity is beneficial to cognitive performance. In conclusion, this in-depth analysis highlights the crucial part endurance exercise plays in treating MS-related cognitive impairment. It improves not only neurological health in general but also cognitive performance. Exercise can help control MS in a way that dramatically improves quality of life and well-being.

Resistance training modifies of serum levels of matrix metalloproteinase 2 and tissue inhibitor of matrix metalloproteinases in multiple sclerosis women - a randomized controlled trail

The objectives of the present study was to investigate the effects of resistance training (RT) on serum levels of controlling blood-brain barrier (BBB) permeability indices and cognitive performance in MS women (MS-W). In this randomized control trail study (IRCT registration code: IRCT20120912010824N3, 07.09.2023), twenty-five MS-W were randomly divided into sedentary (MS) and resistance exercise (12 weeks/3 times per week/ 60-80% of 1RM) (MS + RT) groups. Fifteen healthy aged-matched women participated as a control group (HCON). The serum level of matrix metalloproteinase-2 (MMP-2), matrix metallopeptidase-9 (MMP-9), tissue metalloproteinase inhibitors-1 (TIMP-1), tissue metalloproteinase inhibitors-2 (TIMP-2), and S100 calcium-binding protein B (S100B) were assessed. In addition, cognitive performance was assessed pre- and post- intervention with the Brief International Cognitive Assessment for MS (BICAMS). A significant reduction in MMP-2, TIMP-2 serum levels, and MMP-2/TIMP-2 ratio were observed in post-test for MS + RT group (p < 0.01) in comparison to the HCON and MS groups; however, no changes were observed in MMP-9, TIMP-1, S100B and MMP-9/TIMP-1 ratio after RT (p > 0.05). The verbal learning was improved in post-test for MS + RT group (p < 0.01), although no change were observed for visuospatial memory and information processing speed (p > 0.05). These findings suggest that resistance training can modify some indices of BBB permeability and improve verbal learning in MS-W. The findings may also be beneficial as a non-pharmacological intervention to reduce inflammation.

Task-oriented exercise effects on walking and corticospinal excitability in multiple sclerosis: protocol for a randomized controlled trial

BACKGROUND

Multiple sclerosis (MS) is a degenerative disease of the central nervous system (CNS) that disrupts walking function and results in other debilitating symptoms. This study compares the effects of 'task-oriented exercise' against 'generalized resistance and aerobic exercise' and a 'stretching control' on walking and CNS function in people with MS (PwMS). We hypothesize that task-oriented exercise will enhance walking speed and related neural changes to a greater extent than other exercise approaches.

METHODS

This study is a single-blinded, three-arm randomized controlled trial conducted in Saskatchewan, Canada. Eligible participants are those older than 18 years of age with a diagnosis of MS and an expanded Patient-Determined Disease Steps (PDDS) score between 3 ('gait disability') and 6 ('bilateral support'). Exercise interventions are delivered for 12 weeks (3 × 60-min per week) in-person under the supervision of a qualified exercise professional. Interventions differ in exercise approach, such that task-oriented exercise involves weight-bearing, walking-specific activities, while generalized resistance and aerobic exercise uses seated machine-based resistance training of major upper and lower body muscle groups and recumbent cycling, and the stretching control exercise involves seated flexibility and relaxation activities. Participants are allocated to interventions using blocked randomization that stratifies by PDDS (mild: 3-4; moderate: 5-6). Assessments are conducted at baseline, post-intervention, and at a six-week retention time point. The primary and secondary outcome measures are the Timed 25-Foot Walk Test and corticospinal excitability for the tibialis anterior muscles determined using transcranial magnetic stimulation (TMS), respectively. Tertiary outcomes include assessments of balance, additional TMS measures, blood biomarkers of neural health and inflammation, and measures of cardiorespiratory and musculoskeletal fitness.

DISCUSSION

A paradigm shift in MS healthcare towards the use of "exercise as medicine" was recently proposed to improve outcomes and alleviate the economic burden of MS. Findings will support this shift by informing the development of specialized exercise programming that targets walking and changes in corticospinal excitability in PwMS.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05496881, Registered August 11, 2022. https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05496881 . Protocol amendment number: 01; Issue date: August 1, 2023; Primary reason for amendment: Expand eligibility to include people with all forms of MS rather than progressive forms of MS only.

The MoXFo Initiative: Using consensus methodology to move forward towards internationally shared vocabulary in multiple sclerosis exercise research

BACKGROUND

Multiple sclerosis (MS) exercise terminology lacks consistency across disciplines, hindering research synthesis.

OBJECTIVE

The 'Moving exercise research in MS forward initiative' (MoXFo) aims to establish agreed definitions for key MS exercise terms.

METHODS

The Lexicon development methodology was employed. A three-step process identified key exercise terminology for people with multiple sclerosis (pwMS): (1) consensus and systematic review, (2) Delphi round 1 and consideration of existing definitions and (3) Delphi round 2 for consensus among MoXFo steering group and exercise experts. Final definitions and style harmonisation were agreed upon.

RESULTS

The two-stage Delphi process resulted in the selection and scoring of 30 terminology definitions. The agreement was 100% for resistance exercise, balance and physical activity. Most terms had agreement >75%, but 'posture' (60%) and 'exercise' (65%) had a lower agreement.

CONCLUSION

This study identified key terms and obtained agreement on definitions for 30 terms. The variability in agreement for some terms supports the need for clearly referencing or defining terminology within publications to enable clear communication across disciplines and to support precise synthesis and accurate interpretation of research.

The MoXFo initiative - adherence: Exercise adherence, compliance and sustainability among people with multiple sclerosis: An overview and roadmap for research

We know very little about exercise adherence, compliance and sustainability in multiple sclerosis (MS), yet adherence is seemingly important for yielding immediate and sustained health benefits. This paper is focused on exercise adherence, compliance and sustainability in the context of informing research and practice involving MS. This focus is critical for clarifying terminology for future research and providing a roadmap guiding clinical research and practice. Our objective was accomplished through a narrative summary of the literature by a panel of experts on exercise adherence from the Moving Exercise Research in Multiple Sclerosis Forward (MoXFo) initiative and a concluding summary of the state of the literature and future research directions. The panel of experts identified three overall themes (Background and Importance; Understanding and Promoting Exercise Adherence, Compliance and Sustainability and Challenges to Exercise Adherence, Compliance and Sustainability) that represented a categorization of nine subthemes. These overall themes and subthemes formed the basis of our recommendations regarding future research broadly involving exercise adherence in MS. Overall, there is limited evidence on rates and determinants of exercise adherence and compliance in MS, and little is known about techniques and interventions for immediate and long-term exercise behaviour change.

Admission and discharge profiles of people with MS accessing in-patient rehabilitation in Canada

BACKGROUND

Rehabilitation is the mainstay of management for people with disabilities of neurological origin to maximize function and reduce disability. Access to in-patient rehabilitation is usually reserved for people after crises or those who are discharged from acute care such as in stroke or trauma. Access to people with Multiple Sclerosis (MS) differs across countries and unknown for Canada. With the progression of MS, quality of life (QOL) becomes more closely coupled with independence and hence timely access to rehabilitation is important. The objectives of this paper are (i) to characterize the disability profiles of people with MS admitted to in-patient rehabilitation in Canada; and (ii) to estimate the extent to which disability profiles differ from admission to discharge.

METHODS

A longitudinal study of a rehabilitation admission-to-discharge cohort of 3500 people with MS was conducting using latent class analysis on the five Functional Independence Measure (FIM) subscales for Self-care, Transfers, Locomotion, Bladder/Bowel, and Cognition. The extent to which age, sex, and calendar time was associated with latent class membership, at both admission and discharge, was estimated using ordinal logistic regression, and proportional odds model was calculated for each age and sex.

RESULTS

At admission five classes were identified. The two most prevalent classes included people with total or moderate dependency in all FIM subscales except cognition (n = 1205 and n = 1099). The third most common was dependent in ambulation only (n = 523), followed by dependence in ambulation with varying degree of limitation in self-care and transfers (n = 465, and n = 208). At discharge four classes were identified with the largest class comprising of people dependent in ambulation and to a lesser degree in transfers (n = 1010). The second most prevalent class was no dependency (n = 946), followed by two classes with varying dependency in all subscales but cognition (n = 678 and n = 771).

CONCLUSION

Overall 62.3% of admissions transitioned to a more functional class by discharge. By discharge 28% of the population was characterized by no dependencies; however, 23% remained with dependencies in all areas. Those in the most dependent classes showed the greatest probability of transitioning to a better class at discharge highlighting the importance of reserving scarce rehabilitation services to those with more disability.

The MoxFo initiative - outcomes: Outcome measures in studies of exercise training in multiple sclerosis; scoping review of reviews and classification according to the ICF framework

BACKGROUND

The number of published studies of exercise training in multiple sclerosis (MS) has grown exponentially with increasing numbers of outcomes capturing exercise effects. This has complicated the selection of relevant indicators and interpretation of intervention effects.

OBJECTIVES

The Outcomes subgroup of the MoXFo initiative aimed to (1) identify outcome measures and biomarkers in studies of exercise training in MS; (2) systematically map retrieved outcomes to International Classification of Functioning, Disability and Health (ICF) categories; (3) identify gaps where relevant ICF categories have been omitted.

METHODS

Electronic databases and registers were searched from 2010 to July 2020 to identify systematic reviews or meta-analyses of controlled trials of exercise training on any outcome in MS. Retrieved outcomes/biomarkers were mapped to the corresponding ICF category.

RESULTS

Eighty-one review articles reporting 235 different outcomes were included. The outcomes corresponded to 15 chapters and 45 categories within the ICF. Outcomes mapped primarily to body function (30 categories) and activities and participation (9 categories) components. Few outcomes mapped to body structures (2 categories) or environmental factors (1 category).

CONCLUSION

This sets the stage to develop a resource for researchers/clinicians that will aid in the selection of appropriate outcomes/biomarkers when examining exercise effects in MS.

Interventions to Improve Quality of Life in Multiple Sclerosis: New Opportunities and Key Talking Points

Background

Today, living well with multiple sclerosis (MS) is often measured by a person's overall quality of life rather than being limited to the more traditional metrics of reduced frequency of relapses or progression of disability. This change in focus, to a more holistic view of health, such as overall quality of life, has shifted the views of what both providers and people with multiple sclerosis view as essential for living well with MS.

Purpose

This narrative review aims to examine the relevant literature on existing and emerging non-pharmacological interventions shown to improve the quality of life for people with multiple sclerosis across all health domains.

Methods

A literature search was conducted on MEDLINE, CINAHL, and Scopus electronic databases using the following search terms: quality of life, health-related quality of life, life quality, life satisfaction, non-pharmacological intervention, non-drug, and intervention. After screening the abstracts, 24 were selected for this review.

Results

Common non-pharmacological interventions were used for fatigue and sleep, mental and emotional health, cognition, physical health, and chronic pain. Several non-pharmacological interventions included in this review positively improved the overall quality of life for people with multiple sclerosis. These interventions included exercise, cognitive behavior therapy, and cognitive rehabilitation.

Conclusion

Non-pharmacological interventions such as exercise and cognitive behavioral therapy improve the quality of life for people with MS. These interventions should be prescribed more during routine medical care. Translating this research into standard clinical practice should be one area of focus. In addition, higher quality studies, such as randomized control trials, need to be conducted on emerging nonpharmacological interventions to assess effectiveness.

Orchestrating a New Path for Multiple Sclerosis: Achieving Physical, Cognitive, and Emotional Rehabilitation Goals Through Physical and Music Therapy

BACKGROUND

Interdisciplinary therapies for the management of people with multiple sclerosis (MS) are underappreciated. There is an urgent need to introduce music therapy (MT), either alone or in combination with physical therapy (PT), into clinical practice to achieve synergy with disease-modifying therapies. A holistic approach to rehabilitation for people with MS may mitigate symptoms and reduce polypharmacy, potentially lowering health care costs.

RESULTS

As MS progresses, patients experience a range of worsening symptoms, and many develop psychosocial comorbidities. As disease-modifying therapies delay disability progression, nonpharmacologic treatments become increasingly important. The main aim of PT is to improve or maintain patients' functional mobility, strength, and flexibility. Because it targets multiple functions, MT can help improve functional and psychosocial domains and may be a valuable intervention to help patients achieve the physical, cognitive, and emotional goals of PT. Exploratory studies showed that MT, alone or in combination with PT, can lead to functional improvements in mobility, balance, gait, and fatigue. Similar to PT, MT also has benefits in improving fine motor skills, cognition, learning, and memory and in providing emotional support.

CONCLUSIONS

Both MT and PT have the potential to improve overall well-being and health-related quality of life in physically active patients with MS, and MT can provide added emotional support for those who are less able to engage in physical activity. However, MT is not typically a part of standard of care, and PT visits are limited. Nevertheless, interdisciplinary therapies should be incorporated into clinical practice.

Abnormal thalamic functional connectivity correlates with cardiorespiratory fitness and physical activity in progressive multiple sclerosis

BACKGROUND

Altered thalamic volumes and resting state (RS) functional connectivity (FC) might be associated with physical activity (PA) and cardiorespiratory fitness (CRF) in people with progressive multiple sclerosis (PMS).

OBJECTIVES

To assess thalamic structural and functional alterations and investigate their correlations with PA/CRF levels in people with PMS.

METHODS

Seven-day accelerometry and cardiopulmonary exercise testing were used to assess PA/CRF levels in 91 persons with PMS. They underwent 3.0 T structural and RS fMRI acquisition with 37 age/sex-matched healthy controls (HC). Between-group comparisons of MRI measures and their correlations with PA/CRF variables were assessed.

RESULTS

PMS people had lower volumes compared to HC (all p < 0.001). At corrected threshold, PMS showed decreased intra- and inter-thalamic RS FC, and increased RS FC between the thalamus and the hippocampus, bilaterally. At uncorrected threshold, decreased thalamic RS FC with caudate nucleus, cerebellum and anterior cingulate cortex (ACC), as well as increased thalamic RS FC with occipital regions, were also detected. Lower CRF, measured as peak oxygen consumption (VO_2peak), correlated with lower white matter volume (r = 0.31, p = 0.03). Moreover, lower levels of light PA correlated with increased thalamic RS FC with the right hippocampus (r = - 0.3, p = 0.05).

DISCUSSION

People with PMS showed widespread brain atrophy, as well as pronounced intra-thalamic and thalamo-hippocampal RS FC abnormalities. White matter atrophy correlated with CRF, while increased thalamo-hippocampal RS FC was associated to worse PA levels. Thalamic RS FC might be used to monitor physical impairment and efficacy of rehabilitative and disease-modifying treatments in future studies.

The insula modulates the effects of aerobic training on cardiovascular function and ambulation in multiple sclerosis

BACKGROUND

Impairment of cardiovascular control is common in multiple sclerosis (MS), possibly due to damage of strategic brain regions such as the insula. Aerobic training (AT) targets cardiopulmonary system and may represent a neuroprotective strategy.

PURPOSE

To investigate whether insular damage (T2-hyperintense lesions and volume) is associated with cardiovascular fitness (CF) and influences AT effects in MS.

METHODS

Sixty-one MS patients were randomized to an AT intervention group (MS-AT) and a motor training control group (MS-C). At baseline and after training (24 sessions over 2-3 months), peak of oxygen consumption (VO2max), heart rate reserve (HRR), 6-min walk test (6MWT) and whole brain and insula MRI data were collected. Two healthy control (HC) groups were enrolled for CF and MRI data analysis.

RESULTS

At baseline, MS patients vs HC showed impaired VO2max, HRR and 6MWT (p < 0.001) and widespread gray matter atrophy, including bilateral insula. In MS patients, left insula T2-lesion volume correlated with HRR (r = 0.27, p = 0.042). After training, MS-AT, especially those without insular T2-hyperintense lesions, showed 6MWT improvement (p < 0.05) and a stable insular volume, whereas MS-C showed left insular volume loss (p < 0.001).

CONCLUSIONS

By increasing 6MWT performance, our results suggest that AT may improve walking capacity and submaximal measure of CF in MS patients. Such beneficial effect may be modulated by insula integrity.

Integrating Rehabilomics into the Multi-Omics Approach in the Management of Multiple Sclerosis: The Way for Precision Medicine?

Over recent years, significant improvements have been made in the understanding of (epi)genetics and neuropathophysiological mechanisms driving the different forms of multiple sclerosis (MS). For example, the role and importance of the bidirectional communications between the brain and the gut-also referred to as the gut-brain axis-in the pathogenesis of MS is receiving increasing interest in recent years and is probably one of the most promising areas of research for the management of people with MS. However, despite these important advances, it must be noted that these data are not-yet-used in rehabilitation. Neurorehabilitation is a cornerstone of MS patient management, and there are many techniques available to clinicians and patients, including technology-supported rehabilitation. In this paper, we will discuss how new findings on the gut microbiome could help us to better understand how rehabilitation can improve motor and cognitive functions. We will also see how the data gathered during the rehabilitation can help to get a better diagnosis of the patients. Finally, we will discuss how these new techniques can better guide rehabilitation to lead to precision rehabilitation and ultimately increase the quality of patient care.

The feasibility of a flexible exercise participation programme (FEPP) for individuals with multiple sclerosis

BACKGROUND AND PURPOSE

Individuals with multiple sclerosis (MS) want health advice regarding participation in their choice of exercise. To address this need, a flexible exercise participation programme (FEPP) was developed, underpinned by the MS aerobic exercise guidelines and supported by a physiotherapist using behaviour change techniques. The aim of this study was to investigate the feasibility of the FEPP for individuals with minimal disability from MS.

METHODS

A feasibility study utilising a single group pre/post-intervention design was conducted. The 12-week FEPP was completed by 10 individuals with MS (EDSS 0-3.5). Exercise progression in duration, intensity or frequency of exercise (in line with MS exercise guidelines) was guided by a self-perceived weekly energy level score, and weekly telephone coaching sessions using behavioural change techniques. Trial feasibility was assessed via measures of process (recruitment and retention), resources/management (communication time; data entry) and scientific feasibility (safety; compliance). Secondary FEPP feasibility outcomes included the Goal Attainment Scale (GAS) T-score, exercise participation (weekly exercise diary), high-level mobility (HiMAT), vitality (Subjective Vitality Scale), biomarkers for inflammation (cytokines levels [IL2, IL4, IL6, IL10, TNF and IFNγ]), and acceptability (participant survey).

RESULTS

Process: In total, 11 (85%) of 13 eligible participants enroled at baseline with 10 (91%) completing the study. Resources/management: Coaching sessions included a baseline interview-mean 39 min (SD: 6.6) and telephone coaching-mean 10 min (SD: 3.8) per week. Outcome measure data collection time-mean 44 min (SD: 2.1). Scientific feasibility: Two participants experienced a fall during their exercise participation. Self-reported compliance was high (99%). GAS T-scores increased significantly, indicating achievement of exercise participation goals. Secondary outcomes showed trends towards improvement.

DISCUSSION

The FEPP was feasible, safe and highly acceptable for use with individuals with MS and warrants a larger trial to explore effectiveness.

Moderate Aerobic Exercise Regulates Follicular Dysfunction by Initiating Brain-Derived Neurotrophic Factor (BDNF)-Mediated Anti-Apoptotic Signaling Pathways in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder among women. Moderate aerobic exercise intervention is considered an initial treatment strategy for managing PCOS. Brain-derived neurotrophic factor (BDNF) is an important molecular mediator and a beneficial response to exercise. We aimed to investigate the expression pattern and underlying molecular mechanisms of this neurotrophic factor during follicle development in ovarian tissues. The PCOS model was established by subcutaneous injection of 60 mg/kg dehydroepiandrosterone (DHEA) into the neck of Sprague Dawley rats for 35 consecutive days. PCOS rats then received aerobic exercise for 8 weeks. Body/ovarian weight and peripheral serum hormone levels were observed. Immunohistochemistry combined with Western blot analysis and fluorescence quantitative polymerase chain reaction were used to detect the changes in BDNF-TrkB/p75NTR pathway, apoptosis, and inflammatory factors. We show that moderate aerobic exercise not only reverses the PCOS phenotype but also activates the BDNF-TrkB pathway and initiates downstream targets. p-TrkB upregulates and phosphorylates phosphatidylinositol 3-kinase (PI3K) and protein kinase B (Akt) to inhibit apoptosis. In addition, aerobic exercise therapy reduces the high expression of p75NTR in the ovarian tissue of PCOS rats and initiates the anti-apoptotic effect from the downstream pathway of NF-κB/JNK. Our in vitro results state that treatment with BDNF ameliorated dihydrotestosterone (DHT)-induced granulosa cells (GCs) apoptosis by provoking p-TrkB activation and upregulating the PI3K/AKT pathway. The present study suggests that moderate aerobic exercise regulates follicular dysfunction in PCOS-like rats. One possible mechanism is to initiate the BDNF-mediated anti-apoptotic signaling pathway.

Towards Effective Telerehabilitation: Assessing Effects of Applying Augmented Reality in Remote Rehabilitation of Patients Suffering from Multiple Sclerosis

Multiple Sclerosis (MS) is a chronic, incurable disease of the central nervous system that is also one of the most common causes of disability among young adults. Despite available pharmacological treatments, the patients often require ongoing, supervised rehabilitation. Thus, therapists are constantly searching for new, effective ways of improving functional performance and quality of life without frequently visiting medical centers. One of the most promising methods is remote telerehabilitation enhanced with an immersive augmented reality (AR) interface. Here, we investigated the effectiveness of using a commercially available AR system in MS patients’ treatment. To evaluate such an approach to rehabilitation, we conducted a medical study with 30 MS patients undergoing immunomodulatory treatment. In this study, we evaluated the influence on the patients’ upper limbs’ hand grip strength and efficiency of the patients’ upper limbs. In addition, we also analyzed the level of neurotrophins to assess the potential impact of the training on the brain plasticity process. Our results show that rehabilitation enhanced with AR significantly improves the strength and efficiency of the patients’ upper limbs. Furthermore, we further infer that AR-enhanced systems are a promising possibility of training without leaving home.

Combined progressive functional exercise effect on contactin-1 and contactin-2 level in mildly disabled persons with multiple sclerosis

BACKGROUND

Although contactin-1 and contactin-2 are known as two proteins involved in axonal regeneration, it is unclear whether these proteins are induced by exercise in persons with multiple sclerosis (PwMS).

OBJECTIVE

The aim of this study was to determine the serum levels of contactin-1 and contactin-2 in PwMS and to investigate the change of these markers with exercise.

METHODS

A total of 60 participants with relapsing-remitting MS were divided into groups by stratified randomization. The progressive functional exercise was applied to the intervention group. Participants in the control group continued the treatments and lives of the routines. Participants' contactin-1 and contactin-2, cognitive performance and aerobic capacities were evaluated.

RESULTS

The comparison of the pre-and post-study values of contactin-1 and contactin-2 showed significant differences only in the intervention group. The contactin-1 and contactin-2 values were similar between the groups before the exercise, whereas a significant difference was found in favor of the intervention group after the exercise. Paced Auditory Serial Addition Test-3 value increased significantly only in the intervention group.

CONCLUSION

With this study, it was shown for the first time that contactin-1 and contactin-2, which play an important role in axonal regeneration and axonal organization, can be increased by exercise.

Blood levels of brain-derived neurotrophic factor (BDNF) in people with multiple sclerosis (MS): A systematic review and meta-analysis

BACKGROUND

Multiple sclerosis is an autoimmune demyelinating disease marked by the involvement of multiple pathophysiological pathways, including BDNF. BDNF (brain-derived neurotrophic factor) is one of the main neurotrophic factors in the adult brain. The amount of BDNF in the blood can be utilized as a surrogate for the central expression of this marker. Given contradicting reports, we set out to answer the question, "How do blood levels of BDNF differ in people with multiple sclerosis (PwMS) compared to controls?"

METHODS

We performed a thorough search in MEDLINE, EMBASE, Web of Science, and the Cochrane Library databases, resulting in 13 eligible investigations. Eleven studies compared BDNF in serum of PwMS versus healthy controls (HC), and two studies provided BDNF levels in the plasma of PwMs. R version 4.0.4 was used for meta-analysis and visualizations. Mean difference (MD) was used for the measurement of effect size.

RESULTS

The final analysis included thirteen studies with 689 patients with MS and 583 controls. The preliminary results indicated that MS patients had statistically significant lower levels of BDNF than controls: SMD -5.1992 (95% CI [-8.4488; -1.9496], p-value < 0.0001. Additionally, subgroup analysis revealed a statistically significant difference in serum and plasma levels (p-value=0.01). Performing univariate meta-regression, disease duration and the proportion of males had, respectively, a significant negative and positive correlation with BDNF levels.

CONCLUSION

Circulating levels of BDNF are decreased in MS. Future studies should investigate the role of BDNF as a biomarker of disease severity and/or progression for a personalized approach to MS.

Multimodal Benefits of Exercise in Patients With Multiple Sclerosis and COVID-19

Multiple sclerosis (MS) is a demyelinating disease characterized by plaque formation and neuroinflammation. The plaques can present in various locations, causing a variety of clinical symptoms in patients with MS. Coronavirus disease-2019 (COVID-19) is also associated with systemic inflammation and a cytokine storm which can cause plaque formation in several areas of the brain. These concurring events could exacerbate the disease burden of MS. We review the neuro-invasive properties of SARS-CoV-2 and the possible pathways for the entry of the virus into the central nervous system (CNS). Complications due to this viral infection are similar to those occurring in patients with MS. Conditions related to MS which make patients more susceptible to viral infection include inflammatory status, blood-brain barrier (BBB) permeability, function of CNS cells, and plaque formation. There are also psychoneurological and mood disorders associated with both MS and COVID-19 infections. Finally, we discuss the effects of exercise on peripheral and central inflammation, BBB integrity, glia and neural cells, and remyelination. We conclude that moderate exercise training prior or after infection with SARS-CoV-2 can produce health benefits in patients with MS patients, including reduced mortality and improved physical and mental health of patients with MS.

Fitness, physical activity, and exercise in multiple sclerosis: a systematic review on current evidence for interactions with disease activity and progression

Background

A moderate to high level of physical activity, including regular exercise, represents an established behavioral and rehabilitative approach for persons with multiple sclerosis (pwMS). Although being increasingly proposed to limit disease activity and progression, high-quality evidence is lacking.

Objective

The objective of the study is to provide valuable information for MS clinicians and researchers by systematically evaluating the current state of evidence (i) whether exercise interventions affect established clinical measures of disease activity and progression in pwMS (i.e., EDSS, relapse rate, lesion load, brain volume, MSFC) and (ii) how the physical activity and fitness level interact with these measures.

Methods

Literature search was conducted in MEDLINE, EMBASE, CINAHL, and SPORTDiscus. Evaluation of evidence quality was done based on standards published by The American Academy of Neurology.

Results

It is likely that exercise improves the MSFC score, whereas the EDSS score, lesion load, and brain volume are likely to remain unchanged over the intervention period. It is possible that exercise decreases the relapse rate. Results from cross-sectional studies indicate beneficial effects of a high physical activity or fitness level on clinical measures which, however, is not corroborated by high evidence quality.

Conclusions

A (supportive) disease-modifying effect of exercise in pwMS cannot be concluded. The rather low evidence quality of existing RCTs underlines the need to conduct more well-designed studies assessing different measures of disease activity or progression as primary end points. A major limitation is the short intervention duration of existing studies which limits meaningful exercise-induced effects on most disability measures. Findings from cross-sectional studies are difficult to contextualize regarding clinical importance due to their solely associative character and low evidence quality.

PROSPERO registration number

CRD42020188774.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10935-6.

Therapeutic Benefits of Short-Arm Human Centrifugation in Multiple Sclerosis-A New Approach

Short-arm human centrifugation (SAHC) is proposed as a robust countermeasure to treat deconditioning and prevent progressive disability in a case of secondary progressive multiple sclerosis. Based on long-term physiological knowledge derived from space medicine and missions, artificial gravity training seems to be a promising physical rehabilitation approach toward the prevention of musculoskeletal decrement due to confinement and inactivity. So, the present study proposes a novel infrastructure based on SAHC to investigate the hypothesis that artificial gravity ameliorates the degree of disability. The patient was submitted to a 4-week training programme including three weekly sessions of 30 min of intermittent centrifugation at 1.5–2 g. During sessions, cardiovascular, muscle oxygen saturation (SmO₂) and electroencephalographic (EEG) responses were monitored, whereas neurological and physical performance tests were carried out before and after the intervention. Cardiovascular parameters improved in a way reminiscent of adaptations to aerobic exercise. SmO₂ decreased during sessions concomitant with increased g load, and, as training progressed, SmO₂ of the suffering limb dropped, both effects suggesting increased oxygen use, similar to that seen during hard exercise. EEG showed increased slow and decreased fast brain waves, with brain reorganization/plasticity evidenced through functional connectivity alterations. Multiple-sclerosis-related disability and balance capacity also improved. Overall, this study provides novel evidence supporting SAHC as a promising therapeutic strategy in multiple sclerosis, based on mechanical loading, thereby setting the basis for future randomized controlled trials.

Improving Health of People With Multiple Sclerosis From a Multicenter Randomized Controlled Study in Parallel Groups: Preliminary Results on the Efficacy of a Mindfulness Intervention and Intention Implementation Associated With a Physical Activity Program

Objectives: The objective of this study is to investigate the efficacy of psychological Interventions – Mindfulness or Implementation Intention – associated with a Physical Activity program, delivered via internet, in reducing Multiple Sclerosis symptoms.

Method: Thirty-five adults were randomly assigned to one of the three groups: a Mindfulness-Based Intervention group (N = 12), Implementation Intention group (N = 11), and a Control Group (N = 12). All the groups received the same Physical Activity program. The Mindfulness condition group received daily training in the form of pre-recorded sessions while the Implementation group elaborated their specific plans once a week. Mobility, fatigue, and the impact of the disease on the patient’s life were measured. Two measurement times are carried out in pre-post intervention, at baseline and after eight weeks.

Results: Overall, after 8 weeks intervention, results show that there was a significant increase in Walking distance in the three groups. In addition, the within-group analysis showed a statistically significant improvement between pre and post intervention on the physical component of the Disease Impact scale in the Implementation Intention group (p = 0.023) with large effect size, in the Mindfulness-Based Intervention group (p = 0.008) with a medium effect size and in the control group (p = 0.028) with small effect size. In the Implementation Intention group, all physical, psychosocial and cognitive Fatigue Impact subscales scores decreased significantly (p = 0.022, p = 0.023, and p = 0.012, respectively) and the physical component was statistically and negatively correlated (r = −0.745; p = 0.008) when Implementation Intention group practice a mild to moderate physical activity. In the Mindfulness-Based Intervention group, the physical component (MFIS) showed a statistically significant improvement (p = 0.028) but no correlation with moderate-to-vigorous physical activity (MVPA); the control group outcomes did not reveal any significant change.

Conclusion: The results of this study are very encouraging and show the feasibility of Mindfulness interventions associated with physical activity to improve the health of people with MS. Further study should assess Mindfulness interventions tailored to MS condition and using both hedonic and eudemonic measures of happiness.

Exercise Training for Multiple Sclerosis: A Narrative Review of History, Benefits, Safety, Guidelines, and Promotion

Background: There have been significant advances in the medical treatment and management of multiple sclerosis pathogenesis, relapse and disease progression over the past 30 years. There have been advancements in the symptomatic treatment of multiple sclerosis, including management of secondary multiple sclerosis expressions such as walking, cognitive dysfunction, fatigue and depression. Scientific evidence and expert opinion suggest that exercise may be the single most effective non-pharmacological symptomatic treatment for multiple sclerosis. This article presents the historical context of exercise training within the multidisciplinary management of multiple sclerosis. We guide neurologists and healthcare providers on the recommended prescription of exercise and practical, theoretical methods to overcome barriers to exercise. Method: We undertook a critical search of the historical and current literature regarding exercise and multiple sclerosis from the viewpoint of exercise promotion by neurologists and the multidisciplinary care team. Results: We highlight the ever-strengthening body of research indicating that exercise is safe and effective for improving symptoms of multiple sclerosis. Further, exercise training may be necessary for reducing disease progression. Conclusion: We seek to encourage neurologists and specialists in multidisciplinary healthcare teams to prescribe and promote exercise at diagnosis and across all stages of the disease trajectory using prescriptive guidelines as part of comprehensive MS care. Available tools include clinical education to dispel any historical myths related to exercise in multiple sclerosis, clinical exercise guidelines and behaviour change theory to overcome patients barriers to exercise.

Therapeutic Effects of Physical Exercise and the Mesenchymal Stem Cell Secretome by Modulating Neuroinflammatory Response in Multiple Sclerosis

Multiple sclerosis (MS) is a neurodegenerative, demyelinating, and chronic inflammatory disease characterized by central nervous system (CNS) lesions that lead to high levels of disability and severe physical and cognitive disturbances. Conventional therapies are not enough to control the neuroinflammatory process in MS and are not able to inhibit ongoing damage to the CNS. Thus, the secretome of mesenchymal stem cells (MSC-S) has been postulated as a potential therapy that could mitigate symptoms and disease progression. We considered that its combination with physical exercise (EX) could induce superior effects and increase the MSC-S effectiveness in this condition. Recent studies have revealed that both EX and MSC-S share similar mechanisms of action that mitigate auto-reactive T cell infiltration, regulate the local inflammatory response, modulate the proinflammatory profile of glial cells, and reduce neuronal damage. Clinical and experimental studies have reported that these treatments in an isolated way also improve myelination, regeneration, promote the release of neurotrophic factors, and increase the recruitment of endogenous stem cells. Together, these effects reduce disease progression and improve patient functionality. Despite these results, the combination of these methods has not yet been studied in MS. In this review, we focus on molecular elements and cellular responses induced by these treatments in a separate way, showing their beneficial effects in the control of symptoms and disease progression in MS, as well as indicating their contribution in clinical fields. In addition, we propose the combined use of EX and MSC-S as a strategy to boost their reparative and immunomodulatory effects in this condition, combining their benefits on synaptogenesis, neurogenesis, remyelination, and neuroinflammatory response. The findings here reported are based on the scientific evidence and our professional experience that will bring significant progress to regenerative medicine to deal with this condition.

Systematic Review of Exercise Studies in Persons with Multiple Sclerosis: Exploring the Quality of Interventions According to the Principles of Exercise Training

INTRODUCTION

The objective of this systematic review is to explore the application and reporting of (i) the principles of exercise training in exercise trials, (ii) the components of exercise prescription, and (iii) the adherence towards the prescribed programmes in randomised controlled trials (RCTs) in persons with multiple sclerosis (pwMS).

METHODS

The MEDLINE, CINAHL, SPORTDiscus, PubMed and Embase electronic databases were searched from 1 January 2000 to 16 October 2020. RCTs comprising at least 3 weeks of aerobic and/or resistance exercise intervention in pwMS that reported at least one physiological outcome and were published in peer-reviewed journals were eligible for inclusion.

RESULTS

Out of 52 RCTs included in this review, 58 intervention arms were examined. None applied more than four principles of exercise training. Specificity was addressed by 85%, progression by 33%, overload by 59%, initial values by 26%, reversibility by 0% and diminishing returns by 2% of trials. Fifty-two percent of trials reported all components of exercise prescription, and 3% of trials reported the level of adherence to the prescribed exercise.

CONCLUSION

This systematic review reveals that exercise training principles were not respected in the majority of included RCTs. The weak quality of reported exercise interventions limits the interpretation of the studies' results and potentially leads to an underestimation of 'exercise as medicine' in pwMS. Also, the vague descriptions of exercise prescription and adherence impede the reproducibility of results. Future studies must attend to all principles of exercise training and provide transparent information on the prescribed and performed programmes to develop specific and valid exercise recommendations for pwMS.

SYSTEMATIC REVIEW REGISTRATION

CRD42020162671, 28/04/2020, PROSPERO.

Effects of Exercise Training on Neurotrophic Factors and Subsequent Neuroprotection in Persons with Multiple Sclerosis-A Systematic Review and Meta-Analysis

Background: Evidence indicates that exercise holds the potential to counteract neurodegeneration experienced by persons with multiple sclerosis (pwMS), which is in part believed to be mediated through increases in neurotrophic factors. There is a need to summarize the existing evidence on exercise-induced effects on neurotrophic factors alongside neuroprotection in pwMS. Aim: To (1) systematically review the evidence on acute (one session) and/or chronic (several sessions) exercise-induced changes in neurotrophic factors in pwMS and (2) investigate the potential translational link between exercise-induced changes in neurotrophic factors and neuroprotection. Methods: Five databases (Medline, Scopus, Web of Science, Embase, Sport Discus) were searched for randomized controlled trials (RCT) examining the effects of exercise (all modalities included) on neurotrophic factors as well as measures of neuroprotection if reported. The quality of the study designs and the exercise interventions were assessed by use of the validated tool TESTEX. Results: From N = 337 identified studies, N = 14 RCTs were included. While only N = 2 of the identified studies reported on the acute changes in neurotrophic factors, all N = 14 RCTs reported on the chronic effects, with N = 9 studies revealing between-group differences in favor of exercise. This was most prominent for brain-derived neurotrophic factor (BDNF), with between-group differences in favor of exercise being observed in N = 6 out of N = 12 studies. Meta-analyses were applicable for three out of 10 different identified neurotrophic factors and revealed that exercise can improve the chronic levels of BDNF (delta changes; N = 9, ES = 0.78 (0.27; 1.28), p = 0.003, heterogeneity between studies) and potentially also ciliary neurotrophic factor (CNTF) (N = 3, ES = 0.24 (−0.07; 0.54), p = 0.13, no heterogeneity between studies) but not nerve growth factor (NGF) (N = 4, ES = 0.28 (−0.55; 1.11), p = 0.51, heterogeneity between studies). Indicators of neuroprotection (e.g., with direct measures of brain structure assessed by MRI) were assessed in N = 3 of the identified studies only, with N = 2 partly supporting and thus indicating a potential translational link between increases in neurotrophic factors and neuroprotection. Conclusion: The present study reveals that exercise can elicit improvements in chronic levels of BDNF in pwMS, whereas the effects of exercise on chronic levels of other neurotrophic factors and on acute levels of neurotrophic factors in general, along with a potential translational link (i.e., with exercise-induced improvements in neurotropic factors being associated with or even mediating neuroprotection), are sparse and inconclusive. There is a need for more high-quality studies that assess neurotrophic factors (applying comparable methods of blood handling and analysis) concomitantly with neuroprotective outcome measures. Review Registration: PROSPERO (ID: CRD42020177353).

The effect of aerobic exercise on Neurofilament light chain and glial Fibrillary acidic protein level in patients with relapsing remitting type multiple sclerosis

Background Multiple sclerosis (MS) is an autoimmune and neurodegenerative disease of the central nervous system in which disease activity can be monitored with some biomarkers. The aim of our study was to investigate serum Glial Fibrillary Acidic Protein (GFAP) and Neurofilament Light Chain (NFL) in relapsing-remitting MS (RRMS) patients after the aerobic exercise. Methods A total of 38 participants with RRMS (Expanded Disability Status Scale: 1.0 - 4.5) were randomized to a study group (3 × /week for 8 weeks at 60 - 70 % of maximal aerobic capacity (VO_2max) + home exercises) and a control group (were given home exercises programme 3 times a week for 8 week). Serum NFL and GFAP levels were analyzed using enzyme-linked immunosorbent analysis method before and at the end of 8 weeks. Results: NFL and GFAP levels were statistically lower in the study group at the end of the study than before the study. In the control group, no significant changes were observed in serum NFL and GFAP levels. ΔNFL levels were significantly higher in the study group than control group. Conclusion It was shown, for the first time that serum GFAP and NFL levels (%10 and % 32, respectively) in RRMS patients decreased after aerobic exercise. Our study is important in terms of investigating the effects of aerobic exercise in individuals with RRMS and elucidating the underlying measurable biomarkers. The significant reduction of NFL and GFAP, which have an important role in the pathology associated with nervous system damage in MS, with aerobic exercise may be promising in understanding the regulation of disease activity in MS patients.

Home-based exercise training influences gut bacterial levels in multiple sclerosis

BACKGROUND

Multiple sclerosis is associated with gut microbiome alterations. The current study aimed to investigate the effect of home-based exercise on gut bacteria in people with multiple sclerosis (MS). We also examined the association of exercise-induced gut bacterial modulation with circulating levels of inflammatory and anti-inflammatory cytokines.

MATERIALS AND METHODS

Forty-two people with MS (female/male: 31/11, expanded disability scale status <5) participated in this study and were divided into two groups: 6 months of home-based exercise (5 sessions per week) and controls. Before and after the intervention, the following parameters were assessed: gut microbiota, including faecalibacterium prausnitzii, akkermansia muciniphila, prevotella and bacteroides counts; cytokine levels including interleukin (IL)-10 and tumor necrosis factor-alpha (TNF-α); and psychosocial factors including anxiety, depression, and fatigue.

RESULTS

Home-based exercise significantly increased prevotella counts, and decreased akkermansia muciniphila counts (p < 0.05); however, there were no significant effects on faecalibacterium prausnitzii and bacteroides counts (p > 0.05). There were no significant effects of home-based exercise on circulating cytokine levels (p > 0.05). Moreover, home-based exercise was associated with significant improvements in anxiety and depression (p < 0.05); however, fatigue revealed no significant change (p > 0.05). Akkermansia muciniphila, prevotella and bacteroides count changes in response to the intervention were correlated with changes in IL-10 (r = -0.052, r = 0.67, and r = -0.55, respectively).

CONCLUSION

In general, our data revealed the effect of exercise on gut bacteria, especially prevotella, and akkermansia muciniphila counts, which can probably have a beneficial effect on MS disease pathology and course; however, the lack of changes in cytokines following exercise suggests the possible role of mechanisms other than modulation of circulating IL-10 and TNF- α levels.

Sex-dependent effects of forced exercise in the body composition of adolescent rats

Determining the body composition during adolescence can predict diseases such as obesity, diabetes, and metabolic syndromes later in life; and physical activity became an effective way to restore changes in body composition. However, current available literature assessing the body composition before, during and after adolescence in female and male rodents by in vivo techniques is scarce. Thus, by using computerized tomography, we aimed to define the baseline of the weight and body composition during the adolescence and young adulthood of female and male Sprague-Dawley rats (on P30, P60 and P90) under standard diet. Then, we determined the effect of 18 days of forced exercise on the body weight and composition during the early adolescence (P27-45). The highest percentual increments in weight, body volume and relative adipose contents occurred during the female and male adolescence. Forced running during the early adolescence decreased weight, body volume and relative adipose delta and increment values in males only. The adolescence of rats is a period of drastic body composition changes, where exercise interventions have sex-dependent effects. These results support a model that could open new research windows in the field of adolescent obesity.

Physical activity may contribute to brain health in multiple sclerosis: An MR volumetric and spectroscopy study

BACKGROUND AND PURPOSE

Physical activity may represent a disease-modifying therapy in persons with multiple sclerosis (pwMS). To date, there is limited research regarding mechanisms based on brain imaging for understanding the beneficial effects of physical activity in pwMS. This study examined the relationship between physical activity levels and thalamic and hippocampal volumes and brain metabolism in pwMS.

METHODS

The sample of 52 pwMS (37.3 ± 9.6 years of age; 35 females, 17 males) underwent a combination of volumetric magnetic resonance imaging and magnetic resonance spectroscopy. Current and lifetime physical activity were assessed using actigraphy and the adapted version of the Historical Activity Questionnaire, respectively.

RESULTS

Positive associations were observed between both actigraphy and self-reported levels of moderate-to-vigorous physical activity (MVPA) and thalamic and hippocampal volumes. Regarding brain metabolism, actigraphy and self-reported levels of MVPA were positively associated with higher hippocampal and thalamic levels of N-acetylaspartate/creatine ratio (NAA/Cr: marker of neural integrity and cell energy state).

CONCLUSIONS

This study provides novel evidence for a positive association between physical activity and thalamic and hippocampal volume and metabolism in pwMS. These findings support the hypothesis that physical activity, particularly MVPA, may serve as a disease-modifying treatment by improving brain health in pwMS.

Training the brain: could it improve multiple sclerosis treatment?

Multiple sclerosis (MS) is a neurological disease characterized by neuroinflammation, demyelination and axonal degeneration along with loss of function in the central nervous system. For many years, research in MS has focused on the efficacy of pharmacological treatments. However, during the last years, many publications have been dedicated to the study of the efficacy of non-pharmacological strategies, such as physical exercise and cognitive training. Beneficial effects of the combination of both strategies on cognitive function have been described in both ageing adults and patients with neurodegenerative diseases, such as MS. The analysis of combining both physical and cognitive stimulation can be summarized by the environmental enrichment (EE) experiments, which are more suitable for animal models. EE refers to housing conditions consisting of exercise and cognitive and social stimulation. In this review, we will summarize the available studies that describe the influence of EE in both MS patients and MS animal models.

Systematic Review on Exercise Training as a Neuroplasticity-Inducing Behavior in Multiple Sclerosis

Background. Exercise training is associated with functional improvements in persons with multiple sclerosis (MS), perhaps based on neuroplasticity. However, inferences regarding neuroplasticity require observations of exercise-related changes in the central nervous system that explain functional adaptations. This systematic review critically evaluated studies on exercise training, neuroimaging outcomes, and functional outcomes in MS based on consistency with a well-established conceptual model for characterizing exercise training as a possible neuroplasticity-inducing behavior in this population. Methods. We performed targeted and comprehensive searches of multiple databases for papers involving exercise training interventions on functional and neuroimaging outcomes in persons with MS. Acceptable study designs included randomized controlled trials, single-group pre/post designs, and quasi-experimental designs. Four independent reviewers extracted relevant data from each eligible paper on characteristics of participants, exercise interventions, neuroimaging outcomes, functional outcomes, pattern of study results, and potential risks of bias. Results. The literature search returned only 10 papers (involving 8 original interventions) that met eligibility criteria wherein inferences regarding neuroplasticity could be drawn, based on inclusion of neuroimaging and functional endpoints. Within those 10 papers, there is mixed evidence for exercise training as a neuroplasticity-inducing behavior in persons with MS. Conclusions. Such a paucity of evidence supporting exercise-induced neuroplasticity in MS is likely a product of a very small number of papers that do not sufficiently examine hypothesized mechanisms of action. Future research might consider examining specific neural changes that might result from exercise prescriptions that are specifically designed to induce certain functional changes among persons with MS.

Participation in and outcomes from a 12-month tailored exercise programme for people with multiple sclerosis (MSTEP©): a randomized trial

OBJECTIVE

To estimate, among people with multiple sclerosis, the extent to which a personally tailored exercise programme (MSTEP©) resulted in greater improvements in exercise capacity and related outcomes over 12 months in comparison with general exercise guidelines.

DESIGN

Two-group randomized trial.

SUBJECTS

Ambulatory and sedentary.

INTERVENTIONS

MSTEP©, a personally adapted exercise regimen done on most days including two days of high intensity exercise; guidelines recommending 30 minutes of moderate intensity aerobic and strength training two times per week.

MAIN MEASURES

Primary outcome was peak oxygen consumption (VO_2peak) at 12 months; secondary outcomes were composite measures of physical function, fatigue, and health-related quality of life.

RESULTS

In total, 137 people were randomized, 66 were lost over 12 months leaving 71 with outcome data, 34 in MSTEP© group, and 37 in the Guideline group. Exercise enjoyment and confidence and exercise-induced fatigue predicted retention. There were no differences between groups on the proportion making a 10% increase in VO_2peak (27.1% MSTEP© vs 29.6% Guidelines; OR: 0.83; 95% CI: 0.23-3.08) by the 12 month assessment. The effect on fatigue was larger in the MSTEP© group than the Guideline groups (OR: 1.59; 95% CI: 0.93-2.74), the effect on physical function was more modest (OR: 1.35; 95% CI: 0.80-2.25), and null for health-related quality of life outcomes.

CONCLUSIONS

The disappointing exercise retention suggests that people with multiple sclerosis may not consider exercise important to their brain health. Either type of exercise resulted in stable exercise capacity over 1 year in those sticking with the programme.

Neuroprotective effects of exercise in people with progressive multiple sclerosis (Exercise PRO-MS): study protocol of a phase II trial

Background

Neurodegeneration, rather than inflammation, plays a key role in the progressive phase of multiple sclerosis (MS). Current disease modifying treatment options for people with progressive MS (PMS) do not specifically target neurodegeneration. Preliminary evidence suggests that exercise therapy might have neuroprotective effects. However, neuroprotective effect studies of exercise interventions in PMS are scarce and the possible mode of action underlying neuroprotective effects of exercise are unknown and need to be elucidated. The main aim of this phase II trial is to assess whether progressive resistance training (PRT) and high intensity interval training (HIIT), can slow down neurodegeneration in people with PMS.

Methods

In a single-blinded phase II clinical trial with an extended baseline period, 60 people with PMS will be randomly assigned to PRT or HIIT. The participants should have had a relapse onset of MS with confirmed disease progression, however still ambulatory. The duration of the study is 48 weeks, consisting of 16 weeks baseline period (no intervention), 16 weeks intervention and 16 weeks follow-up. Patient-tailored training will be performed 3 times per week for one hour in groups, led by an experienced physiotherapist. The primary outcome measure is neurodegeneration, measured as whole brain atrophy on magnetic resonance imaging (MRI). Secondary outcome parameters will include other biomarkers associated with neurodegeneration (i.e. regional brain atrophy, lesion load, white matter integrity, resting state functional connectivity, blood biomarkers (brain derived neurotrophic factor (BDNF) and serum neurofilament light (sNFL)), patient functioning (physical and cognitive) and cardiovascular risk factors.

Discussion

Besides the primary outcome measures, this study will examine a large variety of biomarkers associated with neurodegeneration after an exercise intervention. Combining outcome parameters may help to elucidate the mode of action underlying neuroprotective effects of exercise.

Trial registration

This trial is prospectively registered at the Dutch Trial Registry (number NL8265, date 06-01-2020).

Incidence of Free of Charge Physiotherapy in a Danish National Cohort of Stroke, Parkinson's Disease, Multiple Sclerosis and Rheumatoid Arthritis Patients

Background

Denmark is a welfare state with a publically funded healthcare system that includes the right to free of charge physiotherapy (FCP) for patients with chronic or progressive disease who fulfill strict criteria. The aim of this study was to investigate the incidence of referral to FCP in patients with a hospital diagnosis of stroke, multiple sclerosis (MS), Parkinson’s disease (PD) and rheumatoid arthritis (RA) between 2007 and 2016.

Methods

The study was register-based and included data from The Danish National Patient Registry and The National Health Service Registry. The study population included the four largest disease groups receiving FCP in Denmark. The incidence of receiving FCP was reported as the cumulated incidence proportion (CIP).

Results

The study showed that FCP was mainly initiated within the first 2 years after diagnosis. The 2-year CIP was 8% for stroke patients, 53% for PD patients, 49% for MS patients, and 16% for RA patients. The proportion of patients referred to FCP generally increased over the period of the study due to more patients being referred from medical specialists in primary care.

Conclusion

This study found substantial differences in the incidence of referral to FCP in a Danish population of stroke, PD, MS and RA patients.

Vigorous cool room treadmill training to improve walking ability in people with multiple sclerosis who use ambulatory assistive devices: a feasibility study

BACKGROUND

Aerobic training has the potential to restore function, stimulate brain repair, and reduce inflammation in people with Multiple Sclerosis (MS). However, disability, fatigue, and heat sensitivity are major barriers to exercise for people with MS. We aimed to determine the feasibility of conducting vigorous harness-supported treadmill training in a room cooled to 16 °C (10 weeks; 3times/week) and examine the longer-term effects on markers of function, brain repair, and inflammation among those using ambulatory aids.

METHODS

Ten participants (9 females) aged 29 to 74 years with an Expanded Disability Status Scale ranging from 6 to 7 underwent training (40 to 65% heart rate reserve) starting at 80% self-selected walking speed. Feasibility of conducting vigorous training was assessed using a checklist, which included attendance rates, number of missed appointments, reasons for not attending, adverse events, safety hazards during training, reasons for dropout, tolerance to training load, subjective reporting of symptom worsening during and after exercise, and physiological responses to exercise. Functional outcomes were assessed before, after, and 3 months after training. Walking ability was measured using Timed 25 Foot Walk test and on an instrumented walkway at both fast and self-selected speeds. Fatigue was measured using fatigue/energy/vitality sub-scale of 36-Item Short-Form (SF-36) Health Survey, Fatigue Severity Scale, modified Fatigue Impact Scale. Aerobic fitness (maximal oxygen consumption) was measured using maximal graded exercise test (GXT). Quality-of-life was measured using SF-36 Health Survey. Serum levels of neurotrophin (brain-derived neurotrophic factor) and cytokine (interleukin-6) were assessed before and after GXT.

RESULTS

Eight of the ten participants completed training (attendance rates ≥ 80%). No adverse events were observed. Fast walking speed (cm/s), gait quality (double-support (%)) while walking at self-selected speed, fatigue (modified Fatigue Impact Scale), fitness (maximal workload achieved during GXT), and quality-of-life (physical functioning sub-scale of SF-36) improved significantly after training, and improvements were sustained after 3-months. Improvements in fitness (maximal respiratory exchange ratio and maximal oxygen consumption during GXT) were associated with increased brain-derived neurotrophic factor and decreased interleukin-6.

CONCLUSION

Vigorous cool room training is feasible and can potentially improve walking, fatigue, fitness, and quality-of-life among people with moderate to severe MS-related disability.

TRIAL REGISTRATION

The study was approved by the Newfoundland and Labrador Health Research Ethics Board (reference number: 2018.088) on 11/07/2018 prior to the enrollment of first participant (retrospectively registered at ClinicalTrials.gov: NCT04066972. Registered on 26 August 2019.

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.

Influence of combined functional resistance and endurance exercise over 12 weeks on matrix metalloproteinase-2 serum concentration in persons with relapsing-remitting multiple sclerosis - a community-based randomized controlled trial

BACKGROUND

The relevance of regular moderate to intense exercise for ameliorating psychomotor symptoms in persons with multiple sclerosis (pwMS) is becoming increasingly evident. Over the last two decades, emerging evidence from clinical studies and animal models indicate immune regulatory mechanisms in both periphery and the central nervous system that may underlie these beneficial effects. The integrity of the blood-brain barrier as the main structural interface between periphery and brain seems to play an important role in MS. Reducing the secretion of proteolytic matrix metalloproteinases (MMP), i.e. MMP-2, as disruptors of blood-brain barrier integrity could have profound implications for MS.

METHODS

In this two-armed randomized controlled trial 64 participants with relapsing-remitting MS (RRMS) (EDSS 0-4.0) will be allocated to either an intervention group or a passive wait list control group. The intervention group will perform 60 min of combined functional resistance and endurance exercises 3x per week over a period of 12 weeks in a community-based and publicly available setting. Changes in serum concentration of MMP-2 will be the primary outcome. Secondary outcomes are numbers of immune cell subsets, soluble (anti-) inflammatory factors, physical capacity, cognitive performance, physical activity behavior, gait performance, and patient-reported outcomes. All outcome measures will be assessed at baseline and after week 12 with an additional blood sampling before, during and immediately after a single training session in week 6.

DISCUSSION

To our knowledge, this will be the first RCT to investigate both the acute and chronic effects of a community-based intense functional resistance and endurance exercise regimen in persons with RRMS. Combining analysis of biological and cognitive or psychological outcomes may provide a better understanding of the MS-specific symptomology.

TRIAL REGISTRATION

DRKS00017091; 05th of April, 2019; International Clinical Trials Registry Platform.