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.

Finding the right balance with participation in exercise and sport for individuals with multiple sclerosis: protocol for a pre and post intervention feasibility study

INTRODUCTION

Individuals with minimal disability from multiple sclerosis (MS) requested advice on finding the right balance, between too much and too little exercise, when participating in their choice of sport or exercise. To optimise exercise participation during the early stages of the disease, a flexible exercise participation programme (FEPP) has been developed. The FEPP is novel because it provides guidance and support for individuals with MS to participate and progress in their preferred sport or exercise. The primary objective was to assess the feasibility of the FEPP. The secondary objective was to assess the feasibility of a larger trial to demonstrate the efficacy of the FEPP.

METHODS AND ANALYSIS

A stage I feasibility study of the FEPP, using a single group preintervention/post-intervention design, will be conducted with 16 participants with minimal disability from MS (Expanded Disability Status Scale level of 0-3.5). The 12-week FEPP will guide participants to independently participate in their preferred sport or exercise at a location of their choice. Exercise progression will be guided by individual energy levels and a weekly telephone coaching session with a physiotherapist. Participation in exercise or sport will be recorded in parallel with assessment of disease biomarkers (plasma cytokines interleukin (IL)-2, IL-4, IL-6, IL-10, interferon (IFN)-γ and tumour necrosis factor (TNF)), subjective vitality and high-level mobility. Acceptability of the FEPP will be assessed using a sequential explanatory mixed methods design where the findings of a participant survey will inform the interview guide for a series of focus groups.Feasibility of a larger trial will be assessed via process, resources, management and scientific metrics. Progression to a larger trial will depend on the achievement of specified minimum success criteria.

ETHICS AND DISSEMINATION

Ethical approval has been obtained for this study from the James Cook University Human Research Ethics Committee (H7956). Dissemination of findings is planned via peer-reviewed journals, conference presentations and media releases. The protocol date was 21 December 2019, V.1.

TRIAL REGISTRATION NUMBER

The trial is registered with Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12620000076976.

Walking endurance and perceived symptom severity after a single maximal exercise test in persons with mild disability because of multiple sclerosis

People with multiple sclerosis (PwMS) are less physically active compared with the general population. This might also be because of the perception of temporary worsening of symptoms during physical activity. Forty-two PwMS with a mild level of disability underwent a maximal exercise test on a bicycle ergometer. Fifteen minutes before and 15 and 75 min after the maximal exercise test, the 6-minute walking test was conducted and the rate of perceived exertion was recorded. Twice before and three times after the maximal exercise test, participants rated the symptom inventory, including symptom domains of general fatigue, muscle fatigue, balance, gait pattern, muscle weakness, spasticity, pain, sensory disturbance, dizziness, and visual impairment. The visual analogue scale was used to rate the perceived symptoms from 0 (no intensity) to 10 (maximal intensity). The 6-minute walking test distance increased significantly over time, whereas the rate of perceived exertion increased temporarily after the maximal exercise test. Immediately after the maximal exercise test, significant temporary increases were found in balance, gait pattern, muscle weakness, and visual impairment. General and muscle fatigue were elevated, compared with the baseline, till 15 and 75 min after the maximal exercise test, respectively. A short-term impact of a single maximal exercise test was considered as the temporary worsening of perceived symptoms, especially (muscle) fatigue and the gait pattern, in PwMS with a mild level of disability. However, a recovery was observed after 75 min. Walking endurance was not affected by the maximal exercise test.

Environmental temperature and exercise modality independently impact central and muscle fatigue among people with multiple sclerosis

Background

Heat sensitivity and fatigue limit the ability of multiple sclerosis patients to participate in exercise.

Objective

The purpose of this study was to determine the optimal aerobic exercise parameters (environmental temperature and exercise modality) to limit exercise-induced central and muscle fatigue among people with multiple sclerosis.

Methods

Fourteen people with multiple sclerosis with varying levels of disability completed four randomized exercise sessions at 65% of the maximal volume of oxygen: body-weight supported treadmill cool (16°C), body-weight supported treadmill room (21°C), total-body recumbent stepper cool and total-body recumbent stepper room. Maximum voluntary contraction, electromyography, and evoked contractile properties were collected from the more affected plantar flexors along with subjective levels of fatigue, body temperature and perceived level of exertion.

Results

Exercise in cooler room temperature increased maximum voluntary contraction force (p = 0.010) and stabilized body temperature (p = 0.011) compared to standard room temperature. People with multiple sclerosis experienced greater peak twitch torque (p = 0.047), shorter time to peak twitch (p = 0.035) and a longer half relaxation time (p = 0.046) after total-body recumbent stepper suggestive of less muscle fatigue.

Conclusion

Cooling the exercise environment limits the negative effects of central fatigue during aerobic exercise and using total-body recumbent stepper (work distributed among four limbs) rather than body-weight supported treadmill lessens muscular fatigue. Therapists can titrate these two variables to help people with multiple sclerosis achieve sufficient exercise workloads.

Exercise response in Parkinson's disease: insights from a cross-sectional comparison with sedentary controls and a per-protocol analysis of a randomised controlled trial

OBJECTIVES

To investigate the acute and adaptation cardiovascular and metabolic training responses in people with Parkinson's disease (pwP).

DESIGN

(1) A cross-sectional study of exercise response of pwP compared with sedentary controls and (2) an interventional study of exercise training in pwP.

SETTING

Community leisure facilities.

PARTICIPANTS

pwP (n=83) and sedentary controls (n=55).

INTERVENTIONS

Study 1 included participants from a two-arm-parallel single-blind phase II randomised controlled trial (RCT), that undertook a baseline maximal incremental exercise test and study 2 included those randomised to the exercise group in the RCT, who completed a 6-month weekly exercise programme (n=37). The intervention study 2 was a prescribed exercise program consisting of sessions lasting 60 min, two times a week over a 6-month period. The control group followed the same protocol which derived the same cardiorespiratory parameters, except that they were instructed to aim for a cadence of ~60 revolutions per minute and the unloaded phase lasted 3 min with an initial step of 25 W.

PRIMARY AND SECONDARY OUTCOME MEASURES

Stepwise incremental exercise test to volitional exhaustion was the primary outcome measure.

RESULTS

Study 1 showed higher maximum values for heart rate (HR), VO₂ L/min, VCO₂ L/min and ventilation L/min for the control group; respiratory exchange ratio (RER), perceived exertion and O₂ pulse (VO₂ L/min/HR) did not differ between groups. In study 2, for pwP who adhered to training (n=37), RER increased significantly and although there was no significant change in aerobic capacity or HR response, reduced blood pressure was found.

CONCLUSIONS

An abnormal cardiovascular response to exercise was observed in pwP compared to controls. After the exercise programme, metabolic deficiencies remained for pwP. These observations add to the pathogenic understanding of PD, acknowledge an underling metabolic contribution and support that certain cardiovascular symptoms may improve as a result of this type of exercise.

Neuromuscular fatigue during exercise: Methodological considerations, etiology and potential role in chronic fatigue

The term fatigue is used to describe a distressing and persistent symptom of physical and/or mental tiredness in certain clinical populations, with distinct but ultimately complex, multifactorial and heterogenous pathophysiology. Chronic fatigue impacts on quality of life, reduces the capacity to perform activities of daily living, and is typically measured using subjective self-report tools. Fatigue also refers to an acute reduction in the ability to produce maximal force or power due to exercise. The classical measurement of exercise-induced fatigue involves neuromuscular assessments before and after a fatiguing task. The limitations and alternatives to this approach are reviewed in this paper in relation to the lower limb and whole-body exercise, given the functional relevance to locomotion, rehabilitation and activities of daily living. It is suggested that under some circumstances, alterations in the central and/or peripheral mechanisms of fatigue during exercise may be related to the sensations of chronic fatigue. As such, the neurophysiological correlates of exercise-induced fatigue are briefly examined in two clinical examples where chronic fatigue is common: cancer survivors and people with multiple sclerosis. This review highlights the relationship between objective measures of fatigability with whole-body exercise and perceptions of fatigue as a priority for future research, given the importance of exercise in relieving symptoms of chronic fatigue and/or overall disease management. As chronic fatigue is likely to be specific to the individual and unlikely to be due to a simple biological or psychosocial explanation, tailored exercise programmes are a potential target for therapeutic intervention.