This presentation was part of the Chicago Wellness for MS Forum held Saturday April 22, 2023

Watch the full presentation: Benefits, Safety, and Guidelines for Exercise in MS with professor Robert W. Motl

There has been a shift in prevalence of MS in the USA. There are now 1 million people in the US who live with MS, more than previously thought. We used to think of MS affected people age 20 to 40 most, but actually it affects more people age 55 to 60 and the range will only skew older over time as the population ages.

MS is an immune-mediated and neurodegenerative disease of the central nervous system (CNS) that is characterized by demyelination and transection of axons and loss of neurons in the CNS. Symptoms include walking dysfunction and cognitive impairment, fatigue, depression and pain. MS can cause a compromised quality of life and loss of independence.

First line management of MS: Disease Modifying Therapies (DMTs)

There are 17+ FDA approved DMTs for reducing the number of relapses, delaying progression and disability and limiting new disease activity based on MRIs.

  • Injectable medications
    • Avonex
    • Betasseron
    • Copaxone
    • Extavia
    • Glatiramer Acetate
    • Plegridy
    • Refib
  • Oral Medications
    • Aubagio
    • Gilenya
    • Tecfidera
    • Mayzent
    • Mavenclad
  • Infused Medications
    • Lemtrada
    • Novantrone
    • Ocrevus
    • Tysabri

Second line management of MS: Rehabilitation and Wellness

Lifestyle behaviors are the most commonly searched terms by people with MS. People with MS are invested in learning more about chaining their diet and lifestyle behaviors. Exercise is one of the most important stimuli to activate every system in the human body. Aerobic fitness is a primary physiological biomarker to be targeted for disease management and rehabilitation in MS. The body systems adapt and grow better and stronger from regular bouts of exercise in people with and without MS.

Aerobic power is oxygen delivery throughout the body

The cardiovascular system pushes blood through the human body and the muscles extract the oxygen out of the blood to move and work. When people move from rest to heavy exercise the blood travels away from other tissues to the activated tissue so that muscle can move and adapt. Measuring aerobic fitness includes using a bike, treadmill or NuStep on an increased difficulty until they’re unable to continue. People with MS typically have lower aerobic power than the general public. A lot of the lifestyle changes that people with MS undertake to avoid fatigue results in detraining, As the disease worsens, the aerobic power of people with MS decelerates and makes the disease worse over time. This affect systems of the body in a negative way.

Outcomes in reduced fitness in people with MS

Aerobic fitness correlates with volume of brain mass. Maintaining the integrity of the brain is very important for people in MS and can be enhanced through exercise. The brain volume can be increased through exercise. Aerobic fitness is also related to cognitive processing speed. Having higher aerobic fitness correlates with higher cognition when it comes to learning and retaining information. Exercises restores in a clinically meaningful brain health.

Aerobic exercise also correlates positively to walking and motor function. Aerobic exercise improves walking speed and walking endurance over prolonged periods of time. Higher aerobic power means people are less likely to be fatigued and less likely to be depressed. Exercise reduces fatigue over 4 to 6 weeks to being in a non-fatigued state based on the fatigue severity scale, even though people new to exercise may see an increase in fatigue for the first few weeks.

Health-related quality of life is higher in physical and mental domains and  is positively correlated with aerobic strength. People with increased aerobic strength are also able to engage better in daily living: shopping, living independently, housekeeping, laundry related tasks, and taking medications independently. People with MS who have a higher levels of aerobic power are also able to work full time for a longer period of time.

Randomized Control Trials (RTCs) about exercise training for aerobic Power in MS

The first study published on aerobic exercise was by Jack Petajan at the University of Utah. This study was for 15 weeks where participants exercised 3 to 4 days per week on a stationary bike. They were doing this at a time when it was widely thought that aerobic exercise was dangerous for people with MS and could make the disease worse. Many people thought their study would cause damage and increase symptoms. It was a National Institutes of Health study that was controversial at the time. The results were that exercise reduced Expanded Disability Status Scale (EDSS) scores. Most drugs only slow down EDSS worsening, not improve scores. At the time of this study the did not have MRIs, but it did put exercise on the map as something that helps people with MS.

A meta-analysis of RTCs of exercise for people with MS found a half standard deviation improvement in mobility, fatigue, depression and the ability to maintain independence. There have been 54 RTCs on exercise and MS. Dr. Motl conducted a meta analysis of these with a team of neurologists over three day in Canada to parse apart the research to develop evidence informed guidelines for people with MS.

Dr. Motl wrote in the Multiple Sclerosis Journal that exercise should be considered a disease modifying berhavior based on reduction in number of new lesions, reduction in the size of lesions, improvement of symptoms and reduction in the EDSS score for people with relapsing and progressive forms of MS. Exercise both prevents brain shrinkage and actually increases the volume of the thalamus and hippocampus.

Exercise also improves mood and reduces mental health symptoms. It is not yet been proven to treat major depressive disorder but Dr. Motl has received a $3 million grant from the Department of Defense to study the impact of exercise on mood disorders.

Recommendations for aerobic exercises for people with MS

  • People with MS should do aerobic exercise 2 to 3 days per week. Start with 2 days and move up to 3 days as you get stronger.
  • Start with 10 minutes and they don’t have to be continuous. You could do 5 minutes here and 5 minutes there. Go up to 30 minutes per day as you get stronger.
  • Moderate intensity exercise in any form is best. Moderate intensity means you could speak but not have a full on prolonged conversation without running out of breath.
    • Ergometry (peddling with legs or arms or both) is a great choice with arm, leg or combined movement
    • Walking over ground or on a treadmill (with or without a mobility device)
    • Aquatics
    • Elliptical exercises

Don’t do the same routine forever. Start the advanced protocol if you find 3 days per week easy

  • Increase to 5 days per week
  • Increase to 40 minute sessions per day
  • Higher heart rate intensity at 40% to 60% of age-adjusted maximum heart rate (for example 80-120bpm is recommended for a 20 year old)

Safety considerations in exercise for people with MS

Exercise doesn’t cause a higher rate of relapse, in fact there’s a 25% reduction in relapse for individuals engaging in exercise. This reduction percentage is as good as many MS disease modifying therapies in reducing relapses. There are also no increases risks of falling or infections. Serious adverse events are defined as those that put people in the hospital. The rate of serious adverse events was no different than in a control group. Exercise is perfectly safe and very beneficial for people with MS.

Getting people with MS to exercise

Neurologist need to be agents of change to get people with MS to exercise since most people with MS see a neurologist and trust their neurologist’s recommendations. Most neurologists don’t know that much about exercises and while they can say, “you should exercise,” they don’t see patients often enough to help them follow through. Nurses, physical therapists, occupational therapists, and rehabilitation psychologists are the best people on a healthcare team to help patients follow through and create an exercise plan.

Robert W. Motl, PhD in a professor in the Department of Kinesiology and Nutrition, Director of the Integrative Physiology Laboratory, and Director of Exercise Neuroscience Research Laboratory at the College of Applied Health Sciences at University of Illinois Chicago. He has systematically developed a research agenda that focuses on physical activity and its measurement, predictors, consequences, and interventions in persons with neurological diseases, particularly multiple sclerosis (MS). Prof. Motl has generated a body of research on the validity of common physical activity measures in persons with MS. This has resulted in foundational research on quantifying differences in physical activity, particularly rates of moderate-to-vigorous physical activity, in persons with MS. These two lines of research have provided the basis for examining the outcomes of physical activity in MS, particularly beneficial adaptations in brain structure, cognition, depression, fatigue, walking disability, and quality of life. Prof. Motl has undertaken research on social-cognitive predictors of physical activity that has informed the design of behavioral interventions for increasing physical activity in MS. This agenda serves as a test-bed for application and expansion into other conditions such as spinal cord injury and Parkinson’s disease.