202360 EHR525 Week 13 Multiple Sclerosis- Part B (DG) (1 Slide).pdf

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of th...

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice School of Allied Health, Exercise and Sports Sciences 1 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 1 EHR525 EXERCISE FOR NEUROLOGICAL & MENTAL HEALTH CONDITIONS Multiple Sclerosis- Part B Presenter: Darren Dray School of Allied Health, Exercise and Sports Sciences 2 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 2 What We Will Cover: ■ Diagnosis of Multiple Sclerosis. ■ Treatment of Multiple Sclerosis. ■ Exercise response in persons with Multiple Sclerosis. ■ General recommendations and considerations for exercise testing and programming in Multiple Sclerosis. School of Allied Health, Exercise and Sports Sciences 3 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 3 Diagnosis Of Multiple Sclerosis ■ Based on presenting signs/symptoms in combination with medical imaging and laboratory testing. ■ Typical diagnostic tests include: Medical history: Assess past and present signs/symptoms. Neurological exam: Assess health of nervous system. MRI: Can determine spatial and temporal distribution of lesions. Evoked potential response: Measure electrical response to sensory stimulation (visual, auditory, somatosensory). □ Cerebrospinal fluid analysis: Assess for immunoglobulin level and oligoclonal bands. □ Blood tests: To rule out other diseases. □ McDonalds Criteria □ □ □ □ School of Allied Health, Exercise and Sports Sciences 4 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 4 Clinical Course Of Multiple Sclerosis ■ Relapsing remitting MS (RRMS; 85%): Characterised by periodic exacerbations followed by full or partial recovery of deficits. ■ Primary progressive MS (PPMS; 10%): Characterised by continuous disease progression from onset with little or no plateaus or improvements. ■ Secondary progressive MS (PPMS; ??%): Initially characterised by relapsing-remitting course followed by primary-progressive course. ■ Progressive relapsing MS (PRMS; 5%): Characterised by a progression from onset with distinct relapses superimposed on the steady progression. School of Allied Health, Exercise and Sports Sciences 5 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 5 Clinical Course And Prognosis Of Multiple Sclerosis ■ Extent of disability is related to clinical course. ■ Life expectancy is minimally reduced in MS. ■ Most people with MS die from many of the same conditions as non-MS peers (e.g. cancer and heart disease). School of Allied Health, Exercise and Sports Sciences 6 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 6 Outcome measure ■ Kurtzke FSS – Functional Systems Score ■ Kurtzke EDSS- Expanded Disability Status Scale School of Allied Health, Exercise and Sports Sciences 7 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 7 Clinical Course And Prognosis Of Multiple Sclerosis ■ Around two thirds of people diagnosed with MS are able to walk without a wheelchair two decades after their diagnosis. ■ Some people will need crutches or a cane to remain ambulatory. ■ Others use an electric scooter or wheelchair to help them cope with fatigue, balance or gait difficulties. ■ 70% disabled within 10 years of diagnosis. School of Allied Health, Exercise and Sports Sciences Note the MS prognosis 8 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 8 Disability Expectancy Note the general disability expectancy Kister. (2013). Neurology, 80(11); 18-24. School of Allied Health, Exercise and Sports Sciences 9 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 9 Multiple Sclerosis And Employment Restrictions ■ Employment restrictions are significant for people with MS. ■ 62.5% of persons with MS are restricted in their employment. ■ Assistive/mobility devices: □ □ □ □ Canes. Crutches. Orthoses. Wheel chairs. School of Allied Health, Exercise and Sports Sciences MS affects work capacity 10 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 10 Comorbidity In Multiple Sclerosis ■ Comorbidities are a concern throughout the MS course. ■ Comorbidity is associated with: □ □ □ □ □ A longer delay between symptom onset and diagnosis. More severe disability at diagnosis. Greater disability progression. Consider the impact of Increased health-care. comorbidity in MS Higher mortality. patients Marie, (2016). (In J MS care, 18(6); 271-272. School of Allied Health, Exercise and Sports Sciences 11 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 11 Comorbidity In Multiple Sclerosis ■ Most common comorbidities: □ □ □ □ □ □ □ □ □ Depression. Anxiety. Hypertension. Hyperlipidemia. Chronic lung disease. Diabetes. Ischemic heart disease. Fibromyalgia. Inflammatory bowel disease ■ At the time of diagnosis: □ 19% have sought care for depression. □ 11.1% have sought care for anxiety. Marie, (2016). In J MS care, 18(6); 271-272. School of Allied Health, Exercise and Sports Sciences 12 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 12 Treatment Of Multiple Sclerosis ■ No cure for MS. ■ Goal is to reduce or slow effects of MS and treat symptoms. ■ Interferon 1-beta (Betaseron) or 1-alpha (Avonex), Copaxone (copolymer-1): □ Useful for relapsing-remitting, not stable or progressive. □ Prevention of T-cell activation and decreases relapse rate. ■ Immunotherapy with corticosteroids: □ Suppress inflammatory response. □ Decrease severity/duration of exacerbations. □ Inhibit demyelinating process. School of Allied Health, Exercise and Sports Sciences 13 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 13 Medications For MS And Potential SideEffects (Ehrman) School of Allied Health, Exercise and Sports Sciences Ehrman et. al. (2018) 14 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 14 Multidisciplinary Care In Multiple Sclerosis ■ Physiotherapists. ■ Occupational therapists. ■ Speech pathologists. ■ Psychologists. ■ Social workers. ■ Geriatricians. School of Allied Health, Exercise and Sports Sciences 15 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 15 Benefits Of Exercise In Multiple Sclerosis ■ Exercise has no effect on disease progression. ■ Exercise helps to improve: □ □ □ □ □ □ □ □ Cardiorespiratory capacity. Muscular strength. Flexibility. Physical function. Balance. Mobility Mood. Self-report fatigue. Ehrman et. al. (2018) School of Allied Health, Exercise and Sports Sciences 16 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 16 Effect of Aerobic Training On Gait And Maximal Exercise Tolerance In Multiple Sclerosis Note the impact of AT ■ N= 11(8F/ 3M); 20-55 years. ■ EDSS range 1-4. ■ Crossover design: 8 wks AT or 8wks of NR 3 days/week with 8-wk washout. ■ ATG: 30min of 60-80% max work load on cycle ergometer plus lower limb and trunk stretching. ■ NRG: 60-mins of respiratory, postural, motor synergies, and stretching exercises. ■ Outcomes: AT improved walking distance and speed, max work rate, and aerobic efficiency. □ More disability resulted in greater gains. School of Allied Health, Exercise and Sports Sciences Rampello, et al. (2007). Physical Therapy, 87(5); 545-555. 17 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 17 Response To Exercise ■ Individuals with MS generally have lower VO2, strength, balance, mobility compared to a healthy persons. ■ Autonomic dysfunction: □ Thermoregulation: Impaired sweat response. □ Cardiovascular: HR and BP response to exercise may be blunted. • RPE can be used in addition to HR to evaluate exercise intensity. ■ Fatigue: Common in individuals with MS with mild-to-moderate disability. □ Adjust exercise time and intensity as appropriate ■ “Uhthoff phenomenon”: □ Transient (<24 h) worsening of neurological symptoms, most commonly visual impairment, associated with exercise and elevation of body temperature. □ Use cooling strategies and adjusting exercise time and intensity as appropriate. ■ Close monitoring is needed due to unpredictability of symptoms. School of Allied Health, Exercise and Sports Sciences 18 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 18 Pre-Screening And Assessment ■ Performed using ESSA Adult Pre-exercise Screening Tool. ■ History and physical exam: Assess for indicators that will impact the exercise prescription and that can be improved with exercise. □ Review medical history and medications. □ Current symptoms: • Balance. • Flexibility. • Strength. • Vision. • Fatigue/endurance. • Gait abnormalities. School of Allied Health, Exercise and Sports Sciences 19 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 19 Exercise Testing In Multiple Sclerosis ■ Useful for baseline measures for future comparisons of effectiveness of exercise training. ■ Provides information on individual responses and exercise tolerance. ■ Balance, mobility, and gait evaluation: □ □ □ □ □ Functional reach test, tandem stance, single limb stance. 360 turn. Chair sit-to-stand, Timed Up and Go, Tandem walk. Berg Balance Scale. 10-m walk test at a comfortable walking speed. School of Allied Health, Exercise and Sports Sciences 20 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 20 Exercise Testing In Multiple Sclerosis ■ Cardiovascular testing: □ Consider cycle ergometer if ambulatory impairment exists. □ Treadmill if safe gait/balance is not an issue. □ Watch for indications of overheating and fatigue; electric fans, fluid replacement, and cooler room temperatures help. □ Apply low-level protocols for most due to deconditioning. □ Watch for attenuated HR and BP response, especially if autonomic dysfunction has been diagnosed. ■ Muscular strength testing: □ Standard testing typically OK. □ 1RM can be used, but modify if significant weakness. ■ Flexibility: □ Use goniometer □ Can be quite inflexible due to disease progression and level of spasticity. School of Allied Health, Exercise and Sports Sciences 21 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 21 Goals For Exercise In Multiple Sclerosis ■ Primary aim is to maximise physical function and reduce disability or at least slow progression of disability. ■ General goals for exercise in people with Multiple Sclerosis are: Increase or maintain physical activity levels. Maintain ability to perform ADLs. Reduce impact of symptoms. Provide general health benefits to reduce to deconditioning and secondary comorbidities. Note goals should reflect □ Improve QOL. what will have the biggest □ Enhance mental health. impact for the patient □ □ □ □ School of Allied Health, Exercise and Sports Sciences 22 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 22 Recommendations For Balance, Mobility, And Gait Training ■ Balance, mobility, and gait training and mobility is important in MS. ■ Static, dynamic, and balance training during functional activities should be included. ■ Exercises may include a variety of challenging activities: □ Bosu ball, large balls, and so on. School of Allied Health, Exercise and Sports Sciences 23 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 23 Recommendations For Cardiorespiratory Exercise Programming ■ Guidelines for healthy adults apply to MS within the limits of symptoms. ■ Frequency: 3-5 days/week. ■ Intensity: 40-70% MHR or RPE of 11-14. ■ Time: Increase exercise time initially to min of 10 mins before increasing intensity. □ Progress to 20-60 min. □ In individuals with excessive fatigue, begin with lower intensity and discontinuous bouts of 10-15 mins. ■ Type: Walking, cycling, or swimming dependent on the individual’s clinical presentation. □ Stationary cycle, recumbent cycle, or arm ergometer are safer modes for individuals with more advanced MS. School of Allied Health, Exercise and Sports Sciences 24 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 24 Recommendations For Resistance Exercise Programming ■ Recommendations for resistance exercise in healthy adults may be applied to individuals with MS. ■ Frequency: 2-3 days/week (never 2 consecutive days). ■ Intensity: 40-80% of 1-RM. ■ Volume: Initially, 1-2 sets of 8-12 reps until fatigue and progress. □ Increase rest time between sets and exercises (e.g. 2-5 mins) for weaker muscle groups or easily fatigued individuals as needed to allow for full muscle recovery. □ Focus on large antigravity muscle and minimise total number of exercises performed. ■ Type: Body weight, machines, free weights as tolerated and symptoms allow. ■ Resistance exercise in a pool can be beneficial. School of Allied Health, Exercise and Sports Sciences 25 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 25 Recommendations For Flexibility And Joint ROM Exercise Programming ■ Flexibility and ROM exercises are important for management of spasticity. ■ Frequency: 5-7 days/week; 1-2 sessions/day. ■ Intensity: Full extension, flexion, rotation, or stretch to the point of slight discomfort. ■ Time: Hold stretches for 30-60s; 2-4 reps. ■ Type: Slow static stretches for all major muscle groups should be performed. School of Allied Health, Exercise and Sports Sciences 26 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 26 Note the general exercise guidelines School of Allied Health, Exercise and Sports Sciences Ehrman et. al. (2018) 27 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 27 Summary Special Considerations For Exercise ■ Individualised assessment Mobility, strength, balance and functional capacity ■ Stage and Type of MS ■ Heat sensitivity Hydrate, clothing consideration, hydro? And outdoor… ■ Fatigue consideration ■ Safety ■ Cognitive loads School of Allied Health, Exercise and Sports Sciences 28 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 28 Considerations For Exercise ■ In spastic muscles, increase the frequency and time of stretching exercises. □ Muscles and joints with significant tightness or contracture may require longer duration (several minutes to several hours) and lower load positional stretching to achieve lasting improvements. Note these general considerations ■ Whenever possible, incorporate functional activities into the exercise program to promote optimal carryover. □ E.g. Stairs climbing, sit-to-stand, etc. ■ Due to cardiovascular dysautonomia use RPE in addition to HR and BP to evaluate exercise response. □ Blunted HR and BP responses may not provide accurate measures of intensity. School of Allied Health, Exercise and Sports Sciences 29 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 29 Special Considerations For Exercise ■ During an acute exacerbation of symptoms, decrease the dose of exercise based on tolerance (symptom-limited prescription). □ If severe, focus on maintaining functional mobility and/or focus on activities such as cardiorespiratory exercises and flexibility. ■ Fatigue is common in MS but can improve with exercise training. □ Help clients understand the difference between MS-mediated fatigue and exercise-induced fatigue. □ Tracking the effects of fatigue may be helpful using an instrument such as the Modified Fatigue Impact Scale. Note the special considerations ■ Heat sensitivity is common in MS. □ Use of fans, evaporative cooling garments, and cooling vests can increase exercise tolerance and reduce symptoms (↑of 0.5°C core temp can impair nerve conduction). School of Allied Health, Exercise and Sports Sciences 30 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 30 Summary ■ The diagnosis of MS may involves a range of electrophysiological and neuroimaging techniques as well as a physical exam. ■ Treatment of MS aims to slow progression and reduce symptoms through anti-inflammatory agents, such as interferon and corticosteroids. ■ Goal for exercise is to enhance or maintain daily activity levels and/or improve functional capacity, mobility, quality of life, and mental health. ■ There are no exercise training-specific guidelines for those with MS. ■ Adjust exercise prescription to avoid excessive fatigue to ensure client safety as disease progresses. School of Allied Health, Exercise and Sports Sciences 31 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 31 Other resources ■ Pathophysiology summary https://vimeo.com/135254543 ■ Yoga https://vimeo.com/ondemand/tamingthewalrus/102147568 ■ https://www.msaustralia.org.au ■ https://www.nationalmssociety.org/For-Professionals/Clinical-Care/ManagingMS/Rehabilitation School of Allied Health, Exercise and Sports Sciences 32 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 32