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EXERCISE AND MS

Ashley Smith, CPT, MPH Clinical Exercise Specialist Marilyn Hilton MS Achievement Center at UCLA. EXERCISE AND MS. Regional MS Summit Los Angeles, CA September 28, 2019. Objectives. Who prescribes/implements/instructs exercise to people with MS? What does the research say?

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EXERCISE AND MS

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  1. Ashley Smith, CPT, MPH Clinical Exercise Specialist Marilyn Hilton MS Achievement Center at UCLA EXERCISE AND MS Regional MS SummitLos Angeles, CA September 28, 2019

  2. Objectives • Who prescribes/implements/instructs exercise to people with MS? • What does the research say? • What to do in practice and why? • How to overcome MS-Specific barriers to exercise? • Resources to provide patients • Questions

  3. Clinical vs. Community Professionals who prescribe/implement/instruct exercise to people with MS

  4. Community Fitness Professionals Best Options for MS Patients • NCCA-Accredited-Certification requires in-person proctored exam • www.credentialingexcellence.org • American College of Sports Medicine (ACSM) • American Counsel on Exercise (ACE) • TOP Recommendations: Require Bachelors in Exercise Science/Kinesiology • ACE Medical Exercise Specialist • ACSM Clinical Exercise Physiologist (Formerly Clinical Exercise Specialist) • Balance and Mobility Specialist (CSU Fullerton Center for Successful Aging) • Certified Personal Trainer/Group Exercise Instructor • ACE, ACSM, NSCA, NASM • May have specialty designations such as Inclusive Fitness Trainer, Cancer Fitness Trainer, Senior Fitness Trainer etc. • Group Exercise Instructors, Pilates, Yoga, Aquatics and more…

  5. What does the Research Say? Even among studies with similar interventions or aims, there are mixed results.

  6. Why the Mixed Results? Example from review article: Strength Training to Improve Gait in People with Multiple Sclerosis Table 3: “Exercise Parameters of Frequency, intensity and duration by individual study”. Article: Mark M. Mañago, Stephanie Glick, Jeffrey R. Hebert, Susan Coote, and Margaret Schenkman (2019) Strength Training to Improve Gait in People with Multiple Sclerosis. International Journal of MS Care: March/April 2019, Vol. 21, No. 2, pp. 47-56. As you can see, even among studies that focus on strength training, there is a great deal of variation. Given the mixed results how is research translated into practice?

  7. www.csep.ca/CMFiles/Guidelines/specialpops/CSEP_MS_PAGuidelines_adults_en.pdfwww.csep.ca/CMFiles/Guidelines/specialpops/CSEP_MS_PAGuidelines_adults_en.pdf Evidence-informed guidelines are a great starting point, but most patients/clients ask, “What specific exercises should I do?”

  8. Which Exercise is most important Functional “Real-life” movement “Generalized approach” Targeted mobility/strength/Balance “Customized approach” Stretch: Plantar flexors Adductors Hip flexor Upper extremities Strength: Dorsiflexors Quadriceps External Extensor/Abductors Grip strength Balance: Multisensory training • Push • Pull • Squat • Lunge • Rotate • Walk • Climb stairs • Crawl • Scoot • Varying transfers (supine to prone, prone to quadruped, quadruped to tall kneeling etc.) Both are most important! Order of priority may differ depending on the patient’s condition.

  9. Barriers to Exercise • Physiological • Physical • Psychological (Access to facilities, transportation) (Heat Sensitivity, Fatigue, bowel/bladder incontinence, cognition) (Depression, anxiety, poor motivation)

  10. Top Two Barriers to Exercise MS-Related Fatigue Heat sensitivity Temporary worsening of their [MS] symptoms when core body temperature increases. Even a slight elevation (1/4 to 1/2 of a degree) can cause increase in symptoms. Impairs the ability of a demyelinated nerve to conduct electrical impulses • Generally occurs on a daily basis • May occur early in the morning, even after a restful night’s sleep • Tends to worsen as the day progresses • Tends to be aggravated by heat and humidity • Comes on easily and suddenly • Is generally more severe than normal fatigue • Is more likely to interfere with daily responsibilities and activities (Source: NMSS website)

  11. Case: Sample Patient/Client Therapy/ training appointments are at 2pm and she fatigues quickly. Parking for PT/trainer is a quarter-mile away from building entrance, across an open black top parking lot. No recent relapses/changes in MRI/Neuro Fxn/bladder infection to explain perceived decline. • Female • Lives in Los Angeles • 30 years old • No comorbidities • Working part time at desk job • Cares for her 2 young children • Uses single point cane • Wears AFO for right foot drop • Symptoms: Severe fatigue in the afternoon, heat sensitivity, spasticity in calf, mild cognitive impairment (short-term memory, processing), frequent urination. • Complaint: She loves yoga but walking the four blocks to afternoon yoga class has become more challenging. The parking is horrendous at the yoga studio, and she would rather walk than drive or spend money on Uber, since it’s so close to her home. How can we help this patient/client so that she can overcome barriers of heat sensitivity and fatigue and get more out of her exercise sessions?

  12. Solutions • Intermittent (with breaks) vs. Continuous Exercise. • Earlier appointment before too hot and before more fatigue. • Instruct patient to arrive 30-60 minutes earlier to have more time to use the bathroom and rest/cool down. • Suggest that patient get dropped off instead of driving/maybe an aide or volunteer can meet patient and bring wheel chair to push her in. • Pre-cooling/cooling during session with cooling towel or vest and cool drink. • Air conditioning/fans/exercise near ventilation. • If patient is taking anti-spasticity/anti-fatigue medications try to schedule sessions during peak effects of medication. • Advise patient to wear layers. • Other Solutions?

  13. Resources National MS Society: www.nationalmssociety.org • MS Navigators 1-800-FIGHTMS (1-800-344-4867) • Classes in Los Angeles: https://www.nationalmssociety.org/Chapters/CAL/About-this-Chapter/Fitness-Classes • Living Well with MS, Optimal Living, Free From Falls (Fall: Starts Oct 5th 2019), Exercise and MS Online Exercise Communities: • https://www.msworkouts.com • http://www.themsgym.com Fitness Program/Trainer Directories: • IDEA Fitness ProConnect: https://pro.ideafit.com/fitnessconnect • NCCA Accredited Programs: https://www.credentialingexcellence.org/p/cm/ld/fid=121 • Clinical Exercise Physiologist: https://www.acsmcepa.org/content.aspx?page_id=412&club_id=324409 • US Registry of Exercise Professionals: http://www.usreps.org/Pages/Default.aspx

  14. References • Karpatkin, H., & Rzetelny, A. (2012) Effect of a Single Bout of Intermittent versus Continuous Walking on Perceptions of Fatigue in People with Multiple Sclerosis. International Journal of MS Care, 14 (3), 124-131. • Latimer-Cheung A.E., Martin Ginis K.A., Hicks A.L., Motl R.W., Pilutti L.A., Duggan M., Wheeler G., Persad R., Smith K.M. (2013) Development of evidence-informed physical activity guidelines for adults with multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 94(9): 1829-1836.   • Mañago, M.M., Glick, S., Hebert, J.R., Coote, S., & Schenkman, M. (2019) Strength Training to Improve Gait in People with Multiple Sclerosis. International Journal of MS Care, 21(2), 47-56. • Motl, R.W., & Sandroff, B.M. (2015) Benefits of Exercise Training in Multiple Sclerosis. CurrentNeurology and Neuroscience Reports, 15(62), https://doi.org/10.1007/s11910-015-0585-6. • White L.J., Dressendorfer R.H. (2004) Exercise and Multiple Sclerosis. Sports Medicine, 34(15), 1077-1100. • www.csep.ca/CMFiles/Guidelines/specialpops/CSEP_MS_PAGuidelines_adults_en.pdf

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