Case Study: Exercise in MS

Original Editor - Wendy Walker

Top Contributors - Wendy Walker, Kim Jackson, Rucha Gadgil, Evan Thomas and Olajumoke Ogunleye  

Treating therapist & author

This case study was completed by neurological physiotherapist Megan Knowles-Eade. She has given full permission for this to be published on Physiopedia; the individual chosen for the case study (CS) has also given his permission for clinical details and all photographs to be published on Physiopedia.

Introduction

The person chosen for this case study (CS) was a 48 year old male diagnosed with Relapsing-remitting Multiple Sclerosis (MS) 18 years ago. Due to the ceasing of relapses and a gradual deterioration of symptoms and physical presentation the CS was diagnosed with Secondary Progressive MS 8 years ago.

MS is a chronic immune-mediated inflammatory condition of the central nervous system (CNS). It affects approximately 100,000 people in the UK (NICE 2014). The progression of the disease is unpredictable but can have a severe impact on functioning and quality of life. MS affects quality rather than duration of life (Buckley 2008). MS presents with varying signs and symptoms. The CS had typical disease symptoms of weakness in lower limbs and upper limbs, spasms and areas of increased tone, bladder and bowel dysfunction and most significantly, fatigue.

Clinical Details

The CS was a full time wheelchair user requiring assistance from his wife for all activities of daily living (ADLS). He had recently given up driving his adapted vehicle due to fatigue levels and worries about reaction times. The CS had been fully dependent on a wheelchair for the last 10 years, although can transfer through a pull up into standing and a fast pivot to get onto his stair lift.

The CS had taken part in no regular structured exercise apart from weekly Physiotherapy sessions. These sessions involved elements of exercise e.g. assisted stands, active-assisted lower limb activation, sitting balance and posture work. The CS had, over recent years, felt a significant deterioration in his physical presentation and on occasions feels low in mood.

Last year the CS suffered from a chest infection which took a month to clear and three doses of antibiotics. MS can cause weakness to the respiratory muscles with can lead to inefficient ventilation and cough, predisposing them to chest infections (Buyse et al. 1997). The CS was motivated to try for new goals to maintain his current level of ability and physical presentation but felt intimidated by a gym setting. It was thought by the CS that he would not be able to partake in this environment due to his level of disability.

Barriers to exercise in LTNC

Lack of activity is a serious health concern and yet it is estimated that 1 billion people with a disability report barriers to carrying out exercise. Lack of appropriate exercise facilities and negative attitudes towards exercise are common barriers preventing people with Long Term Neurological Conditions (LTNC) seeking out regular exercise.

Components of Physical Fitness

Physical fitness has seven components; aerobic power, aerobic endurance, metabolic function, muscular strength, muscular endurance, flexibility and balance and coordination (Buckley 2008). Inactivity, sedentary lifestyle and neurological signs and symptoms impact heavily on all of these components. It was hypothesised that the CS had a decreased ability in all of the components due to being wheelchair bound for the past eight years and

having not taken part in any regular, structured activity.

Fatigue issues in MS

The CS had limited his ADLs due to his levels of fatigue. Fatigue is the most debilitating symptom of MS and impacts on all aspects of functioning. The CS reported this as his most problematic symptom. Until recent years it was thought that exercise exacerbated fatigue and it was advised to limit physical activities . Exercise is now more understood, and in the NICE guidelines for “Management of Multiple Sclerosis in primary and secondary care” (2014) exercise training is the most recommended non pharmacological intervention for the management of MS.

Risk Assessment

Using the American College of Sports Medicine (ACSM) risk stratification it was deemed that the CS was at “moderate risk” for exercise. This conclusion was based on his age (“over 45 years old”) and his “lack of regular activity”. A Physical Readiness for exercise questionnaire (PARQ) was filled out and indicated no risk for cardiac events during exercise (“No” for all 9 questions). Informed consent was given by the CS to take part in a four week structured exercise programme in a gym environment supported by a physiotherapist.

Methodology

The ASCM risk stratification of “Moderate risk” indicates the need to seek medical clearance before partaking in this project. Clearance was sought and gained from the CS General Practitioner deeming there to be “no medical reason why he cannot take part in supervised exercise in a gym setting”. A local adapted gym for people with disabilities was sought and the Personal Trainer at that gym contacted. An induction was arranged.

Goals & Outcome Measures:

Goal	Outcome Measure
To take part in exercise outside the home without increasing fatigue levels preventing daily functioning	Fatigue Severity Scale [FSS]
To gain a beneficial hobby that can be sustained, without supervision of the author, on a weekly basis	Blood Pressure [BP] Heart Rate [HR] Rating of Perceived Exertion on active cycle [RPE]
To improve function of right upper limb, in particular ease of putting seat-belt on, lifting lap-top from bed onto knees when sitting in bed, and operating the lightswitch when in bed.	Grip strength Range of Movement [ROM] Subjective
To prevent/improve the ability to manage any respiratory complications	Peak Expiratory Flow Rate [PEFR] Posture

Outcome Measures on Initial Assessment.

Outcome measures were used and repeated before exercise commenced, at the middle point and on the last session.

• BP: On initial assessment the CS blood pressure readings were measuring consistently at the pre-hypertension stages ( 120-139/80-89) and in some cases at stage 1 hypertension (140-159/80-89), using the ACSM classification of blood pressure . Blood pressure readings were monitored before each session to ensure that exercise was safe to carry out. The frequency, intensity, type and time (FITT) guidelines for cardiovascular and resistance training for Stage 1 hypertension fall within those recommended for MS, therefore, the MS guidelines were utilised with special precautions to avoid heavy loads, heavy over head loads and isometric work (as per exercise prescription for Stage 1).

• FSS was used to measure fatigue. It is the suggested outcome measure for the energy and drive dimension of the ICF (WHO) for MS. This tool was chosen as it is a “simple and reliable instrument to assess and quantify fatigue” (Valko et al. 2008).
• Grip Strength: An electronic hand dynamometer was used to measure grip strength and goniometer to measure range of movement at the shoulder girdle, both recognised therapy tools for measuring these outcomes.