Vol. 19 Issue 22
A Call to Action
Rehab experts are changing their view of exercise and MS
On a chilly afternoon in suburban Philadelphia, a small but committed group of locals gathers at the Health Sciences Building of Arcadia University in Glenside, PA. Shedding their canes, gloves and hats, they're greeted by students from Arcadia's physical therapy department and escorted downstairs to a brightly lit therapy room stocked with modern equipment.
Director Carol Leiper, PhD, PT, welcomes the class, praises their fortitude in braving the elements, and leads them through a series of warm-up exercises to up-tempo Johnny Cash and Nancy Sinatra standards before breaking them out into individual activities. Today is "balance day," so most of the group works on trunk strength, core stability, stair-stepping and other challenging movements under the direction of Arcadia students, who rotate through the class as part of their curriculum.
This is the Dan Aaron "Stay Fit" exercise program for people with Parkinson's disease or multiple sclerosis, designed for people who aren't in physical therapy but who want to receive professional fitness instruction. And it embodies a profound shift in the way the rehab community looks at neurological disease.
A New Era
Pick up any rehab text from the 1960s, said Ted R. Brown, MD, MPH, and you'll read strict guidelines against exercise for people with multiple sclerosis (MS). "That was the thinking for many years," said Dr. Brown, head of rehab medicine at the Multiple Sclerosis Center at Evergreen Healthcare in Seattle. "Established wisdom held that vigorous exercise could deplete strength reserves, exacerbate flare-ups and speed up the progression of the disease."
That attitude began to change in the 1980s, said Dr. Brown, and todaywhile an arsenal of powerful and well-researched medications can help control symptoms and forestall disease progressionexercise is largely seen as the only intervention proven to reverse strength loss and functional decline.
Fran Consorto of Fort Washington, PA, has had multiple sclerosis since John F. Kennedy was president. She's fiercely protective of her independence, maintains her suburban home herself and proudly relates that she's medication-free. "If it's not broken, I don't want to fix it," she said.
Consorto has been coming to the exercise classes at Arcadia for two years, and swears by their value in keeping her strong and independent, while maintaining a degree of control over her condition.
Like most patients with MS, Consorto has trouble walking, and balance is her biggest concern. But while the sessions can be frustrating on bad days, she always feels invigorated and more stable after class. She uses these sessions as a medically supervised foundation for her own fitness program.
In many ways, Consorto's take-charge approach to her condition reflects the newfound appreciation of the powers of exercise held by rehab clinicians who specialize in MS treatment.
"There's really no form of exercise that's off the list as far as benefits go," said Dr. Brown, adding that baseline strength and aerobic capacity among people with mild MS generally starts at 30 percent below normal, so strengthening is critical to maintain peak condition. "As long as exercise has meaning to them and helps achieve their individual goals, it will lead to improvements."
Recent studies are backing that up. A 2005 study in Archives of Physical Medicine & Rehabilitation demonstrated that resistance training improved walking and functional ability in people with MS. A 2004 study in Neurology showed that six months of yoga significantly reduced fatigue in people with MSresults comparable to those found with more intensive aerobic activity.
And a May 2007 study in Physical Therapy showed aerobic training that focuses on breathing, stretching and flexibility was more effective than neurological rehab in improving walking capacity and exercise tolerance in people with MS. Those with greater disability showed the strongest benefits.
While the surge of public awareness surrounding exercise and MS is encouraging, some rehab professionals express concern that it may lead patients to join gyms on their own, and structure their own fitness plans without oversight or physician
Most MS patients can exercise safely, though many are on immunomodulators and symptom-control medications that can affect the body's response to exercise, cautioned Brian Hutchinson, PT, MSCS, president of The Heuga Center for Multiple Sclerosis in Edwards, CO. "It's important for physical therapists to know their patients' medication schedules and stay in the loop with the treating physician," said Hutchinson.
It's also important that rehab professionals monitor patients closely for fatigue and thermosensitivity, and discern whether these effects are disease-related, medication-related or a normal response to exercise. While MS exacerbations aren't a huge concern with exercise, increased core body temperature can result in increased symptoms or pseudoexacerbations, advised Hutchinson. Patients experiencing a true flare-up may need to scale back or switch to a different activity.
These considerations are the key rationale behind community programs for people who aren't receiving formal physical therapy, said Dr. Leiper. She sees university-sponsored fitness classes as an invaluable way to address a critical community need, while exposing physical therapy students to the complexities of neurological rehab, which will serve them well no matter where their career takes them.
"Even if students plan on working in an orthopedic private practice or sports rehab, they'll be seeing patients with degenerative neurological disorders," she said. "Many times a patient referred for a frozen shoulder will have an underlying neurological condition you must recognize and address."
With insurance restrictions shortening hospital stays, and medical advances lengthening the life spans of people with MS, Dr. Leiper predicts a new wave of MS patients will seek skilled care at outpatient practices specifically outfitted to treat neurological disorders.
At Body Kinetics Rehab in Annandale, VA, owner Jessica To, DPT, dedicates her practice exclusively to the neurologically involved patient.
"We've been in business for two years," said Dr. To, whose patient base consists of patients with stroke, spinal cord injury, traumatic brain injury and degenerative neurological complications. While the first few months were a challenge, Dr. To is now gaining traction among physicians and hospitals in the area, who are referring greater numbers of MS patients to her practice.
She also speaks to doctors, case managers and community support groups about the value of physical therapy clinics that focus on treating patients with neurological conditions.
"A lot of people with MS know they need to stay fit, but my concern is that they may begin a program or join a community gym on their own, without consulting with a physical therapist who is experienced in neurological rehab," said Dr. To. "Many fitness professionals don't have the background to work with this population, and fitness facilities don't always have the necessary adapted equipment."
For this reason, as physicians and therapists become more aware of the benefits of exercise, community classes and specialty clinics such as Dr. To's figure to be an important emerging specialty in the coming years.
"The word is out now," confirmed Dr. Brown. "Neurologists are attuned to the latest research into exercise and what it can do. This is an important evolution for people living with MS." n
Jonathan Bassett is on staff at ADVANCE and can be reached at firstname.lastname@example.org
Breathing Easier: Respiratory Training and MS
While limb weakness, spasticity and cognitive decline are the recognizable hallmarks of multiple sclerosis (MS), it's often weaknesses you can't see that are most deadly.
"One of the major complications that people with MS die from is respiratory infection," said Donna Fry, PhD, PT, associate professor and director of the physical therapy department at the University of Michigan-Flint. "There is a lot of pulmonary dysfunction in this population that's not being addressed."
Improving respiratory weakness isn't an overly complicated affair. "Respiratory training is no different than training the other muscles of the body," Dr. Fry explained.
The principles of overload and specificity apply to breathing function just as they do to the rest of the body, which means increasing load and duration to get stronger, and targeting a program for a specific outcome goal, such as strength, endurance or efficiency.
Respiratory trainers can impose a load on inspiration and expiration to strengthen the breathing muscles, said Toni Chiara, PhD, PT, research and clinical physical therapist at Malcolm Randal VA Medical Center in Gainesville, FL. Some devices are programmable and offer graphic outcome feedback to monitor effectiveness.
Pulmonary training with these devices has been shown in multiple published trials to improve respiratory muscle strength and endurance while minimizing dyspnea related to activities of daily living and during formal exercise programs, said Dr. Chiara.
Depending on the patient's specific function and goals, patients should train one to two times per day, for roughly three sets of 15 repetitions, while carefully monitoring for fatigue. While just five weeks of training resulted in increased respiratory muscle strength in some trials, patients should continue the program indefinitely.
"They lose what they gain," said Dr. Chiara. "Just like extremity training, patients need to continue the program and revisit therapists to reassess progress." She recommended that rehab facilities stock these low-cost trainers to distribute to their patients with neurodegenerative disease who have diminished respiratory muscle strength and endurance.