Components in Designing an Exercise Plan
Though exercise will not reverse or prevent demyelination, nor change the neurologic course of multiple sclerosis, it can support participants with multiple sclerosis in many other ways: increased mood and well being, control of weight and decreased appetite, increased stamina, decreased fatigue, and improved sleep (Britell, MD website). This section will discuss the design of an exercise program: exercise testing, exercise program, muscular fitness, and other pertinent issues.
Before embarking on an exercise program, the physical and psychological profile of the participant with multiple sclerosis must be carefully reviewed. In addition to gathering basic demographic information, it is critical to consider all secondary and associated conditions the participant is experiencing. Moreover, from this point on, and throughout the entire duration of the program, meticulous records must be kept.
Cardiopulmonary function must be examined, and an electrocardiogram performed, as per ACSM guidelines, as well as other surveys and instruments that can help gauge the participant's physical and psychological abilities, including but not limited to the Fatigue Impact Scale or Fatigue Severity Scale, the Sickness Impact Profile, the Yale Physical Activity Scale, the Minimal Record of Disability (Petajan & White, 1999), and the PADS Barriers Scale. If the participant is experiencing paresis or paralysis, one must be aware of the muscle groups affected.
A graded exercise test should then be conducted to determine Vo2peak. Because of the secondary conditions affecting lower limbs (foot drop, balance, spasticity), treadmill testing is not the best mode of testing. Upright or recumbent leg cycle ergometers are good, and a combined leg/arm ergometer covers greater muscle mass and increases cardiopulmonary effort. With the combined arm/leg ergometer, toe clips and heel straps help keep the leg and foot in place, and an arm/leg ergometer with arm/leg movement linked is better for motor coordination issues. Though those who have lower extremity paresis or paralysis can substitute an arm crank ergometer, the participant may fatigue before a true cardiopulmonary level is achieved because of cardiovascular dysautonomia issues (Mulcare, 1997).
Begin with a no resistance warm-up cycle and progress into a continuous or discontinuous protocol of 3-5 minute intervals. Increase the rate 12-25 watts for legs and 8-12 watts for arms, and monitor heart rate and blood pressure. Those without cardiovascular dysautonomia or muscle paresis can achieve between 85-90% of age-estimated maximum heart rate (Mulcare, 1997)(Brawner & Schairer, 2000). Note that because of lower extremity impairment, Vo2max results can be highly variable (Mulcare, 1997).
Other tests should also be conducted, such as strength (isokinetic), flexibility (goniometer), and neuromuscular (gait analysis)(Mulcare, 1997). Note that a functional assessment may be confounded by weakness, spasticity, ataxia, and balance coordination problems, as well as overheating (Petajan & White, 1999).
Petajan & White (1999) created a "physical activity pyramid" model that aptly sums up building blocks that are needed to achieve an optimum level of physical activity, which consists of "ADL/IADL"(activities of daily living/independent activities of daily living),"Built-in Inefficiencies,""Active Recreation," and "Structured Aerobic Program."
At the base of this pyramid are "ADL/IADL," which are essential to attain independence and include a range of activities such as dressing, bathing, and shopping (Peterson & Bell, 1995). As a person gains more strength through a structured strength training program, these activities will be easier to perform. "Built-in Inefficiencies" constitute the second level. It's underlying theory is that engaging in more recreational and social activities with other people helps increase one's energy and mood. An example of a built in inefficiency is parking at the periphery of a parking lot and walking (Petajan & White, 1999). "Active Recreation" is the third level, involving 30 minutes daily of moderate intensity activities, such as gardening, house/yard work, walking, and cycling (Petajan & White, 1999). Other fun recreational activities include bowling, miniature golf, and table tennis (Winnick, 1995).
"Structured Aerobic Program" constitutes the top level. The Kurtzke Expanded Disability Status Score (EDSS) test or another similar test can be utilized as a gauge for developing a proper exercise program for persons with multiple sclerosis according to one's severity and disability. For example, participants with low Kurtzke levels will have the greatest choice of activities; those with Kurtzke levels of 5-6 may have gait problems and will need ambulatory aids; those with high Kurtzke levels (7+) may need to concentrate on wheelchair pushups or transfer training (Rosenthal & Schenberg, 1990). In designing a program, one must be particularly cognizant of the "ebb and flow" (exacerbations and remissions) of multiple sclerosis and alter a program dependent on changes in disability status (Benyas, 1999). In general, the exercise program should be re-evaluated every 6 months (Mulcare, 1997).
Those with minimum impairment, of 30-40 years of age, can engage in an aerobic program at 60%-85% peak heart rate or 50%-70% peak Vo2, 3 or more times per week, for 20-30 minutes, with a 5 minute warm-up and cool-down. (Note, however, that the warm-up and cool-down can be lengthened to reduce overheating and spasticity issues). The type of exercise can involve arm/leg ergometer, walking/treadmill, and aquatic water exercise where body weight is supported and assists in balance and weakness issues (Peterson & Bell, 1995; Mulcare, 1997).
For safety reasons, blood pressure, heart rate, and RPE should be continually monitored. Note that attenuated heart rate or blood pressure response during exercise may occur because of cardiovascular dysautonomia (Mulcare, 1997). Overexercise can lead to increased weakness, fatigue, pain, and spasticity. If one is deconditioned, a cardiovascular workout must be increased slowly because of the complications of angina or heart attack. Also, since muscle weakness around joints can lead to decreased joint mobility, extra care must be taken to protect joints during exercise (Britell, MD website).
Petajan and White also created a "Muscular Fitness Pyramid," which includes both flexibility and strength components and is composed of "Passive ROM (range of motion),""Active Flexibility and Resistance Exercise,""Specific Muscle Strengthening," and an "Intensive Strength Training Program."
At the base of the pyramid is "Passive ROM." For participants with severe paresis, ROM exercises help to prevent further contractures and maintain function. The second level is "Active Flexibility and Resistance Exercise": active resistance exercises should be performed, as well as exercises aiding increased ROM, such as T'ai Chi (see NCHPAD T'ai Chi Factsheet Link), yoga, or use of a Swiss Ball. If strength increases, body weight exercises can be added.
At the third level, "Specific Muscle Strengthening," one must adapt activities to the disability. Issues such as balance/coordination, strength, fatigue, comfort, and motivation must be factored into this program and equipment used such as stretch bands, sandbag weights, and water resistance exercises. At the top level is an "Intensive Strength Training Program," particularly for those without motor deficits, which consists of a program with weights, 3 times per week, of 10-12 repetitions, 3 sets, through full ROM (Petajan & White, 1999).