517594 research-article2013
MSJ0010.1177/1352458513517594Multiple Sclerosis JournalFreeman
MULTIPLE SCLEROSIS MSJ JOURNAL
Controversies in Multiple Sclerosis
Progressive resistance therapy is not the best way to rehabilitate deficits due to multiple sclerosis: Commentary
Multiple Sclerosis Journal 2014, Vol. 20(2) 145–146 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1352458513517594 msj.sagepub.com
Jennifer Freeman The two perspectives presented by Dalgas and Coote clearly highlight the increasing volume of research that has been undertaken in recent years related to exercise in multiple sclerosis (MS), which is very welcome. As Dalgas highlights, this research has transformed the advice we now give to people with MS about exercise to the point where exercise and other health-promoting activities are considered integral to good management. Both Dalgas and Coote agree that the accumulating evidence supports the benefits of progressive resistance therapy (PRT) undertaken 2–3 times per week at a moderate intensity, in improving muscle strength. While there remains contention as to its effects on other outcomes, both of the recent systematic reviews1,2 conclude that the evidence is not of sufficient quality nor volume to be confident with regards to its effects on functions such walking, fatigue, mood and quality of life. Neither systematic review was able to undertake a meta-analysis because of the variability of the participant characteristics, intervention characteristics and outcome assessments, highlighting the need for further research in this area. Making judgements as to how much evidence is enough to change practice is a constant conundrum for clinicians.3 With regard to those with mild to moderate disability the evidence is certainly encouraging; however, there remain important gaps in the evidence. It is unclear whether the beneficial effects of PRT will also apply for people who are more severely impaired, or those in relapse, since these studies have not yet been undertaken. Generalising the findings of this existing research to all individuals with MS is thus not appropriate. The question posed in this debate was whether PRT is the best way to rehabilitate deficits due to MS. While evidence is clearly accumulating to support the notion that PRT can result in a range of improvements across the WHO ICF framework, it is perhaps over-enthusiastic to suggest that PRT is the best way to rehabilitate deficits. There are a myriad of common symptoms in MS (e.g. cognitive impairments, bladder and bowel dysfunction, tremor, ataxia) which have not begun to be explored in relation to this exercise approach; it is unlikely that even the most avid defender of PRT would suggest it will rehabilitate all of these symptoms. To state therefore that exercise is
“the single most effective non-pharmacological type of symptomatic treatment” may be somewhat overstating the point. Moreover, when exploring the current evidence pertaining to PRT, the majority of studies have compared PRT with a control; further research is required to determine its comparative effectiveness to other approaches, such as different forms of exercise or task-specific training. Coote, for example, highlights the strong evidence base relating to task-specific training in people with neurological conditions. A number of the current PRT studies which utilise closed chain methods as their method of resistance training have not attempted to discriminate between the relative benefits gained from the resistance exercise compared with the repetitive practice element of the task. Disentangling the relative contribution of these different components within a programme is complicated, but would provide further insight into the optimal paradigms required. This would be aided by an understanding of the relative contributions of central and peripheral adaptive changes in mediating improvements in strength and function following PRT and task related training. This in turn may depend on a person’s impairment profile and the site and extent of their pathology. Maintaining adherence to exercise over the longer term has not been explored in any depth by existing MS exercise research. While the systematic review on PRT1 demonstrated high adherences and low drop-out rates from the PRT groups in the short term, it is noteworthy that the duration of the studies (which ranged from 8–26 weeks) was short in comparison with lifelong exercise, and involved supervision by a health professional or sports coach. There is plentiful evidence within a range of client groups to demonstrate that sustaining adequate self-motivation to adhere to longer-term ‘real world’ prescribed exercise programmes (such as unsupervised home-based exercise programmes) is challenging. Adherence may be even more problematic Plymouth University, UK Corresponding author: Jennifer Freeman, Faculty of Health and Human Science, Plymouth University, Peninsula Allied Health Centre, Derriford Road, Plymouth, Devon, PL6 8BH, UK. Email: [email protected]
Downloaded from msj.sagepub.com at RENSSELAER POLYTECHNIC INST on April 3, 2015
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Multiple Sclerosis Journal 20(2)
in MS when disability is severe, cognitive and mood impairments may co-exist, and where the disease course may be unpredictable or progressive. Exploring the potential of different methods to enhance adherence, such as the use of peer support, cognitive behavioural therapy, targeting and grading activity, or the provision of refresher sessions is important since poor adherence to exercise and physical activity will inevitably limit long-term effectiveness. Listening to people with MS about what they want, and giving them control and choice over what they do is clearly crucial in this.4 In conclusion, the two contrasting discussions presented here illustrate clearly how evidence-based decisions pertaining to clinical practice are rarely black and white. Making judgements about what is ‘the best form’ of intervention for a person depends not only on an individual’s signs and symptoms, but on a myriad of other factors such as their lifestyle, personality, beliefs and values. These factors are particularly relevant when dealing with interventions such as exercise that require ongoing commitment, sometimes in the face of a relentless progression of disability. Further research in this area is needed, both of a qualitative and quantitative nature, to focus on the operationalisation of these exercise regimens in clinical practice.
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Kjølhede T, Vissing K and Dalgas U. Multiple Sclerosis and progressive resistance training – a systematic review. Mult Scler 2012; 18: 1215–1228. 2. Latimer-Cheung AE, Pilutti LA, Hicks AL, et al. Effects of exercise training on fitness, mobility, fatigue, and healthrelated quality of life among adults with multiple sclerosis: A systematic Review to Inform Guideline Development. Arch Phys Med Rehabil 2013; 94: 1800–1828. 3. Guyatt GH, Haynes RB, Jaeschke RZ, et al. Users’ Guides to the Medical Literature: XXV. Evidence-based medicine: Principles for applying the Users’ Guides to patient care. JAMA 2000; 284: 1290–1296. 4. Hale LA, Smith C, Mulligan H, et al. “Tell me what you want, what you really really want….”: asking people with multiple sclerosis about enhancing their participation in physical activity. Disabil Rehabil 2012; 34: 1887–1893.
Downloaded from msj.sagepub.com at RENSSELAER POLYTECHNIC INST on April 3, 2015
MSJ0010.1177/1352458513517594Multiple Sclerosis JournalFreeman
MULTIPLE SCLEROSIS MSJ JOURNAL
Controversies in Multiple Sclerosis
Progressive resistance therapy is not the best way to rehabilitate deficits due to multiple sclerosis: Commentary
Multiple Sclerosis Journal 2014, Vol. 20(2) 145–146 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1352458513517594 msj.sagepub.com
Jennifer Freeman The two perspectives presented by Dalgas and Coote clearly highlight the increasing volume of research that has been undertaken in recent years related to exercise in multiple sclerosis (MS), which is very welcome. As Dalgas highlights, this research has transformed the advice we now give to people with MS about exercise to the point where exercise and other health-promoting activities are considered integral to good management. Both Dalgas and Coote agree that the accumulating evidence supports the benefits of progressive resistance therapy (PRT) undertaken 2–3 times per week at a moderate intensity, in improving muscle strength. While there remains contention as to its effects on other outcomes, both of the recent systematic reviews1,2 conclude that the evidence is not of sufficient quality nor volume to be confident with regards to its effects on functions such walking, fatigue, mood and quality of life. Neither systematic review was able to undertake a meta-analysis because of the variability of the participant characteristics, intervention characteristics and outcome assessments, highlighting the need for further research in this area. Making judgements as to how much evidence is enough to change practice is a constant conundrum for clinicians.3 With regard to those with mild to moderate disability the evidence is certainly encouraging; however, there remain important gaps in the evidence. It is unclear whether the beneficial effects of PRT will also apply for people who are more severely impaired, or those in relapse, since these studies have not yet been undertaken. Generalising the findings of this existing research to all individuals with MS is thus not appropriate. The question posed in this debate was whether PRT is the best way to rehabilitate deficits due to MS. While evidence is clearly accumulating to support the notion that PRT can result in a range of improvements across the WHO ICF framework, it is perhaps over-enthusiastic to suggest that PRT is the best way to rehabilitate deficits. There are a myriad of common symptoms in MS (e.g. cognitive impairments, bladder and bowel dysfunction, tremor, ataxia) which have not begun to be explored in relation to this exercise approach; it is unlikely that even the most avid defender of PRT would suggest it will rehabilitate all of these symptoms. To state therefore that exercise is
“the single most effective non-pharmacological type of symptomatic treatment” may be somewhat overstating the point. Moreover, when exploring the current evidence pertaining to PRT, the majority of studies have compared PRT with a control; further research is required to determine its comparative effectiveness to other approaches, such as different forms of exercise or task-specific training. Coote, for example, highlights the strong evidence base relating to task-specific training in people with neurological conditions. A number of the current PRT studies which utilise closed chain methods as their method of resistance training have not attempted to discriminate between the relative benefits gained from the resistance exercise compared with the repetitive practice element of the task. Disentangling the relative contribution of these different components within a programme is complicated, but would provide further insight into the optimal paradigms required. This would be aided by an understanding of the relative contributions of central and peripheral adaptive changes in mediating improvements in strength and function following PRT and task related training. This in turn may depend on a person’s impairment profile and the site and extent of their pathology. Maintaining adherence to exercise over the longer term has not been explored in any depth by existing MS exercise research. While the systematic review on PRT1 demonstrated high adherences and low drop-out rates from the PRT groups in the short term, it is noteworthy that the duration of the studies (which ranged from 8–26 weeks) was short in comparison with lifelong exercise, and involved supervision by a health professional or sports coach. There is plentiful evidence within a range of client groups to demonstrate that sustaining adequate self-motivation to adhere to longer-term ‘real world’ prescribed exercise programmes (such as unsupervised home-based exercise programmes) is challenging. Adherence may be even more problematic Plymouth University, UK Corresponding author: Jennifer Freeman, Faculty of Health and Human Science, Plymouth University, Peninsula Allied Health Centre, Derriford Road, Plymouth, Devon, PL6 8BH, UK. Email: [email protected]
Downloaded from msj.sagepub.com at RENSSELAER POLYTECHNIC INST on April 3, 2015
146
Multiple Sclerosis Journal 20(2)
in MS when disability is severe, cognitive and mood impairments may co-exist, and where the disease course may be unpredictable or progressive. Exploring the potential of different methods to enhance adherence, such as the use of peer support, cognitive behavioural therapy, targeting and grading activity, or the provision of refresher sessions is important since poor adherence to exercise and physical activity will inevitably limit long-term effectiveness. Listening to people with MS about what they want, and giving them control and choice over what they do is clearly crucial in this.4 In conclusion, the two contrasting discussions presented here illustrate clearly how evidence-based decisions pertaining to clinical practice are rarely black and white. Making judgements about what is ‘the best form’ of intervention for a person depends not only on an individual’s signs and symptoms, but on a myriad of other factors such as their lifestyle, personality, beliefs and values. These factors are particularly relevant when dealing with interventions such as exercise that require ongoing commitment, sometimes in the face of a relentless progression of disability. Further research in this area is needed, both of a qualitative and quantitative nature, to focus on the operationalisation of these exercise regimens in clinical practice.
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Kjølhede T, Vissing K and Dalgas U. Multiple Sclerosis and progressive resistance training – a systematic review. Mult Scler 2012; 18: 1215–1228. 2. Latimer-Cheung AE, Pilutti LA, Hicks AL, et al. Effects of exercise training on fitness, mobility, fatigue, and healthrelated quality of life among adults with multiple sclerosis: A systematic Review to Inform Guideline Development. Arch Phys Med Rehabil 2013; 94: 1800–1828. 3. Guyatt GH, Haynes RB, Jaeschke RZ, et al. Users’ Guides to the Medical Literature: XXV. Evidence-based medicine: Principles for applying the Users’ Guides to patient care. JAMA 2000; 284: 1290–1296. 4. Hale LA, Smith C, Mulligan H, et al. “Tell me what you want, what you really really want….”: asking people with multiple sclerosis about enhancing their participation in physical activity. Disabil Rehabil 2012; 34: 1887–1893.
Downloaded from msj.sagepub.com at RENSSELAER POLYTECHNIC INST on April 3, 2015
