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[1]). 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.
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.
The exercise programme comprised both cardiovascular components and resistance training.
Passive and active-assisted stretches were carried out during and at the end of the session with the aid of the Physiotherapist.
The prescription was made under guidance the ACSM (2014)[8] recommendations for people with MS:
To take part in cardiovascular activity 3-5 days a week within 40-70% of heart rate reserve (HRR) for 20-60 minutes per session.
Resistance training should be carried out 2-3 days per week, within 60-80% of one repetition maximum (1RM). 1-2 sets with 8- 15 repetitions.
Due to the sedentary lifestyle that the CS had before beginning this project, lower ends of the guidelines were utilised for week one. The CS progression was based on the individuals’ tolerance, physiological and subjective positive responses to the exercise. Cardiovascular aspects of the programme were increased as per ASCM guidance[8] of 5-10 minutes every one-2 weeks for the first 4 weeks. Blood pressure, HR and RPEs were monitored closely throughout.
The results of this four week programme showed an improvement in all subjective and objective outcome measures used.
FSS results, PEFR, upper limb active ROM and RPE scores on active cycling showed the most dramatic improvements. Blood pressure readings slightly reduced over the four week period. Blood Pressure was monitored before each session to ensure safety to perform exercise. Readings varied between 140/90 to 135/85 (see Table 4). By week four the CS diastolic pressure was reading consistently at 85 mmHg. The CS still remains in the ‘Pre hypertensive’ range of blood pressure readings (ACSM) but the no further ‘Stage 1 hypertensive’ readings were recorded after the first session. It was assumed that this was a one off reading due to anxiety of preparing for exercise. Resting heart rate remained consistently at 80 beats per minute throughout this study. When exercising the maximum heart rate achieved was to 136 beats per minute and the CS RPE at this intensity was measured at “16-17; hard-very hard”.
The CS responded well to all aspects of the exercise programme. There were no detrimental effects noted. Research suggests that MS sufferers recover from sessions “normally” despite altered muscle performance[1]. Throughout the programme physiological responses were appropriate for the RPE scale noted. Although temperature regulation is an consideration for MS response to exercise this was not a problem for the CS. At the mid point there were improvements in all outcome measures and it was deemed safe to increase the amount of time spent exercising and the weight during resistance training. The CS showed physical adaptations similar to those without neurological disease. It could be predicted that the physical adaptations of further exercise may not be as dramatic as the first four weeks. The CS began from a very sedentary lifestyle to a huge increase in activity levels which is sure to have a significant effect of physiological response. It is thought that lack of physical activity is related to worsening of symptoms[9] and it might be inferred that the improvement in physical functioning could just be a result of a general increase in activity levels for the CS.
Resistance training weight increased more than was planned. This was due to the difficultly establishing 1 repetition maximum in the first week. The CS found the technique and machinery difficult at first, having never been to a gym before. It took until week two for the CS to feel completely comfortable with this. The resistance work was found to be most helpful in terms of function for the CS. It was found that working multiple muscle groups in functional patterns of movement have helped in ADLs. Rotational pull downs and chest press assisted in reaching for a seat belt, lifting and rotating for a laptop and maintenance of elbow extension for tasks.
