Multiple sclerosis (MS) is a demyelinating, degenerative disease of the central nervous system. It can cause a multitude of motor, sensory, visual, psychological, sexual, and bladder and bowel symptoms. Europe has the highest estimated prevalence of MS in the world at 80 per 100,000[1
] and in Ireland people with MS (PwMS) make up the largest diagnostic group (9.2%) of those registered on the National Physical and Sensory Disability Database[2
]. MS is a progressive disease that can lead to disability, functional limitations and a poor quality of life (QoL). In a recent profiling study[3
], 59% of the people with MS had EDSS scores between 0 and 4.0, 18% had scores of 6.0 ± 6.5, and 6% had a score of 8.0. It is suggested that within 15 – 25 years of diagnosis nearly 50% of PwMS will reach an EDSS score of at least 6 meaning they will require the use of a walking aid[4
]. PwMS have a normal life expectancy, therefore, they may have to live for many years with severe mobility problems and have a need for regular therapeutic intervention. Therefore the importance of appropriate and timely intervention in patients with relapsing disease to slow or prevent the accumulation of physical disability associated with progressive types of disease is apparent.
There is a significant body of evidence to suggest that exercise programmes have a beneficial effect on both disease symptoms and general fitness of people with MS who are ambulatory [6
]. The authors recommend that future studies should adhere to methodological principles of allocation concealment, blind recording and description of dropouts.
A meta-analysis of physical activity levels of people with MS concluded that they engage in significantly less physical activity than non-diseased populations[7
]. In a study investigating coronary heart disease risk in women with MS, those who had higher levels of leisure time physical activity had a lower risk of secondary disease[8
] and ambulatory women with MS who took part in a resistance training programme also had a decreased risk of coronary artery disease[9
]. A meta analysis of the relationship between exercise and quality of life for people with MS suggested that quality of life can be optimally improved through exercise programmes less than three months duration, involve greater than 90 minutes a week, and be evaluated using MS specific measures[10
]. Given the positive relationship between physical activity and improving disease symptoms and quality of life, and reducing secondary disease, it is essential that the optimal physical activity programmes are identified.
In physiotherapy practice it is acknowledged that people with differing levels of mobility will have varying treatment needs therefore the literature has been separately reviewed for those with an EDSS of 0–6 and for those with an EDSS of >6.
The literature published since the Cochrane review[6
] on the specific benefits of physiotherapy and exercise interventions for PwMS with an EDSS of 0–6 suggests that aerobic exercise positively influences fitness, walking speed, gait parameters, disability, fatigue and quality of life [11
]. Additionally, Progressive Resistance Exercise (PRE) improved strength, walking over short distances, improved stepping time, improved fatigue and reduced the physical impact of MS[16
]. However, there was only one intervention followed up at three months [17
] and this found that benefits were maintained for the Functional Assessment of MS and the MSIS-29 only.
Several studies have combined aerobic exercise and PRE, [21
] and have reported no deleterious effects. However, the intervention has been delivered as a home exercise programme, bringing into question the issue of compliance.
To date, a lot of studies considering exercise interventions for people with an EDSS of < 6 have a moderate to high risk of bias – mostly due to lack of blinding or not having a control group, questioning the validity of the results. More rigorous methodologies are needed to eliminate this bias and allow firm conclusions to be drawn.
Yoga is frequently provided to its members by MS Society of Ireland (MSI) and has been show to be feasible in this population[22
] however, only one small scale study has evaluated it.
It is possible that the exercise needs of this group of PwMS can be met by fitness instructors in gyms providing a non medical environment for exercise participation. This study therefore aimed to assess the effect of intervention delivered by fitness instructors, following assessment by a physiotherapist to ensure that no impairments existed that would prevent this.
A review of the literature for those with an EDSS score > 6 suggests that a multitude of interventions can be beneficial in this population. These include physiotherapy, aerobic exercise and strength exercise. It is unclear, however, to what extent the results can be applied to PwMS with an EDSS score of >6 as PwMS with EDSS scores of between 1 and 6.5 were given the same interventions even though their treatment needs vary greatly. The positive outcomes were specific to the intervention used, for example, balance rehabilitation showed improvements in balance scores [12
] and aerobic exercise showed improvements in fitness levels[23
]. The optimal type of intervention and its frequency and duration for this population is, however, still unknown and further research is needed to develop treatment recommendations for clinicians treating PwMS with more severe mobility problems. In completing a large multi centre trial it may be possible to examine the subgroups of individuals with specific needs to establish what intervention is best for which sub groups of people with differing impairments in order to allow clinicians to deliver the optimal intervention to match the differing impairments.
The Getting the Balance Right (GTBR) projects is a collaboration between the Physiotherapy Department of the University of Limerick, and MSI that aims to both deliver and evaluate physiotherapy and exercise interventions for people with MS. There are many unknown variables to be examined in this population, therefore in order to determine the research questions with the highest priority a group of physiotherapists specialising in MS, the regional offices of MSI and the latest findings from the literature were consulted. The conclusions of this consultancy period was that the overarching question was what exercise interventions should MSI provide for their members in order to optimise function, reduce fatigue and increase quality of life.