Does strengthening exercise improve function in persons living with Multiple Sclerosis (MS)?
To answer this question, we performed a comprehensive search of the PubMed database (April 2008) research studies that have
addressed this specific research question.
Six research studies met the criteria for inclusion in this review: Only three of these studies were randomized controlled trials. Five
of these studies (1-2,4-6) evaluated the effect of lower extremity (LE) resistance training only, while the
other employed upper and LE resistance training (5). The sample sizes for these studies ranged from 9 to 36
participants with Extended Disability Severity Scores (EDSS) ranging from 1.0 (only one functional system affected) to 6.5 (requiring
an assistive device for ambulation). All studies utilized progressive resistance training (PRT) with varying intensities, frequencies
of training, and overall duration of training. Functional outcomes included gait speed, stair climbing ability, and balance.
(1-6) Despite the wide range of treatment dosage, 4 of the 5 studies reviewed showed improved muscle strength
and functional task performance. None of the trials reported worsening of function. Functional benefit was seen in gait characteristics
(speed, stride length), chair transfers, and stair climbing performance. In those studies that examined upper extremity resistance training,
no functional benefit appeared to be tested for or reported. Sources of variability in methodology that likely affect the conclusions drawn
from these studies include participant characteristics (age, disease subtype, disease severity), intervention specifics (contraction mode,
dosage, muscles trained), and outcome measures utilized.
Based on this review, it appears that persons with MS may experience improvements in muscle strength and functional mobility as a result
of resistance training. Although specific examples of the exercises were not provided, we have selected sample exercises from
VHI PC-Kits that may improve lower extremity muscle strength and gait-related function in ambulatory
persons with MS. If resistance training is implemented in a person with MS, such an intervention should be done in consultation with
the person's neurologist and physical therapist. Careful monitoring should occur during exercise sessions to avoid abnormal autonomic
responses to exercise as well as overheating and over-fatigue. In addition, avoidance of exercise during exacerbation episodes is recommended.
Knee bend from VHI PC-Kits: Geriatric, Knee #2
Long arc quad from VHI PC-Kits: Geriatric, Total Knee #11
Table 1: Overview of Research Studies1
|Study2||Overview||Description of Intervention||Results & Conclusions3
|1) Dalgas et al., 2009|
To test that progressive resistance training (PRT) of the lower body can improve muscle strength and functional capacity in patients
with MS and that the improvements will be maintained for 12 wks after the trial.
38 adults (mean age: experimental 49.1 yrs, control group 47.7 yrs) with mild to moderate severity MS participated (mean EDSS scores,
experimental group 3.9, control group 3.7). All subjects were ambulatory and functionally independent and had not done resistance
training in the 3 mos prior to study enrollment.
Definite relapsing-remitting MS EDSS between 3.0 and 5.5, ability to walk >100m, no need for help with transportation to training
facility, age >18 yrs.
Persons with dementia, alcoholism, or pacemaker treatment, had any serious medical co-morbidities, had experienced an MS attack within
the past 8 wks, or were pregnant. During the study, participants were excluded if they had an attack influencing pyramidal functions
or if they participated in less than 80% of the training sessions.
12 wks of 2x/wk LE resistance training. After warm-up, 5 exercises were performed (leg press, knee extension, hip flexion, hamstring curl,
and hip extension). All exercises were performed with a fast concentric phase and a slow eccentric phase. Progression was as follows: wks
1 and 2, 3 sets of 10 reps at 15 reps maximum (RM); wks 3 and 4, 3 sets of 12 reps at 12RM; wks 5 and 6, 4 sets of 12 reps at 12RM; wks
7 and 8, 4 sets of 10 reps at 10RM; wks 9 and 10, 4 sets of 8 reps at 8RM; wks 11 and 12, 3 sets of 8 reps at 8RM. All exercise sessions
Maintenance of pre-study daily activity level. After the trial, the control group was enrolled in the resistance training intervention.
Pre-Intervention and post intervention (12 wks later) and at follow-up (24 wks later). After post-testing, the control participated in
the resistance training intervention.
Isometric muscle strength of the knee extensors (knee extensor maximal voluntary contraction [KE MVC]) and functional capacity (FS;
combined score of 4 tests: Chair stand test, stair climb test, 10 meter walk, 6 min walk) were utilized.
KE MVC and FS improved after 12 wks of PRT in the exercise group (KE MVC: 15.7% [95% confidence interval 4.3-27.0], FS: 21.5% [95%
confidence interval 17.0-26.1]; p<0.05). Muscle force and all of the functional tests used for the functional capacity score improved
more in the experimental group than in the control group (p <0.05). The improvements of KE and FS in the exercise group persisted at
follow-up after 24 wks. Also, the exercise effects were reproduced in the control group during the 12-wk follow-up period.
12 wks of lower extremity progressive resistance training in persons with MS leads to improvements of muscle strength and functional
mobility, In addition, the exercise effect remain after 12 wks of independent physical activity.
|2) DeBolt et al, 2004|
In persons with Multiple Sclerosis (MS), to examine the effects of an 8-wk home-based resistance training program on balance abilities,
lower extremity muscle power, and functional mobility.
37 participants (29 females; 8 males) distributed to groups via stratified random allocation (stratification by disability level and age).
Inclusion criteria: Otherwise healthy adults with MS who had the ability to walk (with or without assistive devices) at least 20m without
rest (EDSS > 6.5)
Vestibular exercise group, n=17
2 wks of instructional sessions (3x/wk) followed by resistance training 3x/wk for 8 wks. During each exercise session participants
performed a warm-up, 25-30 mins of resistance training (chair raises, lunges, step-ups, heel toe raises, leg curls), and stretching.
Progression: Using a weighted vest, the vest load started at 0.5% of body weight and increased by percentages of body weight (.05%-1.5%)
every 2 wks; wks 1-2: 2 sets of 8-12 reps, wks 2-4: 3 sets of 8-12 reps; wks 5-8, 2 sets of 8-10 reps.
The control group maintained current level of physical activity.
Bi-monthly home visits and weekly phone contact were made for both groups to encourage and monitor compliance.
Primary outcome measures included balance, using antero-posterior sway, medio-lateral sway, and sway velocity measured on an AccuSwayPLUS
force platform; mobility operationally defined as the time to perform the Up and Go test; and leg power, operationally defined as the sum
of the maximal power of both legs divided by body weight. Leg power was measured with the Leg Extensor Power Rig.
Significant group x time interaction for normalized leg extensor power (exercise group 23% increase control group 4% increase). Clinically
significant, though not statistically significant, changes in mobility also (Up and Go time: exercise group 18% faster, control group: no
The authors concluded that the home-based resistance training program was well tolerated by participants, was feasible enough to allow
compliance and offered a practical means to improve leg extensor power and mobility in a short period of time.
|3) Gutierrez et al, 2005|
6) White et al, 2004
To evaluate the effects of an 8-wk lower-body resistance-training program on 1) walking mechanics [Gutierrez et al., 2005], 2) lower
extremity strength, 4) ambulatory function, 5) fatigue, and 6) self-reported disability in persons with multiple sclerosis (MS)
[White et al., 2004].
8 adults with MS (7 females; 1 male). Inclusion criteria: physician-diagnosed MS with an EDSS score between 1 and 5.
Individuals with cardiovascular disease, thyroid disorders, gout, or orthopedic limitations. In addition, individuals using prednisone
or anti-spasticity drugs were excluded.
These publications are presented together because they report on the same group of subjects undergoing the same intervention. They only
differ in the outcome measures reported.
The first 3 wks consisted of participant screening, study orientation and baseline measurements followed by 8 wks of 2x/wk of progressive
resistance exercise training. Duringthe first wk of training, subjects performed 1 set of 6-10 reps at 50% of MVC. During the second wk,
subjects performed 1 set of 10-15 reps at 60% MVC. From wk 3 until wk 8, subjects completed 1 set of 10-15 reps at 70% of maximal predicted
force for all lower body exercises consisting of knee flexion / extension, plantar flexionand spinal flexion / extension using conventional
weight machines. Each time a participant was able to complete 15 reps of an exercise on consecutive sessions, the resistance was progressed
- Muscle strength testing
- as measured by the force produced during a maximal isometric voluntary contraction.
Muscle activation as measured by central activation ratio.
Muscle cross sectional area as measured by MRI.
Percent body fat as measured by skin-folds.
Ambulatory function: 2 measures were used a) a 25-ft walking test, b) a 3-min step test.
Self-reported fatigue and disability: The modified fatigue impact scale and self-assessed EDSS score were used.
Gait spatiotemporal variables and kinematics as measured by a motion analysis system.
Significant increases in knee extension (7.4%), plantar flexion (52%) and stepping performance (8.7%) were observed (p<0.05).
Self-reported fatigue decreased (p<0.05) . In addition, significant increases were observed in percentage of stride time in the
swing phase, step length, stride length, and foot angle. Significant decreases (p<0.05) in percentage of stride time in the stance
and double-support phases, duration of the double-support phase, and toe clearance.
Resistance training appears to be an effective intervention for improving muscle strength, walking distance, gait characteristics, and
fatigue in mild to moderately disabled persons with MS.
|4) Harvey et al,1999|
To examine the role of quadriceps strengthening on muscle strength and function in persons with Multiple Sclerosis.
17 persons with MS (14 females; 3 males) randomly assigned into 1 of 3 groups. Inclusion criteria: 1) Ambulatory with or without the
use ofwalking aids. 2) Not currently undergoing a MS exacerbation and having been relapse-free for the previous 6 mos.
No exercise (n=5)
Mobility exercise (n=6)
Weighted leg exercise (n=6)
The intervention period lasted 8 wks. The no exercise group was asked to continue with their typical daily activities. The mobility
exercise group participated in a therapist- designed program targeted at functional improvements. Components of the mobility program
included stretching, general balance and mobility exercises, swimming, and stationary bicycling. The weighted leg exercise group
performed seated knee extension exercises with ankle weights. ROM for the exercises was from 90 degrees to 45 degrees of knee flexion.
Participants were asked to perform 5 sets of 10 reps 2x/day.
Assessments were completed at baseline and 3 and 6 wks.
Pulse rate before and after a 50 meter walk.
Timed walk. Time to reach 10 meters.
Electromyography of the Quadriceps. Peak amplitude during a maximal voluntary contraction (MVC).
Muscle force during a MVC of the quadriceps.
Timed chair transfer test.
Mean compliance with the mobility and the weighted exercise groups was 69%. No-exercise group subjects: demonstrated declines in most
outcomes over the study period. The mobility exercise group demonstrated no significant change in quadriceps force and EMG but showed
small but consistent improvement in mobility tests. The weighted exercise group showed greater percentage improvement in all outcomes
relative to the other groups, however these improvements were not statistically significant with the exception of the timed chair transfers.
Both mobility exercises and weighted leg exercises produced improvements in walking and transfers. Weighted leg exercise produced
greater strength gains and EMG activity. Participants in the no exercise group made little to no change on all outcomes.
|5) Taylor et al, 2006|
To determine if resistance training program could: (1) increase the ability to generate maximal muscle force, (2) increase muscle
endurance, (3) increase functional activity, and (4) improve overall psychological function of people with multiple sclerosis (MS).
9 adults with MS (7 females; 2 males) completed the program.Inclusion criteria: Participants had to have MS, be between 18 and 65 yrs
old, be able to walk at least 200 m without aid or rest, be medically cleared to participate, and have no other medical conditions
that could put them at risk.
Acute exacerbation of their MS either immediately prior to or during the study, physiotherapy treatment, or any resistance training
in the 4 wks prior to starting the study.
Single group repeated measures design (pre test, post test).
The first 4 wks consisted of a familiarization phase of 3 sessions in those first 4 wks. This was followed by a 10-wk, 2x/wk progressive
resistance exercise training program. Exercises were: Leg press, knee extension, heel raises, Latissimus pull down, arm press, and
seated row. Training intensity was set at a weight which could be lifted for 2 sets of 12 reps (approximately 60-80% of 1 rep max)
- Muscle strength:
The maximum amount of weight lifted in a single seated arm press and seated leg press (1RM).
- Muscle endurance:
The number of reps able to be performed when the weight on the seated arm press and seated leg press was lowered to half of 1RM.
- Self-selected and maximal walking speed:
The time taken for participants to walk the middle 10m of a level 14m walkway.
- Walking endurance:
The distance covered in 2 minutes of walking at the participants preferred speed was measured (2-min walk test).
- Timed stair walk:
The time taken for participants to walk up a flight of 15 steps at comfortable speed.
- Physical and psychological impact of MS:
The multiple sclerosis impact scale (MSIS-29) was used to gain information on the participant's perspective of the physical and
psychological impact of MS on their day-to-day life.
Participants were compliant, and there were no adverse responses to training. There were statistically significant improvements in
arm strength (14.4%), leg endurance (170.9%), and fast walking speed (6.1%). In addition, the perceived impact of MS was reduced.
Adults with MS experienced improved muscle performance and physical activities without adverse events as a result of participation in a
resistance exercise program. These findings suggest that resistance exercise may be a feasible exercise alternative for people with
mild to moderate disability due to MS.
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relating to the use of the information set forth in this Newsletter.
Resistance training improves muscle strength and functional capacity in multiple sclerosis. Neurology. 2009 Nov 3;73(18):1478-84.
The effects of home-based resistance exercise on balance, power, and mobility in adults with multiple sclerosis. Arch Phys Med
Rehabil 2004; 85: 290-97.
Resistance training improves gait kinematics in persons with multiple sclerosis. Arch Phys Med Rehabil 2005; 86: 1824-29.
The effect of weighted leg raises on quadriceps strength, EMG parameters and functional activities in people with multiple sclerosis.
Physiotherapy 1999; 85: 154-61.
Progressive resistance exercise for people with multiple sclerosis. Disabil Rehabil 2006; 28: 1119-26.
Resistance training improves strength and functional capacity in persons with multiple sclerosis. Mult Scler 2004; 10: 668-74.
NOTE: Qualitative results for this
study were reported in: Dodd KJ, Taylor NF, Denisenko S, Prasad D. A qualitative analysis of a progressive resistance exercise programme
for people with multiple sclerosis. Disabil Rehabil 2006; 28: 1127-34.
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