Multiple Sclerosis--What is it? Is movement beneficial?
The human organism is truly an amazing machine. We are brilliantly designed in our architecture and function. All to often, unfortunately, things go awry for various reasons and the once perfectly functioning body ceases to operate at the same level it once did. This is the case for many diseases including Multiple Sclerosis. Multiple sclerosis (or M.S.) is a condition that attacks the myelin sheaths of the Central Nervous System (CNS). This essay will focus on what Multiple Sclerosis is, the possible causes and risk factors that can lead to one acquiring MS, and how movement may help improve the function and decrease the symptoms of people with this condition.
Multiple sclerosis is an autoimmune disease in which myelin sheaths of nerve fibers degenerate. The myelin sheaths responsibility is to insulate the nerve fiber which speeds along transmission of impulses from the periphery to the brain and vice versa. With a deteriorating myelin sheath, communication through the nervous system is not as effective as the nerve signal is slowed or stopped thus affecting multiple organs and organ systems. Additionally, M.S. is considered a chronic, inflammatory disorder of central white matter (7) with a prognosis that can vary from asymptomatic to severe disability to death. Briefly, there are four types of M.S. that are known to researchers. Most people (~85%) who have M.S. have what is known as Relapsing Remitting Multiple Sclerosis (RRMS). RRMS is characterized by periodic immune attacks against the white matter of the CNS. Quite often, people with RRMS develop what is known as Secondary Progressive Multiple Sclerosis (SPMS). SPMS tend to have fewer episodes of acute attacks but more of a steady chronic attack against the CNS. The most uncommon form (~5%) of M.S. is referred to as Progressive Relapsing Multiple Sclerosis (PRMS) which is similar in nature to Primary Progressive Multiple Sclerosis (PPMS). PPMS is the most difficult to treat and characterized by a steady onslaught of attacks (15). Symptoms vary greatly amongst people diagnosed with MS. As stated above, some people are completely asymptomatic, but that is rare (15). Possible symptoms of M.S. include balance disturbances, muscle spasm, gait and limb function disorders, numbness, coordination issues, tremors, weakness, bowel malfunction, bladder issues, visual disturbances, pain, hearing loss, dizziness, vertigo, decreased attention span, depression, speech and swallowing symptoms. (12,15) As one can see, the effects of MS are systemic and can affect activities of daily living in a profound way.
So what are the risk factors for acquiring Multiple Sclerosis? So far, women have approximately twice the risk of being diagnosed, as the disorder tends to be diagnosed between the ages of 20 and 40. There also might be a genetic tendency as a risk factor, but it’s not a very strong one if isolated from other co-factors. In addition, Caucasians tend to have the highest risk especially if they originated from the northern latitudes of Europe. M.S. seems to be much more uncommon amongst people living closer to the equator (13). Finally, multiple sclerosis is much more common in certain geographical regions such as northern United States and Canada, Europe, Southeastern Australia, and New Zealand (12) which highlights areas that are further away from the equator and exposed to less UV light.
Moving beyond risk factors, multiple sclerosis definitive cause is a bit of an ongoing mystery, Currently, researchers believe there are multiple variables involved. Some scientists believe that there is a link with geography of the northern latitudes and ones genetics, which may cause an epigenetic risk that might alter gene expression. With less UV light exposure, there may be a lower tendency to make Vitamin D and this might put some people at greater risk (8). Another possible cause of M.S. includes Epstein Barr Virus and smoking (Pubmed). Both of which can alter mitochondrial DNA and possibly affect the immune system. Finally, some researchers point out that M.S. is a possible mitochondrial disease although the mechanism is unclear at this point (7). As with most disease processes, more studies need to be done to narrow down the risk factors as well as the scope of variables at play.
So what is the typical treatment of Multiple Sclerosis? Since M.S. has no current cure, there are a few pharmaceutical grade drug options that patients can chose that may help slow the progress of the disease and to possibly help mitigate the symptoms of M.S. attacks. Treatment for attacks generally includes corticosteroids, which help lower inflammation and severity of attacks especially during spikes. Next, since this can and often leads to being a progressive disease, drugs that help slow the progress of it includes beta interferon’s, Tysabri, Gilenya, Copaxone, and Mitoxantrone. Thirdly antidepressants may be used to help quell various mood and behavioral symptoms including depression. Finally, Baclofen, Zanafelx or benzodiazepine may be used to control muscle spasms. Of course, many of these pharmaceutical drugs have major side effects. Some of which include liver damage, nausea, and can cause damage to the heart among other systemic complications. Not to mention they drugs can be very expensive. So unfortunately, taking pharmaceutical drugs is often a double edge sword (12).
Since pharmaceutical grade medications may contribute to some harsh side effects, many people with M.S. turn to alternative and complimentary modalities to help possibly slow the progress of their disease as well as to help manage symptoms. Physical therapy, yoga, tai chi, balance training and resistance training are all modalities that have some research behind them. We will briefly summarize them. Physical Therapy (Chiropractors may also manage care in a similar fashion) is a medical science that uses a hand on approach to deal with many orthopedic and neurological conditions. For M.S. patients, the goal is helping to lower the symptoms of pain, improve balance, enhance strength, and decrease muscle spasms. Physical Therapy (P.T) can lower thresholds of pain by introducing novel and non threatening stimuli that can help down regulate the perception of pain from the cerebral cortex. Next, Physical Therapy may also introduce strength and balance training that is important in maintaining functional capacity of people suffering from M.S. Additionally, Physical Therapists may introduce electrical stimulation, which can help improve functional gains and decrease muscle spasm. Finally, Physical Therapists can fit and discharge patients with various kinds of orthosis depending on functional needs of the patient; especially as it pertains to gait improvement (1,2,5,10,11).
Going a little bit deeper with resistance training, researchers have tried to find out what parameters of strength training work best. While, research is still on going there are a few interesting items to consider. It seems that heat sensitive persons with M.S. are more tolerant to resistance training as compared to endurance training (cycling, biking, etc). Since heat sensitivity is reported by nearly 60% of people with M.S, it’s good to be aware of training modalities that won’t have a tendency to exacerbate symptoms (14). Next, strength training with an emphasis of resistance at 50-70% of maximal voluntary contraction and repetitions in the 5-12 range has been shown to improve muscular strength and enhance functional capacity. Finally, relatively short sessions are encouraged as to not increase core temperature of the body especially for heat sensitive persons. More research is needed as far as more specific parameters, which includes time under tension, volume of exercise, repetition range, rest between sets, complex and dynamic vs. machine based, and how many sessions per week. There is much to learn. (3,4,11)
Finally, mind body modalities such as Yoga and Tai Chi have also been reported in the literature. Both Yoga and Tai Chi have shown to help lower pain, improve balance, enhance mobility, and increase the function of participants (1,6,9). As with resistance training, mind body modalities still need more research especially with coming up with better parameters of what kind of Yoga and Tai Chi works best, how much, and progression of these two ancient arts (1,6,9). It’s also possible that it is case dependent and an N=1 might tell us more than large group studies. The future looks promising as long as we keep asking questions.
In conclusion, Multiple Sclerosis is thought of as an autoimmune condition in which the body attacks the myelin sheaths of the central nervous system. Multiple Sclerosis affects numerous organ systems and it currently has no cure. While medications can help manage symptoms they come at great financial cost and often have side effects that are harmful. It has been shown in many studies in the literature that mindful movement, resistance training, and balance training can be beneficial in helping manage symptoms and potentially slow the progression of the disease. More research is needed to pinpoint exact parameters and help slow the rate of acquiring this disease via public prevention programs.
1. Cattaneo D, Jonsdottir J, Zocchi M, Regola A. Effects of balance exercises on people with multiple sclerosis: a pilot study. Clinical Rehabilitation. 2007: 21; 771-781.
2. Coote S, Garrett M, Hogan N, Larkin A, Saunders J. Getting the balance right: a randomized controlled trial of physiotherapy and Exercise Interventions for ambulatory people with multiple sclerosis. BMC Neurol. 2009;9:34.Garrett M, et al.
3. Dalgas U, Stenager E, Jakobsen J, et al. Resistance training improves muscle strength and functional capacity in multiple sclerosis. Neurology. 2009;73(18):1478-84.
4. Eftekhari E, Mostahfezian M, Etemadifar M, Zafari A. Resistance training and vibration improve muscle strength and functional capacity in female patients with multiple sclerosis. Asian J Sports Med. 2012;3(4):279-84.
5. Garrett M, Hogan N, Larkin A, Saunders J, Jakeman P, Coote S. Exercise in the community for people with minimal gait impairment due to MS: an assessor-blind randomized controlled trial. Mult Scler. 2012.
6.Husted C, Pham L, Hekking A, Niederman R. Improving quality of life for people with chronic conditions: the example of t'ai chi & multiple sclerosis. Altern Ther Health Med. 1999;5(5):70-4.
7. Mao P, Reddy PH. Is multiple sclerosis a mitochondrial disease? Biochim Biophys Acta. 2010 Jan;1802(1):66-79. doi: 10.1016/j.bbadis.2009.07.002. Epub 2009 Jul 14.
8.Munger KL, Ascherio A. Prevention and treatment of MS: studying the effects of vitamin D. Department of Nutrition, Harvard School of Public Health, Boston, MA 02115. Mult Scler. 2011 Dec;17(12):1405-11.
9. Oken BS, Kishiyama S, Zajdel D, Bourdette D, Carlsen J, Haas M, Hugos C, Kraemer DF, Lawrence J, Mass M. Randomized controlled trial of yoga and exercise in multiple sclerosis. Neurology. 2005; 62:2058-2064
13. Sharpe RJ. “The low incidence of multiple sclerosis in areas near the equator may be due to ultraviolet light induced suppressor cells to melanocyte antigens”. Med Hypotheses. 1986 Apr;19(4):319-23.
14. Skjerbæk AG, Møller AB, Jensen E, et al. Heat sensitive persons with multiple sclerosis are more tolerant to resistance exercise than to endurance exercise. Mult Scler. 2012;