SAN DIEGO ― As mounting evidence points to the benefits of physical activity (PA) for patients with multiple sclerosis (MS), researchers at the Hospital for Sick Children in Toronto have developed a mobile app to encourage young patients with the disease to become more active.
The smartphone-based app provides tailored PA information, coaching advice, and tools to increase social connectedness.
A pilot study examining whether the intervention changes activity, depression, and fatigue levels should be wrapped up later this year, but it looks as though the app is succeeding.
“The feedback we’ve gotten so far from our coaches is that the kids seem highly motivated,” one of the creators, E. Ann Yeh, MD, professor in the Faculty of Medicine at the University of Toronto and director of the Pediatric MS and Neuroinflammatory Disorders Program at the Hospital for Sick Children, told Medscape Medical News.
Preliminary work showed that use of the app was associated with a 31% increase in PA.
They discussed this and other studies of the role of exercise in MS here at the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) Forum 2023.
Higher Levels of Depression, Fatigue
Studies show that youths with MS who are less physically active are more likely to experience higher levels of fatigue and depression. Evidence suggests just 15 to 30 more minutes of moderate to vigorous physical activity (MVPA) makes a clinical difference in terms of improved depression and fatigue scores, said Yeh.
With moderate PA (for example, a brisk walk or raking the yard), the maximal heart rate (HRmax) reaches 64% to 76%, while with vigorous PA (which includes jogging/running or participating in a strenuous fitness class), the HRmax reaches 77% to 93%.
Yeh described vigorous PA as “the stuff that makes you sweat, makes your heart rate go up, and makes you not be able to talk when you’re moving.”
As it stands, kids get very little MVPA ― 9.5 min/d, which is well below the recommended 60 min/d.
Adults do a bit better ― 18.7 min/d of MVPA ― but this is still below the recommended 30 min/d.
Being physically active improves fatigue for adults as well as kids. Yeh referred to a network meta-analysis of 27 studies involving 1470 participants that evaluated 10 types of exercise interventions, including yoga, resistance training, dance, and aquatic activities. It found that exercise “does move the needle,” she said. “Regardless of the kind of activity that was studied, fatigue seemed to improve.”
The authors of that study ranked aquatic exercise as the most effective intervention. “It’s possible that aquatics worked better because people who can’t move well feel more comfortable in the water,” Yeh told Medscape Medical News.
But she cautioned that the one study in the meta-analysis that found a “quite strong” effect of aquatic exercise was “very small.”
With regard to depression, which affects about 30% of people with MS, Yeh told the meeting, “unfortunately, the data are less clear” when it comes to PA for adults,. One meta-analysis of 15 randomized controlled trials involving 331 exercising participants and 260 control persons found that only a few studies showed positive effects of exercise on depressive symptoms.
However, Yeh noted that in this review, the baseline depressive symptoms of participants were “above the cutoff level,” which makes it more difficult to demonstrate change in depression levels.
Clear Structural Effects
Researchers have also described clear brain structural and functional effects from being physically active. For example, MVPA has been shown to affect brain volume, and it has been associated with better optical coherence tomography (OCT) metrics, which measures retinal thinning.
As for the impact of exercise on memory deficits, which is of interest, given the current focus on Alzheimer’s disease, “the jury is still out,” said Yeh. One 24-week randomized controlled trial found no difference in results on the Brief Repeatable Battery of Neuropsychological tests between participants who engaged in progressive aerobic exercise and control persons.
However, said Yeh, “the problem may not be with the intervention but with the outcome measures” and potentially with the populations studied.
It might be a different story for high-intensity exercise, though. A study by Danish researchers assessed the effects of a 24-week high-intensity intervention among 84 adult patients with mild-severe impairment.
The primary outcome of that study, which was the percentage of brain volume change, was not met, possibly because the study was too short. There were significant results for some secondary endpoints, including improved cardiorespiratory fitness and lower relapse rate.
“Even though on the face of it, it sounds like a negative study, there were important outcomes,” said Yeh.
Research into the possible mechanisms behind positive effects of PA is limited with regard to patients with MS, said Yeh. Some studies have implicated certain circulating factors, such as the cytokine irisin and brain-derived neurotrophic factor, but more work is needed, she said.
“There is need for further mechanistic knowledge related to exercise in MS, and this must be accomplished through prospective, randomized studies.”
While exercise likely makes some difference for MS patients, the problem is in getting them to be more active. “You can’t just write a prescription,” said Yeh.
“Patients should be doing whatever they can, but gradually, and should not go crazy at the beginning because they’ll just burn out,” she said.
She stressed that patients need to find what works for them personally. It’s also important for them to find ways to be active with a friend who can be “a motivator” to help sustain PA goals, said Yeh.
Patients can also look online for remote PA programs geared to people with MS, which popped up during the pandemic.
Improved Move, Cognition, Pain, Sleep
Commenting for Medscape Medical News, Marwa Kaisey, MD, assistant professor of neurology at Cedars-Sinai Medical Center, in Los Angeles, California, who co-chaired the session highlighting the presentation, praised Yeh’s “excellent talk,” which highlighted the “strong benefit” of exercise for patients with MS.
“As a clinician, I often talk to my patients about the importance of physical exercise and have heard countless anecdotes of how their workout programs helped improve mood, cognition, pain, or sleep.”
However, she agreed there are several areas “where we need more data-driven solutions and a mechanistic understanding of the benefits of physical exercise.”
The pilot study was funded by the Consortium of Multiple Sclerosis Centers. The MS Society of Canada funded early work on the app, and the National MS Society is funding the trial of the app. Yeh receives support from the MS Society of Canada. Kaisey reports no relevant financial relationships.
Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) Forum 2023: Session 6.2. Presented February 25, 2023.
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