We all know that exercise is good for us. It’s shown to reduce blood pressure, cholesterol and protect against infection.
There is evidence for its role in the prevention and management of heart disease, stroke, type 2 diabetes, osteoporosis and dementia.
There’s data to show it can protect against certain types of cancers and reduces your risk of early death by up to one third.
That’s not to mention the wonderful effects of exercise-induced endorphins on your mood.
But for those people living with MS (pwMS), the prescribed wisdom used to be that exercise should be avoided, as increasing your heart rate and temperature could make MS symptoms worse (Uhthoff’s phenomenon).
Whilst this may be true; in the short term at least, there is now absolutely no doubt that exercise is extremely beneficial in MS, and should be an integral part of any MS management program.
Reassuringly, evidence from the HOLISM Study has shown that the greatest benefits of exercise are found in those people going from very little physical activity to moderate levels of activity.
This shows you don’t need to compete in Ironman events to get results. Simply by starting slowly and gradually increasing your levels of activity, under appropriate supervision, you can see meaningful changes in your physical health, mental health and overall quality of life.
For those with greater levels of disability, there is almost always some form of physical activity that will be appropriate, and there many options, from online programs such as the MSGym, to adapted yoga or pilates, many of which are available in local MS Resource Centres.
So “tell me something I don’t already know”, I hear you cry.
Well, further to the initial HOLISM paper on exercise in MS, the team from the Neuroepidemiology Unit at the University of Melbourne has now released some new research on the benefits of exercise in managing MS-related pain. To date, this has been an important omission from the major studies, and one that may have a profound impact.
It is estimated that 85% of pwMS experience pain due to the condition, 30% describe it as their most severe symptom.
PwMS experiencing pain tend to reduce their physical activity, leading to muscle stiffness, weakness and deconditioning. This in turns increases pain and risk of co-morbidities such as heart disease and diabetes, further fuelling a thoroughly vicious cycle.
Pain often leads to increased anxiety, stress, anger or fear, which can cause depression and subsequently heightened one’s perception of pain, and lead to further inactivity. It can also significantly interfere with daily activities of living and employment, all which can have a profound effect on physical functioning, mental health and overall quality of life.
The research team performed a systematic review and meta-analysis to pull together all the published literature on exercise for MS pain.
10 randomised control trials of pwMS met the strict inclusion criteria, and produced some very interesting results. In these studies, participants were undertaking a variety of prescribed exercise programs and were compared to those on waiting lists for the programs or pwMS not changing their lifestyle,
In short, the review found evidence that exercise can reduce pain in pwMS. The observed reduction in pain scores between the exercise and control groups corresponded to a small to medium sized effect.
These results are consistent with previous reviews reporting beneficial effects of exercise on MS disease outcomes such as relapse rates and disability progression.
They are also consistent with the level of benefit seen in those living with chronic pain not due to MS.
Whilst you might be forgiven for thinking that a “small to medium sized benefit” isn’t much to shout about, I would respectfully beg to differ.
The current preferred method for managing chronic MS pain is through the use of anti-epileptic and anti-depressant medications such as gabapentin and amitriptyline.
These treatments are often expensive, come with significant side-effects and often not particularly effective, whereas exercise has many other health benefits, is generally low-cost and accessible, and now there is indication that it may help alleviate pain in pwMS.
The proposed mechanism for such beneficial effects is thought to be due to “exercise-induced neuroplasticity and neuro-regeneration”.
These wordy terms describe the brain’s ability to re-route nerve signals around areas of damage, and to re-grow or repair previously damaged nerve cells. This would therefore fit with pain secondary to areas of MS nerve damage.
Exercise may also improve other factors involved in pain, such as reducing the levels of pro-inflammatory signals in the body, improving muscle strength, posture and mood.
This was a very well-designed and conducted piece of work that gives us important new evidence.
There are however, some notable limitations with this review. They were only 10 appropriate studies included, and inevitably the results of such exercise-based studies are likely to have significant differences between them and are subject to bias on the part of the reporters – all of which can impact on the validity of the results.
The authors quite rightly call for further high-quality randomised control trials to further investigate this potentially promising pain management strategy, and should be credited for opening the discussion.
Until this further evidence becomes available, I still consider it a pretty safe-bet to say that we in the global OMS community have nothing but benefits to expect from whatever type of exercise we choose to engage in, and perhaps even more than we previously thought.
Dr Jonathan White MBChB MRCOG