Impactofhigh-intensityexerciseonendurance
capacityandmusclestrengthinpersonswith
MultipleSclerosis.
Students:
ZeelmaekersKimberly
RihonMathias
Co-promoters:
Dr.InezWens
drs.CharlyKeytsman
Promoter:
Prof.Dr.BertOp‘tEijnde
1
2
Acknowledgement
WewanttoexpressourgratitudetotheREVALRehabilitationResearchCenterofthe
BiomedicalResearchInstituteofHasseltUniversityforallowingustousetheirspaceand
professionalequipmentthatmadethisresearchpossible.Furthermore,weexpressour
gratitudetoourfellowstudentsforalwaysbeingabletocountonthem.Finally,butmost
importantly,wewouldliketothanktheco-promoters,Dr.InezWensanddrs.Charly
Keytsman,andpromotorProfdr.BertOp‘tEijndeforguidingusduringtheprocessand
helpingusintimesofneed.
Landen,Zonhoven,30/03/2016
Z.K.andR.M.
3
4
Researchcontext
ThepresentresearchwasperformedattheREVALRehabilitationResearchCenterofthe
BiomedicalResearchInstituteofHasseltUniversity.Itissituatedwithinthedomainof
‘rehabilitationinneurodegenerativediseases’,specificallymultiplesclerosis(MS)and
investigatedtheeffectsofasupervisedhighintensityenduranceandresistancetraining
programonmusclestrengthandendurance/aerobiccapacityinpeoplewithMS.Physical
therapyisknowntohaveseveralpositiveeffectsinpeoplewithMS,rangingfrom
improvementsinqualityoflifetowalkingcapacityandespeciallyinexercisecapacityand
musclestrength,whichareimportanttodecreasepossiblecomorbidities(1,2).Aguideline
ofLatimer-Cheungetal(2013)statedtheneedtotrainatamoderateintensitytoimprove
fitness,mobility,fatigueandhealth-relatedqualityoflife(QoL)andmoststudiesfollowed
theseguidelinesininvestigatingexerciseprograms.Thereforehighintensityprogramshave
beenavoidedinpeoplewithMStominimizepossiblesideeffectssuchasextremefatigue
andlowadherence(1).However,astudyofWensetal(2015)warrantedtoinvestigatethe
influenceofhigherintensitiestofindpossibleeffectsonbloodglucoseandseruminsulin,
whichcouldnotbedetectedbyusingmoderateintensityexerciseprograms(2).Atpresent,
thereisalackofconsensusconcerningthemostoptimalintensitytoobtainpositiveresults
andminimizethepossiblesideeffectsinpeoplewithMS.
Theaimofthisstudywastodeterminetheeffectsofahighintensitysupervisedendurance
andresistanceexerciseprogramonaerobiccapacityandmusclestrengthinpeoplewithMS.
Thisstudyispartofadoctoralresearchentitled‘theinfluenceofrehabilitationon
cardiometabolicriskfactorsinpeoplewithmultiplesclerosis’,investigatingtheeffectofa
highintensityexerciseprogramonvariouscardiometabolicriskfactorsinpeoplewith
multiplesclerosis.ThestudywasconductedattheREVALRehabilitationResearchCenterof
theBiomedicalResearchInstituteofHasseltUniversityledbyProf.Dr.BertOp‘tEijnde,Dr.
InezWensanddrs.CharlyKeytsman.Althoughthedoctoralresearchconsistsoffourmaster
theses,ZeelmaekersKimberlyandRihonMathiasinvestigatedtheeffectsofasupervised
high-intensityrehabilitationprogramonmusclestrengthandaerobiccapacity.
5
Thecontributionofthestudentsconsistedofseveralparts:sincethiswasanongoingstudy,
theresearchdesignandmethodologywerealreadydetermined.Howeverduringthedata
acquisition,bothstudentsparticipatedintheexecutionofthetestingprotocols,aswellas
theguidanceoftheparticipantsduringtheinterventionprogram.Next,eachstudent
acquiredthedataindependentlyandconductedtheirowndataprocessing.Afterwards,
resultswerecomparedandifdissimilaritieswerefound,datawascheckedforerrors.Finally,
thestudentsworkedtogetheronwritingtheacademicthesis,whichinretrospectwas
controlledforgrammaticalfaultsandenhancementsbytheco-promoters.
6
Abstract
Background:Multiplesclerosis(MS)isachronicneurodegenerativediseasecharacterizedby
progressivedemyelinationofthecentralnervoussystem.Theheterogeneoussymptoms,
suchasdeteriorationofmusclestrengthandendurancecapacity,leadtoapredispositionof
asedentarylifestyle.Todiminishthesesymptoms,exercisetherapyisindicated,preferablya
combinedstrengthandendurancetrainingprogram.However,researchtendstofocuson
low-to-moderateintensitiesandonlyonestudydemonstratestheeffectsofacombined
highintensityexerciseprogram.
Objectives:Todeterminewhethera12-weekcombinedhighintensityintervalprogramhas
animpactonmusclestrength,endurancecapacityandbodycompositioninpeoplewithMS.
Participants:Thirty-onepeoplewithMSwereselectedbasedoninclusionandexclusion
criteriaanddividedintoanexperimentalorcontrolgroup.
Measurements:Exercisecapacityandmusclestrengthwereconsideredasprimaryoutcome
measures,whilstbodycompositionwasconsideredasasecondaryoutcomemeasure.
Results:After12weeksoftrainingworkload,VO2max,meanventilatoryexchange(VE)and
musclestrengthimprovedintheinterventiongroup,especiallyfortheweakestleg.In
contrast,thecontrolgroupremainedstableordeterioratedovertime.Nochangesinbody
compositionweredetectedinbothgroups.
Conclusion:PeoplewithMSbenefitfroma12-weekcombinedhighintensityexercise
program,concerningexercisecapacityandmusclestrengthcomparedtousualcare.
7
8
Introduction
Multiplesclerosis(MS)isachronicneurodegenerativeautoimmunediseasecharacterizedby
progressivedemyelinationofthecentralnervoussystem.Theheterogeneoussymptoms,like
increasedfatigueanddecreasedqualityoflife(QoL),resultinthepredispositionofa
sedentarylifestyle,whichinturncannegativelyaffectmusclestrengthandendurance
capacity.Thelatteronecanpossiblyleadtosecondaryhealth-relatedproblemssuchas
developmentofanelevatedcardiovascularriskprofileandmetabolicdiseases(3-5).Other
therapiesareused,suchasmedication,buttheyonlyaffectthesehealth-relatedsymptoms.
Incontrast,exercisetherapyispreferredbecauseofitsinfluenceontheseimpairmentsand
theminimalofside-effects(6).
Evidenceexiststhatendurance-andresistancetrainingatlowtomoderateintensitybenefits
peoplewithMSintermsofisometricmusclestrength,QoL,riskfordepressionandresting
heartrate(7).AguidelineofLatimer-Cheungetal(2013)statedtheimportanceof
combiningbothenduranceandstrengthmodalitiesinexerciseprograms,bytraining
endurancecapacityatmoderateintensitybiweeklyforaminimumof30minutesand
performingresistancetrainingformajormusclegroups(1).Suchcombinedexercise
interventionswouldentailimprovementsinfatigue,mobilityandQoL.Additionally,other
studiesdemonstratethepositiveeffectsofacombinedmild-tomoderateintensityprogram
onMSrelatedsymptoms,suchasmuscleweaknessandexerciseintolerance(1,2,7,8).
HighintensityexerciseprogramshavebeenavoidedinpeoplewithMSbecauseoftheir
possiblesideeffects,suchasincreasedfatigueandloweradherence.Consequently,previous
researchshowsthetendencytoinvestigatetheeffectsoflowtomoderateintensitytraining
programsinpeoplewithMS.However,exerciseinterventionprogramsconsistingofhigh
intensityintervaltraining(HIIT)arewidelyinvestigatedinhealthypersonsprovidinggood
resultsinmusclestrengthandfitness(9).Similarly,areviewbyRaymondetal(2013)
showedmoreimprovementinolderpeoplewhenperformingtrainingathighintensities
regardinglower-limbstrengthcomparedtolowerintensities(10).Itissuggestedthat
programsfocusingatmoderateintensityaresufficienttoimprovemuscleenduranceand
powerwithoutcausinginjuriesinpeoplewithMS(11).Nevertheless,someauthors
9
suggestedthatpeoplewithMScouldalsobenefitfromahigherintensityenduranceor
resistanceexerciseprogram(8,12).Highintensityexerciseprogramscanbeusedto
investigatetheimpactonseveralsecondaryhealthproblemslikeadisturbedseruminsulin
sensitivityandbloodglucoseintolerance,factorswhichcancontributetoelevated
cardiovascularriskprofilesinpeoplewithMS(2,3).
ThestudyofWensetal(2015)wasthefirsttoshowimprovementsinmildtomoderately
impairedpeoplewithMS(meanEDSS3.25)byusingacombinedhighintensityexercise
programconsistingofbothenduranceandstrengthtraining(2).Aspromisingasthese
resultsseem,fromascientificpointofviewsolelyonestudyisnotsufficientforapplication
inpractice.Therefore,thepurposeofthisresearchistoconfirmtheeffectsofacombined
highintensityexerciseprogramonmusclestrength,exercisecapacityandbodycomposition
inmildtomoderatedisabledpeoplewithMS.
Hypothesis
Expectationsofthestudyareasignificantimprovementofexercisecapacityandstrengthin
theinterventiongroupcomparedtothecontrolgroup.Furthermore,webelievethatthe
interventiongroupwillshowahigherdecreaseinfatmassandincreaseinleanbodymass
comparedtothecontrolgroup.Additionally,theinterventiongroupwillshowasignificant
improvementforallparametersafter12weeksoftraining.
10
Methods
Participants
Thirty-onepeoplewithMSdiagnosedaccordingtotheMcDonaldcriteria(13),EDSS<6and
olderthan18yearswereincludedfollowingwritteninformedconsent.Subjectswere
excludediftheyfulfilledoneoftheexclusioncriteria(Table1).Subsequently,participants
weredividedintoanexperimentalorcontrolgroup(Figure1).Afterapprovalbytheethical
committeeoftheJessaHospital(protocolnumber4.84/cardio14.11)andHasseltUniversity,
thetraininginterventionprogramstartedinApril/May2015.
Studydesign
Aftergroupallocation,baselinemeasurementssuchasage,gender,height,weight,BMI,
EDSSscore,typeMS,physicalactivity,DEXAscan,maximalcardiopulmonaryexercisetest
andBIODEX,wereperformedinApril/May2015,onemonthpriortothestartofthe
interventionprogram.Duringthestudy,thecontrolgroupwasaskedtocontinuetheirusual
care,whiletheexperimentalgroupparticipatedina12-weekhigh-intensityexercise
program.Allpostmeasurementswereperformedsimilarlytobaselineprocedureswithin
twoweeksafterthelasttrainingsession.Thepurposeofthebaselinemeasurementswasto
investigatethetrainingeffectintheinterventiongroup.Topreventmuscleexhaustion,
participantswereinstructedtonotperformphysicalactivitywithin48hourspriortothe
test.Forthesamereason,performanceoftheBIODEXandthemaximalcycleergometry
werescheduledwithseparationofatleast48hoursbetween.Strengthmeasurementswere
performedwithbothlegsseparately,respectivelyfirstwiththerightlegandafterwardsthe
leftleg.
11
Procedure
Primaryoutcomemeasures
Exercisecapacity
Toevaluateexercisecapacity,subjectsperformedamaximalcardiopulmonaryexercisetest
onanelectroniccycleergometer(eBikeBasic,GeneralElectricGmbH,Bitz,Germany). Prior
toinitiationofthetest,participantswereaskedtocycle10minuteswithoutresistanceasa
warmingup.Duringthetest,participantswereinstructedtocycleatanaveragespeedof70
roundsperminute(rpm).Thetestwasstoppedwhentheparticipantcouldnotmaintainat
least50rpmorwhenthepointofexhaustionwasreached.Femaleparticipantsbeganata
resistanceof20Wwithanadditionof10Wperminute.Maleparticipants,incontrast,
startedat30Wwithanadditionof15Wperminute.Duringexecutionofthetest,pulmonary
gasexchange(JaegerOxycon,ErichJaegerGmbH,Germany)wascontinuouslymeasured.
Everyminute,meanventilatoryexchange(VE)(l/min),VO2max(ml/kg/min)andrespiratory
exchangerate(RER)weredetermined.ExaminersexecutedaJaegercalibrationeverytesting
day.Meanheartrateperminutewasassessedusinga12leadECG.HRmaxwasdetermined
astheheartrateatthetimetheparticipantceasedtheexercisetest.Furthermore,every2
minutesbloodsamplesfromtheearlobewereobtainedtoassessthebloodlactate
concentrations(mmol/l)usingaportablelactateanalyzer(AccuTrend)(14).
Strength
Bothisometricandisokineticmusclestrengthweremeasuredusinganisokinetic
dynamometer(BIODEXREVAL,UHasselt).First,maximalvoluntaryisometricstrength(Nm)
wasmeasured.Participantswereseateduprightwiththehipsina90°angle,wherebetween
testskneeangledifferedfrom45°and90°.Participantswereinstructedtoperformtwo
maximalisometricextensionsandflexionsalternatedbya30secondrestinterval.The
highestvalueofeachattemptwasconsideredasthemaximalvoluntaryisometricmuscle
strengthofthem.Quadricepsandm.Hamstrings.
Secondly,isokineticstrength(Nm/s)wasdeterminedinthesamepositionbyexecutingone
setof20repetitionsasfastandhardaspossible.Thehighestvaluesofflexionandextension
wereconsideredasthemaximalvoluntaryisokineticmusclestrength.
12
Secondaryoutcomemeasures
Bodycomposition
Fatmass(kg),leanbodymass(kg),totalmass(kg)andfatpercentage(%)weredetermined
usingaDualEnergyX-rayAbsorptiometry(DEXA)scan.Participantswereallowedtoeat
priortotesting.TheDEXAscanwasperformedatREVAL(UHasselt).
Interventionprotocol
Theexerciseinterventionprogramconsistedofprogressiveendurancehigh-intensityinterval
trainingandstrengthtraining,whichconsistedof5trainingsessionsper2weeks.Endurance
trainingwasahighintensityintervaltrainingprogramonacycleergometerwhichwas
individualizedbasedontheresultsofthemaximalexercisetest.Participantscycled5x1
minuteonahighresistancelevelmatching100%ofthemaximalworkload,which
correspondswithapproximately80-90%ofthemaximalheartrate,alternatedbyalow
resistanceduringtherestintervals.Duringthefirst6weeks,therestintervalslasted1
minute,whilsthighresistancecyclingprogressedto2minutesbyadding10secondsevery
week.Forweek7-12,thesametrainingprogramofweek6wasused,withadjustmentof
resistancelevelstocompensatewhenmaximalheartratecouldnotbereachedanymore.
Strengthtrainingfocusedon6majormusclegroupsandprogressedfrom10repetitionsto2
times20repetitionsatamaximalattainableload.Thestrengthtrainingprogramconsistedof
3exercisesforboththeupperandlowerextremities.AtargetBORGscoreof14-16was
consideredidealtodetermineexerciseintensity.Bothstrength-andendurancetraining
wereperformedundersupervisionofatherapist,whoguidedthepatientsandrecorded
possibleproblems.
Statisticalanalysis
AlldatawereanalyzedusingJMPPro12software(SASInstituteInc,Cary,NC).Since
parametrictestingwasnotallowedasthegroupnumberislowerthan30,baseline
differencesandgroupdifferencesbetweenMSgroupswereanalyzedusingtheWilcoxon
test.Possiblechangesovertimeintheexperimentalandcontrolgroupwereevaluatedbya
Wilcoxonsignedranktest.Alldataarepresentedasmean±SEMandp<0.05wassetas
statisticalsignificantthreshold.
13
14
Results
Baselinecharacteristics
Atbaseline,thecontrolgroupconsistedofmorewomenthanmenandsubjectswith
primaryprogressiveMS.However,nodifferencesinbaselinemeasurementswerefound
betweengroups(Table2).
Primaryoutcomemeasure
Exercisecapacity
After12weeksoftraining,theinterventiongroupimprovedsignificantlyforworkload
(144.06wattvs.168.44watt),VO2max(26.77ml/kg/minvs.32.66ml/kg/min)andVE(82.6
L/minvs.99.4L/min)comparedtobaselinemeasurements(Table3).Thecontrolgroup
howeverdeterioratedsignificantlyovertimeforworkload(114.62wattvs.100.77watt)and
RER(1.18vs.1.09).
Forpremeasurements,therewasasignificantdifferenceinVO2max(26.77ml/kg/minvs.
20.78ml/kg/min)betweentheinterventionandcontrolgroup,whichremainedsignificantin
thepostmeasurements(32.66ml/kg/minvs.21.24ml/kg/min).After12weeks,thesame
appliestoworkload(168.44wattvs.100.77),HRmax(162.25bpmvs.140.23bpm),lactate
(5.756mmol/Lvs.4.618mmol/L),VE(99.4L/minvs.59.77L/min),RER(1.18vs.1.09)and
recoverylactate(10.547mmol/Lvs.6.391mmol/L)betweengroups.Thelatterone
deteriorated(8.2mmol/Lvs.10.547mmol/L)overtimefortheinterventiongroup,however
notsignificantly.
Strength
Strongestleg
Bothgroupsdifferedsignificantlyovertimeforboth45°isometricflexion(80.25Nmvs.
90.06Nm;69.08Nmvs.62.92Nm)andextension(111.63Nmvs.123.25Nm;109.67Nmvs.
98.17Nm),howeverwhencomparingmeans,theinterventiongroupdemonstratedan
improvementwhilethecontrolgroupshowedadeterioration(Table4).Thesame
deteriorationwasdetectedforisometric90°extensioninthecontrolgroup(133.75Nmvs.
15
122.5Nm).Forisokineticstrength(Table5),theinterventiongroupshowedasignificant
effectforextension(83.88Nm/svs.89.56Nm/s).
Whencomparingbaselineandpost-measurements,nosignificantgroupeffectswere
establishedforthestrongestleg,exceptfor45°isometricflexioninfavoroftheintervention
groupafter12weeks(90.06Nmvs.62.92Nm).Intheinterventiongrouptheisokinetic
extensionimprovedsignificantlyovertime.
Weakestleg
Nochangeswerefoundovertimeforthecontrolgroup.Theinterventiongroupontheother
handincreasedsignificantlyforisometric45°flexion(63.69Nmvs.75.19Nm)andextension
(101.13Nmvs.116.13Nm),isometric90°flexion(50.38Nmvs.60.5Nm)andextension
(111.75Nmvs.127.63Nm)(Table6)andisokineticextension(74.13Nmvs.80.94Nm/s)
(Table7).Intheinterventionandcontrolgroup,nochangesacrossgroupsforbothbaseline
andpost-measurementswerefound.
Secondaryoutcomemeasure
Bodycomposition
After12weeks,nochangeswereestablishedintheinterventionandcontrolgroup
separately(Table8).Whencomparingbaselinemeasurementsbetweengroups,fatmass
(17,8kgvs.23,1kg)differedsignificantlyinfavoroftheinterventiongroup.Thesameresults
applyforthepostmeasurements(17,0kgvs.23,2kg)andtotalmass(61,2kgvs.70,3kg)
after12weeks.Furthermore,nogroupeffectswerefoundforleanmassandfatpercentage,
however,thelatterdidshowapositivetrend(28.15625%vs.33.030769%).
16
Discussion
ThisstudyshowsthatpeoplewithMScanalsobenefitfroma12-weekcombinedhigh
intensitytrainingprogramintermsofendurancecapacityandmusclestrength.Itiswell
knownthatthesepatientshavehealth-relatedsymptomssuchaselevatedlevelsoffatigue
anddecreasedmusclestrengthandexercisecapacity.Literaturestatesthatlowtomoderate
exercisetherapyhasapositiveinfluenceonthesenegativeconsequences.Nevertheless,at
present,onlyoneotherstudydemonstratedtheeffectsofahigh-intensityenduranceand
strengthexerciseprogram(2).
Theinfluenceofhigh-intensityintervaltraininginMS
Exercisecapacity(workload,VO2max,VE,lactateandrecoverylactate)remainedstableor
improvedovertimeintheinterventiongroup,demonstratingthattrainingiseffectiveto
preventthedeteriorationofexercisecapacity.Incontrast,usualcarepostulates
deterioration.
Likewise,Schmidtetal(2014)investigatedtheeffectofacombinedenduranceandinterval
trainingat65-70%and70-80%oftheparticipants’peakHRrespectively,onpeakoxygen
consumptionandobservedasignificantimprovementafter12months,provingthatthe
declineinexercisecapacityduetotheprogressivecharacterofthediseasecannotonlybe
prevented,butcanalsobereversed(15).
Recoverylactatehowever,increasedunexpectedlybutnotsignificantlyintheintervention
groupafter12weeks.Apossiblehypothesisisthattheparticipantscantolerateahigher
levelduringexercise,whereasbeforetheinterventionprogrampatientshadtocease
trainingatlowerlevels.Anotherpotentialexplanationistheenhancedprocessingofa
higheramountoflactateafterexertion.
Asmentionedintheresults,isometricmusclestrengthoftheweakestlegincreased
significantlyintheexperimentalgroupasexpected,howeverflexion/extensionratiosdid
not.Furthermore,thecontrolgroupdeterioratedingeneralovertime.
Inadditiontothisstudy,Dalgasetal(2009)showedthat12weeksofhighintensity
progressiveresistancetraininghadasignificanteffectonkneeextensorisometricmuscle
strength(16).Thus,itcanbeestablishedthatexerciseathighintensitiescanimprove
17
isometricmusclestrengthinpeoplewithMS.
Incontrast,theflexion/extensionratiosdidnotalterwhichcanbeexplainedbyanincrease
inbothflexionandextensionisometricstrength.
Ingeneral,itcouldbestatedthattheweakestlegimprovedmorethanthestrongerlegin
theinterventiongroup.Likewise,Wensetal(2015)reportedthesamedifferencesbetween
bothlegsaftera24-weekresistanceandendurancetrainingprogram(2).Possible
explanationsforbilateraldifferencesinthepresentstudycouldbethattheweakestleghas
moreroomforimprovementcomparedtothestrongerlegorthatthetrainingprogram
accountsforbilateraldifferences.
Inthepresentstudy,bothisokineticextensorandflexorstrengthimprovedinthe
interventiongroup,howeverthisincreasewasonlysignificantfortheextensors.Similarly,
Souza-Teixeiraetal(2008)reportedthataneight-weeklowtomoderateprogressive
resistancetraininghasapositiveeffectonmuscularenduranceofthekneeextensors(11).
Thisispossiblyduetothefactthattheexerciseprogramconsistedoftwoexercisesforthe
extensorsandonlyonefortheflexors.Theflexion/extensionratiodidnotchangeas
anticipated.Thesamestatementappliestotheisokineticmusclestrengthofthestrongleg.
Ingeneral,itcouldbestatedthattheinterventionprogramhadnoeffectonbody
compositionwhichissurprisingsincehighintensityintervaltrainingisproventohavea
positiveeffectonfatmassinhealthyadolescents(17).Thiscouldbeexplainedbythehigh
intensityofthetrainingprograminwhichalterationsinbodycompositionarenotthemean
purpose.Furthermore,baselinedifferencesinfatmassmakeinterpretationbetweengroup
differencesat12weeksdifficult.Nevertheless,totalmassimprovedafter12weeksinfavor
oftheexperimentalgroup.Wensetal(2015)ontheotherhandreportedasignificant
increaseinleantissuemassafter24-weeksofcombinedtraining.Otheroutcome
parameterssuchastotalmass,adiposeandleantissuemassremainedstable(2).
Overall,theeffectsofcombinedhighintensityintervaltraininginpeoplewithMSonmuscle
strength,endurancecapacityandbodycompositionarescarcelyinvestigated.Inthisstudy,
participantsdidnothaveinjuriesrelatedtotheexerciseprogramanditcanbestatedthat
thecombinedhighintensityprogramwaswelltolerated.
18
Oneofthelimitationsofthepresentstudywasthelackofrandomizationintogroups;the
enrollmentwasbasedonthechoiceoftheparticipants.Thiscanaccountforaself-selection
bias,nevertheless,baselinecharacteristicsdidnotdifferbetweengroups.Duringthestudy,
oneparticipantchangedgroupsbecauseofbreathingdifficultiesduringexerciseandone
decidedtoquitforpersonalreasons.Also,participants,therapistsandassessorswerenot
blinded.
Incontrast,DEXAscan,whichiscommonlyreferredtoinliteratureasthegoldenstandardto
evaluatebodycomposition,isproventobehighlyaccurateinmeasuringfat-freemassand
musclemass(18-23).Inaddition,BIODEXandmaximalcycleergospirometrytestswereused
torespectivelymeasuremusclestrengthandendurancecapacity,whichareproventobe
validandreliablemeasurementtechniques(24,25).Finally,tointerprettheresultsof
musclestrength,adistinctionwasmadebetweenisometricandisokineticstrengthinorder
tobethorough.However,someresultswerenotasexpected.Therefore,furtherresearchis
neededtoinvestigatetheeffectofalong-termcombinedexerciseprogram.
Newperspectives
Inthepresentstudy,peoplewithMSbenefitfromacombined12-weekhigh-intensity
intervalandstrengthexerciseprogramintermsofendurancecapacityandmusclestrength.
However,noconclusionscanbemadeconcerningthemaintenanceofeffectsorpossible
deteriorationonthelongtermaspostmeasurementswereassessedimmediatelyattheend
oftheinterventionprotocol.Furthermore,astudybyMedina-Perezetal(2014)reported
thatresistancetrainingfollowedbyaperiodofdetraining,bothlasting12weeks,returned
maximalvoluntaryisometriccontractiontopre-trainingvalues(26).Consequently,other
trainingstrategiesareneededtosustaintheestablishedeffects.Home-basedtherapy
programsmaybeusefultopreventrelapsesordeterioration.However,researchisscarce
andthereislackofconsistentknowledgeoftheimpactofahome-basedtrainingprogram
onmusclestrength,exercisecapacity,qualityoflifeandfatiguebecausemoststudiesin
peoplewithMSarehospital-basedorconcernanin-oroutpatientrehabilitation.The
disadvantagesofasupervisedprograminpersonswithalong-termdiseasearehighercosts
andtheneedfortransportation(27).Inorderforhome-basedtherapytobeeffective,high
adherencerateandastandardizedrehabilitationprogramisessential.Socialcontactwith
19
thetherapistbycombiningadiarywithvideoortelephonecallsisalsoimportantandgives
theopportunitytoassessprogression.Thiscouldgiveanewperspectiveandchancefor
patientstomaintaintheirresultsathome.However,furtherresearchisindicatedto
investigatethepossibleeffects,butalsootheraspectslikecost-effectiveness.
20
Conclusion
Inconclusion,peoplewithMSbenefitfromacombinedenduranceandstrengthhighintensityprogramconcerningexercisecapacityandmusclestrengthcomparedtousualcare.
Furtherresearchisindicatedtoinvestigatewhetherlongertrainingperiodshavestronger
effectandwhetherthesepositiveeffectscanbemaintainedduringahomebasedhighintensityprogram.
21
22
Referencelist
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Wens.Impactof24weeksofresistanceandenduranceexerciseonglucosetolerance
inpersonswithmultiplesclerosis..2015.
3.
Wens.Doesmultiplesclerosisaffectglucosetolerance?2013.
4.
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5.
Motl.Physicalactivityandmultiplesclerosis:ameta-analysis.2005.
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Motl.Effectofexercisetrainingonqualityoflifeinmultiplesclerosis:ametaanalysis.2008.
7.
Dalgas.Multiplesclerosisandphysicalexercise:recommendationsfortheapplication
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8.
Collett.Exerciseformultiplesclerosis:asingle-blindrandomizedtrialcomparing
threeexerciseintensities.2011.
9.
Weston.Effectsoflow-volumehigh-intensityintervaltraining(HIT)onfitnessin
adults:ameta-analysisofcontrolledandnon-controlledtrials.2014.
10. Raymond.Systematicreviewofhigh-intensityprogressiveresistancestrength
trainingofthelowerlimbcomparedwithotherintensitiesofstrengthtraininginolder
adults.2013.
11. Souza-Teixeira.Effectsofresistancetraininginmultiplesclerosis.2009.
12. Ramos.Theimpactofhigh-intensityintervaltrainingversusmoderate-intensity
continuoustrainingonvascularfunction:asystematicreviewandmeta-analysis.2015.
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22. Ronan.Theevaluationofbodycomposition:ausefultoolforclinicalpractice.2011.
23. Visser.Validityoffan-beamdual-energyX-rayabsorptiometryformeasuringfat-free
massandlegmusclemass.1999.
24. Langeskov-Christensen.ValidityandreliabilityofVO2-maxmeasurementsinpersons
withmultiplesclerosis.2014.
23
25. Surakka.Assessmentofmusclestrengthandmotorfatiguewithakneedynamometer
insubjectswithmultiplesclerosis:anewfatigueindex.2004.
26. Medina-Perez.Effectsofaresistancetrainingprogramandsubsequentdetrainingon
musclestrengthandmusclepowerinmultiplesclerosispatients.2014.
27. Pozzilli.Homebasedmanagementinmultiplesclerosis:resultsofarandomised
controlledtrial.2002.
24
Appendix
Table1Exclusioncriteria
MSrelapsewithin6monthspriortothestudy
Contra-indicationsforincreasedphysicalactivitydiagnosedbyamedicalprofessional
Pregnancy
InadequatecomprehensionoftheDutchlanguage
Participationinanotherstudy
Assessedforeligibility(n=52)
Allocaqon(n=32)
Allocatedtointervenqongroup(n=17)
Allocatedtocontrolgroup(n=15)
Trainingorusualcare
Analysis(n=29)
Intervenqongroup
Controlgroup
• Analysed(n=16)
• Excludedforanalysis(n=1)
• Analysed(n=13)
• Excludedforanalysis(n=2)
Figure1:flowchart
25
TABLE2Baselinesubjectanddiseasecharacteristics
Interventiongroup
Controlgroup
P
Age(years)
NS
52±7
53±10
Gender(M/F)
8/8
4/9
NS
Height(m)
NS
170,7±0,1
170,6±0,1
Weight(kg)
NS
68,8±13,2
76,6±12,2
BMI
NS
23,5±3,1
26,3±3,7
EDSS
2,5
3,3
NS
TypeMS
NS
RR
11
9
SP
5
2
PP
0
2
PA
NS
18,3±11,7
22,9±16,5
Datapresentedasmean±SEM;SEM,standarderrorofmean;NS,notsignificant;S,
significant;BMI,bodymassindex;EDSS,expandeddisabilitystatusscale;MS,multiple
sclerosis;RR,relapseremitting;SP,secondaryprogressive;PP,primaryprogressive;PA,
physicalactivity
Table3Exercisecapacity
Interventiongroup(n=16)
Controlgroup(n=13)
Pre
Post
Pre
Post
a,c
b
VO2max
26,8±8,6
32,7±11
20,8±6,6
21,2±7,5
(ml/kg/min)
HRmax(bpm),
160,6±13,6
162,3±17,9b
145,3±22,2
140,2±22,5
b
c
RER
1,2±0,1
1,2±0,2
1,2±0,1
1,1±0,1
Workload(W)
144,1±68,4c
168,4±74,8b
114,6±43,7c
100,8±38,7
VE
82,5±30,3c
99,4±37,3b,1
68,2±20,7
59,8±22,5
Lact(mmol/l)
5,8±1,73
5,8±1,4b
5,2±2,11
4,6±1,32
1
RecoveryHR
117,6±19,3
122,9±18,6
106,7±14,6
108,2±20,3
(bpm)
Recovery
8,2±33
10,5±10,6b,1
7,4±2,31
6,4±1,62
lactate(mmol/l)
Datapresentedasmean±SEM;Measurementswereperformedatbaselineandafter12
weekstoevaluatepossibleeffectsofusualcareandacombinedtrainingprogram.
a
=P<0,05,differencebetweeninterventionandcontrolatbaseline.
b
=P<0,05,differencebetweeninterventionandcontrolat12weeks.
c
=P<0,05,differencebaselinemeasurementsandmeasurementsat12weeks.
1
=1missingvalue
2
=2missingvalues
3
=3missingvalues
SD,standarddeviation;HRmax,maximumheartrate;RER,respiratoryexchangeratio;VE,
ventilatoryexchange;Lact,lactate
26
Table4Isometricmusclestrengthstrongestleg
Interventiongroup(n=16)
Controlgroup(n=12)
Pre
Post
Pre
Post
b
b
Ext45°(Nm)
111,6±35,1
123,3±41,9
109,7±27,3
98,2±39,9
b
a
b
Flex45°(Nm)
80,3±26,6
90,1±30,7
69,1±22
62,9±21,3
Flex/ext45°
72,9±17,9
74,3±14,4
63,3±16,7
74,9±48,9
b
Ext90°(Nm)
142,4±48,5
144,8±49,7
133,8±40,5 122,5±39,1
Flex90°(Nm)
62,1±19,7
69,1±22,0
57,3±14,9
53,2±19,2
Flex/ext90°
45,1±11,1
49,6±11,9
44,2±9,6
43,9±10,7
Datapresentedasmean±SEM;Measurementswereperformedatbaselineandafter12
weekstoevaluatepossibleeffectsofusualcareandacombinedtrainingprogram.
a
=P<0,05,differencebetweeninterventionandcontrolat12weeks.
b
=P<0,05,differencebaselinemeasurementsandmeasurementsat12weeks.
SD,standarddeviation;Flex,flexion;Ext,extension;Nm,newtonmeter;
Table5Isokineticmusclestrengthstrongestleg
Interventiongroup(n=16)
Controlgroup(n=12)
Pre
Post
Pre
Post
a
Ext(Nm/s)
83,9±28,9
89,6±35,5
73,2±20,6
68,8±19,1
Flex(Nm/s)
52,7±22,4
55,9±22,9
44,6±13,4
42,5±10,6
Ext/flex
62,6±13,3
62,6±9,1
61,2±10,4
62,9±10
Datapresentedasmean±SEM;Measurementswereperformedatbaselineandafter12
weekstoevaluatepossibleeffectsofusualcareandacombinedtrainingprogram.
a
=P<0,05,differencebaselinemeasurementsandmeasurementsat12weeks.
SD,standarddeviation;Flex,flexion;Ext,extension;Nm,newtonmeter;s,seconds;
Table6Isometricmusclestrengthweakestleg
Interventiongroup(n=16)
Controlgroup(n=12)
Pre
Post
Pre
Post
a
Ext45°(Nm)
101,1±45
116,1±45,8
100±36
97,6±40,9
a
Flex45°(Nm)
63,7±26,1
75,2±24,9
61,7±28,3
57,1±29,5
Flex/ext45°
65,2±18,3
68,2±18,2
60,8±15,4
56,8±18,4
Ext90°(Nm)
111,8±49,4a
127,6±47,7
115,6±44,6
113,1±41,5
Flex90°(Nm)
50,4±18,1a
60,5±21,8
51,5±20,1
47,8±22,9
Flex/ext90°
51±24
49,6±16,2
46±12,6
40,7±14,2
Datapresentedasmean±SEM;Measurementswereperformedatbaselineandafter12
weekstoevaluatepossibleeffectsofusualcareandacombinedtrainingprogram.
a
=P<0,05,differencebaselinemeasurementsandmeasurementsat12weeks.
SD,standarddeviation;Flex,flexion;Ext,extension;Nm,newtonmeter;
27
Table7Isokineticmusclestrengthweakestleg
Interventiongroup(n=16)
Controlgroup(n=12)
Pre
Post
Pre
Post
a
Ext(Nm/s)
74,1±35,5
80,9±37,2
69,5±22,1
67,2±23,7
Flex(Nm/s)
42,3±24,7
45,7±24,1
38,6±15,5
37,6±15,2
Ext/flex
56,3±19,8
56,9±20,7
54,7±11
56,3±18,7
Datapresentedasmean±SEM;Measurementswereperformedatbaselineandafter12
weekstoevaluatepossibleeffectsofusualcareandacombinedtrainingprogram.
a
=P<0,05,differencebaselinemeasurementsandmeasurementsat12weeks.
SD,standarddeviation;Flex,flexion;Ext,extension;Nm,newtonmeter;s,seconds;
Table8Bodycomposition
Interventiongroup(n=16)
Controlgroup(n=13)
Pre
Post
Pre
Post
a
b
FatM
17,8±4,7
17±4,8
23,1±6,4
23,2±6,2
(kg)
LeanM
44,4±10,7
44,2±10,3
46,9±9,4
47,1±8,6
(kg)
Total
62,3±12,5
61,2±11,3b
70±11,6
70,3±10,6
M(kg)
%Fat
29±6,7
28,2±7,5
33,1±7,3
33±7
Datapresentedasmean±SEM;Measurementswereperformedatbaselineandafter12
weekstoevaluatepossibleeffectsofusualcareandacombinedtrainingprogram.
a
=P<0,05,differencebetweeninterventionandcontrolatbaseline.
b
=P<0,05,differencebetweeninterventionandcontrolat12weeks.
SD,standarddeviation;g,grams;M,mass;
28
Auteursrechtelijke overeenkomst
Ik/wij verlenen het wereldwijde auteursrecht voor de ingediende eindverhandeling:
Impact of high-intensity exercise on endurance capacity and
in persons with multiple sclerosis
muscle
strength
Richting:
master
in
de
revalidatiewetenschappen
en
kinesitherapie-revalidatiewetenschappen
en
kinesitherapie
musculoskeletale aandoeningen
Jaar: 2016
in alle mogelijke mediaformaten,
Universiteit Hasselt.
-
bestaande
en
in
de
toekomst
te
ontwikkelen
-
de
bij
,
aan
de
Niet tegenstaand deze toekenning van het auteursrecht aan de Universiteit Hasselt
behoud ik als auteur het recht om de eindverhandeling, - in zijn geheel of gedeeltelijk -,
vrij te reproduceren, (her)publiceren of distribueren zonder de toelating te moeten
verkrijgen van de Universiteit Hasselt.
Ik bevestig dat de eindverhandeling mijn origineel werk is, en dat ik het recht heb om de
rechten te verlenen die in deze overeenkomst worden beschreven. Ik verklaar tevens dat
de eindverhandeling, naar mijn weten, het auteursrecht van anderen niet overtreedt.
Ik verklaar tevens dat ik voor het materiaal in de eindverhandeling dat beschermd wordt
door het auteursrecht, de nodige toelatingen heb verkregen zodat ik deze ook aan de
Universiteit Hasselt kan overdragen en dat dit duidelijk in de tekst en inhoud van de
eindverhandeling werd genotificeerd.
Universiteit Hasselt zal
wijzigingen
aanbrengen
overeenkomst.
mij als auteur(s) van de
aan
de
eindverhandeling,
eindverhandeling identificeren en zal
uitgezonderd
deze
toegelaten
door
Voor akkoord,
Rihon, Mathias
Zeelmaekers, Kimberly
geen
deze