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Exercise during Rehabilitation in PwMS

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Identification of the main targets when quantifying exercise intensities during training in PwMS. …

Identification of the main targets when quantifying exercise intensities during training in PwMS.

Content:
1.Definitions
2.Introduction

3.Endurance Training
3.1 Maximum Oxygen Consumption(VO2max)
3.2 Maximum Heart rate (HRmax)
3.3 Rating of percieved exertion
3.4 Recommendations

4.
Resistance Training
4.1 Normatives
4.2 Quantification of the training intensity
4.3 Conclusions

5.
Discussion

Published in: Health & Medicine

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  • 1. Exercise during Rehabilitation in PwMS Jens Bansi, Sports Scientist, MSc Lucerne, 11.01.2014
  • 2. Aims of this talk 11.01.2014: Identification of the main targets when quantifying exercise intensities during training in PwMS
  • 3. Overview 1. Definitions 2. Introduction 3. Endurance Training 3.1 Maximum Oxygen Consumption(VO2max) 3.2 Maximum Heart rate (HRmax) 3.3 Rating of percieved exertion 3.4 Recommendations 4. Resistance Training 4.1 Normatives 4.2 Quantification of the training intensity 4.3 Conclusions 5. Discussion
  • 4. Definition „Sports therapy“ „Sports therapy is a therapeutic option that regenerates impaired motor, cognitive and social functions, prevents secondary injuries and promotes health orientated behaviours through the resources of sporting activities.“ (Schüle, Huber, 2004) Nice Training !
  • 5. Differences to Physiotherapy? • No sports therapy in the acute phases • Patients must be able to stand or walk • Mainly group therapy
  • 6. Introduction • MS is a chronic disease of the central nervous system (CNS) and is accompanied by varying inflammatory manifestations, demyelinization and axonal loss. Brück 2005
  • 7. Introduction • PwMS develop impaired functional capacity and deficts in cardiovascular functions (Mostert and Kesselring 2002; NG Kent Braun 1997) • MS is associated with reduced physical activity (Motl 2005) • Inactivation often results in comorbidities which further decrease health status (White & Dressendorfer 2004)
  • 8. Circulus vitiosus
  • 9. Exercise = Relapses ? • MS-relapses are not associated with exercise • Results of retrospective analysis show that high levels of exercise are not harmful in PwMS
  • 10. Exercise and disease progression ? • Data show that exercise has the potential of disease- modifying effects
  • 11. Effects of exercise in PwMS ? • Long-termed progressive strength and endrance training intervention over six months • Significant improvements of walking speed (500m walking test)
  • 12. Why exercise PwMS ? • Endurance exercise and resistance training influences fatigue and quality of life • Endurance 11 (1 RCT) , Resistance 4 (1 RCT), Combined 5 (1 RCT)
  • 13. Why exercise PwMS ? • Endurance exercise under immersion enhances BDNF regulation • Moderate exercise intensities were well tolerated although PwMS were severely fatigued and impaired
  • 14. Introduction Taken together • The beneficial effects are well studied • Effects on cytokine response, fatigue and cardiorespiratory fitness are promising • Important aspect of rehabilitation in PwMS
  • 15. 3. Quantification of training intensities in PwMS Endurance training
  • 16. 3.1 Cardiopulmonary parameters Modified according to SWI Magglingen, 2009 VO2 Lactate Heart rate Performance (Speed, Watt) RPE (BORG)
  • 17. Gas- Sampler Turbine ECG / BP Laktat 3.3 Cardiopulmonary exercise testing (CPET)
  • 18. Limitating factors of VO2 max. LUNGS HEART BLOOD central VESSELS MUSCLE peripherial VO2 max. = CO x a-vO2 difference (Cardiac Output = HR x SV) Wasserman et.al 2004
  • 19. KO / GA I GA I/II GA II WK Test start Threshold 1 (LT) Test stop Aerobic, LT Aerobic-anaerobic Anaerobic, RCP Training zones Physiological Zones Training Zones Extensive Stamina Aktive Regeneration, long slow Moderate endurance Intensive Endurance Basic endurance ability Transistion Zone Stamina Supramax. Threshold 2 (RCP)
  • 20. Example of CPET with MS-Patient • MS since 1979; EDSS 5.0 • Relapsing, remitting, since 2010 secondary progressive
  • 21. Example of CPET with MS-Patient • MS since 1979; EDSS 5.0 • Relapsing, remitting, since 2010 secondary progressive
  • 22. Example of CPET with MS-Patient • MS since 1979; EDSS 5.0 • Relapsing, remitting, since 2010 secondary progressive
  • 23. 3.2 Heart rate peak (HRmax) Age predicted maximum heart rate (HRmax): 220 – Age (upright) or 210 – Age (cycle) (SD +/- 10 beats) Chronotropic incompetence: Normal trained subjects will not achieve the calculated values! (Wassermann et al. 2005)
  • 24. 3.2 HRpeak • Better Karvonen formula (1975) (HRmax – HRrest) * X + HRrest (SD +/- five beats) (HRmax – HR rest) = Heart rate Reserve (HRR), X = exercise factor (0.65, 0.7, 0.8) dependent of training status
  • 25. Comparison of estimated training heart rates via formulas with threshold values (Data given as means, SD and p-values of given heart rates) 180-LA;p>0.05 (210-LA)*0,65;p>0.05 (210-LA)*0,70;p>0.05 (210-LA)*0,75;p>0.05 (210-LA)*0,80;p<0.05) 170-0,5LA;p<0.05 65%Hfmax;p>0.05 70%Hfmax;p>0.05 80%Hfmax;p>0.05 75%IANS 85%IANS 70 80 90 100 110 120 130 140 150 160 MeanHR(beats*min-1) Rheuma Neuro Rheuma-75-85%IANS Neuro 75-85%IANS Fenzl and Brockmann SGSM 2006; 54(4): 117-120
  • 26. 3.1 Rating of percieved exertion (RPE) Intensity Very light Fairly light Some- what hard Hard Very hard RPE with Borg sclaes: 6-20 or (1-10) 8-9 (1-2) 10-12 (3-4) 13-14 5-6) 15-16 (7-8) 17-20 (9-10) RPE (Speech) Steadysp eech Prattling Whole senten- ces Exchange of words Strongly accelerated breathing % Heart rate peak (highest value achieved in CPET) 60-70% 70-80% 80-90% 90-95% 95-100% % VO2peak 45-55% 55-70% 70-80% 80-90% 90-100% Training modes Regen- eration Exten- sive in- tensities Inten- sive Endurance run > 2h Stamina, Competitions
  • 27. Diagnostical Drawbacks • Borg scales are subjective measurements • Interactions with fatigue • Do the verbal anchors mean the same for clinical groups ?
  • 28. 3.5 Recommandtions for Endurance training Extensive Intervalltraining… “.. implements intensive exercise bouts on the peripherical muscles which are lower and less intense for the cardiopulmonal system.“ Meyer et al. Z Kardiol 1998;87:8-14. “..leads to significant training effects that are equal to those performed with continuous intensities but use double the amount of time.”Kortianou et al, Cardiopulm Phys Ther 2012;21(3):12-19.
  • 29. 3.5 Recommandtions for Endurance training “Higher training levels lead to short-term immune adaptations that influence HR-QOL, fatigue and cardiorespiratory fitness in PwMS.” Bansi et al, J Neurol 2013;260(12):2993-3001
  • 30. 4. Quantification of training intensity Resistance training
  • 31. Resistance Training in PwMS ? • 12 weeks of PRT improved strength of knee flexors and extensors • Significant effects compared to control group on MVC Dalgas et al. Mult Scler 2010;16(4):480-490
  • 32. Why Resistance Training Florida Group: White et al. Mult Scler 2004; 10: 668-674 • Within group effects for resistance training on MVC • Fatigue Reduction on the MFIS
  • 33. Why Resistance Training Skjerbaek et al: Mult Scler 2013; 19(7): 932- 940 • Higher core temperatures for endurance than for resistance training • Significant correlations to subjective symptom intentensity
  • 34. Resistance Training: Intensity Variantion 1: One –Repetition maximum (1-RPM) Problems: Technique, reliability/validity  Subjectively felt „exhausting- maximum“
  • 35. Quantification of Intensity Variation 2: Dynamometer • Determination of maximum strength through by means of three reference exercises: bench presses, bench traction, and leg presses
  • 36. Example resistance training: Correct training dosage MS since 1985 Secondary, chronic progressive, EDSS 6.0
  • 37. Recommendations Valens clinic : Combined training for PwMS: 3x / Week  Endurance training twice over 30 - 60 Min with 70% of HRpeak  Progressive resistance training twice per week with 65-70% of 1-RPM  Further activation in form of ADL or leisurely activities using lower intensities (< 50% of HRpeak)
  • 38. Conclusions  Literature gives very pricise spezifications which are not always feasible in training practice (laboratory conditions, cost intensive instruments)  Training should be individually suited so that specified goals can be maintained  For resistance training: PwMS should exhausted be at the end of the series
  • 39. Conclusions  Endurance and resistance training are important aspects during standardized rehabilitation with PwMS  Quantified status of cardiorerespiratory fitness influences HR-QoL and fatigue in PwMS  Moderate training intensities are then well tolerated by PwMS
  • 40. Thank you for your attention ! www.kliniken-valens.ch
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