MULTIPLE SCLEROSIS slide.pptx

MULTIPLE
SCLEROSIS (MS)
GROUP 5
Azman Bin Kasim - 2021836888
Mohd Sharizal Bin Che Jamel - 2021656678
Nurul Najwa Ab Rahman - 2021638124
Jass Nuur Farah Farzanah - 2021425446

Introduction Of Multiple Sclerosis (MS)
Idiopathic Inflammatory demyelinating disease of the central nervous system
involve white matter mainly
● Hall mark : characterized typical lesions disseminated in time and space
● Multiple – different areas of the Central nervous system
● Sclerosis – greek word ‘scleros” –Scarring due to plaque formation

Causes of MS
Why the immune system attacks the myelin sheath is unknown.
It appears likely that a combination of external triggers and genes passed down from
your parents contribute to the condition.
As potential causes of MS, the following are some factors that have been put forth:
● Genetics - MS is not inherited, but people who are related to someone who has it
are more likely to develop it; the chance of a sibling or child of someone with MS
developing it is estimated to be 2 to 3 in 100.
● Environmental - lack of vitamin D, Infectious agents, Smoking

Pathophysiology
● MS causes inflammation and demyelination of nerves in the central nervous
system (CNS):
the brain and spinal cord → Loss of insulation (myelin) → poor electrical
conduction, poor coordination of signals → impaired nerve functions,
depending on affected locations
● Continued inflammation results in axonal damage and loss.

● Figure 2.1 Multiple sclerosis
pathophysiology.
Lymphocytes, microglia, and
macrophages destroy myelin
by an as-yet-unknown
mechanism. Antibodies
against myelin also play a
role in the pathogenesis of
this disease.

EPIDEMIOLOGY
● MS affects more than 2 million people worldwide, including about 1 million
individuals in the United States.
● The incidence of MS varies greatly. It is highest among young adults (ages 20–
40),12 but the disease can occur in persons of any age.
● Females are affected more commonly than males, with an approximate female-
to-male ratio of 3:1.
● Genetic risk:
- General population: 0.1%
- People with an affected first-degree relative: 2–4%.
- Monozygotic twins: 30–50%.

Sign & Symptoms
No single symptom or constellation of symptoms is pathognomonic of MS (Thompson
AJ et.al, 2018). However, clinical symptoms stem from neuronal demyelination and loss
of saltatory conduction, resulting in slowing of action potential propagation.
Visual Loss
● Optic neuritis is due to demyelination of the optic nerve, which typically presents
as rapidly progressive visual acuity loss, pain on eye movement, and color
(especially red) desaturation.
Sensory Symptoms
● Impaired vibratory sensation , Loss of proprioception, Pain and temperature loss,
Paresthesias, Numbness

Motor Symptoms
● Weakness affects most patients with MS. Focal weakness is usually due to involvement of
the corticospinal tracts.
● Spasticity is defined as a velocity-dependent increase in resistance to passive muscle
stretch associated with stiffness, pain, spasms, cramping, and gait impairment. Spasticity
typically improves with stretching, exercise, or ambulation.
Gait Abnormalities
● Multiple factors can cause gait abnormalities, including cerebellar or vestibular
dysfunction, weakness, spasticity, and sensory loss.
Pain
● The different types of pain associated with MS can be neurogenic or non- neurogenic, as
well as intermittent or persistent.
Fatigue
● Fatigue is a characteristic finding in patients with MS.It is typically described as physical
exhaustion that is out of proportion to the amount of physical activity performed.

Types Of MS
1. Clinically isolated syndrome (CIS)
● The first clinical presentation of neurological symptoms attributed to inflammation and loss of
myelin in the central nervous system, or CNS, which includes the brain, spinal cord, and optic
nerves.
● This episode must last 24 hours or more, and not be accompanied by fever or infection, to be
considered a first presentation of the disease.
1. Relapsing-remitting MS - The most common form of MS is relapsing-remitting MS (RRMS).
● This form of the disease is characterized by relapses (also called exacerbations), which are
defined by the appearance of new symptoms or the worsening of old symptoms for 24 hours or
more, without a change in body temperature or an infection.
● These relapses are followed by remissions, which are periods of partial or complete recovery
from symptoms. During remissions, all symptoms may disappear or some may continue and
become permanent. However, no apparent progression of the disease occurs during this time.

3. Secondary progressive MS
● Secondary progressive MS (SPMS) is a disease stage that follows RRMS. With this type of MS, a
person’s symptoms steadily worsen, even if the individual experiences no relapses.
● Notably, disease exacerbations still may occur in SPMS. But symptom changes generally are
much less drastic than in the RRMS stage. Also, symptoms do not completely disappear in the
remission phases.
4. Primary progressive MS
● Primary progressive MS (PPMS) is a progressive form of the disease that is diagnosed in about
15% of MS patients.
● Similar to SPMS, it also is characterized by symptoms that become worse over time, without
periods of relapse and remission. However, disease progression starts right from disease
onset — hence the term “primary” progressive.

MS prevalence in Malaysia
● MS is an important neurological disease in Asian neurological practice because of the
high morbidity and mortality although it is not frequently encountered in Asia as
compared to the West.
● Malaysia is an equatorial country located at the latitudes 3°8′N and 101°41′E, with an
estimated 2017 population of 32,179,572, of which 28.7 million are citizens. (Malaysian
Department of Statistics: The 2010 Population and Housing Census of Malaysia,
Malaysian Department of Statistics, 2010)
● Observed MS crude prevalence was defined as the ratio of persons with a confirmed
diagnosis of MS residing nationwide on the prevalence day 29 December 2017, to the
total distribution of the Malaysian population nationwide on the same day, expressed
per 100,000 population, and revalidated using the capture–recapture method on 1
March 2018.

● Data were analyzed using SPSS version 16 (SPSS Inc., Chicago, IL, USA) looking at the descriptive
data, means, medians, percentages, standard deviations, variances, and confidence intervals (CIs)
● Survey has identified 767 cases with validated MS.
● The national crude prevalence rate for MS was 2.73 per 100,000 (95% CI: 2.53; 2.92 per 100,000
population).
● The observed crude annual incidence was 0.55 per 100,000 (95% CI: 0.43; 0.58) for MS.
● These results were comparable to those of the 2013 prevalence study from MOH hospitals, where
MS was 3.23 per 100,000 population, respectively. (S Viswanathan, 2019)

Prevalence of MS by capture–recapture method
● The capture–recapture method revealed the estimated MS population of 913
(95% CI: 910.0; 915.9).
● The estimated MS prevalence values were 3.26 per 100,000 (95% CI: 3.05,
3.47 per 100,000) population.
Prevalence for MS in most urbanized states in Malaysia
● The crude prevalence rates for the most urbanized states with the highest
number of MS patients, is the Federal Territories (FT) and Selangor, were 6.0
per 100,000 (95% CI: 5.28; 6.53 per 100,000 population).

● MS and NMOSD in Malaysia appear to have an urban bias. This may be due to hospital
referral bias and the improved availability/accessibility to neurological/ radiological
services in highly urbanized Selangor and FT. Future studies incorporating the rural
community may reconfirm this and explore the causes. Epidemiologically, the urban-to-
rural mismatch in South East Asia needs more research and attention.
● On a global scale, the prevalence of MS in Malaysia is reflective of the estimated
prevalence in the 2013 revised MSIF Atlas of MS which is applicable to date6. However,
compared to Caucasian-predominant regions and the Middle East, the prevalence of MS
in our study remains low although increasing modestly compared to the past Malaysian
studies from the 1980s suggesting a combination of environmental rather than pure
latitudinal/genetic effects. (Cheong et al., 2018)

Management for MS
Oral Management
● Fingolimod (Gilenya), Dimethyl fumarate (Tecfidera) to
reduce relapse rate.
● Siponimod (Mayzent) to reduce relapse rate and slowing MS
progression.
● Cladribine (Mavenclad) as a second line treatment for relapsing-
remitting MS.

Infusion Management
● Ocrelizumab (Ocrevus). Humanized monoclonal antibody medication is the
only DMT approved by the FDA to treat both the relapse-remitting and
primary-progressive forms of MS.
● Natalizumab (Tysabri). To block the movement of potentially damaging
immune cells from bloodstream to the brain and spinal cord.
● Alemtuzumab (Campath, Lemtrada). Helps to reduce relapses of MS by
targeting a protein on the surface of immune cells and depleting white blood
cells. This effect can limit potential nerve damage caused by the white blood
cells.

Physical Management
Impairment of MS patients like limited mobility, spasticity or paresis is primarily a consequence
of the disease itself, but it can be aggravated by reduced physical activity. (Dalgas et al., 2008).
Exercise has been shown to improve various clinical symptoms in MS patients, particularly
inactivity-related impairment.
Flexibility exercises such as stretching the muscles may diminish spasticity and prevent
future painful contractions.
Cardiorespiratory exercises a review of studies has shown that cardiorespiratory exercise at
low- or moderate-intensity have positive effects on both physiological and psychological factors
among people with MS
Resistance and endurance training enhances muscle strength, and showed beneficial
effects on walking-speed, stepping endurance, stair climbing, timed up and go test, self-
reported disability, and self-reported fatigue have been described in MS patients (Cakit et al.,
2010).

● General therapeutic recommendations can be defined. Since exercise programs have not sufficiently
been investigated in more severely disabled patients, these recommendations are restricted to MS
patients with a maximum EDSS score of 7.0. (Asano et al., 2009)
● Patients should be supervised until they can perform the program adequately and independently.
● Exercise programs should specifically target weaker muscles and encompass preferably multi-
segmental complex movements.
● The intensity should be increased only slowly and should not reach the point of pain. Special care
should be paid to peripheral nerves, particularly overstretching should be avoided.
● Training sessions are recommended to start at a low level, include a light warm up, progress
according to the patients’ clinical state and specific problems, and finally reach light to moderate
intensity

Flexibility Exercises
● Child’s Pose Yoga Stretch - Flexibility for back muscles and glutes
● Arm Circles - Flexibility for upper body
● Seated Hamstring Stretch - Flexibility for hamstring muscles
Cardiorespiratory Exercises
● Walking - A low impact activity that can improve cardiorespiratory
fitness and functional fitness
● Stairmaster - Improving cardiorespiratory fitness
● Seated Cycle - A low impact stationary activity that can improve
cardiorespiratory fitness and increase lower body strength

Resistance and Endurance Training
● Squatting - Strengthen leg muscles. Muscle groups are activated
to simulate functional movements of daily tasks
● Shoulder Press - Strengthen deltoids and triceps and provide
functional movement
● Plank - Strengthen core muscles and incorporates balance

Treatment goals for MS population
● Modify the course of the disease.
● Treat flare-ups.
● Control symptoms.
● Improve physical function.

1. Modify the course disease
Disease-modifying agents are medications that reduce disease activity and slow the progression of MS.
They’re most often used for relapsing forms of MS, which are characterized by a flare-up of symptoms
followed by periods of remission. These medications reduce the frequency and severity of those flare-ups.
Each drug works a little differently, so together with the doctor can decide which is best for the
patient, based on the disease characteristics and health history. There are currently 14 FDA-
approved disease-modifying medications for MS.

Type oF FDA-approved disease-modifying medications for MS
● Aubagio (teriflunomide), a daily pill
● Avonex (interferon beta-1a), a weekly injection
● Betaseron (interferon), an injection taken every other day
● Copaxone (glatiramer), a daily injection
● Extavia (interferon beta-1b), an injection taken every other day
● Glatopa (glatiramer), a subcutaneous injection taken every other day
● Gilenya (fingolimod), a daily pill
● Lemtrada (alemtuzumab), a five-day daily infusion
● Novantrone (mitoxantrone), an IV infusion taken four times a year
● Ocrevus (ocrelizumab), an IV infusion taken once every six months following a pair of initial
infusions taken two weeks apart
● Plegridy (interferon beta-1a), a biweekly injection
● Rebif (interferon beta-1a), an injection taken three times per week
● Tecfidera (dimethyl fumarate), a twice-daily pill
● Tysabri (natalizumab), an IV infusion taken every four weeks

2. Treat Flare-Ups
Because of the anti-inflammatory qualities, corticosteroids are the most commonly
used as medication when MS symptoms flare up. Not all flare-ups require
treatment. However, if the symptoms significantly impair the capacity to function in
daily life, the doctor may recommend a course of corticosteroids.
A flare-up is often treated with a 3 to 5-day course of high-dose corticosteroids
delivered intravenously. Patient may be able to get the IV medication as an
outpatient, either at home or any place Some patients may require hospitalisation
for this treatment.

3. Control Symptoms
Overview of some of the types of medications used to treat different symptoms.
● Ampyra (dalfampridine)—helps walking speed and leg strength
● Antivert (meclizine)—helps control nausea, vomiting, and dizziness
● Cymbalta (duloxetine)—for depression and pain
● Detrol (tolterodine), Minipress (prazosin), and Oxytrol (oxybutynin)—for
bladder dysfunction
● Nydrazid (ixoniazid)—controls tremors
● Levitra (vardenafil)—for erectile dysfunction

4. Improve Physical Function
As part of the treatment, MS patient may be participate in several forms of rehabilitation to help improve how they might be
function in different aspects of their life.
Physical and Occupational Therapy
- Improve in ADL activities
- Improve in balance and coordination
- Improve in cognitive function
- Physical fitness
- Walking mobility
- Improve Balance
- Reduce Fatigue and Depressive symptoms
- Quality of life
- Cognition: Ongoing Study: Study of Exercise on Impact of Cognitive Functioning in Multiple Sclerosis
Patients

Exercises and Multiple Sclerosis
● Impairments related to the disease process itself are irreversible by exercise, but
impairments resulting from deconditioning are often reversible with exercise
(Sandoval, 2013).
● Furthermore, inactivity places MS patients in raised possibility of comorbid health
dependent conditions. (functioning & sclerosis, 2021)
● regular exercise and training is a possible solution during disease period by
limiting the deconditioning process and achieving an optimal level of patient
activity, functions and many physical and mental health benefits without any
concern about a triggering onset or exacerbation of disease symptoms or relapse
(Hvid et al., 2022).
● Appropriate exercise can lead to significant and important improvements in
different areas of cardiorespiratory fitness (Aerobic fitness), muscle strength,
flexibility, stability, tiredness, cognition, quality of life and respiratory
function.(Motl & Sandroff, 2015)

Exercise Screening and Testing for MS
● The 6-min walk test (endurance), timed 5-repetition sit to- stand (strength), timed 25-ft
walk (gait speed), Berg Balance Scale (balance) (Berg, 1989), and Dynamic Gait Index
(dynamic balance) (Herman et al., 2009) are commonly used functional tests for special
population such as stroke, geriatrics, Multiple Sclerosis and etc.
● aerobic training of low to moderate intensity is effective on cardiovascular fitness, mood
and QOL(quality of life) in multiple sclerosis patients with EDSS < 7. (Heine et al., 2015)
(Mostert & Kesselring, 2002)
● resistance training with moderate intensity can induce improvements in muscle strength
and function among moderately impaired persons with MS. (Sandoval, 2013)

patients (Halabchi et al., 2017)
Types Fitness Parameter Measures Comments
Aerobic fitness 6-min walk test
It is used to measure
improvements and
differences in Pre and
Post program
performances but not
to compare them
to “healthy
individuals.”
Total distance walked,
heart rate, RPEa, BP.
The HR response to
exercise may be
decreased
due to autonomic
dysfunction.
Therefore, the
use of the RPE scale
is preferred in these
patients.
Using air conditioner
for all aerobic testing.
Spasticity, lower limb
weakness, and
paralysis
will preclude walking
tests in some patients.
(Halabchi et al., 2017)

Aerobic fitness Submaximal, upright,
or recumbent leg cycle
ergometry. Intermittent
instead of continuous
protocol may be
indicated. Increase
work rate
by 12–25 W per stage.
Workload and steady-
state heart rate to
predict VO2peak;
RPE.
Toe clips and foot
straps may be
necessary in
persons with tremors,
spasticity, or
weakness in
the lower extremities.
Begin with a warm-up
of
unloaded pedaling or
cranking.

Aerobic fitness Combination arm/leg
cycle ergometry.
state heart rate to
predict VO2peak;
RPE.
May reduce difficulty in
individuals with
lower extremity
uncoordination
Experience.
Arm ergometry—
increase work rate 8–
12
W per stage.
state heart rate to
predict VO2peak;RPE.
Alternative for persons
with lower extremity
weakness or paralysis.

Muscular
Strength/Endurance
30-s sit-to-stand test
These tests are used
to measure
improvements
and differences in pre-
and postprogram
performance but not to
compare them to
“healthy individuals.”
Number of times
patient comes to a full
stand with arms
crossing a standard
size chair.
A functional measure
of lower extremity
strength, power, and
muscle endurance.
10RM Testing. Maximal weight lifted
for 10 repetitions
(reps).
Machines provide test
reliability, support, and
joint stability. Remind
patients to exhale on
concentric action and
avoid breath holding.

Flexibility Modified bench sit and
reach test
(1 ft on floor and other
straight).
Distance reached in
hip/trunk flexion.
Administer test with
client seated on a
table.
Goniometry. Range of motion. Focus on flexibility of
hamstrings, hip
flexors,
ankle plantar flexors,
shoulder adductors,
and
internal rotators.

Power/functional Timed up and go test. Time to stand from a
chair, walk a 3-m
round
trip, and sit back down
on the same chair.
Results correlate with
gait speed, balance,
functional level, the
ability to go out.
Five-times sit-to-stand
test.
Time to stand and sit 5
consecutive times on
a standard size chair.
Most useful in patients
≤60 y.

General Exercise Guidelines
● Guidelines from the AHA and the ACSM :
○ A minimum of 30 minutes of moderate-intensity aerobic activity on five
days each week, or a minimum of 20 minutes of vigorous-intensity
activity on three days each week, or some combination of the two.
Exceeding the recommended minimum amount of physical activity will
lead to greater health benefits.
● Muscle strengthening
○ A minimum of two non-consecutive days of the week and should
target 8 to 10 major muscle groups (abdomen, bilateral arms, legs,
shoulders, and hips).
○ Individuals should strive to perform 10 to 15 repetitions of each
exercise at a moderate to high level of intensity and gradually
increase resistance over time.
❖ Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart
Association.AUNelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, Macera CA, Castaneda-Sceppa C, American College of Sports Medicine,
American Heart Association SOCirculation. 2007;116(9):1094. Epub 2007 Aug 1.

Guidelines Cont.
● Flexibility Training
● Flexibility exercises should be performed twice a week
for at least 10 minutes
● Balance Training
○ Balance training may involve activities that challenge gait patterns, such as heel-to-toe walking;
increase awareness of use of the center of gravity for basic movements; and augment different
sensorial systems involved in balance maintenance

Measurement of Intensity
● MET:
○ A metabolic equivalent (MET) is an estimate of oxygen consumed at rest. A
three-MET activity would be an activity that utilizes roughly three times the
amount of resting energy expenditure. Activities between three to six METs are
considered moderate, and activities greater than six METs are considered
vigorous
○ MET are a highly effective way for therapists to measure their patients
progress. Treadmills and other gym equipment will often display METS and
they are a useful method of working out how many calories are burned during
exercise.
○ 1MET = 3.5 mL O2 uptake x body weight in KG x 1minutes.
● Borg Rating of Perceived Exertion
● OMNI-Resistance Exercise Scale

Max and Target HR
● For moderate-intensity physical activity, a person's target heart rate should be 50 to 70% of his or her
maximum heart rate. This maximum rate is based on the person's age. An estimate of a person's maximum
age-related heart rate can be obtained by subtracting the person's age from 220.
● For example, for a 50-year-old person, the estimated maximum age-related heart rate would be
calculated as 220 - 50 years = 170 beats per minute (bpm). The 50% and 70% levels would be:
○ 50% level: 170 x 0.50 = 85 bpm, and
○ 70% level: 170 x 0.70 = 119 bpm
● For vigorous-intensity physical activity, a person's target heart rate should be 70 to 85% of his or her
maximum heart rate
● For example, for a 35-year-old person, the estimated maximum age-related heart rate would be
calculated as 220 - 35 years = 185 beats per minute (bpm). The 70% and 85% levels would be:
○ 70% level: 185 x 0.70 = 130 bpm, and
○ 85% level: 185 x 0.85 = 157 bpm

Guidelines for Exercise in MS
⚫ American Academy of Neurology (AAN) systematic review on rehabilitation in multiple sclerosis (MS) 2015:
● Comprehensive multidisciplinary outpatient rehabilitation (six weeks) is possibly effective for improving
disability/function as measured by functional independence measure (1 Class II study).
● Weekly home PT or outpatient PT (eight weeks) is probably effective for improving balance,
disability, and gait. (1 Class I study)
● Motor and sensory balance training or motor balance training (three weeks) is possibly effective for
improving static and dynamic balance.
● Motor balance training (three weeks) is possibly effective for improving static balance (1 Class II study).

Exercises in MS
● Passive Exercise: Stretching
● Strengthening specific muscle groups: Bands or active
repetitions or weights
● Aerobic Exercise
● Balance Exercise
● Core exercise

MS Benefits of Exercise
● MS specific in the literature:
○ Physical fitness
○ Walking mobility
○ Balance
○ Fatigue
○ Depressive symptoms
○ Quality of life
○ Brain Derived Neurotrophic Factor
■ Brain derived neurotrophic factor (BDNF) is suggested to play a
neuroprotective role in multiple sclerosis (MS)
“Brain derived neurotrophic factor in multiple sclerosis: effect of 24 weeks endurance and resistance training”
Wens I1, Keytsman C1, Deckx N2, Cools N2, Dalgas U3, Eijnde BO1. Eur J Neurol. 2016 Jun;23(6):1028-35

Exercise Training Considerations
● Whenever possible, incorporate functional activities (e.g., stairs, sit-to-stand)
into the exercise program.
● With individuals who have significant paresis, consider assessing RPE of the
extremities separately using the 0–10 OMNI scale to evaluate effects of local
muscle fatigue on exercise tolerance.
● When strengthening weaker muscle groups or working with easily fatigued
individuals, increase rest time (e.g., 2–5 min) between sets and exercises as
needed to allow for full muscle recovery. Focus on large postural muscle
groups and minimize total number of exercises performed.

Exercise Training Considerations
Cont.
● Stretching is most effective when muscles are “warmed up” via exercise.
Caution should be used if moist heat packs are used to warm a muscle due to
the possibility of a reduced ability to thermoregulate body temperature due
to MS.
● Slow and gentle passive ROM exercise should be performed while seated or
lying down to eliminate balance concerns.
● In spastic muscles, increase the frequency and time of flexibility exercises.
Muscles and joints with significant tightness or contracture may require
longer duration (several minutes to several hours) and lower load positional
stretching to achieve lasting improvements. Very low-intensity, low-speed, or
no-load cycling may be beneficial in those with frequent spasticity.
● Watch for signs and symptoms of the Uhthoff phenomenon which typically
involves a transient (<24 h) worsening of neurological symptoms, most
commonly, visual impairment associated with exercise and elevation of body
temperature. Symptoms can be minimized by using cooling strategies and
adjusting exercise time and intensity.

References
Berg, K. (1989). Measuring balance in the elderly: preliminary development of an instrument. Physiotherapy Canada, 41(6), 304–311. https://doi.org/10.3138/ptc.41.6.304
functioning, T. role of aerobic exercise in improving, & sclerosis. (2021). The role of aerobic exercise in improving functioning and treating the symptoms of individuals with multiple
sclerosis. International Journal of Advanced Research in Medicine, 3(2), 91–94. https://doi.org/10.22271/27069567.2021.v3.i2b.222
Heine, M., van de Port, I., Rietberg, M. B., van Wegen, E. E., & Kwakkel, G. (2015). Exercise therapy for fatigue in multiple sclerosis. Cochrane Database of Systematic Reviews.
https://doi.org/10.1002/14651858.cd009956.pub2
Herman, T., Inbar-Borovsky, N., Brozgol, M., Giladi, N., & Hausdorff, J. M. (2009). The Dynamic Gait Index in Healthy Older Adults: The Role of Stair Climbing, Fear of Falling and Gender. Gait
& Posture, 29(2), 237–241. https://doi.org/10.1016/j.gaitpost.2008.08.013
Hvid, L. G., Langeskov-Christensen, M., Stenager, E., & Dalgas, U. (2022). Exercise training and neuroprotection in multiple sclerosis. The Lancet Neurology, 21(8), 681–682.
https://doi.org/10.1016/s1474-4422(22)00219-8
Latimer-Cheung, A. E., Martin Ginis, K. A., Hicks, A. L., Motl, R. W., Pilutti, L. A., Duggan, M., Wheeler, G., Persad, R., & Smith, K. M. (2013). Development of Evidence-Informed Physical
Activity Guidelines for Adults With Multiple Sclerosis. Archives of Physical Medicine and Rehabilitation, 94(9), 1829-1836.e7. https://doi.org/10.1016/j.apmr.2013.05.015
Mostert, S., & Kesselring, J. (2002). Effects of a short-term exercise training program on aerobic fitness, fatigue, health perception and activity level of subjects with multiple sclerosis.
Multiple Sclerosis Journal, 8(2), 161–168. https://doi.org/10.1191/1352458502ms779oa
Motl, R. W., & Sandroff, B. M. (2015). Benefits of Exercise Training in Multiple Sclerosis. Current Neurology and Neuroscience Reports, 15(9). https://doi.org/10.1007/s11910-015-0585-6
Sandoval, A. E. G. (2013). Exercise in Multiple Sclerosis. Physical Medicine and Rehabilitation Clinics of North America, 24(4), 605–618. https://doi.org/10.1016/j.pmr.2013.06.010

MULTIPLE SCLEROSIS slide.pptx

Recommended

Recommended

More Related Content

Similar to MULTIPLE SCLEROSIS slide.pptx

Similar to MULTIPLE SCLEROSIS slide.pptx (20)

Recently uploaded

Recently uploaded (20)

MULTIPLE SCLEROSIS slide.pptx

Editor's Notes