This document summarizes a presentation on quantifying exercise intensity during rehabilitation training for people with multiple sclerosis (PwMS). It defines sports therapy and discusses the benefits of exercise for PwMS. It then focuses on quantifying intensities for endurance and resistance training, discussing methods like maximum oxygen consumption, heart rate peaks, ratings of perceived exertion, and resistance training norms. Recommendations are given for endurance training intensities and a case study is presented. The document concludes that moderate training intensities are well tolerated and beneficial for improving quality of life and reducing fatigue in PwMS.

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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