Comparing Two Protocols of Exercise on Physical Fitness and Psychological Factors of Mild to Moderate Multiple Sclerosis Patients

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS). The prevalence of multiple sclerosis is increasing at an alarming rate in adulthood. The disease can lead to functional limitations in daily activities, progressive disability, and ultimately reduced health-related quality of life (HRQoL) (1). Previous studies have shown that aerobic activity is inversely related to MS symptoms and may be restorative and possibly protective (2, 3). Some of these studies have identified that aerobic exercise improves the quality of life (4), fatigue, aerobic power (5), and depression (6) in MS patients.

Contrary to these studies, other studies have demonstrated no significant effect of this type of exercise (7, 8). Then the study data are controversial and there is no general agreement about the effects of aerobic exercise. High-intensity functional exercise (HIFT) is a type of short-term explosive aerobic exercise that emphasizes functional and multimodal movements; it can improve any level of physical fitness and can increase muscle tone more than traditional aerobic exercise (9). HIFT is a type of aerobic exercise, but in that short period of intense activity separated by a short period of rest is done.

So far, there have still been no attempts to examine scientifically the effect of HIFT exercises and the comparison of this type of exercise with aerobic exercise on the functional readiness of MS patients then there is a notable paucity of studies investigating HIFT exercises.

This study investigated and evaluated the effectiveness of HIFT exercises and aerobic exercise on functional fitness, psychological factors, Expanded Disability Status Scale (EDSS) level, fatigue, cognitive impairment and endurance, health-related quality of life, and stability of female patients with MS.

A total of thirty females from 150 patients with MS were included in this study voluntarily with mean and standard deviation in age range: 31.0 69 ± 5.69 years, height: 159.6 ± 36 6.36 cm, weight: 64.3 ± 8.15 kg, and BMI: 25.1 ± 2.14 kg / m², respectively (Table 1). According to the level of disability, they were divided into three groups: HIFT (10 people), aerobic exercise (10 people), and control (10 people). Patients were pre-tested before and after the primary protocol. The average EDSS of the HIFT group before exposure was 2.35 ± 0.9 changed to 1.35 ± 0.8 after exposure. The average EDSS in the aerobic group from 2.7 ± 0.6 before exposure changed to 1.7 ± 0.9 after exposure and the average EDSS in the control group was changed from 2.85 ± 0.6 before exposure to 3.2 ± 0.7 after it. We recorded a significant meaningful change in EDSS in the HIFT and aerobic group compared to the control group (P ≤ 0.001). The mean lower body strength of the HIFT group before exposure was 13.7 ± 1.8 and changed to 23.7 ± 2.8. In the aerobic group mean of this measurement was changed from 11.1 ± 2.1 to 13.6 ± 1.9 and in the control group from 9.6 ± 2.2 to 8.2 ± 1.8. Lower body strength changes in HIFT and the aerobic group were significantly improved compared to the control group (P ≤ 0.001). we know that lower body strength weakness is one of the most important problems of MS patients and its improvement could make EDSS better. Based on the DAS-21 questionnaire mean level depression in HIFT, aerobic, and control groups were changed from 24.1 ± 1.9, 24.1 ± 1.9, and 24.4 ± 2.1 to 20.8 ± 2.5, 13.2 ± 2.2 and 27.9 ± 2.0. Significant depression improvement in HIFT and the especially aerobic group was seen compared to the control group (P ≤ 0.001). Fatigue is the most common complaint of MS patients. The mean of the MS fatigue scale in the HIFT group was decreased from 41.3 ± 3.1 to 39.8 ± 2.3 and in the aerobic group from 41.3 ± 3.0 to 34.0 ± 3.2 significantly (P ≤ 0.001). However, changes in this scale in the control group from 39.9 ± 3.8 to 40.3 ± 3.4 were incremental. One of the most important questions in our study was the effect of exercise on patients’ quality of life. The mean of patients’ HRQL in the HIFT group was 483.4 ± 2.7 increased significantly to 512.4 ± 806. These changes in the aerobic group were significantly meaningful and recovered from 483.2 ± 2.6 to 509 ± 9.4 (P ≤ 0.001).

The results of the Shapiro-Wilk test showed that the data distribution was normal. Thus, one-way assessment of variance (ANOVA), Tukey post hoc test and Pearson correlation coefficient (Pearson correlation) were used to analyze the data. The following results were obtained by comparing the data before and after the exercises.

The present study results revealed that The HIFT group was more effective than the aerobic exercise group in the lower body strength, upper body strength, static balance, and dynamic balance, of female patients with MS (Table 2).

The Pearson correlation coefficient test results showed a meaningful relationship between lower body strength, upper body strength, anxiety, quality of life, and endurance and stability of patients. Still, there was no meaningful relationship between upper body plus lower body strength and depression, stress, fatigue, and patients' cognitive impairment (Table 2).

Static balance showed a meaningful relationship with anxiety while no meaningful relationship was found with fatigue or cognitive function (Table 2). Dynamic balance did not show any meaningful relationship either with anxiety, fatigue, and cognitive functions (Table 2).

Also, the aerobic activity group was more effective than HIFT on depression, stress, and fatigue, but HIFT showed more effect on anxiety, EDSS, and cognitive disturbances than aerobic exercises did in female patients with MS. Both HIFT and aerobic exercises showed a meaningful effect on Health-related quality of life (HRQoL) equally (Table 2).

The results of the present study indicated that there was a meaningful difference between the mean scores in the intervention groups compared to the control group. Specifically, the level of upper body strength, lower body strength, static balance, and dynamic balance, in the experimental groups increased significantly after six weeks of training compared to the control group. Also, the high-intensity functional training (HIFT) group was better than the aerobic group in other functional components except for dynamic balance. On the other hand, regarding psychological factors and cognitive function, the experimental groups showed a meaningful decrease in depression scores, stress, and anxiety compared to the control group. When comparing the two experimental groups, the aerobic group showed better results in stress and depression variables than the high-intensity functional training group. In contrast, anxiety had worse results.

Treadmill aerobic exercise for four weeks on 19 MS patients significantly increased walking time by ten meters and walking power. Still, the subjects' fatigue level in the study by treadmill aerobic exercise remained unchanged (21). The insufficient number of training sessions and the type of exercise, and the lack of adequate preparation before aerobic exercise could explain the subjects' lack of response to the intervention.

In contrast, Romberg et al., in their study, examined the effect of six months of aerobic hydrotherapy and strength training on 40 MS patients with a disease grade of 1.5 - 5. After six months, the exercise group did not significantly improve balance and oxygen consumption in MS patients (7). The discrepancy in the degree of illness and the power of exercise performed by these patients is one reason for this discrepancy. This is because when the patient performs the exercises at home without the researcher's supervision, it is not possible to accurately control the intensity of the exercise, bearing in mind that determining the appropriate intensity of these exercises according to the degree of the disease can play a decisive role in their effects.

In another study on MS, 34 patients with MS were assigned to a sedentary control group (SED, 11 patients) and two exercise groups, which did 12 weeks of high-intensity exercise (HITR, 12 patients) or high-intensity interval cardiovascular exercise (HCTR, n = 11). This study showed that muscle strength improved in HCTR and HITR, while body fat percentage decreased. Also, endurance capacity and lean tissue mass increased only at HITR (22).

In another study, the effects of various rehabilitation aerobic exercise programs were examined on signaling (anti-inflammatory), functional and cognitive capacity in people with MS. They evaluated seventy-two patients with secondary progressive or relapsing-remitting MS with EDSS 0.6 - 0.3 within three weeks of rehabilitation. The participants participated in a high-intensity interval training (HIIT) course or a moderate-intensity continuous training group. Both groups exercised three times a week. The HIIT group performed high-intensity 1.5 × 5-minute training sessions at 95 to 100% of maximal heart rate (HRmax) followed by 2-minute active load-free pedaling intervals (60% HRmax). That research showed that the study of both chronic and acute effects of exercise in a sample is a robust methodological approach allowing the investigation of any interaction between long-term and short-term immune system function (14). This study is consistent with the present study in terms of the type of intervention and intensity of sports activity. Still, it differs from the present study in terms of the level and degree of disability as well as the number of subjects, training time, and lack of control group.

In the present study, we found that improving the balance of inpatients may also enhance the strength of these muscles. These mechanisms behind these changes can be traced to the effectiveness of resistance training on deep sensory receptors. The present study results are not consistent with DE Bolt & McCubbin's (2004) 's research, which reported that resistance training did not cause significant changes in increasing balance (15). This discrepancy can be associated with the intensity of sports activity, duration, and type of intervention. Those researchers examined the effect of home exercise on their patients' balance and monitored exercise by phone. While in the present study, six weeks of controlled and regular exercise were followed in the research design.

This study is consistent with other studies, which showed that exercise therapy, in addition to the physical impacts, improves the behavior of patients with MS by reducing depression and increasing self-confidence (23, 24). HIFT training was more effective in the anxiety score than in other groups, but aerobic exercise improved and reduced depression and stress scores. The current study results showed a meaningful difference between the mean scores of the HIFT group and aerobic exercise on all three psychological indicators, namely depression, anxiety, and stress in female patients with MS. Perhaps HIFT enhances strength and balance in MS patients by strengthening the systems involved in balance. HIFT can boost the patient's ability to perform his daily activities better and more independently, reduce physical disability, relieve depression, anxiety, and stress, and improve mental health in MS patients. Secondary symptoms are common in MS. Fatigue, cognitive disorders, depression, and anxiety reduce the quality of life of these patients (25). On the other hand, existing drugs have not been able to have a significant effect on improving these symptoms, while they will impose new complications on the patient. Therefore, if exercise can have this significant effect, these symptoms will be managed and treated without complications. And this will be a significant improvement in the management of secondary symptoms of MS.

The limitation of our study is the small sample size in the studied groups, which, although it has caused statistically significant results, it seems that future studies with a higher sample size will provide more reliable results.