Multiple prescription guidelines for patients with MS, current

 Multiple Sclerosis (MS) is a chronic, unpredictable
auto immune disease of the central nervous system. The body’s immune system
starts to eat away at the protective coverings of the nerve known as myelin
sheaths. This causes a disruption of the flow of information from the brain to
any part of the body. People who suffer from MS can experience a loss in muscle
coordination, numbness and tingling, fatigue, weakness, pain, spasticity, gait
problems, vision problems, bladder and bowel problems, dizziness, depression,
and emotional and cognitive problems. (NIH, 2017) They can also experience a
host of other symptoms that are less common such as seizures and hearing
problems. Typically, women are more prone to MS then men and the first signs
appear during the ages of 20 to 40 years of age. Currently there is no known
cure for MS. However, there are different treatments being used to help manage the
symptoms and insure that people living with MS can maintain quality of life.
The treatments include pharmaceutical medications, acupuncture, Cannabis, and
physical exercise. Many MS patients invest in different therapies such as; physical,
cognitive, speech, occupational, and vocational therapy to help alleviate some
of their symptoms. The next few paragraphs will explain the exercise prescription
guidelines for patients with MS, current treatment therapies, and lastly,
future treatment options for MS. First up is the physiological mechanism of MS.

               As mentioned before, MS is a
disease that affects the Central Nervous System. Everything we do from taking a
breath to solving a problem requires the use of the CNS. Neurons are the
pathways used to send and receive messages form the brain to the body and vice
versa. A neuron is made up of three main parts; a cell body, an axon, and
dendrites. The cell body houses the nucleus which controls the activities of
the cell. The axon is a long tube like structure that transmits information to
different parts of the body. Dendrites look similar to tree branches and they
are the receivers of information for the neuron. Additionally, myelin sheaths
are thick, protective coverings that surround the axons providing insulation
and rapidly speeding up the transmission of information from neuron to neuron.
(Lodish, H., 1970) The body’s immune system is designed to attack foreign
agents and destroy them. However, in patients with MS their immune system misinterprets
the myelin sheaths as the enemy. The immune cystem is made up of T-cell. When the
T-cells get in to the brain they release cytokines, which trigger macrophages
and B-cells to show up. The B-cells release antibodies that attack the myelin
sheaths. This process is known as a MS attack. (Miljkovi?, D., 2013) Eventually,
this demyelination results in scars of the CNS known as plaque. Once this
happens the myelin sheaths are no longer effective and the axon begins to
degenerate. When the axon becomes deteriorated the messages can become distorted
or they can be completely blocked. (Su, K., 2009) There are four types of MS. The
most common type is relapsing/remitting MS (RRMS) affecting about 85% of this diseased
population. People with RRMS experience attacks that last for days to weeks
followed by some relief of symptoms for weeks to months. In-between these
attacks there is no worsening of neurological function. Secondary Progressive
MS (SPMS) patients experience attacks followed by gradual worsening of neurological
function. Primary Progressive MS (PPMS) patients experience a steady decline of
neurological function without ever experiencing relapses. Progressive Relapsing
MS (PRMS) patients experience a steady decline of neurological function with
the presence of relapses. (Loma, I., 2011) Because MS attacks the CNS almost
anything can be effected in the body. The first sign of MS is usually blurred
or double vision, red or green color distortion, or blindness in an eye. Most
patients experience muscle weakness and difficulties in coordination and balance
that can gradually lead to impaired walking and standing. Exercise is used to alleviate
the pain associated with symptoms of MS.  

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               Exercise has been shown to
improve physiological aspects and quality of life as well as the benefits of
exercise people without the disease experience. It is important for MS patients
to stay physically active because inactivity has been shown to worsen symptoms.
Exercise has not been shown to effect the prognosis or progression of MS. (ACSM,
2011) Of course like most diseased populations there are some considerations that
must be considered when exercising this population. MS patients are at higher
risks for heat sensitivity, incontinence, cardiovascular dysautonomia, tremors,
fatigue, limited balance and coordination, and side effects from medication. (NCHPAD,
2017) According to NCHPAD, The National Center on Physical Activity and
Disability, the patient should participate in cardiovascular exercise 3 to 4
times a week for 20 to 60 minutes a session. The intensity should fall between
12 and 14 on the RPE scale. The modes of exercise should include swimming,
stationary cycling, walking, and aerobic classes. (NCHPAD, 2017) Low to
moderate aerobic fitness intensities are shown to be most effective on quality
of life and cardiovascular fitness in this population. An increase of VO2max, VO2peak,
working capacity, and respiratory function as well as a decrease in tiredness
have been shown to occur. (Halabchi, F., 2017) ACSM’s Aerobic FITT Principle
for MS patients with increased disability include a frequency of 3 to 5 days a
week. They should start off with an intensity of 40% to 70% of their VO2R/HRR
or an RPE of 11 to 14. They should progress from 20 minutes to 60 minutes. If
the patient experiences fatigue quickly they should participate in discontinuous
exercise sessions of at least 10 minutes each. (ACSM, 2013) According to
NCHPAD, the patient should participate in resistance training 2 to 3 times a
week for 10 to 15 minutes a session. The sessions should not be consecutive if
the same muscle groups are being trained. The intensity should be 70% of a 10
rep max, 3 sets with 8 to 12 reps each set. When the patient can lift the weight
for 25 reps during two consecutive sessions the weight can be increased by 10%.
The patient can use any type of resistance training equipment. Depending on the
level of disability the patient should avoid anything that requires
coordination, balance, or anything that fatigues them quickly. (NCHPAD, 2017) Resistance
training has been shown to improve mobility, balance, and a reduction in
fatigue. Strength training the lower body, specifically the knee extensor and
plantar flexor muscles, have been shown to improve walking ability in patients
with an increased disability level. (Halabchi, F., 2017) ACSM’s Resistance FITT
Principle for MS patients with increased disability include a frequency of 2
days a week. They should start off with an intensity of 60% to 80% of their 1RM.
They should start with 1 to 2 sets with 8 to 15 reps each set. Rest times should
be 2 to 5 minutes. Individuals who are more prone to fatigue or those exercising
weaker muscles should stick to the higher end of the rest intervals. They are
recommended to focus on large muscles groups to limit the amount of exercises
performed. (ACSM, 2013) According to NCHPAD, the patient should perform stretching
exercises daily for 10 to 15 minutes. Each stretch should be held for 15 to 30 seconds
each to be most effective. Dynamic stretching should be performed before a
workout and static stretching should be performed after a workout. Stretching
should never be held to the point of pain. Some recommended flexibility
practices include yoga and tai chi. (NCHPAD, 2017) Flexibility training in MS
patients have shown to improve joint mobility impaired from inactivity and
spasticity. Lengthening of the muscles due to stretching contribute to
stability, balance, and maintaining proper posture. (Halabchi, F., 2017) ACSM’s
Flexibility FITT Principle for MS patients with increased disability include a
frequency of 5 to 7 days a week, 1 to 2 times a day. They should stretch to the
point of mild discomfort, but never to the point of pain. They should complete
2 to 4 sets and hold each static stretches for 30 to 60 seconds. (ACSM, 2013)
The best choice of equipment for GXT is leg cycling because some people with MS
experience balance issues. The increase in workload should be mild. Treadmill
GXT can be done in patients with mild MS. (ACSM, 2013) Other therapies used in MS
treatment include medications.

               The most common medications used
to treat MS are anti-inflammatory drugs. MS is caused by inflammation and these
drugs can prevent or counteract the inflammation of joints and tissues.  Examples include Avonex, Betaseron, and Rebif.
(Loma, I., 2011) Immunosuppressant drugs are also used. They limit the immune
systems response that cause the damaging of the myelin sheaths. Examples include Peginterferon
Beta-1a, Azasan, and Gilenya. (Loma, I., 2011) Acupuncture is a common form
of treatment for these patients. Acupuncture uses the insertion of needles to
specific locations on the body to help treat pain. Managing stress and a
healthy diet are also known to stop symptoms from worsening. (NMSS, 2017)

               Stem cell
therapy is a new route that scientists are researching. The idea is to destroy
the body’s immune system and then replace it with new stem cells might possibly
reboot the immune system of someone diagnosed with MS. The therapy has not been
approved yet because more studies are needed to determine its safety and
efficacy. Researches are doing clinical trials to see which stem cell type will
be most effective. (NMSS, 2017) Another treatment that is currently being researched is
Vitamin D supplementation. There have been studies that show vitamin d levels
are lower in patients with MS. (Alharbi, F., 2015) A study done at the New
Jersey Medical School suggested that having an adequate amount of vitamin d in
the system may lower the risk of developing MS. Because African-Americans are more
likely to become vitamin d deficient their levels should be checked when trying
to diagnosis MS. (Swanson, J., 2016) There is not currently one test to
diagnosis MS. However, optical coherence tomography is a relatively new tool
used to help identify patients who might possibly have MS. Studies have shown
that the retinal nerve fiber layer is different in people with MS compared to
people without. (Lamirel, C., 2010) There are plenty of different research
trials and studies currently being conducted to find new treatments and a
possible cure for this life-long disease.