Multimodal Agility-Based Exercise Training for Persons With Multiple Sclerosis: A New Framework

Abstract

Introduction Multimodal agility-based exercise training (MAT) has been described as a framework for fall prevention in the elderly but might also be a valuable concept for exercise training in persons with Multiple Sclerosis (pwMS). The Problem Current recommendations advise pwMS to perform a multitude of different exercise training activities, as each of these has its separate evidence. However, pwMS struggle even more than the general population to be physically active. Additionally, Multiple Sclerosis often leads to co-occurring mobility and cognitive dysfunctions, for which simultaneous, time-efficient, and engaging training approaches are still limited in clinical practice and healthcare. The solution The MAT framework has been developed to integratively improve cardiovascular, neuromuscular, and cognitive function by combining aspects of perception and orientation, change of direction, as well as stop-and-go patterns (ie, agility), in a group-training format. For pwMS, the MAT framework is conceptualized to include 3 Components: standing balance, dynamic balance (including functional leg strength), and agility-based exercises. Within these Components sensory, cognitive, and cardiovascular challenges can be adapted to individual needs. Recommendations We recommend investigating multimodal exercise interventions that go beyond easily standardized, unimodal types of exercise (eg, aerobic or resistance exercise), which could allow for time-efficient training, targeting multiple frequent symptoms of persons with mild disability at once. MAT should be compared to unimodal approaches, regarding sensor-based gait outcomes, fatigue-related outcomes, cognition, as well as neuroprotective, and (supportive) disease-modifying effects.

Multimodal agility-based exercise training (MAT) versus strength and endurance training (SET) to improve multiple sclerosis-related fatigue and fatigability during inpatient rehabilitation: a randomized controlled pilot and feasibility study [ReFEx]

“…This study examined the feasibility of a trial comparing a ‘new’ group-based exercise framework for pwMS (MAT) [ 15 ] with ‘traditional’ exercise (SET) in an inpatient rehabilitation setting. Main clinical outcomes of interest for a definitive RCT were fatigue and fatigability [ 8 ].…”

“…MAT consisted of three components: (I) standing balance exercises, (II) dynamic balance exercises including functional leg strength, and (III) agility-like exercises. Agility-like exercises have been defined as ‘[…] tasks, that require changes of direction, stop-and-go patterns, turns, and changing footwork strategies, with or without responding to a stimulus’ [ 15 ]. For load management in the gym-setting, three sessions with higher physical demands (i.e., agility-like components and functional leg strength) were interspersed with two sessions of lower physical strain (i.e., standing balance and exercises with a cognitive focus).…”

“…We have recently described a group-based exercise training framework for pwMS (multimodal agility-based exercise training [MAT] [ 15 ]), which might comprise several aspects that have been proposed to be beneficial for fatigue reduction, e.g., (I) balance training for making ‘navigating the environment’ less effortful [ 11 ], (II) ‘coordination of eye, head, and whole-body movements’ to ‘reduce the cognitive load associated with conscious compensatory strategies in dynamic environments’ [ 16 ], and (III) ‘improvement of sensory integration with a subsequent reduction of the cognitive load associated with motor processing’ [ 17 ]. As the MAT approach also includes other aspects suitable for inpatient rehabilitation (i.e., group-based, applicable to other neurological conditions [ 18 ]) and is proposed to be beneficial for several symptoms, including fatigability [ 15 ], the ReFEx (Rehabilitation, Fatigue, and Exercise) project aims to compare MAT with a ‘traditional’ exercise approach, namely, strength and endurance training (SET) [ 19 ] during inpatient rehabilitation. Both, strength and endurance training can be considered standard elements in neurorehabilitation facilities in Germany (and for the current clinic) and are part of national-level MS exercise guidelines [ 20 ].…”

Experiences of fatigued persons with multiple sclerosis with multimodal agility-based exercise training and the ReFEx study protocol: a qualitative extension of a feasibility study

“…The MAT group exercised 5 x/week for 30 min in the gym and 3 x/week for 30 min in the pool, both in a group setting of maximum eight participants. The group followed a MAT-manual (see protocol), 21 based on the three components of MAT 16 : (1) standing balance exercises, (2) dynamic balance exercises including functional leg strength and (3) agility-like exercises (eg, change of direction, change of velocity); each with defined sensory modifications and cognitive challenges. For load management in the gym-setting, three sessions with higher physical demands (ie, agility-like components and functional leg strength) were interspersed with two sessions on standing balance or exercises with a cognitive focus.…”

“… 20 Therefore, it was important to ascertain from participants how the high-frequency training (8 sessions/week), and overall rehabilitation schedule affected their fatigue and ability to recover. As MAT has not been applied to pwMS and is designed to challenge motor as well as cognitive aspects 16 —which both are domains of fatigue experience 6 —it was particularly important to ensure that MAT was not perceived as too fatiguing. Second, the type of exercise has been reported as one of the most common facilitators for exercise adherence/participation, and it should match the persons’ capabilities and preferences.…”