Highlights
- •Exercise is effective for improving overall HRQOL in MS.
- •The effect is greater in the physical domain compared to the mental domain of HRQOL.
- •The effect is heavily influenced by exercise parameters.
- •Future studies should examine social support in exercise training for MS.
Abstract
Background
Multiple sclerosis (MS) is an immune-mediated, neurodegenerative disease of the central
nervous system that manifests in symptoms that compromise health-related quality of
life (HRQOL). HRQOL focuses on a person's overall, subjective evaluation of health
status primarily in the physical and mental domains. Exercise training is a form of
rehabilitation for managing MS-related outcomes that might influence HRQOL. Reviews
on exercise training are available, but we are unaware of a recent comprehensive review
and meta-analysis of exercise effects for improving physical and mental domains of
HRQOL. This analysis provides an updated review and meta-analysis of randomized controlled
trials (RCTs) examining interventions consisting of aerobic, resistance and combined
exercise training for improving HRQOL in persons with MS. This systematic review 1)
assessed the overall strength of evidence for exercise interventions on HRQOL, 2)
evaluated the relative effect of exercise interventions on physical and mental domains
of HRQOL, and 3) determined moderators of exercise intervention effects on HRQOL.
Methods
Seven databases were searched for RCTs evaluating physical and/or mental domains of
HRQOL with adults diagnosed with MS and undergoing an intervention of aerobic, resistance
or combined exercise training compared with a non-exercise comparator. Data extraction
included participant and intervention characteristics, and pre- and post-intervention
HRQOL outcome data. Effect sizes (ESs) were calculated as standardized mean differences
(SMDs) and a multilevel random-effects model was used to generate an aggregated SMD
that compared exercise with non-exercise control conditions.
Results
Twelve RCTs met the inclusion criteria and yielded 23 ESs to be analyzed. Participants
(N = 593; 308 intervention vs. 285 control conditions) had a mean (±standard deviation)
age of 42.4 (6.5) years and 80% (18.3%) were female. Results generated a medium effect
of exercise for improving overall HRQOL (ES=0.64, p = 0.0001) with high heterogeneity (Q11=58.8, I2=86.7%). Exercise training yielded a large effect on the physical domain (k = 12, ES=0.82, p<0.0009) and a medium effect on the mental domain (k = 11, ES=0.41, p<0.0001). Moderator analyses identified exercise modality, supervision level, intervention
delivery and length, HRQOL tool, and number of participants with relapsing-remitting
MS as significant influences of ES for HRQOL.
Conclusions
Exercise training is clinically effective for improving overall HRQOL in MS and produces
greater improvements in the physical domain of HRQOL than the mental domain. The moderator
analysis suggests that supervised, aerobic, and group-delivered exercise training
of ≥3 months yields the most influence on HRQOL. Such results may have major implications
for MS treatment and care.
Keywords
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References
- Effect of exercise therapy on quality of life of patients with multiple sclerosis in Iran: a systematic review and meta-analysis.Neurol. Sci. 2017; 38 (Epub 2017/07/09PubMed PMID: 28687973): 1901-1911https://doi.org/10.1007/s10072-017-3047-x
- Effect of 8-week aerobic exercise and yoga training on depression, anxiety, and quality of life among multiple sclerosis patients.Iranian Rehabil. J. 2013; 11 (Epub 12 March 2013): 75-80
- Fast-velocity resistance training improves force development and mobility in multiple sclerosis.Int. J. Sports Med. 2022; 43 (Epub 2021/12/01PubMed PMID: 34847589): 593-599https://doi.org/10.1055/a-1710-1492
- A short questionnaire for the measurement of habitual physical activity in epidemiological studies.Am. J. Clin. Nutr. 1982; 36: 936-942
- Synthesizing standardized mean-change measures.Br. J. Math. Stat. Psychol. 1988; 41: 257-278
- Operating characteristics of a rank correlation test for publication bias.Biometrics. 1994; : 1088-1101
- A review about the impact of multiple sclerosis on health-related quality of life.Disabil. Rehabil. 2003; 25: 1291-1303
- The sickness impact profile: development and final revision of a health status measure.Med. Care. 1981; 19 (Epub 1981/08/01PubMed PMID: 7278416): 787-805https://doi.org/10.1097/00005650-198108000-00001
- Multiple sclerosis and brief moderate exercise. A randomised study.Mult. Scler. 2007; 13: 776-782
- Physical activity, fitness, and health: The model and key concepts. Physical activity, fitness, and health: International proceedings and consensus statement. Human Kinetics Publishers, Champaign, IL, England1994: 77-88
- Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research.Public Health Rep. 1985; 100 (Epub 1985/03/01. PubMed PMID: 3920711; PubMed Central PMCID: PMCPMC1424733): 126-131
- The combination of estimates from different experiments.Biometrics. 1954; 10: 101-129https://doi.org/10.2307/3001666
- Statistical Power Analysis For the Behavioral Sciences.Lawrence Erlbaum Associates, Hillsdale, NJ1988 (2 ed.)
- Multiple sclerosis.Lancet (Lond, Engl). 2008; 372: 1502-1517
- Effects of combined endurance and resistance training in women with multiple sclerosis: a randomized controlled study.Front. Neurol. 2021; 12 (Epub 2021/08/24PubMed PMID: 34421801; PubMed Central PMCID: PMCPMC8374042)698460https://doi.org/10.3389/fneur.2021.698460
- Effects of resistance training in relapsing-remitting multiple sclerosis-a randomised controlled trial.Mult. Scler. 2009; 15 (PubMed PMID: CN-00789720): S13https://doi.org/10.1177/1352458509106961
- Fatigue, mood and quality of life improve in MS patients after progressive resistance training.Mult. Scler. 2010; 16 (Epub 2010/03/03PubMed PMID: 20194584): 480-490https://doi.org/10.1177/1352458509360040
- WHOQOL-BREF quality of life assessment. The WHOQOL Group.Psychol. Med. 1998; 28 (Epub 1998/06/17PubMed PMID: 9626712): 551-558https://doi.org/10.1017/s0033291798006667
- Progressive resistance training did not improve walking but can improve muscle performance, quality of life and fatigue in adults with multiple sclerosis: a randomized controlled trial.Mult. Scler. 2011; 17 (Epub 2011/06/17PubMed PMID: 21677021): 1362-1374https://doi.org/10.1177/1352458511409084
- A nonparametric “trim and fill” method of accounting for publication bias in meta-analysis.J. Am. Stat. Assoc. 2000; 95: 89-98
- The effect of exercise training in adults with multiple sclerosis with severe mobility disability: a systematic review and future research directions.Mult. Scler. Relat. Disord. 2017; 16 (Epub 2017/08/02PubMed PMID: 28755682): 31-39https://doi.org/10.1016/j.msard.2017.06.003
- Bias in meta-analysis detected by a simple, graphical test.BMJ. 1997; 315: 629-634
- ACSM's guidelines for exercise testing and prescription.J. Can. Chiropr. Assoc. 2014; 58 (© jcca 2014.; 2014): 328
- Effects of an individual 12-week community-located "start-to-run" program on physical capacity, walking, fatigue, cognitive function, brain volumes, and structures in persons with multiple sclerosis.Mult Scler. 2019; 25 (Epub 2017/11/09PubMed PMID: 29113572): 92-103https://doi.org/10.1177/1352458517740211
- Exercise in the community for people with minimal gait impairment due to MS: an assessor-blind randomized controlled trial.Mult. Scler. 2013; 19 (Epub 2012/11/07PubMed PMID: 23128667): 782-829https://doi.org/10.1177/1352458512461966
- Exploration of the value of health-related quality-of-life information from clinical research and into clinical practice.in: Mayo Clinic Proceedings. Elsevier, 2007
- GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology.J Clin. Epidemiol. 2011; 64 (Epub 2010/12/28PubMed PMID: 21185693): 380-382https://doi.org/10.1016/j.jclinepi.2010.09.011
- The structure of self-reported health in chronic disease patients.J. Consult. Clin. Psychol. 1990; 2: 22
- Measuring inconsistency in meta-analyses.BMJ. 2003; 327 (Epub 2003/09/06PubMed PMID: 12958120; PubMed Central PMCID: PMCPMC192859): 557-560https://doi.org/10.1136/bmj.327.7414.557
- Quantifying heterogeneity in a meta-analysis.Stat. Med. 2002; 21: 1539-1558
- The multiple sclerosis impact scale (MSIS-29): a new patient-based outcome measure.Brain. 2001; 124 (Epub 2001/05/04PubMed PMID: 11335698): 962-973https://doi.org/10.1093/brain/124.5.962
- Meta-Analytic Statistical Inferences For Continuous Measure Outcomes as a Function of Effect Size Metric and Other Assumptions (Prepared By the University of Connecticut, Hartford Hospital Evidence-Based Practice Center under Contract No. 290-2007-10067-I).AHRQ Publication No, 2013
- Effect of aquatic exercise training on fatigue and health-related quality of life in patients with multiple sclerosis.Arch. Phys. Med. Rehabil. 2012; 93 (Epub 2012/05/23PubMed PMID: 22609300): 1701-1708https://doi.org/10.1016/j.apmr.2012.05.006
- Fatigue and quality of life of women with multiple sclerosis: a randomized controlled clinical trial.J. Sports Med. Phys. Fitness. 2015; 55: 668-674
- Efficacy of high-intensity aerobic exercise on common multiple sclerosis symptoms.Acta Neurol. Scand. 2022; 145 (Epub 2021/10/24PubMed PMID: 34687036): 229-238https://doi.org/10.1111/ane.13540
- Effects of exercise training on fitness, mobility, fatigue, and health-related quality of life among adults with multiple sclerosis: a systematic review to inform guideline development.Arch. Phys. Med. 2013; 94 (PubMed PMID: WOS:000324151900019): 1800-1828https://doi.org/10.1016/j.apmr.2013.04.020
- The multicultural quality of life index: presentation and validation.J. Eval. Clin. Pract. 2011; 17 (Epub 2011/01/07PubMed PMID: 21208350): 357-364https://doi.org/10.1111/j.1365-2753.2010.01609.x
Miller D., Rudick R.A., Hutchinson M. Patient-centered outcomes. Translating clinical efficacy into benefits on health-related quality of life. 2010;74(17 Supplement 3):S24–S35. doi: 10.1212/WNL.0b013e3181dbb884.
- Effect of aerobic interval training on serum IL-10, TNFα, and adipokines levels in women with multiple sclerosis: possible relations with fatigue and quality of life.Endocrine. 2017; 57 (Epub 2017/06/16PubMed PMID: 28616851): 262-271https://doi.org/10.1007/s12020-017-1337-y
- Effects of a short-term exercise training program on aerobic fitness, fatigue, health perception and activity level of subjects with multiple sclerosis.Mult. Scler. 2002; 8 (Epub 2002/05/07PubMed PMID: 11990874): 161-168https://doi.org/10.1191/1352458502ms779oa
- Does the relationship between physical activity and quality of life differ based on generic versus disease-targeted instruments?.Ann. Behav. Med. 2008; 36 (Epub 2008/08/23PubMed PMID: 18719976; PubMed Central PMCID: PMCPMC2893359): 93-99https://doi.org/10.1007/s12160-008-9049-4
- Physical activity and quality of life in multiple sclerosis: intermediary roles of disability, fatigue, mood, pain, self-efficacy and social support.Psychol. Health Med. 2009; 14: 111-124
- Physical activity, self-efficacy, and health-related quality of life in persons with multiple sclerosis: analysis of associations between individual-level changes over one year.Qual. Life Res. 2013; 22 (Epub 2012/03/10PubMed PMID: 22403041): 253-261https://doi.org/10.1007/s11136-012-0149-z
- The benefits of exercise training in multiple sclerosis.Nat. Rev. Neurol. 2012; 8: 487-497
- Benefits of exercise training in multiple sclerosis.Curr. Neurol. Neurosci. Rep. 2015; 15: 1-9
- The truly remarkable universality of half a standard deviation: confirmation through another look.Expert Rev. Pharmacoecon. Outcomes Res. 2004; 4 (Epub 2004/10/01PubMed PMID: 19807551): 581-585https://doi.org/10.1586/14737167.4.5.581
- Randomized controlled trial of yoga and exercise in multiple sclerosis.Neurology. 2004; 62 (Epub 2004/06/09PubMed PMID: 15184614): 2058-2064https://doi.org/10.1212/01.wnl.0000129534.88602.5c
- Impact of aerobic training on fitness and quality of life in multiple sclerosis.Ann. Neurol. 1996; 39 (Epub 1996/04/01PubMed PMID: 8619521): 432-441https://doi.org/10.1002/ana.410390405
- The type of exercise most beneficial for quality of life in people with multiple sclerosis: a network meta-analysis.Ann. Phys. Rehabil. Med. 2022; 65101578
- Long-term exercise improves functional impairment but not quality of life in multiple sclerosis.J. Neurol. 2005; 252 (Epub 2005/03/15PubMed PMID: 15765197): 839-845https://doi.org/10.1007/s00415-005-0759-2
- Multimodal exercise training in multiple sclerosis: a randomized controlled trial in persons with substantial mobility disability.Contemp. Clin. Trials. 2017; 61: 39-47https://doi.org/10.1016/j.cct.2017.07.016
- Comparisons of resistance training and "cardio" exercise modalities as countermeasures to microgravity-induced physical deconditioning: new perspectives and lessons learned from terrestrial studies.Front. Physiol. 2019; 10 (Epub 2019/09/26PubMed PMID: 31551818; PubMed Central PMCID: PMCPMC6746842): 1150https://doi.org/10.3389/fphys.2019.01150
- RoB 2: a revised tool for assessing risk of bias in randomised trials.BMJ. 2019; 366: l4898https://doi.org/10.1136/bmj.l4898
- Evaluating the efficacy of physical activity for influencing quality-of-life outcomes in older adults.Ann. Behav. Med. 1991; 13: 108-116
- Exercise and multiple sclerosis: physiological, psychological, and quality of life issues.J. Sports Med. Phys. Fitness. 2001; 41: 421
- Exercise effects on multiple sclerosis quality of life and clinical-motor symptoms.Med. Sci. Sports Exerc. 2020; 52 (Epub 2019/12/27PubMed PMID: 31876670): 1007-1014https://doi.org/10.1249/mss.0000000000002228
- A health-related quality of life measure for multiple sclerosis.Qual. Life Res. 1995; 4 (Epub 1995/06/01PubMed PMID: 7613530): 187-206https://doi.org/10.1007/bf02260859
- Conducting meta-analyses in r with the metafor package.J. Stat. Softw. 2010; 36: 1-48https://doi.org/10.18637/jss.v036.i03
- Rising prevalence of multiple sclerosis worldwide: insights from the Atlas of MS, third edition.Mult. Scler. 2020; 26 (Epub 2020/11/12PubMed PMID: 33174475; PubMed Central PMCID: PMCPMC7720355): 1816-1821https://doi.org/10.1177/1352458520970841
- The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.Med. Care. 1992; 30 (Epub 1992/06/11. PubMed PMID: 1593914): 473-483
Article info
Publication history
Published online: May 01, 2023
Accepted:
April 30,
2023
Received in revised form:
March 30,
2023
Received:
January 23,
2023
Identification
Copyright
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