Neuroprotective influence of macular xanthophylls and retinal integrity on cognitive function among persons with multiple sclerosis.

BACKGROUND: No studies to date have examined if macular xanthophyll accumulation and retinal integrity are independently associated with cognitive function in individuals with multiple sclerosis (MS). This study explored whether macular xanthophyll accumulation and structural morphometry in the retina were associated with behavioral performance and neuroelectric function during a computerized cognitive task among persons with MS and healthy controls (HCs). METHODS: 42 HCs and 42 individuals with MS aged 18-64 years were enrolled. Macular pigment optical density (MPOD) was measured using heterochromatic flicker photometry. Optic disc retinal nerve fiber layer (odRNFL), macular retinal nerve fiber layer, and total macular volume were assessed via optical coherence tomography. Attentional inhibition was assessed using an Eriksen flanker task while underlying neuroelectric function was recorded using event-related potentials. RESULTS: Persons with MS had a slower reaction time, lower accuracy, and delayed P3 peak latency time during both congruent and incongruent trials compared with HCs. Within the MS group, MPOD explained variance in incongruent P3 peak latency, and odRNFL explained variance in congruent reaction time and congruent P3 peak latency. CONCLUSIONS: Persons with MS exhibited poorer attentional inhibition and slower processing speed, yet higher MPOD and odRNFL levels were independently associated with greater attentional inhibition and faster processing speed among persons with MS. Future interventions are necessary to determine if improvements in these metrics may promote cognitive function among persons with MS.

A syndemics approach to exercise is medicine.

This paper offers new insights into the promotion of the Exercise is Medicine (EIM) framework for mental illness and chronic disease. Utilising the Syndemics Framework, which posits mental health conditions as corollaries of social conditions, we argue that medicalized exercise promotion paradigms both ignore the social conditions that can contribute to mental illness and can contribute to mental illness via discrimination and worsening self-concept based on disability. We first address the ways in which the current EIM framework may be too narrow in scope in considering the impact of social factors as determinants of health. We then consider how this narrow scope in combination with the emphasis on independence and individual prescriptions may serve to reinforce stigma and shame associated with both chronic disease and mental illness. We draw on examples from two distinct research projects, one on exercise interventions for depression and one on exercise interventions for multiple sclerosis (MS), in order to consider ways to improve the approach to exercise promotion for these and other, related populations.

Moderate-to-Vigorous Physical Activity is Related With Retinal Neuronal and Axonal Integrity in Persons With Multiple Sclerosis.

BACKGROUND: Moderate-to-vigorous physical activity (MVPA) may confer benefits for axonal and/or neuronal integrity in adults with multiple sclerosis (MS). PURPOSE: Examine the association between device-measured MVPA with optical coherence tomography (OCT) metrics of retinal nerve fiber layer (RNFL) thickness and total macular volume (TMV) in persons with and without MS. METHODS: Adults with MS (N = 41), along with sex-matched healthy control (HC) participants (N = 79), underwent measurements of retinal morphology via OCT and wore an accelerometer for a period of 7 days as a measure of MVPA. RESULTS: Persons with MS had significantly lower MVPA, RNFL thickness, and TMV compared with HCs. MVPA was correlated with RNFL (r = .38, P < .01) thickness and TMV (r = .49, P < .01). Hierarchical linear regression analyses indicated that addition of MVPA attenuated the Group effect on RNFL and TMV. MVPA accounted for 8% and 3% of the variance in TMV (ß = .343, P < .01) and RNFL thickness (ß = .217, P = .03), respectively. CONCLUSION: MVPA was positively associated with axonal and neuronal integrity assessed by OCT and partially explained group differences in those metrics. These results present possible future targets for MS management by increasing MVPA.

Macular Xanthophylls and Markers of the Anterior Visual Pathway among Persons with Multiple Sclerosis.

BACKGROUND: Multiple sclerosis (MS) can cause retinal thinning among persons with MS with optic neuritis (MS-ON). Macular xanthophylls are carotenoids that comprise the macular pigment, filtering blue light and countering photo-oxidation. However, macular xanthophyll status and its implications for markers of neuroaxonal degeneration have not been examined in MS. OBJECTIVES: This study characterized differences in macular and serum xanthophylls, and retinal morphometry [retinal nerve fiber layer thickness at the macular (mRNFL) and optic disc (odRNFL) and total macular volume (TMV)] in individuals with MS and healthy controls (HC). Associations between macular pigment optical density (MPOD) and retinal morphometry were also examined. METHODS: Adults aged 45-64 y (HC, n = 42; MS, n = 40) participated in a cross-sectional study. MPOD was measured via heterochromatic flicker photometry. Retinal morphometry was measured via optical coherence tomography (OCT). Serum carotenoids were quantified using HPLC. Dietary carotenoids were collected using 7-d records. One-factor ANOVA was conducted to determine group effects on macular, serum, and dietary carotenoids. Partial correlations examined the relations between MPOD, retinal morphometry, diet, and serum carotenoids. RESULTS: Relative to HC, persons with MS-ON had lower MPOD (Cohen's d = 0.84, P = 0.014), lower odRNFL (Cohen's d = 2.16, P <0.001), lower mRNFL (Cohen's d = 0.57, P = 0.028), and lower TMV (Cohen's d = 0.95, P = 0.011). MS without ON (MS) had lower odRNFL (Cohen's d = 0.93, P = 0.001) than HC and lower serum lutein than MS-ON subjects (Cohen's d = 0.65, P = 0.014). Among MS, MPOD was positively correlated with odRNFL thickness (ρ = 0.43, P = 0.049) and TMV (ρ = 0.45, P = 0.039), whereas odRNFL was negatively correlated with serum lutein (ρ = -0.68, P = 0.016) and zeaxanthin (ρ = -0.62, P = 0.028). CONCLUSIONS: Persons with MS-ON exhibited poorer xanthophyll status in the macula and serum. MPOD was associated with beneficial anatomical features in the MS group. These findings warrant confirmation with larger cohorts and prospective trials to evaluate xanthophyll effects on the anterior visual pathway in MS.

Home-based, square-stepping exercise program among older adults with multiple sclerosis: results of a feasibility randomized controlled study.

There is very little known about exercise rehabilitation approaches for older adults with multiple sclerosis (MS), yet this growing segment of the MS population experiences declines in cognition and mobility associated with disease progression and aging. We conducted a RCT examining the feasibility of a 12-week, home-based Square-Stepping Exercise (SSE) program in older adults with MS. Older adults with MS (N = 26) with mild-to-moderate levels of disability were recruited and randomized into the intervention (i.e., SSE) or a minimal activity, attention-control conditions. Participants in the SSE condition received a mat for home-based practice of the step patterns, an instruction manual, and a logbook along with a pedometer for monitoring compliance. Both conditions received weekly Skype™ calls and had biweekly meetings with an exercise trainer. Feasibility was assessed based on process, resource, management and scientific outcomes. Regarding scientific outcomes, participants in both conditions completed in-lab assessments before and after the 12-week period. Twenty-five participants completed the study (96%) and the total cost of the study was $13,387.00 USD. Pedometer data demonstrated good compliance with the SSE intervention condition. Effect sizes calculated for all treatment outcomes ranged from small-to-moderate for both mobility and cognitive variables between the intervention and attention-control conditions, thereby providing preliminary evidence that participation in the SSE program may improve cognition and mobility function. The results support the feasibility, acceptability, and possible efficacy of a home-based SSE intervention for older adults with MS.

Investigating the needs and wants of healthcare providers for promoting exercise in persons with multiple sclerosis: a qualitative study.

PURPOSE: We undertook a qualitative study that explored the needs of healthcare providers for promoting exercise behaviour among persons with mild or moderate multiple sclerosis (MS). METHODS: We used interpretive description methodology, and conducted semi-structured interviews with Neurologists (n = 13), occupational therapists (n = 10), physical therapists (n = 11), and nurses (n = 10). The interviews were analysed using thematic analysis. RESULTS: We identified three themes with multiple subthemes regarding exercise promotion by healthcare providers. The first theme was "opportunities for exercise promotion" through the healthcare system, healthcare team, and clinical appointment. The second theme was "healthcare provider education" that included professional training, training among healthcare providers, and clear and defined exercise promotion protocols. The third theme was "patient tools/strategies" that should be delivered among persons with MS as part of the exercise prescription. CONCLUSIONS: Providers in MS healthcare consider the patient-provider interaction within the healthcare system, healthcare team, and clinical appointment as a novel opportunity for exercise promotion. Such an opportunity requires education of healthcare providers and provision of tools and strategies for exercise promotion among persons with MS. Implications for rehabilitation Healthcare providers are interested in and motivated for promoting exercise participation among persons with multiple sclerosis. Successful exercise promotion must consider opportunities at three different organisational levels, namely the healthcare system, the local healthcare team, and clinical appointment. Healthcare providers need further training for promoting exercise among persons with multiple sclerosis. The promotion of exercise among persons with multiple sclerosis will require resources and strategies that can be readily offered by providers.

Randomized controlled trial of an e-learning designed behavioral intervention for increasing physical activity behavior in multiple sclerosis.

BACKGROUND: Internet-delivered, behavioral interventions represent a cost-effective, broadly disseminable approach for teaching persons with multiple sclerosis (MS) the theory-based skills, techniques, and strategies for changing physical activity. OBJECTIVES: This pilot, randomized controlled trial examined the efficacy of a newly developed Internet website based on e-learning approaches that delivered a theory-based behavior intervention for increasing physical activity and improving symptoms, walking impairment, and neurological disability. METHODS: Participants with MS (N = 47) were randomly assigned into behavioral intervention (n = 23) or waitlist control (n = 24) conditions delivered over a six-month period. Outcomes were administered before and after the six-month period using blinded assessors, and data were analyzed using analysis of covariance in SPSS. RESULTS: There was a significant, positive intervention effect on self-reported physical activity (P = 0.05, [Formula: see text] = 0.10), and non-significant improvement in objectively measured physical activity (P = 0.24, [Formula: see text] = 0.04). There were significant, positive effects of the intervention on overall (P = 0.018, [Formula: see text] = 0.13) and physical impact of fatigue (P = 0.003, [Formula: see text] = 0.20), self-reported walking impairment (P = 0.047, [Formula: see text] = 0.10), and disability status (P = 0.033, [Formula: see text] = 0.11). There were non-significant improvements in fatigue severity (P = 0.10, [Formula: see text] = 0.06), depression (P = 0.10, [Formula: see text] = 0.07) and anxiety (P = 0.06, [Formula: see text] = 0.09) symptoms, and self-reported disability (P = 0.10, [Formula: see text] = 0.07). CONCLUSIONS: We provide evidence for the efficacy of an Internet-based behavioral intervention with content delivered through interactive video courses grounded in e-learning principles for increasing physical activity and possibly improving secondary outcomes of fatigue, depression, anxiety, and walking impairment/disability in persons with MS.

Identifying preferred format and source of exercise information in persons with multiple sclerosis that can be delivered by health-care providers.

BACKGROUND: There is increasing recognition of the benefits of exercise in individuals with multiple sclerosis (MS), yet the MS population does not engage in sufficient amounts of exercise to accrue health benefits. There has been little qualitative inquiry to establish the preferred format and source for receiving exercise information from health-care providers among persons with MS. OBJECTIVE: We sought to identify the desired and preferred format and source of exercise information for persons with MS that can be delivered through health-care providers. SETTING AND PARTICIPANTS: Participants were adults with MS who had mild or moderate disability and participated in a range of exercise levels. All participants lived in the Midwest of the United States. METHODS: Fifty semi-structured interviews were conducted and analysed using thematic analysis. RESULTS: Two themes emerged, (i) approach for receiving exercise promotion and (ii) ideal person for promoting exercise. Persons with MS want to receive exercise information through in-person consultations with health-care providers, print media and electronic media. Persons with MS want to receive exercise promotion from health-care providers with expertise in MS (ie neurologists) and with expertise in exercise (eg physical therapists). CONCLUSIONS: These data support the importance of understanding how to provide exercise information to persons with MS and identifying that health-care providers including neurologists and physical therapists should be involved in exercise promotion.

Results of a feasibility randomised controlled study of the guidelines for exercise in multiple sclerosis project.

There is increasing recognition that exercise is an efficacious strategy for managing many consequences of multiple sclerosis (MS), yet persons with MS are not engaging in sufficient exercise for accruing health benefits. Poor exercise uptake might be associated with the design of previous research. We conducted a randomised controlled trial (RCT) for examining the feasibility of a 4-month home-based, exercise-training program designed based on recent physical activity guidelines for MS and supplemented by behavioural strategies for compliance. Feasibility was assessed in the domains of process (e.g., recruitment), resource (e.g., monetary costs), management (e.g., personnel time requirements) and scientific outcomes (e.g., treatment effect). We recruited persons with mild-to-moderate MS who were randomised into an intervention or wait-list control condition. Intervention participants received a pedometer, elastic resistance bands, DVD, training manual, calendars, log-book, video coaching calls and newsletters. Participants in both conditions completed home-based assessments before and after the 4-month period. Ninety-nine persons with MS were assessed for eligibility, and 57 were randomised. Fifty-one persons completed the study (90%). Total costs of the study were US $5331.03. Personnel time to conduct the study totaled 263h. Participants in the intervention group complied fully with 71% of all exercise sessions. There was a moderate increase in self-reported exercise behaviour of the intervention participants as measured by the Godin Leisure-Time Exercise Questionnaire (d≥0.5). The results support the feasibility and acceptability of a home-based exercise intervention based on physical activity guidelines and supplemented with behavioural strategies for adults with mild-to-moderate MS.

Multiple sclerosis patients need and want information on exercise promotion from healthcare providers: a qualitative study.

BACKGROUND: There is growing recognition of the benefits and safety of exercise and its importance in the comprehensive care of persons with multiple sclerosis (MS), yet uptake is low. OBJECTIVE: We explored the needs and wants of patients with MS regarding exercise promotion through healthcare providers. SETTING AND PARTICIPANTS: Participants were adults with MS who had mild-or-moderate disability and a range of exercise levels. All participants lived in the Midwest of the United States. METHODS: Fifty semi-structured interviews were conducted and analysed using thematic analysis. Two themes emerged, namely interactions between patients and healthcare providers and needs and wants of patients. RESULTS: Analysis of participant accounts illustrate that current exercise promotion by healthcare providers does not meet patient needs and wants. The identified needs and wants of persons with MS involved (i) information and knowledge on the benefits of exercise and exercise prescription, (ii) materials to allow home and community exercise and (iii) tools for initiating and maintaining exercise behaviour. DISCUSSION AND CONCLUSION: Patients with MS frequently interact with healthcare providers and are generally unsatisfied with exercise promotion during interactions. Healthcare providers can address the low uptake of exercise among persons with MS by acting upon the identified unmet needs involving materials, knowledge and behaviour change strategies for exercise.

Association between compliance with physical activity guidelines, sedentary behavior and depressive symptoms.

Physical inactivity, i.e. not engaging in adequate moderate-to-vigorous physical activity (MVPA), has been identified as a risk factor for depression. Increased sedentary time has further been identified as a potential risk factor for depression. We analyzed NHANES 2005-2006 data to examine the associations between compliance with physical activity guidelines (PAG) and sedentary time with depression. We utilized accelerometer data to assess compliance with PAG and sedentary time, and we used the Patient Health Questionnaire (PHQ-9) to assess presence of depression. Participants were classified as compliant with PAG or non-compliant based on MVPA accumulated in bouts of 10min or more. We further divided these two groups into quartiles of sedentary time. We conducted logistic regression analyses to test for the interaction effect of PAG compliance and sedentary behavior on depression. Analyses were conducted in 2014-2015 at the University of Illinois at Urbana-Champaign. Mean depression score among compliant participants was 1.65 (SD=2.61), whereas it was higher among the non-compliant participants (mean=2.52, SD=3.51). Logistic regression indicated a statistically significant interaction effect between MVPA and sedentary time on depression scores. There was no apparent trend in depression scores across quartiles of sedentary time in the compliant group. However, adjusted odds ratios for depression increased with increasing sedentary time among the non-compliant group. We provide evidence that compliance with PAG is associated with reduced depressive symptoms regardless of sedentary behavior; however, increased sedentary behavior may increase the risk of depression among those who are not physically active at a level which meets national guidelines.

Longitudinal association between depressive symptoms and walking impairment in people with relapsing-remitting multiple sclerosis.

Worsening depressive symptoms and walking impairment are significant burdens in multiple sclerosis. We explored the reciprocal relationship between depressive symptoms and walking impairment in a cohort of 269 people with relapsing-remitting multiple sclerosis over 2 years. The data were examined using longitudinal panel analysis in Mplus. Baseline depressive symptoms predicted change in walking impairment at 1-year follow-up (path coefficient = .074), and change in walking impairment at 1-year follow-up predicted change in depressive symptoms at 2-year follow-up (path coefficient = .177). Our study provides preliminary evidence for initiation of a reciprocal relationship between depressive symptoms and walking impairment in relapsing-remitting multiple sclerosis.

Feasibility study design and methods for Project GEMS: Guidelines for Exercise in Multiple Sclerosis.

The Guidelines for Exercise in Multiple Sclerosis (GEMS) program is a randomized controlled trial (RCT) examining the feasibility and efficacy of a home-based exercise training program based on recent physical activity guidelines and principles of behavior change for improving symptoms and health-related quality of life (HRQOL) in adults with multiple sclerosis (MS). The primary aim is to assess program feasibility in the four domains of process (e.g., recruitment, retention, and adherence), resources (e.g., communication, staff requirements, and monetary costs), management (e.g., time and accuracy in data collection/entry, and reporting of adverse events) and scientific outcomes (e.g., safety, burden, participant feedback and efficacy/outcomes). The trial will recruit individuals with mild-to-moderate MS-related disability across the United States who will be randomized into intervention or waitlist control conditions. All participants will complete home-based assessments (including wearing an accelerometer for 7 days and completion of a questionnaire booklet) prior to and upon completion of the 4-month program. Participants in the intervention will receive a 4-month home-based exercise program emphasizing aerobic and resistance training. Participants will be provided with exercise equipment, a DVD, a manual and a log-book. The exercise program will be supplemented with periodic newsletters in the mail highlighting principles of behavior change, and video-chats with an exercise specialist to provide motivation and social accountability. This trial serves to inform development of Phase II and III RCTs which can determine the actual efficacy and effectiveness of home-based exercise based on the MS-specific physical activity guidelines for improving symptoms and HRQOL.

Effect of exercise on depressive symptoms in adults with neurologic disorders: a systematic review and meta-analysis.

OBJECTIVES: To review and quantify the effect of exercise on depression in adults with neurologic disorders. DATA SOURCES: CINAHL, Cochrane Register of Controlled Clinical Trials, EMBASE, ERIC, MEDLINE, PsycINFO, PubMed, and SPORTDiscus were searched, with the last search performed in May 2014. STUDY SELECTION: Included were randomized controlled trials conducted in adults with a diagnosed neurologic disorder that compared an exercise intervention group with a control group and used depression as an outcome measure. DATA EXTRACTION: Depression data were extracted independently by 2 authors. Methodological quality was assessed independently by 2 authors. DATA SYNTHESIS: Forty-three full-length articles were reviewed, and 26 trials met our inclusion criteria. These trials represented 1324 participants with 7 different neurologic disorders: Alzheimer disease (n=4 trials), migraine (n=1), multiple sclerosis (n=13), Parkinson disease (n=2), spinal cord injury (n=1), stroke (n=2), and traumatic brain injury (n=3). Data measuring depression were extracted and effect sizes were computed for 23 trials. Results from a meta-analysis yielded an overall effect size of .28 (SE=.07; 95% confidence interval, .15-.41; P=.00) favoring a reduction in depression outcomes after an exercise intervention compared with the control condition. Of note, interventions that met physical activity guidelines yielded an overall effect of .38 compared with .19 for studies that did not meet physical activity guidelines. CONCLUSIONS: This review provides evidence that exercise, particularly when meeting physical activity guidelines, can improve depressive symptoms in adults with neurologic disorders.