HIT Workout Helps MS Patients Reach New Highs

Nancy A. Melville

June 06, 2019

SEATTLE —  While the advice regarding exercise for multiple sclerosis (MS) patients until just a few decades ago was simple — don't do it — the latest evidence has evolved to show benefit not only from conventional exercise, but from high-intensity interval training (HIT), new research shows.

For one MS center in Belgium, the program culminated with a practitioner joining his MS patients on a trek to the top of a 1900-meter mountain in the South of France.

Dr Charly Keytsman

"The main [response] I hear from patients after this training is 'Wow, look at what I still can do despite my disease. I would have never dreamed of doing something as hard as this,' " lead author Charly Keytsman, PhD, Faculty of Medicine and Life Sciences, REVAL Rehabilitation Research Center, Biomedical Research Institute (BIOMED), Hasselt University, Diepenbeek, Belgium, told Medscape Medical News.

"The climb to the top of Mont Ventoux was to raise awareness and make patients and the MS community aware of what these people can still achieve, despite their diagnosis," he said.

The group climb was the culmination of a 6-month study of a home-based HIT intervention for MS patients that takes the general principles of HIT — intensive exercise interspersed with recovery periods — but applies a non-linear pattern of progress in an effort to achieve more effective results.

"We know a high performance sports team doesn't train in a linear progressive way," explained Keytsman in discussing his research here at the 2019 Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC).

"They have variety in the training intensity, frequency, and duration, and they may have entire weeks of recovery because they want to be fit for the whole season and maximize their training and performance," he said.

"This can mean one-week shorter training sessions, one-week longer and one-week none, in order to give your body the chance to recover."

To apply such "periodized" principles to the HIT program for MS patients, Keytsman and colleagues enrolled 23 MS patients with relatively mild symptoms (Expanded Disability Status Scale [EDSS] score 1.9 ± 1.1) and 22 healthy controls for participation in a 6-month home-based program of high-intensity exercise with stationary cycling.

Patients were also provided with remote activity trackers (Polar M200) for supervision.

Under the regimen, participants start week 1 with three sessions of high volume (90 to 120 minutes) low- to moderate-intensity exercise on 3 days (Tuesday, Saturday, and Sunday).

For the second week, the regimen includes 3 HIT sessions of 20 minutes each, on a Tuesday, Thursday and Saturday, amounting to just 1 hour of exercise for the week.

The third week includes five days of recovery, Monday through Friday, and just one 20-minute session of HIT on Saturday, with an optional high-intensity session on Sunday.

The results of the study, published in February in Multiple Sclerosis and Related Disorders, showed that after the 3-week rotation was repeated for 6 months, participants had statistically significant improvements in various measures compared with baseline, including body weight (−3%, P = .008), body mass index (BMI; −3%, P = .01), total mass (−2%, P  = .023), VO2max (+ 5%, P = .016), workload (+ 11%; P = .001), time until exhaustion (+ 14%, P = .001), recovery heart rate (+ 4%, P = .04), lactate peak (+ 16%, P = .03) and respiratory exchange ratio (RER; + 4%, P = .04) in MS.

Importantly, the program was safe and well-tolerated, Keytsman said." The improvements in MS patients were similar to the improvements in healthy controls, which is a nice observation."

The tracking devices provided important information on the patients' exercise patterns and adherence, he noted.

"We had very high adherence. The tracking devices showed patients performed 95% of the prescribed training sessions, so there really was good adherence to the program," Keytsman said.

"In personal communication, patients reported that they enjoyed the protocol due to the variety of the longer and shorter sessions," he said. "We now need to compare the program to a conventional program in a supervised setting, and we plan to randomize 50 patients to see the difference between the programs."


At the end of the training program, all participants with MS and healthy controls who finished the program (17 in each group) took part in the climb, accompanied by Keytsman, to the top of the 1901-meter Mont Ventoux, in the Provence region of southern France.

All were able to successfully make the climb, with the exception of two of the MS patients, who ended their climbs within 2 km and 1 km, respectively, from the top as a result of exhaustion.

There were no adverse events or injuries that occurred during the challenge.

"When they reached to top of Mont Ventoux, the MS patients started to hug each other, most in tears as they were so happy about what they had just achieved after 6 months of training," Keytsman said.

"Even 1.5 years later, I still often receive messages from the patients to thank me, as for many of them, this project was an eye-opener regarding their physical activities."

Ongoing Research Looks at "All-Out" Intensity

In their latest ongoing study further exploring the benefits of HIT training in MS patients, Keytsman and colleagues' study enrolled patients with EDSS scores up to 6 for a regimen similar to the previous protocol in terms of the first 2 weeks of training.

However, the second week involves 3 days of 10-minute sessions on Monday, Wednesday, and Friday, which include 20-second repetitions of exceptionally intense exercise, followed by just one session in week 3 with a 10-minute high-intensity interval training.

Keytsman, who takes part in the training protocol as well, said the intensity in this approach is even greater.

"The intensity in week 2 is really all-out because it's very short — the shorter you go the higher intensity it is," he said. "So it's not just going 100%, it's going to 120% of one's maximum intensity."

The study is still ongoing, but Keytsman reported preliminary findings showing improvement in both groups after 12 weeks.

Notably, while improvements do not appear superior to those seen in the periodic study, the effects are similar — despite the latter regimen involving 57% less exercise in the third week.

"The main message here is that we have a medicine — and that medicine is exercise — where patients need to take half the dose to achieve the same effects," Keytsman said. "We are continuously seeing long-term adherence with the approach and this wave of training may further optimize high-intensity interval training."

Keytsman noted that while his research hasn't looked at improvement in depression associated with HIT, patients in general report highly favorable feedback.

"Very often, because of this, you'll see that patients start picking up activities that they stopped doing in their life because they believed it was too hard for them after the diagnosis," he said.

Keytsman described research from other recent studies also looking at variations of HIT in MS and showing substantial benefits in exercise capacity and strength, VO2max, glycemic control, and cognitive function, including verbal memory.

The studies, including from his center, have all shown HIT to be safe and tolerable.

Keytsman noted that all patients receive cardiovascular screening prior to taking part in any high-intensity training program, and protocols can be adjusted to suit the patients' unique needs or disabilities.

There are a variety of high-intensity training protocols offered through mobile apps, and Keytsman noted that "the main thing you need really is to have peaks with recovery periods, and [then] you can design the high-intensity protocol."

"You can make the intensity a bit lower if you think the patient may not be able to do it, but you just have to make sure you have peaks and recovery."

Show Patients the Data

Keytsman said he introduces MS patients to the concept of HIT by discussing the data showing beneficial effects — and some patients, as expected, express hesitancy.

"Some patients hold back at first and say, 'I won't be able to do this with my disease, this will be too hard,' " Keytsman said. "This uncertainty is understandable, I think, as many [older] patients were often advised to pay attention when performing too much physical activity."

"On the other hand," Keytsman continued, "many patients are very curious and when they hear about the benefits, they become enthusiastic and say 'OK, I want this too!' "

Reluctance about HIT in MS can extend to clinicians as well, Keytsman said.

"In my opinion, [HIT] has not been adopted sufficiently," he said. "I believe many practitioners and healthcare providers are still afraid of 'overtraining' their patients, and thus afraid to use something like HIT."

He noted that the studies thus far have mainly focused on MS patients who are still mobile, with an EDSS score below 6. However, benefits for patients with more disability have not been ruled out.

"We haven't used this intervention in more disabled patients, but that's definitely something for the future," Keytsman said.

"We need to keep optimizing these protocols to improve adherence and clinical outcomes, with, for example, the periodized strategy."

"Single Greatest Change to Our Practice"

One practitioner who utilizes the HIT approach with MS patients, Matthew H. Sutliff, PT, MSCS, of the Cleveland Clinic in Twinsburg, Ohio, described the addition of the high-intensity interval training program as "probably the single greatest change made to our practice in the last 2 to 3 years."

He noted that the core concept of HIT followed by recovery can be applied to patients' specific disabilities.

"For instance, if I have a patient with weakness in the hip, I may have them start by kicking to the side repetitively and we may start with a low target and have them kick sideways. And then we raise the target and have them go faster," Sutliff told Medscape Medical News.

In terms of safety, Sutliff noted that he follows a "2-hour rule" to gauge a patient's progress. "Under the rule, 2 hours after exercise, you should either feel better or the same as before you started. If you feel worse, then you probably did too much."

Sutliff, like Keytsman, said he also takes part in the HIT training along with his patients, and agreed that beyond the physical gains, patients see important quality-of-life benefits in gaining a sense of control.

"It's very confidence building, Sutliff said. "When you first talk to patients about this, they tend to think you're crazy and you're mean and that there's no way they can do it. But if you start low enough, they realize 'Oh, I can do this.'

"So I think for most people it's empowering that they can actually do this and work hard at it and do well, as long as it's not too hard."

Keytsman and Sutliff have disclosed no relevant financial relationships.

Consortium of Multiple Sclerosis Centers (CMSC) 2019 Annual Meeting: Presented May 30, 2019.

Mult Scler Relat Disord. Published February 2019. Abstract

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