FES Cycling - Is it valid for clients with MS

Multiple Sclerosis can restrict exercise participation and lead to a reduction in fitness. Along with this restriction goes a higher risk of health complications and illness in the longer term. 

It's understandable that many people with Multiple Sclerosis steer clear of regular exercise because they're afraid it might increase their fatigue or because they feel they simply aren't up to it.  But with a properly managed regime, always taking into account a person's individual limitations, exercise is a good thing both
physically and mentally.  In this article we examine whether FES Cycling can provide that precisely controlled exercise sought by persons with Multiple Sclerosis.

We know that exercise helps increase mobility, build up muscle strength and strengthens the heart. Importantly regular exercise has been shown to release "happy chemicals" in the brain, known as endorphins, so can help combat depression or emotional problems brought on by living with Multiple Sclerosis. 

We are looking to apply a new exercise approach to the challenge of enhancing fitness in Multiple Sclerosis. This approach relies on combining FES (Functional Electrical Stimulation) with a motorised exercise cycle. We have a great deal of experience applying this FES Cycling technology in Spinal Cord Injury and new work ongoing in Germany with Multiple Sclerosis has encouraged us to apply the knowledge and skills we have developed in this direction too.

The latest multi-center trials based on FES Cycling programmes with Spinal Cord Injury show important improvements in cardiopulmonary (heart and lung) fitness, bone density (resistance to fractures), circulatory function and muscle bulk and strength can be expected through regular exercise.

In clinical terms there are some aspects of FES Cycling that will transfer directly to Multiple Sclerosis from what we have already learned with Spinal Cord Injury. As you already know, it is difficult to perform controlled research trials with Multiple Sclerosis but there is an emerging clinical consensus in Germany that supports the value of FES Cycling.

The Process is as follows:

• A client with Multiple Sclerosis is tested to determine their individual exercise performance limits.
• Clients train under supervision for up to 2 hours per session, depending on their individual performance capability.
• This session is repeated every 2 weeks to see if there is a confirmed medical benefit.
• After a few weeks training with confirmed positive benefits clients may continue at home or at a Centre without direct supervision.

In Munich, this test training is free of charge and participants who apply via their health insurance are able to purchase equipment for home use.

Outcomes
In Munich they recommend FES Cycling for clients who have leg weakness and/or spasticity. These individuals are showing positive effects however researchers have not found an explanation for this.
It seems to work but the reasons are not scientifically confirmed. Many of the clients report a benefit in reducing spasticity and researchers are suggesting that this is because of a change in nerve structures.

However there is no evidence or suggestion that FES can make nerves grow again. This is potentially an important finding as it is known that a spasticity is highly prevalent and associated with a reduced level of functional independence. (See Barnes et al).

Some participants commencing exercise had hyperesthesia, or oversensitivity to touch although the researchers suggest that participants have adjusted quickly to the stimulation and reported improvements - although again there is no known reason for this.

How does it work?
You may have already heard of FES because it is being widely using used to assist with muscle weakness causing drop foot in Multiple Sclerosis. This technology is well established and FES Cycling is a more
sophisticated application of the same principles. FES has decades of research behind it although it is only in recent years that this has started to be routinely applied in therapy situations.

RehaMove
To use the system, sticky pads (electrodes) are placed over leg muscles - up to four muscle groups on each leg are exercised at one time. A sophisticated control system delivers precisely controlled stimulation to
the muscles of the legs in the right sequence to allow the muscles to contract and generate power. At the push of a button the cycle pedals starts to rotate, the system detects the position of the crank arms, calculates the time at which each muscle needs to work and sends the correct stimulation impulses to the
electrodes. Thus it creates a fluent cycling movement.

Over time, as the condition of the muscles improve, they can take a greater share of the effort required to work against resistance - producing a training effect. The system automatically senses the contribution that a users muscles can make from moment to moment and adjusts how hard the user is working – making up the difference with motor power.

Any time a user wishes a break or if the muscles start to fatigue, the built-in motor takes over and
passively moves the users legs. By adjusting the stimulation, the user can easily set exercise targets to work progressively against resistance.

How is this better than using a motiontrainer alone?
One component of the RehaMove system is the popular Reck MOTOMed Viva2 motion trainer. Many people with Multiple Sclerosis already use such a trainer to keep their legs moving at home. ReckÙs partner company, Hasomed GmbH, developed the stimulator unit and the sophisticated software that made RehaMove possible.

Although, in theory each user of a motion trainer can use it to exercise their legs, in practice the precise control and quality of muscle contraction, makes FES Cycling with RehaMove a much more effective form of exercise. The stimulator unit is programmed through an intuitive touch screen interface ensuring precise control of exercise.

Does the system need maintenance?
In an institutional setting we generally expect to work with that organisation via a contract to ensure that the system is inspected regularly because of the likely high frequency of usage.

For home users we suggest that the stimulator unit is returned to us after two years for routine safety testing. There are no particular maintenance requirements other than following our guidance on keeping the equipment clean. Care needs to be taken with the electrode cables to keep them clear of the cycle pedals.

What ongoing costs are there?
Electrodes are the only consumable cost. Electrodes we provide are good quality, reusable ones that last between 15 and 25 sessions before replacement. Each user needs their own electrode set.

Support?
We provide professional training and support to clients or clinicians. We can also provide specialist personal training services with individuals knowledgeable in exercise science as well as Multiple Sclerosis.

References

Management of MS Related Fatigue. Expert Opinion Paper, Medical Advisory Board of the National Multiple Sclerosis Society. (2002)
Mostert, S. & Kesselring, J. (2002). Effects of a short term exercise training program on aerobic fitness, fatigue, health perception and activity level of subjects with MS Mult Scler. 2002 Apr; 8(2):161-168. Department of Neurology, Rehabilitation Centre, CH-7317 Valens, Switzerland.
Petajan, J.H.; Gappmaier, E.; White, A.T.; Spencer, M.K.; Mino, L. & Hicks, R.W. (1996). Impact of aerobic training on fitness and quality of life in multiple sclerosis. Ann Neurol. 1996 Apr; 39(4):432-41. Department of Neurology, University of Utah, Salt Lake City 84112, USA.
Stui'ergen, A.K. (1997). Physical activity and perceived health status in persons with multiple sclerosis. J Neurosci Nurs. 1997 Aug; 29(4):238-243. University of Texas at Austin, School of Nursing 78701, USA. Rehab Center for Physical Medicine, Ichenhausen, Germany
Reduction of spasm using movement trainers, a report for Medicamedizintechnik, Hochdorf, Germany.
Barnes, M. P.; Kent, R. M.; Semlyen, J. K. & McMullen, K. M. (2003). Spasticity in Multiple Sclerosis. Neurorehabilitation and Neural Repair, 2003 März; Vol. 17, No. 1, 66-70.
Krause, P.; Szecsi, J. & Straube, A. (2007). ‘FES cycling reduces spastic muscle tone in a patient with multiple sclerosis. In: Neurorehabilitation 22 (4), 335-337. Department of Neurology, University of Munich, Germany.

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