Today I talk with Prof. Dr. Ulrik Dalgas from the Aarhus University in Denmark about various evidence proven effects of exercise on the immune system and existing symptoms of MS patients.
One thing is absolutely clear, exercise helps in symptomatic treatment and maintenance or best possible recovery of good physical and mental condition. The achievable goals are, of course, determined by the individual conditions of each person living with MS.
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Table of Contents
Introduction – Who is Prof. Dr. Ulrik Dalgas?
Nele Handwerker: Hello, Ulrik. It’s such a pleasure to have you on the show today and a warm welcome to Aarhus in Denmark. #00:00:04#
Prof. Dr. Ulrik Dalgas: Thank you very much. It’s a pleasure to be here. #00:00:08#
Nele Handwerker: And before we start with the interview, it would be lovely if you could introduce yourself to the audience, so they know who is my interview guest today. #00:00:14#
Prof. Dr. Ulrik Dalgas: Sure. Well, my name is Ulrik Dalgas and I’m professor at Aarhus University in Denmark. I have been interested in exercise rehabilitation in multiple sclerosis for the past 20 years. And I run a research team that is specialized in this particular aspect. We also do some studies in Parkinson, but multiple sclerosis is our main focus. #00:00:40#
Nele Handwerker: Okay, great. #00:00:41#
Prof. Dr. Ulrik Dalgas: And maybe I should also declare that I’m an exercise physiologist by background. I’m not a medical doctor or a physiotherapist which many people tend to think. But I come from the more exercise background. Yeah. #00:00:55#
Knowledge about the importance of exercise
How does exercise impact the immune system and inflammation in individuals with MS?
Prof. Dr. Ulrik Dalgas: Well, it’s a complicated story. And to be honest, we still have a lot to learn and understand ahead of us. But it seems that exercise may have some down regulatory effects on the inflammation, which is probably a good thing for the nervous system. But we also know from other disorders that there is this anti-inflammatory effect of exercise that is very interesting. But we still have to really understand all the details because many of the factors that is affected are doing it are following very different patterns. So some parameters are affected at a very high pace, even maybe during exercise, others immediately after. And then again, we also see factors that react at a slower pace at even later stages. So it’s a complex story and we still have a lot to learn. And at the same time, we are dealing with a disorder where many people are taking medication that is also impacting the immune system quite dramatically. And therefore, this interaction makes it even more complicated to study because you always need to also take medication into account. So it’s a complex story, but we think it’s doing something good. That’s kind of the overall. #00:02:38#
What did doctors suggest to people with MS when it came to exercise 40 years ago? And what was the effect of this?
Nele Handwerker: Because there are still some rumors about that flying around on the internet. #00:02:55#
Prof. Dr. Ulrik Dalgas: Yes, you can still meet people that have the understanding that exercise can be harmful. And this was taking its origin already back in the 1800 century, where a neurologist called Utov studied a phenomenon where people with MS who had an increase in body temperature, they showed some worsening of different symptoms, particularly the visual symptom. And based on that, many doctors got the idea that, well, exercise was harmful, and it was best to kind of avoid that. At the same time, we also have many dealing with fatigue as a common thing. And it was also thought, well, it’s better to preserve energy for like daily activities that is more essential than exercise. So that has been kind of the paradigm for almost a hundred years.
And then back in the 90s, we saw the first studies coming out actually showing that exercise had the exact opposite effect, that people actually felt more energetic. It did something really good to their cardiorespiratory system, to their muscles but also fatigue seemed to be positively impacted. And that has been…that was kind of the start of a changing paradigm. And since then, many studies have appeared. And we have now more than 200 exercise studies. And the overall findings is really that exercise benefits people on a lot of the most common symptoms that we see in this disorder. So at least it has a very strong symptomatic effect, it seems. And that is why we have been spending quite some time in changing this paradigm, so that doctors are prescribing exercise rather than really advising people to avoid it. #00:05:03#
Nele Handwerker: Yeah. So important. And I experienced this myself quite often. I mean, I love to play badminton, for example. And I always tell the people I’m playing with „Sorry, I’m not sure if I can see correctly if the ball is in or out, when it is near the border. You have to be fine with that.“But playing is good and I’m quite fast in everything. And of course, I feel better afterwards. And I mean, I can play badminton 20 years after diagnosis. So, such an important thing.
What types of exercises are recommended for people with MS, and how do they effect different aspects of the disease?
Prof. Dr. Ulrik Dalgas: The thing is that most research has focused on what we call basic types of exercise. And that covers resistance training on the one hand where you lift heavy weights, but only you only do that a few times. And then on the other hand, you have what we call aerobic training, or endurance training, which is really affecting the cardiorespiratory system to a much larger extent. So these are really basic types of exercise, but then we have a lot of things in between. That badminton, as you mentioned, is one of them where you are both doing some jumping and sprinting and things that challenge your nervous system and your muscle strength. But you also get a high heart rate while playing, which is a cardiorespiratory challenge. So that’s kind of covering both types of training in a way.
And those types of more mixed training formats have not been extensively investigated. We have now studies on climbing, showing really good effects. We have studies on kickboxing. We have studies on things like dancing and also yoga, Pilates, and all these types of things. And now starting to appear, and essentially, they show really good effects. So it seems that the format can…I mean, you can choose formats of exercise that you really like, rather than only these basic types where we have most of our knowledge based from. But when you are trying to understand how things work, it’s a good thing to work with these basic types of training because they are essentially the building stones of more mixed formats of training as well. #00:07:38#
Nele Handwerker: Yeah. And that’s so good. I mean, yes. Choosing the type of sport you like, the type of movement, and you don’t have to do something. „Oh, I don’t like it.“ I don’t know. Jogging, for example, is not something everybody likes. #00:07:51#
Prof. Dr. Ulrik Dalgas: Exactly. And I didn’t really come to the recommendations. But what we recommend is that you do activities on a weekly basis that cover essentially both some strengths training and also some endurance training or aerobic training. But, I mean, if you play badminton, you may be covering both aspects quite well by doing only that. So you also need to choose something that you actually like to do, and that motivates you. Because, otherwise, we know that it’s very hard to sustain doing these activities if it’s not really something that you are motivated by. So that’s also something to consider, of course. But we recommend that you do these types of training at least a couple of times a week. And there are also some recommendations on that. You should do it also with a higher level of intensity, at least a certain amount of time every week. But of course, these are what we call minimal recommendations. So essentially that’s what you should at least do, but feel free to do more and do also different formats and stuff like that. So that’s also something you need to remember when you are reading the recommendation. That is really what you at least you do, not… #00:09:15#
Nele Handwerker: Not to maximum. So minimal. #00:09:16#
Prof. Dr. Ulrik Dalgas: Exactly. #00:09:16#
Why is exercise and movement so important in the wider scope of living a healthy life?
Prof. Dr. Ulrik Dalgas: Well, the thing about exercise is that it affects essentially all tissues in our body and all organ systems in a beneficial way. So when you are exercising, you of course strengthen your heart, but you also strengthen your blood vessels. You get more bloods, you get the content of your blood changes. It affects your liver, it affects your guts, it affects your endocrine system and so on. Your bones, your ligaments and all these tissues and organs, they are strengthened. So in a way, you are strengthening your whole body while at the same time not really having a big chance of getting side effects. We see only very few side effects. Of course, you can have an injury if you are playing badminton. You do see injuries, but you can do exercise in a very safe way, if you like.
And of course, you can also find formats of exercise that are much more dangerous than others. But what we do know now is that the level of side effects is really, really low compared to the gains you get. So I think that’s really the main secret that it has this very broad effect on your whole body. And while at the same time we really don’t see much to the side effects. So that’s a really strong combination when you’re trying to build your body stronger. #00:10:56#
Nele Handwerker: Yes, absolutely.
Details on the effect of exercise on MS
Can exercise help to reduce fatigue?
Prof. Dr. Ulrik Dalgas: Yeah. Well, we know that it reduces fatigue. We are still trying to figure out why. I mean, the thing is, fatigue is really a complex phenomenon. There can be many different causes for fatigue. Some people get fatigue because of medication, because they are deconditioned, because they maybe sleep poorly or eat poorly. Whereas others, they get it because the disease is has caused damage to certain brain areas that gives fatigue. So in a way, we separate fatigue into what we call primary and what we call secondary fatigue, where the primary is what is caused directly by multiple sclerosis. And the secondary is if it’s caused by poor diet or medication or these more secondary steps. So therefore, exercise may not be the best solution in all cases. It may not have big effects for everybody. But on average, we see quite good effects.
But we still need to figure out if it’s only because it is affecting more secondary things, or if it is actually also changing some of these more primary things. But we have done quite a few studies now, and they have all shown a reduction in fatigue when we ask people about their fatigue level. And the way we ask people about fatigue is we ask them, „How have you felt over the past two weeks?“ So therefore, it’s kind of an average level of fatigue because as you know probably after you have played badminton, you will eventually become quite tired or feel fatigue. So therefore, the acute effect of exercise can be that you feel exhausted. I mean, you don’t have to have multiple sclerosis to feel tired after having played badminton.
That’s normal. But if you look at kind of the chronic level, the level you feel on average over a longer period of time, can be reduced. So that’s a little bit the thing you need to remember when you’re talking about fatigue. That the acute effect of exercise may be actually that, well, you sometimes you feel very energized immediately after having exercise, but then two, three hours after you feel very tired. But it’ll have a positive effect on your general fatigue level already maybe from the next day. #00:13:46#
Nele Handwerker: Absolutely. #00:13:47#
Prof. Dr. Ulrik Dalgas: So that’s some of the complexity that is surrounding this a little bit. #00:13:51#
Nele Handwerker: Yeah. I’m the owl type. So I’m working very often in the evening; playing, of course, badminton in the evening. But after badminton, my brain is not working. I have to go to sleep. I sleep very well. But yes, of course I feel better. #00:14:07#
Prof. Dr. Ulrik Dalgas: Another aspect we have noted is that there are actually people using exercise as a kind of energizer. So if they have to go or attend an important meeting, maybe at 12 o’clock there are people that exercise at 11 o’clock, because then they experience kind of an energy wave that is hitting them afterwards. And they feel very energized for that important meeting that maybe, let’s say, the meeting lasts an hour. And then after that they start really getting tired again. But that can also be, you know, a strategy to manage fatigue that you can at least in some cases maybe use exercise as kind of an energizer. #00:14:53#
Nele Handwerker: Yeah. Of course. I mean, if it’s let’s say half an hour or 20 minutes of quite good level of sport. Not maximum, but whereas the blood is really running through the body, oxygen is put everywhere. And that helps a lot, of course.
How does exercise affect balance and coordination in people with MS, and are there specific exercises you can recommend?
Prof. Dr. Ulrik Dalgas: We also have quite good evidence that exercise can improve balance. Of course, you can do some more specific balance training which is quite a complex type of training. Because you need to challenge a person very hard on some specific systems that can be very different from person to person. Some persons may have problems when they are standing and initiating a movement. Others may have more problems when they are transitioning from, let’s say, sitting to standing. Or others may have problems if they are rotating a lot and stuff like that. So it can be quite different how these balance problems are experienced and, therefore, also has to be treated. But one problem that balance training has compared to exercise is that it is a little bit more very difficult to make a progression during your training.
Because when you do let’s say you do running, you can say, okay, today I run two kilometers. Tomorrow I run, again, two kilometers, but I do it a little fast. But that’s a little bit more difficult with balance training because you need to say, okay, I start by doing it on two legs. Okay, then I can do it on one leg, but how do I then make it even harder? Okay, then I can blindfold my eyes. But it’s more difficult than just running a little faster, if you can see the point. So therefore, we still have some work to do on how we best deliver optimal balance training. But we are working hard on that actually. And a colleague of mine is really trying to dig into this balance field. John Banks also from university college in Aarhus. He is kind of a leader on that.
So hopefully we will have much more knowledge on balance. But if you do, let’s say, regular exercise like running or resistance training or playing badminton, well, there are also studies showing that that can improve your balance. And so there are, again, many ways of getting to the goal, which would be to improve balance, and exercise can definitely be a part of it. But the most effective way of doing is probably by very targeted balanced training, but that really requires an expert to design a good intervention there. So that’s a little bit…it’s harder to give a general advice on balance, I would say. #00:18:05#
Nele Handwerker: Yeah, of course. A good physiotherapist can tell you different types of modulations, of a certain type of training. But I always keep telling people, if you have a little kid and you go to the playground, you can at least exercise there quite a lot with your kids together. #00:18:23#
Prof. Dr. Ulrik Dalgas: Absolutely. I mean, that’s actually a very important point that you can very often build exercise into your daily life. We see many attempts on that. Of course, the classical example is the, okay, I take the stairs rather than the elevator, or I use my bicycle to get to work, or these types of things. And, of course, if you are on the playground, well, you can use the time there to do some balance training maybe, or other activities that can be really beneficial to you. So trying to think about how to integrate it into your daily life is very important. Because many people have or many people get the disease at a very busy time of their life, and therefore may not be able to go to the gym three times a week. And then in these cases, it’s very important to think like you just suggested there. So I’d say it’s a very good point. #00:19:27#
Is it safe for individuals with MS to engage in high-intensity exercises, or should they go for a more moderate approach?
Prof. Dr. Ulrik Dalgas: Again, the answer is a little bit complex maybe because when you start exercising, it’s not clever to start exercising at a very high intensity level. I mean, thereby you would probably be very exhausted, and it would take a lot of recovery time. We know people with MS have probably slightly longer recovery times than healthy people have. So if you do it very extensive or intensive at the beginning of a training program, then you will probably be hit by some of these problems. And also, the injury rate is higher and stuff. So there are many…there are some arguments against starting too hard. Therefore, what we recommend is that you kind of build a training program where you start at a more moderate level. But to keep progressing your training, to not kind of hit like a plateau where you are just sustaining rather than improving. Well, then you need to push yourself a little bit once in a while.
And in the past people have been very cautious on using more high intense training. In our team, we have both used high intensity aerobic training where you do like interval training at really high intensities. We’ve also tested high intensity resistance training. But in both cases, we built like a safe base before that where we had maybe two months of training, that kind of led to the high intensity phase of the training. So we didn’t do it from day one at a very high level. We kind of built it piece by piece. So don’t be afraid of challenging yourself. But maybe not challenge yourself overly ambitious from the first day, but build it over time. I mean, it’s should after all be a lifelong commitment. So you are not in a rush. It’s better to build it a little bit more, not to build it too steep in a way. #00:21:48#
Nele Handwerker: Yes. And of course, you can always bring your training to the level that you need. For example, I have a cold right now, so I will not want that extreme. But in a week or so, I can be back to the level I trained. So that I think is well fine. Another big problem with MS is spasticity.
Are there specific exercises that can help relieve spasticity or muscle stiffness caused by MS?
Prof. Dr. Ulrik Dalgas: Well, there are not that many published studies on this. We have some experience from our previous studies where we have, for instance, been doing resistance training where you’re lifting weights. But we often target the lower extremity because that’s where we see the largest deficit in muscle strength as compared to healthy people. But what we have experienced there is that when we start, we often see people having problems with spasticity during the training. It kind of worsens while they train. So what we do is…what we then observe is that if we keep training consistently over maybe three, four weeks, then we start seeing this lowering. And suddenly they can do…maybe in the beginning, they can only do, let’s say, one set of repetitions. Maybe only 10 repetitions and then it starts. But then after another week of training, well, suddenly they can do two times 10 repetitions. And then eventually we don’t see the spasticity worsening during training. So we actually see this kind of lowering of spasticity while training. If you’re asking if you can also kind of lowering the level during daily life, well, we have only very poor data on that. But at least more anecdotally, our patients report that they experience less spasticity during daily life. But again, this is really an area where we don’t have strong data, I have to admit. #00:24:05#
Nele Handwerker: Okay. But yeah, so please stay on track and don’t get demotivated when it’s not so easy at the beginning. #00:24:11#
Prof. Dr. Ulrik Dalgas: Yeah. We always say that if you can survive the first month of training, then you really start to see that many of these initial problems, they either disappear completely or at least they reduce to a much more tolerable level. So you really have to challenge yourself to stay on board for the first three-four weeks. And then you would most often have a much better and much more convenient experience when you are doing exercise. #00:24:43#
Nele Handwerker: That sounds good. I mean, one month. Or maybe for some people when they can’t train, that often two months. I think that’s okay.
Can regular exercise help improve cognitive function and reduce cognitive impairments in individuals with MS?
Prof. Dr. Ulrik Dalgas: The literature is a little bit unclear here. And that’s probably because if you want to show an improvement in cognition, you need to have people that have a cognitive problem when they enter the study. Otherwise, if you have a kind of normal cognitive performance, it’s very hard to show an improvement of exercise. And to be honest, most of the studies that we have out there, they have recruited people with multiple sclerosis that haven’t necessarily a cognitive problem when they enter the study. And in those cases, it’s hard to show effects. So my interpretation of the literature is a little bit, and that’s also a little bit what we see at least in the aging literature, that the main effect of exercise on cognitive function is probably that it protects the cognitive function really well over time.
It may not have a huge improvement of your cognitive function, but it preserves your cognitive performance much longer in life. So that’s probably how we should look at exercise in this respect that it really keeps your brain healthy, and thereby it can function well over a longer time. It may not improve function a lot. That being said, you can find studies and we are just about to publish one. I can’t, unfortunately, tell you about the results. But we actually have done a study where we only included people with cognitive impairments with progressive multiple sclerosis. But it do seem that you can still improve that. You actually can see improvements at least in certain cognitive domains if you’re doing the right training.
And that study, we actually combined exercise with also specific cognitive training. So it’s a little bit of a complex study to interpret also, but that’ll be out there soon. So I know this answer may be a little bit blurry. But I think the overwhelming interpretation is that you can preserve your brain function better over time, whether it improves a lot while exercising is probably less likely to happen. But it’ll keep your brain at a better place for a longer time. I’m pretty sure about that. #00:27:38#
Nele Handwerker: Nice. And I think you were talking about the CogEx study, which we just used in our statistics module at the multiple sclerosis management masters. This is a study protocol, not the final results. #00:27:52#
Prof. Dr. Ulrik Dalgas: No. We are just about to publish the main results in a high impact journal. And we have a little bit of what we call…#00:28:06#
Nele Handwerker: Not allowed to talk about it upfront. #00:28:08#
Prof. Dr. Ulrik Dalgas: No. We have clauses with the journal that…and it will be published within the coming weeks. So it’s soon about to happen, but we we’ll have to wait with really going into the details of that stuff. But it’s worthwhile looking at it. #00:28:27#
Nele Handwerker: Yes. And I mean, just one comment on that. Most people lose their job or have problems with their job due to cognitive impairment. So if you can keep on with your cognitive function and you don’t lose it, that helps with many aspects of life. So I think it’s really a big benefit if you can train. #00:28:55#
Prof. Dr. Ulrik Dalgas: Absolutely. And I’m not a neuropsychologist. But there are being some really important steps taken in the cognitive rehabilitation at this point in time. So a lot is going on there. And they are really developing the interventions in that field as well, so that we actually have tools that can really help preserve or maybe even improve at least in some patients certain cognitive areas. So I think we have…exercise and cognitive rehabilitation are two of the really promising areas that we have in the MS rehab at this point in time. #00:29:35#
Nele Handwerker: Sounds great.
What are some exercises that can be done at home or in a limited space for MS patients who may have mobility challenges?
Prof. Dr. Ulrik Dalgas: Yeah. Of course, it can be sometimes a little bit hard when you’re training at home to follow, you know, a gradual plan that is progressing over time because sometimes you need to have certain equipment to really do that. But of course, you can do a lot of things at home. We are just about to publish a paper on simple walking training, which you can essentially do everywhere. Of course, if you have mobility problems, it can be very hard. I completely understand that. But just to say even very simple types of training such as walking training can actually benefit your walking quite substantially. And you can essentially do it everywhere. Of course, if you have some serious balance issues or mobility restrict, again, it may require some special equipment that only can be offered at a physiotherapist or at a training facility somehow.
There are also programs developed that you could do at home. Also, if you have mobility problems, they are already available out there. So that’s another area that is also being developed because we can now do much more things remotely where we can also supervise or instruct online, which of course makes things more efficient, and people may not have to transport. So this is also an area there’s a huge ongoing study in United States at the moment where they are using this type of tailored rehabilitation approach where people are being guided more at a distant place. So that is also really a field that is being developed. But again, if you have some serious mobility problems, well, sometimes it really requires some specialized equipment and that can be a challenge to do at home, really.
But, I mean, if you have a good physiotherapist, you can often discuss it with them. And very often they can build a program that you can do at home. Then you may restrict it to your upper body where you can maybe do some sitting exercises, or maybe you can do some sit to stand movements, or you can do some trenchers or other things that is actually kind of good training also. But it may require a little bit of instruction very often to get that to work at a good place. #00:32:33#
Nele Handwerker: Makes sense.
How does exercise impact mood and emotional well-being in individuals with MS?
Prof. Dr. Ulrik Dalgas: We were curious about this six-seven years ago. And therefore, we decided to look at the entire field of studies in this field. And what we saw was that overall, we had a little bit the same problem as we saw with cognition; that people entered the study, but they were not really depressed at least not at a like clinical level when they entered the study in general. And, therefore, it can be a little bit hard to observe effects if you are trying to improve a mood that is already quite good. But still, when we looked at the scores across all the studies we could find, we actually saw quite nice effects of exercise on what we call depressive symptoms. So you can actually reduce depressive symptoms, which is not the same as having a major depression. But you can have some symptoms where your mood is not as good as it maybe should be or could be. So you can actually gain some improvements in many cases by doing exercise. We also know this from a lot of other populations. You also use exercise in treatment of depression. So it’s not really a big surprise. But just to say that we actually do have evidence suggesting that you can reduce the level of depressive symptoms in people with MS by exercise. #00:34:14#
Nele Handwerker: Fantastic. And let’s come to another big issue, bladder and bowel dysfunction.
Are there any particular exercises or strategies that can help manage bladder or bowel dysfunction in MS patients? And why should people let their doctor know about these problems right away and check the severity at a (Neuro)Urologist?
Prof. Dr. Ulrik Dalgas: To my knowledge, there are no studies out there that have really in depth investigated this. I know the Danish MS hospitals are working hard on getting a study started on this field. So things will probably appear. I also know that you can give some exercises that can be good that are targeting…I’m not sure what it’s called in English. But, you know, the whole hip and lower stomach area, which may be helpful. But we don’t have like scientific evidence really supporting this. But acknowledging how big a problem this can be in people with MS. This is definitely something we need to investigate much better. But it’s a little bit also outside my core field, so there may be a literature I’m not familiar with. But as far as I know, there are really no good exercise studies at least that have looked into this. #00:35:38#
Nele Handwerker: Okay. But maybe some data will be published in the upcoming years.
What type of training would you recommend people with MS to prevent the loss of muscle strength and flexibility?
Prof. Dr. Ulrik Dalgas: If muscle strength is a big issue, resistance training is by far the most effective way of regaining muscle strength. We have a number of studies showing that you can really…actually that people with MS, have the same muscular response to resistance training as healthy people have. So we see essentially the same positive effects. You can also build muscle mass to the same extent as healthy people can. We also see that the nervous system is getting better, because when you do, when you’re lifting a heavy weight, your nervous system is also really challenged. It has to really perform at a maximum level. And that’s a really good training also for the nervous system. So we really see that resistance training is a very efficient way of increasing muscle strength. And thereby preserving important bodily functions such as getting up from a chair or walking upstairs or these types of things, which are quite dependent on a good muscle strength.
For flexibility, which you also asked about. We would more recommend specific flexibility training where you are doing different types of stretching regimes. There’s a whole research area around how to do stretching, because that has also shown to be quite complex, because you can of course do stretching before or after your normal training. You can do it in many different ways. And there’s still not really consensus on how to optimally do that, but that can at least in many cases be very helpful if you want to improve your flexibility. #00:37:41#
Nele Handwerker: And I was never really good with that. I always loved sport and training, but not so much training my flexibility. I should become better on that.
Can exercise help improve sleep quality and reduce sleep disturbances?
Prof. Dr. Ulrik Dalgas: Yes. The are studies suggesting that. We know that also from other populations that you can often get a better sleep if you are in a good physical condition and thereby exercising. And we also have now studies appearing to confirm that in people with MS. You can say that in MS, this is of particular importance because many people are dealing with fatigue. So this might also be kind of a pathway to improve the daily fatigue level. So this is definitely it’s a relatively new topic in the field. But it is one that is really gaining a lot of focus at this point in time. #00:38:42#
Nele Handwerker: Very nice.
Are there any precautions or modifications that should be considered when exercising with heat sensitivity, the Uhthoff phenomenon?
Prof. Dr. Ulrik Dalgas: Yeah, this is a really good question. And particularly in some people we see it and it sounded as if you are familiar with this problem. And in some cases, we experience that this is something that is more or less always present when you are exercising. And we also see that a hot environment can sometimes be a challenge that causes some of the same problems. But if we isolate it more to exercise, there are things you can do. There are some like low tech solutions where you are, you know, opening the window while training or having a fan that is rotating and cooling you down. There are some different systems you can wear like a vest with some cooling liquid circulating that is cooling your body. There are helmets you can use, there are hand garments you can use, and stuff like that.
People have also been experimenting with taking cold showers before exercise. It’s actually quite efficient. But as you might think it, it is really lowering the motivation for training if you have to sit in a cold shower for 30 minutes before exercise. So what we have been doing is we have a little bit…we try to compare. If you have people with this problem, well, if you let them do resistance training where you’re lifting weights, having a break, lifting a little bit of weight again. If you compare what they experience to what the same people experience when they do bicycling, which we compare to where they’re just sitting on a bicycle. Well, what we saw was that the body temperature increased much more during bicycling, because you are doing continuous activity.
But the number of symptoms was also much higher. That was when you did bicycle. So if you do aerobic types of training and you have this problem, well, then you will probably see much more problems than if you do other types of training. So one step could be to start your training program by doing activities where your body temperature is not increasing that as much as it does on regular aerobic training. So maybe start doing some resistance training activities. And when you get a little bit more familiar with that, our experience is that you also train your whole temperature regulation system, so it gets better. And then can you try to move into aerobic type of training at a later stage? So that’s a little bit of, again, a low-tech solution that can maybe benefit at least some patients.
And then the final thing is that we have now…there is a study from that is performed by Victoria Leavitt group in New York, that has shown some beneficial effects of taking aspirin before training if you have this problem. So there might also be some medical things that can at least reduce the problem to some extent. So there are different ways of going. You can try different types of training. You can use some of these cooling systems or equipment. And then you can also try with medication if that’s a possibility. #00:42:29#
Nele Handwerker: Okay. Sounds good. I mean, I always use lots of drinking of water and my cooling vest. For example, it’s now 30 degrees Celsius here in Dresden. And when I go by bike to my parents with my little one on the back of the bike, I have my cooling Vest, and I make a lot of pauses for drinking water. So it helps already quite a bit. #00:42:51#
Prof. Dr. Ulrik Dalgas: It does. And I think that’s how you should try to deal with it really from a practical level and try to find some easy solutions to this issue so that it does not get the reason why you don’t want to exercise. Because very often you can find quite easy solutions that can at least alleviate this to an extent that makes it possible for you to bicycle and get the good effects of doing this. #00:43:21#
Can exercise help with pain management and can you share some tips?
Prof. Dr. Ulrik Dalgas: This is, again, a field that is in the very beginning of really getting started. There are studies out there showing that you can have some pain reductions by exercising. We still don’t know whether certain types of exercise is better than others. We still don’t know if it only works on certain types of pain. So, there’s still a lot of of things to do. But overall, we do see a reduced pain level after training and in people who are training. So, that’s a little bit where we are right now. But this is something we need to understand much better. But this may be also an area where medication and rehabilitation are in a way closely connected and where we need to really optimize, well, when do you take certain medications in relation to your training? Do you do it immediately before or do you have to do it a little bit early, or how should you do that? So there are many unresolved things. And I think here we may need to look at it from a more combined perspective where we are really also taking the medical treatment into account. #00:44:55#
Nele Handwerker: Okay. Interesting. And now, let’s come to the topic of establishing a routine and stick to it, because this is kind of hard.
Establish a routine and stick to it
Are there any specific exercise programs or classes designed specifically for individuals with MS that you would recommend?
Prof. Dr. Ulrik Dalgas: Well, here in Denmark, we have physiotherapists that are specialized in, for instance, neurological populations. And they often form groups that are training together, where they have kind of adapted the training to people with multiple sclerosis, for instance. And then you go there, and you are part of a team that is doing really good training, maybe one or two times a week. So that can be a really good starting point to have advice from people that are familiar with some of these special challenges, for instance, heat sensitivity, or balance problems, or maybe cognitive challenges, or other types of things that are common in people with MS. And that you need to take into account when you’re designing the program. So that can be really helpful. We don’t have like a fixed and fit solution because it’s so individualized. And it should be to really be optimal because it’s a little bit the same as with…I mean, of course with medication you do have…if you are taking, let’s say, a specific drug, well, then there is a very precise prescription on how to do that.
We are not quite there yet. But, I mean, if that drug doesn’t work as we intend, then you can shift to another type of drug. And it’s a little bit the same here that, well, okay, you have a specific problem. Well, we take the best option we have available, we think from the exercise box. And if that’s not really working, well, then we can try to shift to a little bit of a different type of exercise maybe and see if that works better. And therefore, it’s very hard to put it on one equation and say, this is the program, this is how you should do it. Some people can handle to train two times a week. Other people are exercising maybe five- six times a week. And depending on all these factors, you really need to individualize or tailor things to the individual. And that’s why it’s difficult for us to say this one program is working. But my general advice is, if you want to get started, seek advice from an experienced physiotherapist or exercise physiologist who are familiar with this area, and then get started that way. And then you can individualize or tailor your program in collaboration with these experts. #00:47:48#
Nele Handwerker: Sounds, yeah, makes sense totally. And maybe my next question doesn’t make sense.
How frequently and for how long should individuals with MS engage in exercise to experience noticeable benefits?
Prof. Dr. Ulrik Dalgas: Yeah. It depends on a little bit about the starting level of a person, because if you are already at a really high functioning level while doing exercise once a week, you will probably not make a big difference. There, you might have to be doing exercise two or even three times a week to really experience an improvement. In other patients, we have seen remarkable effects of only doing exercise two times, 10 minutes a week. That was what was possible, but they really felt it very clearly. And then, of course, we build it from there. And sometimes you can see some remarkable progression. In one of our resistance training studies, we had a female patient who was about 60 years old. And when she started doing, she did, you know, the leg press where you’re doing a leg press exercise.
She was able to lift around 30 kilos. And after 12 weeks we managed to move that to 150 kilos. So that’s quite dramatic increase. And what we did was just we, you know, added a little bit every time. But if the starting point is very low then you can have some extreme gains quite fast, really. But of course, if you come in and you already are capable of lifting 150 kilos, well, we’ll not be able to move you to four-five probably. But we may still improve you, but maybe not quite as dramatic as we see in some cases. So it is a little bit hard, but we recommend that you do at least two times a week if possible, as a minimum.
If you have more effort to put into it, that’s also fine. In the beginning, we do see people have long recovery times. Some people may have to recover two or even three days after which is very different from, you know, athletes where we see that they can do exercise maybe three times a day, sometimes. But that’s not what we are, you know, comparing to. But that’s just to say that there’s a huge individual factor in this that must be taken into account. And therefore, we have to tailor it to individuals, to every person really to get the optimal output. #00:50:25#
Nele Handwerker: Okay. Great.
What resources or tools are available to assist individuals with MS in incorporating exercise into their daily routine and tracking their progress?
Prof. Dr. Ulrik Dalgas: Are you thinking about like an app or? # 00:50:40#
Nele Handwerker: For example. Yes. #00:50:42#
Prof. Dr. Ulrik Dalgas: Yeah. There have been some developments of apps, but I think some of them are maybe now being commercialized. I’m not really fully sure about that. But I’m not really sure if there are any particular app or device I can guide you through here. But there is…we did a paper. I was part of a panel that was asked to do some recommendations on what and how to do it. And we did a paper in collaboration with the American MS Society. It was led by Dr. Kelp, who was the first author on this paper. And in that paper, you can really get some practical advice on what to do. We tried to base it on the available evidence. And in the cases where we didn’t have scientific evidence, well, we made like an expert panel recommendation. So that’s something you can bring maybe to your physiotherapist or those that are helping you to have like…it may be giving you some advice on how to start. Or it can be used in that kind of discussion phase of how to do the training. #00:52:17#
Nele Handwerker: Okay. Thank you. #00:52:18#
Prof. Dr. Ulrik Dalgas: But these are the types of things we have right now. #00:52:23#
Nele Handwerker: Okay. And, of course, you can always use just a notepad and make some notes what you achieved this week and what you achieved the next week. And after my rehab, I was at a physiotherapist where they had it all digitalized and I could increase then the weight. So it was a very let’s say local solution, but it helped to see efforts of my training and it motivated me.
What are the benefits of training with somebody else or in a larger group?
Prof. Dr. Ulrik Dalgas: Well, the main problem here is really that people with MS are pretty much like healthy people. We do have like a general problem and motivating people to sustain exercising over a long time. The thing about MS is that if you have this disease, it’s probably even more important to be exercising because there are certain functions you are losing a little bit faster than healthy people do. So therefore, it’s very important. But the problem and the challenge is really the same. If you ask people with MS, there is Canadian study where they ask people with MS about what the barriers and facilitators towards training was. And when you ask them if they wanted to…if they preferred doing exercise on their own or in groups, or like sometimes in groups, sometimes on their own. About one third said I want to do it on my own. Another third said I want to do it in groups. And the last third said, well, a mix is best for me.
So this is a little bit individual again. So there are definitely people that are much better motivated if they are exercising groups, but there are also other people that really prefer to do it on their own. So the answer is, again, a little bit individualized. But if you are doing things or activities that are like if you play badminton, well, you have to do it with somebody, right? It’s very boring to do on your own. So there are, of course, certain activities that are building on you exercising with others. So if you are kind of attracted to those type of activities, well, then you are probably in that third that prefer to do exercise in groups. And if you are taking those people and let them exercise on their own, they will probably get demotivated very fast. So you need to identify if you are…what type of format you really want to train in. And then try to establish that afterwards. #00:55:03#
Nele Handwerker: Makes sense.
How can people with MS get back into routine, when they dropped out of it for a while?
Prof. Dr. Ulrik Dalgas: Yeah. That’s something that can be hard. Of course, you need to take a few steps back if you are, and maybe figure out why did I stop exercising? What was the real cause of this? And if it was that you felt, okay, the training was really boring. Or I need to have a training partner or whatever, you need to kind of identify what is the reason why I’m not really eager to do exercise. And then you can maybe design a new set up which is better for you. So that could be a first step. If you’re just like had, you know, sometimes during summer where you are maybe traveling or your normal routine is not the same, then sometimes it can be hard to get started again afterwards. Well, our best advice is to take a few steps back and not be too ambitious again. Maybe start…if you normally do exercise three times a week, well, start doing it one or two times a week, and maybe not as intensive as you used to do. So take it a little bit brief, just to not crush while getting started again. But this is definitely something that is challenging. It’s not an MS specific thing. This is something that is for really everybody, I guess. #00:56:36#
Nele Handwerker: Absolutely.
Which breakthrough in research about exercise or low-threshold offers would you like to see in the next 5 years?
Prof. Dr. Ulrik Dalgas: In my team, we have been very focused on trying to investigate if exercise can actually influence the progression of multiple sclerosis. Because if that is the case, then exercise is actually another treatment avenue to the disease as opposed to the medical approach. I’m not saying it’s replacing the medical approach, but I’m just saying that then we would have not only medication that can slow down the progression, but we would have another thing we could add on that maybe. And if exercise works through other mechanisms than the medication does, then you might have an even better long-term treatment here. Unfortunately, we don’t have medical companies that is investing in this type of interventions. So it’s very hard to get these studies funded. We need to follow people for years when they’re doing exercise.
We are scanning their brains to see can exercise preserve brain volume, brain quality, brain functions better. We still think that’s the case, but it’s hard to prove it scientifically. We have done some pilot studies where we have been training people for six months up to 12 months and then been doing MRI scans before and after that. And those studies, they indicate that exercise has a preserving effect on the brain. But the studies are not like straightforward and they’re small and should of course be interpreted very cautiously. But we do have some initial support here for this idea. Also, there is an animal model of multiple sclerosis where you give animals, mostly mice or rats, a disease that looks a little bit like MS.
And if you are allowed these animals to do exercise, then you see a very, very strong, very clear pattern that those animals that are allowed to exercise, they have a much milder degree of or much milder disease cause of MS than those animals that are not exercising. But again, it’s animal studies. You cannot always transfer findings. These animals are caged in a small cage and therefore very different from, I mean, human life. So there are lots of things. But just to say, we do have some studies that is supporting this direction of thinking. And now we are just trying to really put up a large-scale study where we can really investigate this to see is exercise really an additional treatment that we should offer not just a symptomatic treatment, but really a disease modified treatment. But the answer is still not really given. #01:00:03#
Nele Handwerker: Yeah. Not evidence-based yet, but I totally trust in that direction. So my approach is always doing as much as I can with all my lifestyle stuff and, of course, disease modifying treatment. And so far, of course, I’m probably lucky for some reasons we will find out scientifically in some years upfront. But it works out for me at least. But of course, it’s always a difference. Eminence and evidence-based data. #01:00:35#
Prof. Dr. Ulrik Dalgas: Exactly. And the optimal combination of medication and exercise, diet, sleep, and all these lifestyle things. Well, we still need to figure it out. But, I mean, as we know that more or less all symptoms can be…at least many symptoms can be treated with exercise, then we strongly recommend it for that purpose. And if you use it for that purpose, well, then you also gain the disease modifying effects if they are there. So, I mean, we hope we that it has a disease modifying effect. But we cannot recommend it saying that it has at this point in time. But what we do recommend now is that you start exercising also at a very early stage of the disease. Because for many years it has been so that we have actually waited with the whole rehabilitation treatment until people started to show problems.
So we will not treat a balance until there was a balance problem that was very clear, or we would not start building muscles until the muscle strength was really getting low. We want to have another focus here that is more like a prevention focus. So say, okay, let’s build some reserve capacity in the beginning of the disease as soon as you get the disease. Let’s build people as strong as possible. And then you have a much more, much bigger reserve capacity when the disease kind of kicks in. And that will probably slow down the development over time. So early efforts are really key. Although they are more preventive than actually, you know, rebuilding things. #01:02:29#
Nele Handwerker: Use it or lose it. That means that counts for healthy people. And, of course, even more for people who have a chronic disease like MS.
Farewell
How and where can interested people follow your research activities?
Prof. Dr. Ulrik Dalgas: Yes. Well, I have my personal homepage on the webpage of Aarhus university where you can see what we are working with and what we are publishing. And then also we do have both Twitter and LinkedIn accounts and stuff like that, where we also publish some of these things when we think there are interesting things. And we are also collaborating closely with the Danish MS Society. So when we have interesting results, we really try to break them there as well. So these would be the best channels. And we also, by the way, work with a number of German groups. There is a really strong exercise team in Hamburg led by Christopher Hansen, which I think you have spoken to earlier. And also, a professor called Philip Simmer, who is located in Dortmund. So we have really good German collaborators in this field as well. And we are also planning joint studies ahead with these people. So we hope we can make a strong Danish German connection in this field. #01:04:01#
- Homepage of Prof. Dr. Ulrik Dalgas on the webpage of Aarhus University
- Twitter / X Account of Prof. Dr. Ulrik Dalgas
- LinkedIn Account of Prof. Dr. Ulrik Dalgas
Nele Handwerker: Fantastic. Yes. I had both gentlemen on the German podcast, not yet on the English one. But I mean Google translate is so good that you can maybe check the script as a blog article and translate it into English if you are not a German native speaker. And I think I will invite them to the English podcast as well.
Is there anything else you would like to share with the listeners?
Prof. Dr. Ulrik Dalgas: I think we’ve covered many important areas here. So that I think that’s a pretty good update on the field right now. So yeah, that’s good. #01:04:47#
Nele Handwerker: Thank you very much, Ulrik. And, yes, please dear reader and listener exercise, exercise, exercise. It helps with so many aspects of MS, probably even with kind of disease modifying cause. But for sure with many, many, many symptoms. And it’s always good. It’s good for your mood, it’s good for your symptoms. It’s good for your cognition. So please exercise as much as possible and do it in a way that fits your special condition. #01:05:15#
Prof. Dr. Ulrik Dalgas: Yeah, exactly. Don’t focus too much on that it has to be a certain type of training. It’s much more important to do something that you can sustain and that you actually gain some pleasure from. That’s much, much more important I think in the long run. #01:05:32#
Nele Handwerker: Thank you very much, Ulrik. Bye-Bye. #01:05:33#
Prof. Dr. Ulrik Dalgas: It was a pleasure. Bye. #01:05:35#
See you soon and try to make the best out of your life,
Nele
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