Review article
High intensity interval training for people with multiple sclerosis: A systematic review

https://doi.org/10.1016/j.msard.2018.06.005Get rights and content

Highlights

  • HIIT is safe in people with MS.

  • HIIT is a promising modality for improving fitness outcomes in people with MS.

  • Further research is required focussing on high levels of disability and progressive MS.

Abstract

Background

Aerobic high intensity interval training (HIIT) is safe in the general population and more efficient in improving fitness than continuous moderate intensity training. The body of literature examining HIIT in multiple sclerosis (MS) is expanding but to date a systematic review has not been conducted. The aim of this review was to investigate the efficacy and safety of HIIT in people with MS.

Methods

A systematic search was carried out in September 2017 in EMBASE, MEDline, PEDro, CENTRAL and Web of Science Core collections using appropriate keywords and MeSH descriptors. Reference lists of relevant articles were also searched. Articles were eligible for inclusion if they were published in English, used HIIT, and included participants with MS. Quality was assessed using the PEDro scale. The following data were extracted using a standardised form: study design and characteristics, outcome measures, significant results, drop-outs, and adverse events.

Results

Seven studies (described by 11 articles) were identified: four randomised controlled trials, one randomised cross-over trial and two cohort studies. PEDro scores ranged from 3 to 8. Included participants (n = 249) were predominantly mildly disabled; one study included only people with progressive MS. Six studies used cycle ergometry and one used arm ergometry to deliver HIIT. One study reported six adverse events, four which could be attributed to the intervention. The other six reported that there were no adverse events. Six studies reported improvements in at least one outcome measure, however there were 60 different outcome measures in the seven studies. The most commonly measured domain was fitness, which improved in five of the six studies measuring aspects of fitness. The only trial not to report positive results included people with progressive and a more severe level of disability (Extended Disability Status Scale 6.0–8.0).

Conclusion

HIIT appears to be safe and effective in increasing fitness in people with MS and low levels of disability. Further research is required to explore the effectiveness of HIIT in people with progressive MS and in those with higher levels of disability.

Introduction

Exercise is a safe and feasible intervention for people with multiple sclerosis (MS) (Heine et al., 2015) and is recommended for increasing cardiovascular fitness and muscular strength (Latimer-Cheung et al., 2013). Cardiovascular fitness in people with MS is lower compared to healthy individuals (Langeskov-Christensen et al., 2015) and is inversely correlated with disease severity and impairment, with fitness decreasing as disability and fatigue rise (Heine et al., 2014Heine et al., 2016, Kuspinar et al., 2010, Marrie and Horwitz, 2010, Motl and Fernhall, 2012, Valet et al., 2016). Reviews of trials evaluating the effects of exercise in people with MS have indicated that exercise training is beneficial for increasing and maintaining cardiovascular fitness (Dalgas et al., 2008, Rietberg et al., 2005).

Traditionally, continuous moderate intensity training programmes, to increase fitness and reduce cardiovascular disease risk factors in healthy adults, last 30–60 min at 40–85% of maximal intensity, with higher intensities producing a greater increase in fitness (Garber et al., 2011). High intensity interval training (HIIT), however, involves short bursts of exercise at very high intensity with either a complete or working rest in between bursts. Total time for training sessions typically last around 20 min, have 4–6 cycles of 80–95% of maximal effort for 1–4 min with a similar time of working recovery or rest (Cassidy et al., 2017, Kessler et al., 2012).

Compared to continuous moderate intensity training, HIIT is more efficient in improving VO2 max in healthy individuals (Milanovic et al., 2015), people with coronary artery disease (Elliott et al., 2015), increased cardio-metabolic risk (Weston et al., 2014), and heart failure (Haykowsky et al., 2013, Ismail et al., 2013, Smart et al., 2013, Wisloff et al., 2007). HIIT also produces greater or equal effects, to continuous moderate intensity training, in improving cardiovascular risk factors such as high blood pressure and altered glucose metabolism (Fleg, 2016). The main advantage of HIIT over continuous moderate intensity training is the shorter time required to achieve similar energy expenditure, and comparable, or greater benefits (Fleg, 2016). This is due to an increase in oxygen consumption after acute strenuous exercise known as Excess Post-exercise Oxygen Consumption (Gaesser and Brooks, 1984). Furthermore, shorter exercise intervals of 2 min or less have been found to be more enjoyable than continuous moderate intensity training by participants due to the shorter duration of each burst at high intensity (Cassidy et al., 2017).

Previous work examining the effect of HIIT in people with Parkinson's found an increase in Brain Derived Neurotrophic Factor (BDNF) production, decrease parkinsonian rigidity and muscle tone (Marusiak et al., 2015), improved gait parameters (Pohl et al., 2003) and cognitive performance (Alves et al., 2014). In addition there is limited but positive evidence for using HIIT to improve walking endurance in stroke survivors (Boyne et al., 20152016). However, given that only one of five studies compared HIIT to another form of aerobic exercise (Boyne et al., 2016) indicates that HIIT is an emerging modality in these conditions.

High intensity interval training has been recommended as a possible effective intervention for people with MS as it can allow people to exercise at higher intensities while avoiding thermosensitive reactions (Dalgas et al., 2008). Over the past several years there has been increasing interest in HIIT in MS and several interventional trials published; however no systematic review of HIIT in people with MS has been undertaken. Therefore the aim of this review was to establish the efficacy and safety of HIIT in people with MS.

Section snippets

Methods

An electronic search was undertaken of the following databases in September 2017: EMBASE, MEDline, PEDro, CENTRAL and Web of Science Core collections. The search terms used can be seen in Table 1. The Boolean operators ‘AND’ and ‘OR’ were used to combine searches as appropriate. No limits were placed on time of publication. The reference lists of included articles were also searched.

Articles were eligible for inclusion if they were clinical trials that consisted of an aerobic intervention of

Results

The electronic search identified 935 potential articles and hand searching of relevant reference lists provided one additional article. After the removal of 264 duplicates, the remaining 671 articles were screened by title and abstract. From titles alone, 575 were excluded. Following this, another 58 were excluded by abstract. The full text of 38 articles were read for eligibility by at least two members of the research team and 27 were subsequently excluded (Fig. 1). Eleven articles, which

Discussion

This was the first systematic review for the use of HIIT in MS. Overall, the seven studies included in the review provided positive evidence for the use of HIIT in people with MS. All studies except one (Skjerbæk et al., 2014) found improvements in multiple outcome measures. Predominantly improvements were observed in outcome measures relating to fitness. It should however, be noted that fitness outcome measures were not primary outcomes in any of the studies included. High intensity interval

Conclusion

The evidence presented in this review suggests that HIIT, via cycle ergometry, is a safe and effective way of improving fitness in people with MS and requires fewer, shorter training sessions compared to a moderate intensity, continuous training mode to gain benefits. Further investigation of HIIT is required in people with progressive MS and/or those with a moderate and severe level of disability. In addition, future research should examine the possible benefits of HIIT in people with MS,

Acknowledgements

This project was part of Mr. Evan Campbell's PhD which was funded by the Bevan Scholarship from NHS Ayrshire & Arran, United Kingdom.

Conflict of interest statement

The authors declare that there are no conflicts of interest.

Reference (50)

  • M. Valet et al.

    Is fatigue associated with cardiorespiratory endurance among patients suffering from multiple sclerosis?

    Ann. Phys. Rehabil. Med.

    (2016)
  • P. Zaenker et al.

    High intensity interval training combined to resistance training improve physiological capacities, strength and quality of life of people with multiple sclerosis

    Ann. Phys. Rehabil. Med.

    (2016)
  • C.R. Alves et al.

    Influence of acute high-intensity aerobic interval exercise bout on selective attention and short-term memory tasks

    Percept. Mot. Skills

    (2014)
  • P. Boyne et al.

    Within-session responses to high-intensity interval training in chronic stroke

    Med. Sci. Sports Exerc.

    (2015)
  • P. Boyne et al.

    High-intensity interval training and moderate-intensity continuous training in ambulatory chronic stroke: feasibility study

    Phys. Ther

    (2016)
  • S. Briken et al.

    Effects of exercise on fitness and cognition in progressive MS: a randomized, controlled pilot trial.

    Mult Scler J

    (2014)
  • S. Cassidy et al.

    High-intensity interval training: a review of its impact on glucose control and cardiometabolic health

    Diabetologia

    (2017)
  • J. Collett et al.

    Exercise for multiple sclerosis: a single-blind randomized trial comparing three exercise intensities

    Mult. Scler. J.

    (2011)
  • J. Collett et al.

    Acute recovery from exercise in people with multiple sclerosis: an exploratory study on the effect of exercise intensities

    Disabil. Rehabil.

    (2017)
  • U. Dalgas et al.

    Multiple sclerosis and physical exercise: recommendations for the application of resistance-, endurance- and combined training

    Mult. Scler.

    (2008)
  • J. Farup et al.

    High intensity training may reverse the fiber type specific decline in myogenic stem cells in multiple sclerosis patients

    Front. Physiol.

    (2016)
  • M. Feltham et al.

    Cardiovascular adaptation in people with multiple sclerosis following a twelve week exercise programme suggest deconditioning rather than autonomic dysfunction caused by the disease. Results from a randomized controlled trial.

    Eur. J. Phys. Rehabil. Med.

    (2013)
  • J.L. Fleg

    Salutary effects of high-intensity interval training in persons with elevated cardiovascular risk

    F1000Res 2016

    (2016)
  • G.A. Gaesser et al.

    Metabolic bases of excess post-exercise oxygen consumption: a review

    Med. Sci. Sports Exerc.

    (1984)
  • C.E. Garber et al.

    American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise

    Med. Sci. Sports Exerc.

    (2011)
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