Hip weakness is a common symptom affecting walking ability in people with multiple sclerosis. Isolated muscle strengthening is a useful method to target specific weaknesses. This protocol describes a progressive resistance-training program using exercise bands to increase hip muscle strength.
Hip weakness is a common symptom affecting walking ability in people with multiple sclerosis (MS). It is known that resistance strength training (RST) can improve strength in individuals with MS, however; it remains unclear the duration of RST that is needed to make strength gains and how to adapt hip strengthening exercises for individuals of varying strength using only resistance bands. This paper describes the methodology to set up and implement an adapted resistance strength training program, using resistance bands, for individuals with MS. Directions for pre- and post-strength tests to evaluate efficacy of the strength-training program are included. Safety features and detailed instructions outline the weekly program content and progression. Current evidence is presented showing that significant strength gains can be made within 8 weeks of starting a RST program. Evidence is also presented showing that resistance strength training can be successfully adapted for individuals with MS of varying strength with little equipment.
In MS, compromised neural function typically leads to motor dysfunction, resulting in weakness. It is known that muscle weakness contributes to reduced daily activity in people with MS and inactivity further compromises functional ability1;2. Our lab has shown that weak hip flexor muscles in individuals with MS affect walking speed3, particularly in the weakest individuals4. The significance of weak proximal hip muscles to walking has been shown in MS as well as in other neurodegenerative conditions4;5. This vicious cycle contributes to increased disability and reduced quality of life6;7. Regular exercise can improve daily activity8, cardiovascular fitness8;9, muscle strength10, and fatigue8;11 in people with MS12. Strength training is known to promote neural adaptations that can lead to favorable functional outcomes in MS participants13-16. Since physical rehabilitation is often the only treatment offered to individuals with MS for recovery of function, it is critical to determine what is the most efficient way to improve strength.
Resistance strength training has been evaluated with no clear consensus on the minimal amount of time needed to see significant changes in muscle strength or the best method for optimizing strengthening. A current review reports that resistance training studies have varied in length from 3 to 26 weeks, mainly targeting the lower extremities in persons with MS suffering from low to moderate impairments (with an Expanded Disability Status Scale of 0-6.5)14;17;18. These studies primarily use isokinetic devices for training with direct supervision in a gym location. The use of isokinetic equipment is one way to isolate and strengthen single muscles, but it limits a person’s ability to complete the exercises without use of expensive equipment that is not always accessible. Resistance bands offer the advantage of controlling the direction of resistance as well as the placement of the resistance on the limb, thereby avoiding stresses to distal joints. Resistance bands also offer the opportunity to grade the resistance in finer increments then with other equipment such as with cuff weights.
Alignment and movement patterns are carefully addressed in the training of athletes, yet little attention is given to these factors in individuals with chronic degenerating conditions, in part because their limitations are so complex (e.g., sensory, motor control, cognition). The need to address alignment in exercises, as well as in everyday activities is critical19. Simple, but well-selected exercises that are precisely performed aid in the resolution of musculoskeletal syndromes in individuals with intact nervous systems19. Although many generic exercise programs are available, they do not address the specific impairments in MS that affect mobility and modifications necessary, given the progressive nature of the disease. For this program, we emphasize postural alignment, as well as specific exercises that are done in a position that is most optimal for how the muscle is used functionally.
The goal in this study was to create an accessible, inexpensive, resistance training program for the hip muscles that is generalizable to individuals with variable degrees of disability. Simple but precisely described hip strengthening exercises are adapted here emphasizing the strengthening of isolated muscles and guidelines are provided for individuals to further adapt the exercises depending on their current muscle strength. Recommendations are made so individuals can exercise with resistance bands in a systematic way that is easily adaptable to the home and details needed to replicate the program are specified.
NOTE: The institutional review boards at Johns Hopkins University School of Medicine and Kennedy Krieger Institute approved this work. All participants provided written consent before participating.
1. Training
2. Select Location and Equipment Required for Exercise Class
3. Resistance Bands
4. Participant Recruitment
5. Phone Screening
NOTE: This is essential to explain to the interested person what participation requires and to assess the participant’s eligibility.
6. Participant Pre-test
NOTE: Conduct pre-tests within 2 weeks before starting the resistance-training program.
7. Program
NOTE: Instruct the participants in introductory material and specifics of the exercises as detailed in sections 7 and 8. 7.1 – 7.8 need to be explained in the first session and reviewed as necessary. Instruct exercises one at a time and no more than three per day for optimal participant training. Instruct one-on-one whenever possible for optimal supervision and performance. Anticipate 1-2 weeks for higher functioning individuals to learn the basics of exercise performance and 2-3 weeks for more impaired individuals. Anticipate need for supervision and assistance to decrease over the course of the program. However, instructors will continue to provide direct observation and cuing as needed throughout the program as increasing resistance often results in increased effort and more difficulty attending to alignment.
8. General Considerations
9. Post-test Evaluation
10. Statistical Analysis
We show results from 26 individuals with MS who participated in a 12-week lower extremity progressive, resistance training (PRT) at our facility. Our participants have varying levels of disability with a median EDSS of 4.0 (range: 1-6.5), are on average 50.0 (11.3) years of age (youngest is 23 years, oldest is 64 years), 17 are female, and have an average symptom duration of 12.5 (8.7) years.
Figure 1 shows that hip strength improved following 12-weeks of training (p<0.005 for all hip muscles). For hip flexion, statistically significant improvements were first made following 8-weeks of training (p=0.013), with additional improvement at the end of 12-weeks. Individual muscle groups were compared using paired t-tests with the p-value set at 0.017 to control for multiple comparisons. When we assess each individual’s strength change from pre-intervention to post-intervention, we see varied responses with most showing good improvement: more than half improved strength by more than 44 N. To demonstrate this, Figure 2 shows three examples of participants who improved their strength despite hip muscles having different degrees of weakness to start with. Figure 2A shows an example of an individual with asymmetric hip strength (left weaker than right) at baseline, this person presented with a hemi-paretic walking pattern. Following strength training, this person specifically gained hip flexion strength on the weaker, left side. By contrast, hip abductor and extensor muscles were more symmetric and both sides gained strength post intervention. Note: this person (2A) started on the right for hip flexion at 1 level 5 band at loop 3 for a total of 40 N at 100% stretch and progressed to 1 level 5 and 1 level 3 band at loop 2 (1/3 shorter overall length), for a total of 67 N at 100% stretch. Figure 2B shows an individual with very weak hip muscles compared to control values (hip flexion: 195 ± 44 N)5. This individual gained strength in all three muscles and on both the right and left sides even with profound initial weakness. Note: this person (2B) started on the right for the hip flexion exercise in side-lying without bands and progressed to doing the exercise in supine without bands. Figure 2C shows an individual who is relatively strong in his hip muscles at baseline, relative to control values (hip flexion: 304 ± 52 N)5. Though this person had only very mild weakness, all muscles show improvements on the order of 22-44 N following the strength training intervention. Note this person (2C) started on the right for hip flexion with 2 level 5 bands and 2 level 3 bands at loop 4 for a total of 146 N at 100% stretch and progressed to 1 level 5 band and 1 level 2 and all three tubes doubled at loop 4 length for a total of 469 N at 100% stretch.
Figure 1. Hip flexion strength. Line graph from 26 individuals with MS showing mean values + standard deviation for strength of the hip flexor muscles in Newtons. (A) summed hip flexion strength. (B) summed hip abduction strength. (C) Summed hip extension strength. Base: baseline measure; pre-intervention; 4 wk: mean after 4 weeks of the intervention; 8 wk: mean after 8 weeks of the intervention; 12 wk: mean value after 12 weeks of the intervention.
Figure 2. Three representative examples of strength change, before and after the resistance strength training program. The bar graphs show the mean strength measure for the right and left sides of the hip flexor, hip extensor and hip abductor muscles for three MS participants. The dark columns are left hip flexion and the lighter columns are right hip flexion measures. (A) participant with notable hip flexor asymmetry at baseline (age: 46, female, symptom duration: 4 yrs, EDSS: 1) (B) participant with notably weak hip muscles at baseline (age: 58, female, symptom duration: 34 yrs, EDSS: 6). (C) participant with very mild weakness in hip muscles at baseline (age: 37, male, symptom duration: 1 yrs, EDSS: 2). The y-axis is strength, in Newtons. The x-axis indicates the right and left muscle strength for visit 1 and visit 2 for the three hip muscles. Pre, is baseline or pre training; Post, is 12-week or post-training.
The protocol describes a progressive resistance training program using isolated muscle strengthening with resistance bands for people with MS. This protocol has unique features for individuals with degenerative conditions whose strength limitations may be compromising their ability to ambulate and maintain their quality of life. The focus is on improving proximal muscle strength in the lower extremities that is important for walking speed in MS21;4. One advantage of this protocol is that it emphasizes isolated muscles in appropriate alignment (e.g., hip abduction with hips extended). The protocol can be individualized to accommodate for asymmetric weakness, profound weakness, or individuals with mild weakness. By contrast, traditional gym equipment often allows for substitution of stronger muscles without optimizing muscle alignment for functional performance (e.g., hip abduction with hips flexed). While resistance bands are inexpensive relative to gym equipment they may stretch out over time, losing their resistance. However, we found that one set of bands was effective for the 12-week exercise program, for groups of 4 people. Other advantages of the protocol are that it is inexpensive, feasible to do in a small group setting, and requires minimal equipment. Lastly, we emphasize pre- and post-tests using a quantitative device such as a hand held dynamometer to better evaluate for subtle but significant changes in individuals as well as for group comparisons.
These preliminary results, taken from a larger ongoing study, demonstrate that significant strength improvements occur within 8 weeks of training. This is important because participants often want to know when to expect to see improvements from their rehabilitation efforts. This information can be valuable in motivating participants and obtaining funding. Participant testimonials were reflective of this, an example is shown in highlighted textbox. Finally, in designing clinical trials testing pharmacologic or rehabilitative interventions, seeing change in 8-weeks allows for expedient results.
MS is characterized by heterogeneous signs and symptoms in which weakness occurs in combination with other symptoms (i.e., cognitive, sensory, spasticity, ataxia). For successful use of this protocol, individualizing the program based on daily performance is essential. Each participant was supervised by a rehabilitation professional within their group, ensuring that: proper alignment was used; the exercises were of adequate intensity; and safety was maintained throughout the program. One modification to the protocol in order to ensure adequate supervision was to enroll participants sequentially (one per week). Professional clinical judgment is valuable for careful attention to skin integrity, safety with ambulation between stations to prevent falls, whole body alignment to prevent secondary pain complications with exercise, and for monitoring adequate environmental temperature control. As with other intervention studies, participant compliance both with frequency and quality of performance is a potential issue so should be addressed proactively. Effective strategies used in this protocol include offering monthly make up sessions and allowing 10%-15% longer duration to complete the required number of training sessions. Direct supervision as well as the group dynamic provides a means for accountability and camaraderie to optimize compliance.
As part of the larger study, we will be assessing for longevity, application to walking, functional performance, and quality of life in a controlled study, which was one of the limitations of the current study. In the future, application of this protocol to home or community environments would provide greater access for participants to benefit from this program. Better access to this protocol could allow the application to rare neurodegenerative disorders that also have leg weakness as a key symptom. Ideally, a program such as this could be optimized for the community under the instruction of non-clinically trained individuals as has been done for interventions in Parkinson’s Disease22. More research is needed to generalize this information safely while maintaining the fidelity of the program.
Participant Testimonial: One participant (Figure 2A) reports, “I have a step-stool in my kitchen, and I used to have trouble climbing on it to put dishes away. Now it’s easy, I just hop right up there!” And, “I went to my granddaughter’s birthday party over the weekend and both of my daughters commented on how much better I look. They noticed that I wasn’t as tired, didn’t need breaks and could walk and move around better. It’s nice when other people start to notice!”
The authors have nothing to disclose.
The authors would like to thankfully acknowledge Rhul Marasigan and all of the participants in the study. The exercise illustrations were provided by Tziporah Thompson.
microFET2 | Hoggan Scientific, LLC | Digital hand held muscle tester | |
REP Bands (all colors) | Power Systems | 5600-011 | Resistance bands for the exercise program |
TheraBand Latex-Free Exercise Bands (all colors) | TheraBand | 11726-11730 | Resistance bands for the exercise program |
8'' Cable Ties | Lowes Home Improvement | 76329 | Tied into the resistance bands to provide places for the carabiner to clip onto |
Door Anchor | GoFit | Anchors the REP bands to doors | |
Hollow-Braid Poly Rope | Home Depot | 140538 | Anchors REP bands to table legs/other fixtures |
Zinc-Plated Steel Hang All | Home Depot | 550768 | Thigh straps for the hip exercises |
Neoprene Ankle Strap | TKO | 106 BK | Ankle strap for leg exercises |
Positron Carabiner | Black Diamond | BD2102610000ALL1 | Carabiners to link ankle/thigh strap to REP bands |
Fitness Gear 3mm Mat | Dick's Sporting Goods | 41857546 | Yoga mat for exercises on the ground |
1/2 inch, 2 by 2 Exercise Tiles | FoamTiles | Gym matting for exercies on the ground | |
Spirit LT Portable Massage Table | EarthLite | Table for hip extension and other exercises that required a raised platform | |
Performa Treatment Table | Sammons Preston | 553736 | Heavy treatment table for testing/anchoring REP bands |
STATA SE 11 | STATA | Software for statistical analysis | |
STATISTICA | Dell Software | Software for statistical analysis |