← RealTalk MS
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- [00:01]
A
I'm john strum, and this is real talk, mississippi. It's April 14th and we have a lot to talk about. By now, I think we all know that an exercise program can be hard to start and even more difficult to stick with. But we also know that exercise can lead to a better quality of life for someone living with Ms. And that's true for people with Ms. At every level of physical ability. My guest this week is Dr. Robert Mottle, the director of the Exercise Neuroscience Research Laboratory at the College of Applied Health Sciences at the University of Illinois, Chicago. Dr. Mottle suggests that we think of exercise as medicine for people living with Ms. And this medicine doesn't require a prescription. No prior authorization is necessary. In fact, it doesn't cost anything and you won't be required to endure one more pill, injection or infusion. Today we're talking about the evidence based benefits of exercise for people living with Ms. But before we get to my conversation with Dr. Model, there are a few other things that you should know about. Evidence from a landmark study in 2022 showed that the Epstein Barr virus, or EBV, was a trigger for Ms. It's estimated that about 95% of the world population is carrying the Epstein Barr virus, and clearly 95% of the world hasn't developed multiple sclerosis. So while EBV is a necessary condition, it's not sufficient to cause Ms. Now, about 25% of the teenagers and young adults who carry the Epstein Barr virus go on to develop infectious mononucleosis, often simply referred to as mono. And newly published study results show that someone who is diagnosed with mono during those adolescent or young adult years is three times more likely to develop Ms. Compared to someone who never developed mono, making mononucleosis a known risk factor for Ms. The study was conducted at the Mayo Clinic and it analyzed data from thousands of people who were followed from 1998 to 2022 as part of the Rochester Epidemiology Project, a large study that's been collecting public health data since the 1960s. Following 4721 people who had been diagnosed with EBV positive mono, as well as over 14,000 people who had no history of mono or EBV infection. The research team found that over six years of follow up, 0.17% of the study participants in the mono group developed MS, while only.07% of those in the comparison group developed Ms. Over an average follow up of eight years. The research team created a formula that took other factors that could influence the risk of ms, such as race and ethnicity, smoking status, the number of other health conditions an individual might have, and their socioeconomic status. And the team was able to determine that the study participants with a history of mononucleosis were 3.14 times more likely to develop Ms. Than those study participants who did not experience mono. Now, this does not mean that mono leads to Ms. It does show a significant association between mono and ms, making mono a significant risk factor for ms, which means that by preventing the Epstein Barr virus, we prevent mononucleosis and we prevent Ms. And I guess it's also worth noting that this study was actually funded by Moderna, a company actively engaged in developing an Epstein Barr vaccine. If you'd like to review the details of this study, you'll find that link in today's show. Notes. As most of you know, an Ms. Diagnosis relies heavily on MRI scans that reveal lesions in the brain and spinal cord. Those scans show the aftermath of Ms. By showing the structural damage that's been caused. But those MRI scans are far less than ideal. MRI is enabled to distinguish between old, inactive lesions and areas of active inflammation. In other words, it doesn't reveal anything about the ongoing immune battle that's taking place in an individual's central nervous system. MRI can't identify which specific immune cells are causing that inflammatory activity normal Nor can it determine how severe the disease is. But all that could be changing. Researchers at Stanford University have developed a powerful imaging agent that can detect the cellular activity of ms, the specific immune cell activation, in real time before an individual experiences any physical Ms. Symptoms. This is an important step forward, so I want to make sure we're clear on a couple of definitions. First, this imaging agent is a PET tracer. Now, PET stands for Positron Emission Tomography. If you want to compare PET to mri, an MRI shows the structure and anatomy of the body. It shows what everything looks like. While a PET scan shows the function and activity of the cells in the body. It shows how everything is working. Now, a tracer is a safe, specialized liquid injected into your body before a PET scan. It acts like a detective or a marker that helps doctors see how specific organs and tissues are working at a cellular level. So the Stanford researchers developed a new tracer called FMD that targets specific cells called myeloid cells. These are the cells that drive the inflammation that damages myelin and nerve cells in Ms. To test their new tracer, the research team performed PET scans on mice that had the mouse version of Ms. They actually performed these scans twice. First, before any symptoms appeared and Then after the mice had developed hind leg weakness or paralysis, and the results were surprising. Even in the presymptomatic mice, the FMD tracer was able to reveal areas of elevated immune activity in the spinal cord, particularly in the lumbar region that controls the hind legs. Now that's the autoimmune response that drives Ms. As the disease progressed, the tracer signal visually intensified. The PET scans could follow this activity, spreading up the spinal cord to the cervical region and into the brain. This ability to not only see Ms. Before symptoms occur, but to assess disease severity is something that no current imaging method can show. Then the researchers tested whether the FMD tracer could track responses to therapies. So they treated the mice with two different drugs, Gilenia, an FDA approved disease modifying therapy, and an experimental compound. They chose Gilenia because Gilenia is known to target microglia activity and they found that the FND tracer could visually show the effects of these treatments, showing dramatically reduced disease activity and microglia activation in the clinic. This would let your neurologist see in a non invasive procedure whether a specific DMT is actually working, whether it's suppressing the immune system attack that drives disease progression instead of having to wait for months to see whether your symptoms improve. Clinical trials are already underway to translate this new development into clinical use, and you can be sure we'll keep you updated as this work moves forward. If you'd like to review the details of this pretty remarkable step forward in what may very well become an important part of the next generation of Ms. Care, you'll find a link to the study in today's Show Notes I want to remind you that this episode of Real Talk Ms. Is sponsored by Able now, a tax advantaged savings program for people with disabilities. If you're living with multiple sclerosis, this is important news. Expanded federal rules mean more adults with disabilities, including many people with ms, can open an Able now account. Able now lets individuals save and invest money without affecting their eligibility for certain public benefits such as SSI or Medicaid. For many of you, it can be an essential financial tool. To learn more and understand if you're eligible to open an account, visit ablenow.com and you'll find that link in today's Show Notes. We've just been talking about what might be a key part of future Ms. Care. I think the most overlooked part of current Ms. Care is exercise and physical activity. It does so much more than make you feel better, and that's why my guest, Dr. Robert Mottle calls exercise medicine for people with Ms. In a moment, we'll meet Dr. Model. Just 25 years ago, neurologists assumed exercise would work, worsen Ms. Symptoms and trigger relapses. Since then, science has proven that exercise improves symptoms and reduces relapse rates. Being physically active boosts brain health and may even support myelin repair. Joining me today for a conversation about how exercise can be a powerful tool when it comes to living well with Ms. Is a longtime friend of the podcast, Dr. Robert Model, a professor in the Department of Kinesiology and Nutrition at the University of Illinois, Chicago. Welcome back to the podcast, Dr. Model.
- [10:48]
B
Thanks, John. I'm really happy to be here today.
- [10:51]
A
We live in a time where between work, family, and other obligations, it's hard to find time for something new or something extra. So maybe a good place for us to start our conversation is by having you talk about the benefits that someone living with Ms. Might gain by spending just 30 minutes a day being active.
- [11:13]
B
Yeah, we talk about exercise as something that we call a pleiotropic stimulus. What that means in simple terms is exercise affects just about every single system and outcome in the human body, from cells to daily life functioning. So in people with multiple sclerosis, we know that exercise can affect the immune system. It can affect neurotrophic or nerve growth factors, both of those in a positive way. We know that exercise can affect the brain, both the structures of the brain as well as the connections among the structures of the brain. Those benefits at the cellular level, on the brain level translate into improvements in cognition or thinking, translate into improvements in physical function, such as walking. Those things translate into better management of fatigue, depression, and anxiety. And ultimately, all of those things add together into better quality of life and full participation in life activities. And so, really, exercise is a very, very powerful stimulus and something that we might even think of as exercise as medicine for multiple sclerosis.
- [12:32]
A
One of the invisible symptoms of multiple sclerosis is brain fog. Can physical activity help the brain work better?
- [12:40]
B
So most scientists didn't really start their research by focusing on the brain with exercise. And we're seeing a lot more believers now that exercise really can have effects on the brain. And as we're seeing more believers, we're seeing more. More scientists focus on exercise effects on the central nervous system. I think it's clear that when people with Ms. Engage in a single bout of exercise, that is one bout of exercise, from before that bout of exercise, they get changes in their cognitive processes. That is, they can process information quicker and more accurately. They have improvements in learning and memory so they can learn information and retain it for longer periods of time. And those changes are probably rooted in the way the brain is functioning and that the brain is becoming more efficient, the neural connections are improving in their function even in that short term period of time. That's probably brought about by changes in brain blood flow and also utilization of metabolites for nerve cell energy. And we also know that when people engage in these single bouts of exercise, they feel better, their anxiety is lower, their depression is lower, and their general mood is just better and they feel happier. And a lot of people attribute that to changes in brain neurochemistry. Exercise helps to release neurotransmitters that ultimately make people feel better. And what a powerful effect, because I think if you attribute feeling better to engaging in that bout of exercise, you're probably more likely to do that bout of exercise again.
- [14:37]
A
Fatigue can be one of the most challenging Ms. Symptoms and people often worry that exercise is going to make their Ms. Related fatigue even worse. But it turns out that the opposite happens. So here's a chance to bust a major myth. Can you explain how overtime exercise can actually reduce fatigue?
- [15:00]
B
Yeah, and I think it's a real concern that people with Ms. Have because they're severely fatigued, they do things that extend beyond their normal routine and oftentimes they feel like they pay the price and that they're just wiped out for the rest of the day and maybe a couple of days. And we might even call that it the post exertional malaise type phenomenon. And, and so exercise is a behavior that causes people to expend energy. And as you expend energy, you know you're going to feel some degree of fatigue. And so I, I don't think it's an unrealistic thing for people to believe that if they engage in exercise it might make their, their fatigue worse. But the science actually doesn't support that. And so when we look at randomized controlled trials of long periods of exercise and we look at fatigue as an outcome, what we find is fatigue is actually reduced. And it's reduced by an amount that is considered to be clinically meaningful. That is, you take individuals who have severe fatigue and the fatigue is low enough that it falls under a threshold for severe fatigue, meaning that it doesn't impact their daily life as bad as it did before. Now how does all this happen? I think that there are a number of hypotheses that people are throwing out there. I think the simplest hypothesis to think about is that when we engage in exercise, our Cardiovascular system becomes stronger, our aerobic capacity becomes more powerful, our muscles become stronger and able to generate more force. And if our physiological systems, like our aerobic power, our muscle strength are getting stronger, it makes doing every single thing in life easier and less energetically demanding. And if we can make all those things in life easier, at the end of the day, life becomes less draining on us and we have less fatigue.
- [17:10]
A
When I introduced this segment a moment ago, I said that being physically active may even support myelin repair. What can you tell us about that?
- [17:20]
B
Yeah, such an exciting area. It wasn't that long ago that we used to think that when you had tissue damage in your brain, that it was just there and there's nothing that you can do. And one of the biggest discoveries is in the field of kinesiology and exercise science, is that exercise is a stimulus that can actually promote new nerve growth in the brain, which we call neurogenesis. It can support the generation of new connections within the brain and it can protect the brain from degradation. And one of those areas of degradation might be the, the protection against the decline of, of or, or the decline of myelination or demyelination. And so the exact cellular pathways and processes through which that occurs, we're not 100% sure right now, but we do know that when you engage in exercise and you're contracting your skeletal muscles while you're engaging exercise, it stimulates a cascade of events that release chemicals into the bloodstream that circulate into the brain. And ultimately those chemicals result in an upregulation of neurotrophic factors, brain growth factors. So brain derived neurotrophic factor, nerve growth factor, IGF and others. And in the brain, these are nutrients, they help the brain tissue repair itself, such as remyelination. They help the brain repair develop new connections such as neurogenesis. There's recent data suggesting that engaging in exercise training actually prevents the breakdown of the cytoskeleton within the axon of neurons in the central nervous system of people with Ms. And so these data are showing that if you engage in exercise training, you actually have a reduction in, in serum neurofilament, light and gfab. And these are blood based biomarkers that reflect degradation of neural tissue, including the skeletal structure of the axon, in people with multiple sclerosis. And exercise is stopping that from occurring or slowing it down. So all powerful ways to explain how exercise can have effects on the tissue in the brain.
- [19:52]
A
As people live with ms, it's not unusual for them to develop other health conditions. Or comorbidities, things like high blood pressure, high cholesterol or diabetes. How does exercise affect these other health conditions and what does that mean for an individual's long term outcome?
- [20:11]
B
So I think a lot of people with ms, as they get diagnosed with Ms. In particular, and they, they start to kind of withdraw from engaging in physical activity and exercise and, and sometimes they, they become sedentary. And I think as we reduce physical activity and we become sedentary, there's strong evidence that you experience comorbid conditions. So you'll have hypertension, cardiovascular disease, you're at increased risk of type 2 diabetes, and a variety of other chronic conditions that as you referred to, we call comorbidity. We know in people with Ms. That comorbidity makes the disease substantially worse. So people who have a high burden of comorbidity, their disease accelerates at a much faster rate. They have atrophy of the brain at a much faster rate. They progress from relapsing to progressive courses earlier in the disease process. What's great is that exercise and physical activity can do two things. One is they can prevent comorbid conditions from occurring in the first place. From the field of physical activity epidemiology, we know that individuals who engage in regular physical activity and exercise behavior have lower risks of hypertension, they have lower risk of cardiovascular disease, such as coronary heart disease, they have a lower risk of, of type 2 diabetes and many other chronic conditions. Secondly, we know that if you are engaging in an exercise routine and you have comorbidities, that we can actually reverse those comorbidities. So individuals who are hypertensive, if they gauge in exercise training, they can reduce their blood pressure to a point that they become normotensive or having normal blood pressure. We know people who engage in exercise who have type 2 diabetes better regulate their insulin, they better regulate their blood glucose, and ultimately they can reverse the course of type 2 diabetes. And those changes of exercise on comorbidities actually might in and of themselves offer some disease modifying and protective effects. In multiple sclerosis.
- [22:26]
A
What about people who are living with more progressed ms, people who may have physical limitations or who may use a wheelchair for mobility? Can they still benefit from exercise?
- [22:39]
B
Absolutely. I think every person with multiple sclerosis can benefit. I think what happens is people develop more advanced disease where they have physical limitations. We have to be a little bit more creative and clever about the exercise programs that they can engage in. So we can't just send them to the gym and have them jump on the Stair stepper. Right. That's not going to be appropriate. So we need to think about adapted forms of exercise and adapted exercise equipment. And so nowadays there are pieces of equipment where you can do aerobic exercise from a seated position. So you can do arm ergometry, you can do seated arm leg stepping on a recumbent stepper, you can do seated recumbent cycling where you're pedaling with your legs. You can do a lot of things for aerobic exercise in a more safe position, resistance training. So to build muscle strength and muscle power, you know, you don't have to go to the gym and lift hefty weights to get stronger. You can use resistance bands, you can use things that you might find around the house. But again, it's a matter of choosing exercise equipment that's appropriate and utilizing that equipment in a safe way. And all individuals with ms, even those with physical limitations, can get benefits. I will say that more and more we're seeing these seeded exercise programs that involve yoga or Pilates. And I really see those as great options for people with Ms. Who have advanced disease and they're experiencing physical limitations. And the reason why I say that is because these forms of movement involve two things. They involve a lot of brain activation and combining that with physical movement itself. And so you're strengthening the brain at the same time as you're strengthening your physical body out in your appendages like your arms or your legs. And so really we're combining the brain and the body into a more powerful exercise stimulus.
- [24:57]
A
As we're talking about these truly remarkable benefits of exercise for someone living with ms, I feel like I have to ask, should exercise be considered a replacement for disease modifying therapy?
- [25:13]
B
So I don't think we want to go to the space of thinking we could replace disease modifying therapies with exercise or diet, which is something else I've heard. I think rather we should be thinking about how we use exercise and other lifestyle behaviors in concert with our disease modifying therapies, so that we can maybe help to think about multiple avenues in which we can manage the expression of multiple sclerosis. And in doing so, maybe we can double the benefits of our behaviors, both utilizing disease modifying therapies and exercise in concert to have an even larger bang for the buck, if you will.
- [26:05]
A
Some people might say that the hardest part of any exercise program is actually staying on it. Are there strategies a person living with Ms. Can use to stay consistent with their exercise routine?
- [26:18]
B
The first thing I'll mention, and this is the most obvious thing in the World, right, Is if you want to start exercising, today's a great day to start exercising. Right. You have to take that first step somewhere, literally. And then you need to think about all the things that you can do to keep you in that exercise program. Because I don't want to infer that starting an exercise program and staying with an exercise program is easy. We all know that it's challenging, and it's particularly challenging for people with Ms. What we often do is we ask people with Ms. To first think about the reason why they're starting an exercise program and dig deep. Not the surface of, I want to lose weight, I want to look better. Because that's not a real deep meaning. Thinking about, like, why do you want to exercise? Because I want to be able to spend more time with my kids. I want to be able to do things with my kids. I want to be able to live a full life. Those are meaningful things. And we want people to think about that because those, those personal meanings of why we're going to engage in exercise will keep you coming back time and time and time again. The second thing we, we suggest people do is share their personal meanings with other individuals. Those individuals will keep you accountable. They'll remind you why you're doing what you're doing and what it really means to you and encourage you along the way. I mean, there's nothing better than having a strong person in our. That reinforces that what we want to achieve is valuable and helps us along the way. And then there are some other little tricks of the trade. So we always suggest that people put their exercise into a calendar and actually schedule it and schedule it around everything else they have in life, whether that's work or doctor's appointments or getting the kids to soccer practice or the dentist or whatever you have to do. But putting it in your calendar and sticking rigidly with what's in your calendar. And the value of that is it's harder to replace it once it's in there. Right. The second value of that is that you can review all your success. Right. You look back over your past month and you can see, wow, for the past four weeks, I exercised three times a week during that period of time and really feel rewarded and as though you've accomplished something. And that's always something that brings us back. And the last thing I would say is start small. Don't try to jump into 30 minutes of walking on the treadmill on day one. I think that's a recipe for disaster. Start with five minutes or as little as two minutes on day one and do that three times a week for two weeks and just see how you feel at that point in time. If you're doing good, build a little bit more. If you're not, stick with what you've been doing. But start small, listen to your body and slowly build what you're doing over time. And you'll find out that it doesn't take long before you begin to adapt to the exercise. It gets easier for you, and all those little subtle benefits that you're experiencing become more apparent to you. And then it's rewarding every single day and it becomes something that you look forward to as opposed to dread.
- [29:42]
A
What role can a physical therapist play, not only when it comes to recommending a specific exercise, but in putting together a structured exercise program that's customized to an individual's abilities and goals?
- [29:57]
B
So I think physical therapists, particularly neurological physical therapists, who are uniquely trained to work with individuals who have neurological diseases like multiple sclerosis or Parkinson's as examples, are really a good place to start because the the physical therapist can do an evaluation. They can find out if you have any sort of underlying musculoskeletal problems or neural activation problems. So, for example, think drop foot as an example and first begin to address those underlying problems that exercise might actually make a little worse. Neurological physical therapists will help to figure out where there might be these underlying deficiencies or problems and address those. And at the same time, begin to recommend exercises that you can do that will help you start to build that exercise program and specifically build that exercise program around the needs of the individual. Some people might need more muscle strength. The neuropt can help identify that in that program. Others might need better balance and vestibular control, and we can develop programs around that. Other individuals might have aerobic deconditioning and we can build programs around that. But the neurological physical therapist is a great place to start in getting evaluation, getting recommendations, and then working with them to develop the right program for you.
- [31:30]
A
Dr. Robert Model, I want to thank you for all you do to improve the quality of life for people living with Ms. And thanks so much for talking with me today.
- [31:39]
B
Thanks, John. It's been a real pleasure talking with you and being on your show.
- [31:43]
A
That's going to wrap up this episode of Real Talk Ms. Real Talk Ms. Is powered by the National Ms. Society and you can share this episode of the podcast by letting your friends or family members know that all they have to do is please point their web browser@realtalkms.com 450. You'll find that link in today's show notes, so you can easily copy and paste it right into an email or a text. If you're on any of the more than 20 Ms. Disease modifying therapies available today, you're directly benefiting from the work of Dr. Ludwig Kappos. Next week at the American Academy of neurology annual meeting, Dr. Kapos will receive the John Distel Prize for Ms. Research. And next week on Real Talk MS, Dr. Kapos joins me to review the future direction of Ms. Clinical research and discuss how Ms. Clinical trials have to change. I hope you're planning to join me as well. I'm John Strum. Thanks for listening. Stay safe and make healthy choices. Sam.