Case Report: Blood Flow Restriction and Therapeutic Exercise for a Patient with Multiple Sclerosis and Advanced Disability

Background: Muscle weakness is commonly experienced by persons with multiple sclerosis (MS) and worsens as disability advances. Moderate-to-high intensity resistance training has been found to improve strength in persons with EDSS scores of 0-5.5, but those with more advanced disability (EDSS >6.0) may struggle to achieve that intensity due to more severe weakness and/or fatigue. Low-load resistance training with blood flow restriction (BFR) may be an important alternative. While BFR is well-studied in other populations, less is known of its use in those with MS, especially in those with advanced disability.

Objectives: To describe the use of low-load resistance training with BFR for a person with advanced MS disability, and report associated changes in impairments (strength, fatigue, and balance), activities (30 sec sit to stand-30STS, gait speed), and participation (Patient-Specific Functional Scale-PSFS).

Methods: Case description: A 58-year-old woman with a 19-year history of MS (EDSS 6.0) who presented with weakness and difficulty walking, participated in a twice-weekly program of low-load resistance training with BFR for 8 weeks. BFR was utilized bilaterally during leg press, calf press, and hip abduction exercises with existing dosing guidelines: 20-30% 1RM, 1 set of 30 repetitions (reps) followed by 3 sets of 15 reps using up to 80% of maximal limb occlusion pressure (LOP) based the person’s rate of perceived exertion and tolerance. Pain, fatigue, and adverse events were recorded at each session. Outcomes were assessed before and after the intervention

Results: The participant completed all sessions and all exercises during each session. No increase in pain or fatigue was reported at any visit. LOP started at 60% for all exercises and progressed to 80% by the 10th visit. The participant had no adverse events related to the intervention but experienced one non-injurious fall in the community. Notable improvements were found for knee extension strength (hand-held dynamometry, left: +22.4%, right: +16.9%), fatigue (Modified Fatigue Impact Scale, 45/84 to 25/84), balance (Berg Balance Scale, 44/56 to 49/56), functional activity (30STS, 10 to 13 reps), and participation (PSFS, 5.33/10 to 8.67/10 average on 3 items). In addition, the patient reported “feeling stronger” and “having more energy” following the intervention. Negligible changes were found for gait speed, ankle, and hip strength.

Conclusions: BFR coupled with low-load resistance training was safe and well-tolerated by this participant and led to notable improvements in several clinically important domains. Overall, there is a lack of evidence for effective resistance training for people with MS and EDSS ≥ 6.0. Further study is warranted to examine the safety, feasibility, and efficacy of resistance training with BFR this population.