Symptom Awareness

Mobility Independence and Safety

Written by Patricia G. Provance, PT, MSCS

Part II: Improving Functional Mobility with Exercise

(Please note that Part III will appear in a future issue of The Motivator.)

In Part I of this series on mobility independence and safety, appearing in the Fall 2008 issue of The Motivator, we emphasized the need for a baseline evaluation by a physical therapist (PT). We also discussed the downside of inactivity; fatigue and energy management; cooling tips; and some issues and equipment related to ambulation. In this article - Part II of the series - the focus will be on an extremely important, and often overlooked, component of wellness: exercise!

In the past, many physicians recommended rest instead of activity because of fatigue issues and the fact that MS was a "progressive" neurological disease. However, research in the past 10 years has shown that well-paced exercise and activity can, indeed, result in positive outcomes relating to improved functional strength, endurance and quality of life.

As a PT, I have many times heard the refrain, "Why exercise? I have MS!" Burdened by sometimes overwhelming fatigue and frustration, many individuals with MS feel that exercise will just make their situation worse. In fact, that could be true - especially if the exercise or activity is not appropriate or is "overdone." Unfortunately, some therapists and trainers who are not familiar with MS (especially the symptom fluctuations, fatigue issues, and heat sensitivity) will unknowingly push you to failure and more frustration.

My desire in writing this article is to help you become an informed advocate in developing your own, customized, exercise and activity program. The guidance of a PT with experience in MS care can be helpful- but there are many things you can do on your own. However, before starting, some planning is necessary. Here are some questions to ask:

• What positions, movements, or activities are difficult for you right now?
• How much time and energy (if any) do you have to devote to exercise?
• Are you doing considerably less than you did a year or two ago?
• Are your goals realistic?
• Are you motivated to go into low-level "training?"
• Do you have support at home for this new change in behavior?
• Can you be flexible if circumstances, weather, energy, or other factors require changes to your routine?

Helpful Advice for Planning an Exercise and Activity Program

1. Activities This refers to "Activities of Daily Living" (ADLs) that are the cornerstone of functional independence. For example, if you have trouble standing up without using your arms to push off (or a grab-bar to pull up) - that is where you need to start. If you use a wheelchair and have trouble sitting unsupported or doing a chair push-up with good trunk control to assist in transfers - that is where you need to start. Simple exercises or activities that are focused on function can be extremely helpful in the effort to improve strength, safety, and independence.

2. Time and Energy Remember the four "Ps" - Planning, Pacing, Positioning, and Prioritization. This will allow you to incorporate some of the exercises throughout the day instead of trying to do them in a single session. A good rule of thumb is to try to do something (such as isometrics, balance exercises, chair push-ups, walking practice, etc.) at brief intervals throughout the day, with a focus on quality and control instead of quantity.

3.De-conditioning This is a common problem when activity declines, and it usually is a slow, steady process of muscles weakening from disuse, resulting in less endurance. The "primary" weakness caused by MS plaques in the central nervous system will require some compensatory measures (such as a foot-drop brace or cane). However, the "secondary" weakness due to de-conditioning is reversible! "Use it, or lose it!"

4. Realistic Goal Setting If you haven't done much activity in years, it's important to realize that progress will be slow. Patience and persistence are the keys to success as you begin the process of "attitude adjustment" and "behavior modification." Setting realistic and attainable short-term goals will ease frustration - and seeing slow, steady progress will motivate you to continue.

5. "Training" In this case, we are not referring to the grueling workouts of athletes in the gym, but a commitment to improving both strength and health by starting a regular wellness routine. This concept of "going into training" includes healthful eating, good sleep habits, and regular, appropriate low-level exercise and/or activity.

6. Support I have had the opportunity for many years to work with thousands of patients with MS. In spite of the wide variation in symptoms and abilities, my observation has been that those with the highest quality of life had two things: SPUNK and SUPPORT. Those attributes will greatly improve the chances of a positive outcome as one begins an exercise program. Having the spunk and desire to do something is important - but having support of family and friends (as cheerleaders and assistants) will help to get it done!

7. Flexibility This does not refer to stretching (which is important for tight muscles), but the need to "flex" your exercises and activities depending on many factors, such as how you're feeling, a busy schedule, transportation or weather challenges, etc. Having a basic home program that can be done at any time (or many brief times) in the day will allow you to continue on the road to functional strengthening, balance, and mobility.

Where to Start!?...

The developmental model requires one to have stability before you can achieve independent mobility. Therefore, the first goals should be attaining good balance and control in many positions - holding still (or static) at first, and then moving (or dynamic). This will vary greatly, depending on your strength and abilities, but it's always good to review the basics.

The list below can be a starting point for simple exercises in different positions - but please take caution not to try any exercise or position that may be too difficult or unsafe for you. If you are extremely weak, a PT evaluation is strongly advised, and you should have a care partner present to assist with your home program.

Editor's note: Please consult your physician before making any changes to your exercise and activity programs.

Position # 1: LYING DOWN WITH HIPS AND KNEES STRAIGHT

1. Isometric Gluteals, or "Glut Sets:" squeeze buttocks together - hold and breathe - relax and repeat.
2. Isometric Quads: tighten thigh muscles that hold knee straight.
3. "Foot Pumps:" pull toes toward your nose until you feel a stretch in the back of your calf - hold - relax - then alternate with other foot; repeat several times.
4. "Tummy Tucks:" pull lower belly up and in - hold for several breaths - relax and repeat.
5. "Bent-Knee Leg Lifts:" bend both knees with feet on bed or floor - then alternately lift legs like you're marching; this is much less strenuous than straight leg raises!
6. Overhead Reach: clasp hands together or put hands on opposite elbows and try to raise both arms completely overhead until they touch the bed.
7. Roll to and from front to back and vice versa; repeat.
8. Roll to each side and press up to raise shoulders off the bed.
9. Roll to each side and slide legs off the bed and come to a sitting position.

Position # 2: SITTING IN A STURDY ARMCHAIR WITH FEET ON THE FLOOR

1. Sit away from the back of the chair and correct posture: knees forward (like "headlights"), belly up and in, shoulder blades down and back, chin level and eyes forward (this is "static balance").
2. "Trunk Clocks:" pretending that you're sitting in the middle of a clock and lean from side to side, forward and back, and diagonally, as if aiming toward the "numbers" on a clock (this is "dynamic balance").
3. "Chair Push-Ups:" sit tall, put hands on chair arms beside hips, and press up so that your hips raise up from the seat of the chair; hold, then slowly return to a sitting position.
4. Knee Flexion and Extension: sit tall and slowly straighten, then bend each knee.
5. Low Back Stretch: clasp hands behind knees and pull your chest to your thighs; hold, breathe, and relax.
6. "Arm Ballet:" sit tall and raise both arms overhead and out to the side in different patterns such as "a ballet dancer," "V for victory," "airplane wings," etc.
7. Go from sitting to standing: work for smooth control without using your arms, if possible (but do not risk falling or losing your balance).

Position # 3: ON HANDS AND KNEES

1. "Rocking:" balance on hands and knees and rock slowly forward and backward.
2. Arm/Leg Lifts: from hands and knees position, slowly lift one arm and then return to starting position; then lift the other arm and return. Next, try lifting one leg out straight behind you - return to starting position - then lift the other leg. If this is not a challenge, you can try to lift the opposite arm and leg at the same time.
3. Crawling forward and backward.
4. Static Kneeling: support with your hands on a firm, soft chair or ottoman (or bed headboard) and tighten belly and buttocks. If this is not a challenge, try to maintain balance without hand support. If you can balance for several minutes, then you are ready to attempt dynamic kneeling, by bowing and twisting slowly to work your trunk and buttock muscles.

Position # 4: STANDING (with light hand support, as needed)

1. Practice good standing posture: feet comfortably apart, knees forward (but not locked), hips straight, belly up and in, shoulder blades down and back, chin level, and eyes forward.
2. "Mini-Squats:" do small, slow knee bends; then return, relax, and repeat.
3. Single-Leg Stand: slowly lift one foot (forward, backward, or out to the side) and balance on the other leg - relax - then do the same with the other foot.
4. Marching: slowly lift one knee after the other while keeping good posture.

Other Exercise Options

Numerous other exercises and activities can provide both variety and fun when the "basics" have been conquered. Many individuals with MS have found low-level exercise, yoga, tai chi, or pilates instruction on DVDs to be a convenient way to exercise at home (alone or with a friend), and many programs can be done from a chair if supported standing is not possible.

Others report more motivation and socialization from joining an exercise class. Aqua-exercises in a cool pool (at no more than 85 degrees) can have wonderful benefits because the water provides support for balance, mild resistance for exercise, and minimal interference by gravity. Hippotherapy (or therapeutic horseback riding) is another popular activity that works on balance and strength. If you choose to exercise in a gym or fitness center (or if you have equipment at home), it 's important to take plenty of rest breaks, to have an oscillating fan keeping you cool, and to have an appropriate, effective and well-paced program. Aerobic conditioning is an option when exercise tolerance improves, but fatigue must be respected and rest breaks taken as needed. Regardless of the exercises or activities you choose, there are some rules to remember:

• WHEN IN DOUBT - DON'T!
• IF IT HURTS - STOP!
• MORE IS NOT BETTER!
• FASTER IS NOT BETTER!
• YOUR ACTIVITY SHOULD BE A CHALLENGE, BUT NEVER A STRUGGLE!

Transient Symptoms brought on by Exercise or Heat

Maureen Shanahan is a nurse with MS and client of Pat Provance (the author of this article). Maureen notes the impact of "Uhthoff's symptom," which is a temporary worsening of vision resulting from exercise or an increase in body temperature. Exercise (which naturally increases body temperature) and other factors contributing to feeling warmer - such as one's surrounding temperature or taking a hot bath - can also cause a transient worsening of other (non-visual) symptoms, including weakness and numbness or tingling sensations.

Maureen explains, "Once the internal temperature is raised in most persons with multiple sclerosis, performance begins to slip. It is barely perceptible in some of us, but a seriously inhibiting factor for exercise in many of us. One can feel sloppy, clumsy, dizzy, and less coordinated. One may also have visual problems and be less able to concentrate or communicate. For example, I have difficulty expressing myself in words, during and immediately after I have been exercising. I cannot write or push buttons, and I also have difficulty lifting a glass to my lips to drink. Using a straw helps me reach the glass, and drinking very cold water can help improve how I feel.

"Individuals with MS need to be reassured that any symptoms brought on by exercise and overheating are temporary and resolve completely, once you have rested and cooled down. They also need to know that getting to this point, does not damage them in some way, though it certainly feels that it would. Experiencing heat-related symptoms isn 't an ominous sign, but it should be taken as a warning to be cautious. People with MS who may experience this symptom need to protect themselves from falls and other accidents. They also should consider this when setting realistic goals, and have someone check on them while exercising. The good news is that it has been my experience that the tolerance for heat and exercise is improved over time, and seems to correlate with endurance. "

As noted in Part I of this article series, individuals who are heat-sensitive may use cooling techniques to help avoid overheating and reduce the effects of heat-related worsening of symptoms. Among others, strategies include taking a cool bath, sucking on ice chips, or using cooling devices such as collars or vests.

Editor's note: Individuals with MS are advised to stop, rest, and cool down if they begin to feel such symptoms as weakness, tingling, visual issues, lack of concentration, or other neurologic changes during exercise.

Exercise Equipment Considerations

"Try before you buy!" Many tempting advertisements lure us into purchasing that piece of "miracle" exercise equipment. If you are seriously considering making a major purchase, an evaluation by a PT is advised so that you can be assessed and trained by a professional. A treadmill, for example, needs to be both safe and user-friendly, with features such as side hand supports, a wide belt, low ramp-up speed, easy controls, etc. Additionally, it does not need to go faster than four mph if you will just be walking. An exercise bike can help with overall leg strength and conditioning - but it won't improve your "wobbly walking," because you are exercising while sitting! Hand weights are popular, but can be exhausting. A "Theraband," which is a specially designed, large elastic band, is cheaper, more portable, and you can adjust the resistance for each exercise.

Summary

In a recent MSAA survey, more than one-third of the respondents reported that they rarely or never exercised! Hopefully this article will help broaden your horizons to understand that exercise does not have to be an exhausting workout, but instead, can be easily done at home with a focus on carefully paced, functional strengthening activities. Just call it "Back to the Basics!" Then when you're stronger, you might want to supplement your exercise program by joining a program in your community, to enhance the fun and fitness. Good luck!

This article is one of a series of three that have been written and generously provided to MSAA by Patricia G. Provance, PT, MSCS. Pat is an esteemed member of MSAA 's Healthcare Advisory Council.

Pat has 37 years of experience in physical rehabilitation, having been in clinical practice since 1971. In 1982, she started the first MS Rehabilitation Program in Maryland at The Union Memorial Hospital, in addition to her orthopedic caseload. In 2000, Pat joined the University of Maryland Medical System at Kernan Hospital to dedicate her practice to MS, and continued as a clinical consultant with the Maryland Center for MS until her "semi-retirement" in December 2006. She became an MS Certified Specialist in 2005 and continues as a clinical consultant with the National Multiple Sclerosis Society. Pat is also an active member of The Consortium of Multiple Sclerosis Centers. She currently is teaching and consulting on MS care to patients and professionals throughout the country. Publications include the clinical bulletin, "Physical Therapy in Multiple Sclerosis Rehabilitation," and co-authorship of the textbook, Muscles, Testing and Function with Posture and Pain, 4th and 5th editions.