1. Exercise and MS Patricia G. Provance, PT, MSCS Maryland Center for MS & Kernan Rehabilitation Hospital

3. The Rehabilitation Team Always has something to offer Should have knowledge about the unique and individual nature of MS Can provide education, sensitivity, resources and monitoring of functional needs.

4. Function and Quality of Life The goals of both patients and therapists are to achieve and maintain an acceptable level of functional independence and control. The need for therapy intervention will vary, but should be timely and appropriate, as the need will increase over a lifetime. The “orthopedic strengthening model” is usually a failure.

5. Periodic Assessments are needed To determine need for adaptive tools, ambulation aids, wheelchairs, safety equipment, community resources, exercise program modifications, etc. To continue support and education regarding energy management, work issues, wellness and conditioning

6. Deconditioning can have a major impact on function Often overlooked as a symptom Often preventable Secondary weakness from disuse is common and is reversible Adaptive muscle shortening from inactivity can be resolved with corrective exercise

7. Fatigue in MS MS fatigue: Persistent, overwhelming sense of tiredness and exhaustion Causes –Reduced conduction of nerve impulses –Excessive spasticity and/or muscle tightness –Increased core body temperature due to weather, fever, or exertion –General deconditioning –Poor trunk stability

8. Fatigue in MS (continued) Aggravating factors –Obesity –Sleep disruption –Restless leg syndrome –Inactivity/over-activity –Side effects of medications –Depression –Stress –Other medical conditions, e.g., anemia, hypothyroidism

9. Energy Management Strategies Effective pacing Flexible home and work schedules Recognition of warning signals Successful use of compensatory strategies Acceptance of a request for assistance Home/work modifications

10. Energy Management Strategies Appropriate ambulatory aids Maintenance of mobility Control of spasticity Improved trunk control Correct compensatory movement patterns ADL assistive devices Heat control Habit change/Lifestyle modification Medications

11. Adaptive Muscle Shortening Occurs with inactivity Most often affects the Iliopsoas (1-joint hip flexor that attaches on the lumbar spine)., Hamstrings, Gastrocnemius, Pectoralis major and minor (slouched posture) and posterior neck (fwd head & substitution) Impact: Low back pain, spasticity, poor posture, limited overhead reach

12. Secondary Weakness Common in MS Trunk, abdominal and gluteal weakness secondary to prolonged sitting –Often exacerbated by adaptive shortening of hip flexors and contributes to poor posture and balance problems in standing Neck and trapezius weakness secondary to poor sitting posture and inactivity –Affects arm function in overhead reach and is exacerbated by tightness in pectoralis major and minor, latissimus dorsi and upper trapezius

13. Weakness: Common Gait Deviations “Hip-Hiking” Circumduction (swinging leg out to the side) Trunk lean to the side Backward trunk lean Foot drag Shuffling Vaulting to clear weak leg

14. Management of MS Weakness Primary weakness –Strengthening muscles –Requires compensatory intervention (mobility aids, bracing, etc.) Secondary weakness –Often overlooked –Can be minimized with early intervention and appropriate follow-up to maintain posture & stability, correct compensatory gait, encourage healthy lifestyle, and teach energy management strategies

15. Corrective Exercises Should be: Functionally focused Done throughout the day Successful in demonstrating improvement Performed independently, if possible

16. Heat Intolerance Treatment: Reduce core temperature –Cool environment (Room 62-68 degrees, Water <85 degrees F) –Hydration with cool liquids –Popsicles, “slurpees” –Light/loose clothing –Rest after activity/exercise –Cooling vest/garment –Ice/cooling gel packs –Use of an oscillating fan when exercising –Avoid hot baths/showers

17. Mobility Mobility: Ability to move independently from one location to another Mobility limitation leads to increased risk for ADL dependence Mobility limitation leads to increased risk for other health and psychosocial problems

18. Elements of Mobility Bed mobility Transfers Ambulation (independent or aided) Wheeled mobility (manual, power, scooter) Driving: hand controls, left gas pedal

19. MS Symptoms That May Interfere with Mobility Spasticity Weakness Fatigue Impaired balance Impaired sensation Pain Contractures Vestibular Disturbances Impaired cognition Limited range of motion Heat intolerance Vision problems Ataxia (incoordination) Environment

20. Mobility: Interventions Equipment prescription –AFO (ankle-foot orthosis or “foot drop” brace) –Assistive devices Cane (straight or “sure-foot”) Lightweight forearm crutch(es) Walkers (standard, 2-wheeled, 4- wheeled, wheeled with seat) Wheelchairs: manual, power, scooter (controls, positioning) Car/van modifications

21. Effects of Exercise - Improvements in Impairments Improved range of motion Improved strength Improved endurance/ decreased fatigue Decreased pain

22. Effects of Exercise – Improvements in Disability Improved mobility - bed mobility - transfers - ambulation Improved independence with ADLs

23. Effects of Exercise – Improvements in Quality of Life Improved emotional behavior Improved social interaction Recreational enjoyment Improved home management independence

24. Summary MS and accompanying symptoms can cause difficulty with exercise The benefits of exercise outweigh the potential difficulties because of the positive potential for reducing disability, improving quality of life and improving overall health

25. Remember… If you don’t USE it… You LOSE it!

26. Useful Websites www.abledata.com www.beabletodo.com www.abilityhub.com www.assistivetech.net www.rehabtool.com www.Infogrip.com www.ocelco.com www.maxiaids.com www.orthoticmobility.com www.clarkehealthcare.com www.invacare.com www.sunrisemedical.com www.sammonspreston.com www.walkeasy.com www.gaiam.com www.medicalmailorder.com www.phc-online.com www.allegromedical.com