How to optimise exercise and good posture in people with MS

How to optimise exercise and good posture in people with MS.
JODY BARBER MS SPECIALIST PHYSIOTHERAPIST CENTRAL LONDON COMMUNITY HEALTHCARE
HELEN MS SPECIALIST PHYSIOTHERAPIST POOLE HOSPITAL FOUNDATION

Objectives
What types of exercise pwMS should and could be doing
Why different types of exercise are needed for pwMS to live well
How to overcome barriers to exercise
How to start a conversation about exercise and empower a pwMS to
start.
How exercise can be adapted to suit the level of disability that pwMS
may be experiencing with advancing MS
Demonstrating that exercise can be fun.
Inspiring you to lead by example so your patients do as you do!!

In groups of x,y,z. Carry out the
test / exercises instructed and
then pick out statements that
best describe the benefits and
reasons why a PWMS should be
doing this exercise.
THINK OF A PWMS YOU KNOW AND HOW YOU
WOULD SELL THIS EXERCISE TO THEM?

Exercise
Station 1
 Feet: Mobilise your feet 5 mins every
day, here are a few suggestions:
 Do these in sitting or standing depending
on balance, do one foot at a time
 Rolling onto outside edge of your foot
 Rolling onto inside edge of your foot
 Going onto toe edge, rolling through
foot, moving up and down, heel to toe.
 Going onto front of foot to stretch out
the front of the ankle
 Tracing the outside edge of your foot in
standing.
 Rolling your foot over a ball, choose
different balls

Exercise
Station 2
 Stand in the standing frame or with your
back to a kitchen worksurface and;
 Move your hips a small distance side to
side very slowly, feel more weight on one
leg as you do this
 Stand still and upright. Lift alternate arms
 Repeat 10 times, rest, repeat, rest, repeat
for up to 5 mins
 See link below on how to use a standing
frame
 https://youtu.be/EgKUSkq-9hg

The “ Hallelujah” sit to stand: make sure your feet
are underneath you and you have warmed them
up, reach forward and up as you stand up , like you
are saying hallelujah
It may help to imagine your arms are attached to
your belly button, and keep reaching from there
REPEAT THIS SLOWLY 5 X AND AS FAST AS YOU CAN
5X
REST REPEAT
Exercise Station 3

With Your Arms folded across your Chest stand up
and sit down as fast as you can: time how long it
takes you to do 5
Now see how many sit to stands you can do in a
minute
Record your results on the sheet provided.
Exercise Station 3

The one handed “ Hallelujah” sit to stand: make sure
your feet are underneath you and you have warmed
them up, reach forward and up as you stand up , like
you are saying hallelujah.
It may help to imagine your arms are attached to
your belly button, and keep reaching from there.
DO THIS EXERCISE AS SLOWLY ON THE WAY UP AND
DOWN. TRY NOT TO ‘PLONK’ YOUR BOTTOM.
https://youtu.be/W46Y4CE2NCc
Exercise Station 3

Exercise Station 4
With the kazoo hum the tune:
Somewhere over the rainbow
Forget your inhibitions and chant or
hum down the Kazoo your favourite
football song,

Exercise Station 5
Seated Arm Circuits
Sitting upright in the chair Hold the
ball weights in your hands with
elbows bent into your sides and move
your elbows outwards, then raise your
arms straight up and out to the side
https://youtu.be/kp_eOXii7Nk
Sit on a wobble cushion on the chair
with feet flat on the floor.
Reach in multiple directions, imagine
your little finger is attached to your
belly button. Or look at this link from
2.30 mins in:
https://youtu.be/W46Y4CE2NC
In sitting press hands together in
prayer position and keeping feet flat.
Do a seated twist. See link below:
https://youtu.be/GGcHSo1n-W0
Sit upright in a chair and march up
and down with your arms and or legs
like you are brisk walking as fast and
as hard as you can for a minute and
look at link below:
https://youtu.be/jnATUKQCIdc
Sit upright in a chair and give firm
controlled punches to the small
punch bag one arm at a time for a
minute
Using the theraband tied to a table
sitting upright in the chair do bicep
curls, pull the band diagonally across
your body. Or look at the link
below:
https://youtu.be/0YXukdwjRFA

Exercise Station 6
FALL PROOF PROGRAM: CENTER FOR SUCCESSFUL AGING, CAL STATE
FULLERTON
Modified Clinical Test of Sensory Interaction in Balance
(CTSIB-M)
*Administer only one trial per condition if participant able to complete first trial without loss of balance.
Condition One: Eyes Open, Firm Surface
Trial One Total Time: _______ / 30 sec
Trial Two Total Time: _______ / 30 sec
Trial Three Total Time: _______ / 30 sec
Condition Two: Eyes Closed, Firm Surface
Condition Three: Eyes Open, Foam Surface
Condition Four: Eyes Closed, Foam Surface
TOTAL: _______ / 120
sec
Purpose of Test:
This test is designed to assess how well an older adult is using sensory inputs when one or more sensory
systems are compromised. In condition one, all sensory systems (i.e., vision, somatosensory, and
vestibular) are available for maintaining balance. In condition two, vision has been removed and the older
adult must rely on the somatosensory and vestibular systems to balance. In condition three, the
somatosensory system has been compromised and the older adults must use vision and the vestibular
system to balance. In condition four, vision has been removed and the somatosensory system has been
compromised. The older adults must not rely primarily on the vestibular inputs to balance.
Begin timing each trial using a stopwatch. The trial is over when (a) the participant opens
his/her eyes in an eyes closed condition, (b) raises arms from sides, (c) loses balance and
requires manual assistance to prevent a fall.
This test provides some insight into whether each of the sensory system available for balance are being used
effectively. Failure to maintain balance in condition two indicates that the older adults is visually dependent. They
are not using somatosensory inputs to maintain balance when eyes are closed. Failure to maintain balance in
conditions 3 and 4 indicate that the visual and/or vestibular system is not being used to maintain balance. Poor
performance on this test would suggest the need for multisensory training if the medial history does not indicate that
 Test your balance and score with a colleague using the
following instruction sheet.
 Now practice the following:
 Standing feet together eyes closed
 Standing with one foot in front of the other, feet touching
or like a medium sized step.
 Standing on the folded blankets, eyes open arms folded,
eyes closed arms folded, now ¼ turn on the blanket with
yours eyes closed and arms folded
 Standing on the cushion eyes open and eyes closed
 https://youtu.be/33ET__fWMrI

Exercise Station 7
Seated leg stretch: In sitting leg on the ball ball roll the
ball away slowly and back keeping an symmetrical upright
posture: see the link. https://youtu.be/IwgfNoq_rTg
AND / OR
 Warrior standing: Stand with feet parallel and hips
facing forwards, bend front knee, make sure knee is in
line with toes, keep back leg straight and working with
the front leg breathe and expand arms and hands from
the belly button.
 If you struggle to balance do the warrior standing
holding on with one hand on the back of a chair or
kitchen worksurface.

Exercise Station 7
WALKING IS A MUTLITASK!
Practice the following several
times along the corridor with
someone.
Walking forwards eyes closed
Walking backwards eyes open
then closed
Walking and looking left, looking
up, looking down, looking right.
Ask your colleague to instruct you
where to look.
Walk along the corridor and your
colleague will instruct you to step
and turn, do this quickly pivoting
on the spot.
Stepping over the shoe boxes
Walk and count backwards in 2’s,
5’s, 7’s:

A note on Posture
 Why is posture important when carrying out an activity?
 In sitting and standing, postural muscles are better orientated so “switch on”
better to support the body when aligned in a good posture.
 If the postural muscles are supporting the body in better alignment then there
is less stress on the joints and muscles and hence less likelihood of injury and
pain eg our backs or necks.
 For some people with increasing disability, postural muscles may be weaker,
have reduced core stability or sitting balance, or are sat for most of the time. If
there is more support in a good posture in sitting, then arms can be used more
for function and activity rather than balance.
 With increased disability if someone cannot move themselves, it is important to
help maintain a functional, neutral posture to help orientate postural muscles to
give them the best chance of working and access the movement they do have.
 eg if sitting in a good sitting posture more able to use arms than if slouched.

A note on Posture
 What simple activities can I encourage someone to do to help
improve their posture?
 For those able, practice standing by the sink at home as upright as possible eg
with a chair or perching stool behind.
 If less mobile, this can also be done standing with a frame in front and arm
chair or wheelchair behind.
 Practice sitting up straight on edge of seat when adverts come on tv
 Can make this more challenging by raising arms up or out to the side.

Mood booster
and analgesic
Can increase brain sensitivity for hormones serotonin and
noradrenalin which relieve feelings of depression (1)
Can increase the production of endorphins which are known
to produce positive feelings and reduce pain perception
The benefits of mood boosting is not dependent on how
intense you work out.
A study of 24 women who had been diagnosed with
depression showed that exercise of any intensity significantly
decreased the feelings of depression (2)

Fat Buster
Your body expends energy
in 3 ways: digesting food,
exercising and maintaining
body functions like
breathing and your
heartbeat.
Regular exercise will increase
your metabolic rate which
will burn more calories and
help you loose weight
Combining aerobic exercise
with resistance training can
maximise fat loss and muscle
mass maintenance which is
essentially to keep the
weight off.

Strong
Muscles and
Bones
Weight lifting can stimulate muscle building when paired with
adequate protein intake.
Exercise helps release hormones that promote the ability of your
muscles to absorb amino acids. This helps muscles grow and
reduces their breakdown.
Weight lifting can include resistance bands, hand weights,
gravitational pull, carrying shopping.
As we age or if we are inactive we loose muscle mass and function
(atrophy)
High impact exercise ( running )and weight bearing ( standing) help
promote a higher bone density than lower impact like swimming

Energy
Booster How are you a feeling at the end of conference??
Exercise can be a real energy booster.
One study found that 6 weeks of regular exercise
reduced the feelings of fatigue for healthy individuals
who had reported persistent fatigue (9)
Exercise has been shown to increase the energy levels
in people suffering from long term conditions
/progressive illnesses such as MS cancer HIV/ AIDS (8)

Staying Alive!
Ahh
Lack of regular physical activity is a
primary cause of chronic disease
Ahh
Regular exercise is shown to improve
insulin sensitivity, cardiovascular fitness
and body composition, yet decrease
blood pressure and blood fat levels.
Ahh
Lack of regular exercise can lead to
significant increase in belly fat which
increases the risk of Type II diabetes,
heart disease and early death.

Glowing complexions
Your skin can be affected by the amount of oxidative stress on your body
Oxidative stress occurs when the body’s antioxidant defenses cannot completely repair
the damage free radicals cause to cells. This can damage and deteriorate your skin.
Regular moderate exercise can increase the body’s production of natural antioxidants
which help protect cells
Exercise can provide antioxidant protection and promote blood flow which can protect
the skin and delay the signs of aging

Happy Healthy Brains
 Exercise particularly aerobic exercises can improve
brain function and protect memory and thinking skills.
 It increases your heart rate which promotes the flow of
blood and oxygen to your brain
 It can stimulate the production of hormones that
enhance the growth of brain cells
 Exercise has been shown to cause the hippocampus
vital for memory and learning to grow in size
 The capacity for the brain to adapt is known as
neurological reserve to compensate for damage. (10).

Sleep like a baby
 The energy depletion that occurs during exercise stimulates the
recuperative process during sleeping
 The increase in body temperature that occurs during exercise is
thought to to improve sleep quality by helping it drop during
sleep.
 One study found that 150 mins of moderate to vigorous activity
per week can provide up to 65% improvement in sleep quality
(11)
 Another study showed that 16 weeks of physical activity
increased sleep quality and helped 17 people with insomnia
sleep longer and more deeply than the control. It also helped
them feel more energized over the day (12)
 Any type of exercise/ activity increase can help improve sleep
quality

Exercise as an analgesic
ENDORPHIN RELEASE: PAIN PERCEPTION

Flexibility /
Joint Heath
 Did you know that the discs in our backs have no
blood supply and to keep them hydrated we rely
entirely on movement which creates a change in
osmotic pressure that draws the hydration in.

Spasticity
Can give feelings of stiffness
It is velocity dependent.
Slow controlled stretches and weight bearing
exercises are reported to relieve symptoms

Lets talk
about sex
baby
Engaging in regular exercise can strengthen the cardiovascular
system, improve blood circulation, tone muscles and enhance
flexibility all of which can improve your sex life
Exercise can improve sexual performance and sexual pleasure
A group of women in their 40’s observed that they experienced
orgasms more frequently when they incorporated more
strenuous exercise into their lifestyles(13)

Sensory changes
In a study of 428 people with
MS, 8 in every 100 reported
experiencing painful altered
sensations (dysaesthesia) in
the previous six months. 12 in
every 100 people in the same
study reported experiencing
dysaesthesia at some point in
their life. The total number of
people who experience
altered sensations is likely to
be much higher because this
study did not count those
who had non-painful changes
in sensation, such as
numbness.(4)
In a study of 224 people with
MS, 40% reported
experiencing periods of
altered sensation lasting from
seconds to minutes. The most
common description was
burning followed by electric
shock, insects crawling and
then itching. People with early
disease and without disability
had sensory symptoms just as
often as those with disability.
This reflects the observation
that altered sensation is often
one of the first symptoms of
multiple sclerosis.(6)
While the symptoms of
altered sensation cannot
always be resolved,
understanding how lack of
sensation can alter or prevent
normal movement and giving
exercises to minimise the
effects of not moving due to
not feeling or excite the
sensation that is other wise
dull. In preparation for
movement eg use of a spikey
ball before standing up.

Balance and
Sensory
Symptoms
Balance problems are common in MS. Lesions in the areas of the brain
responsible for movement and balance or in the sense areas and systems can
cause problems with balance, which can result in walking difficulties and
sometimes falls.
A study by Cattaneo D, Jonsdottir J, Regola et al 2014, indicated that after
rehabilitation people with MS can recover from sensory impairments and
improve their balance. The exercises used were tailored to each individual's
impairments and the results showed that with training, people could become
less dependent on visual information and improve their use of information
coming from their other senses to improve their balance (6)

Functional activities
Trying to fit
exercises into a
busy day when you
feel tired is
challenging
Making the
exercises functional
will help make this
possible
Doing repeat sit to stands in the toilet after
going, or at the table before a meal.
Balance exercises when the kettle is boiling
or the microwave is heating something.
Step ups after you have climbed the stairs

Exercise Questionnaires
1) How frequently do you
exercise?
2) How much do you think you
should be exercising?
3a) When you exercise do you
include vigorous exercise?
3b) If you answered yes, how
many minutes of vigorous
exercise do you do a week?
4a)When you exercise do you
include moderate aerobic
activity?
4b)If you answered yes how
many minutes of aerobic activity
do you a week?
5) When you exercise do you
include any types of muscle
strengthening?
6) What types of exercise do
you do?
7) What are your barriers to
exercising?
8) Why do you exercise?
9) If you are happy with the
amount of exercise you do: How
confident are you that you can
maintain your current exercise ?
10) If you intend to do more
exercise how confident are you
that you can start doing more?

Canadian Guidelines
 http://csep.ca/CMFiles/Guidelines/specialpops/CSEP_MS_PAGuidelines_adults_en.
pdf

How to start a
conversation
with a pwMS
about exercise
 Put the patient in the perspective of learner
 It is our role as health care professionals to educate
and empower pwMS to exercise.
 We have put the case forward in these slides in the
context of the general population and along side
some specific MS symptoms.
 We need to talk to pwMS in a language they
understand and outside the context of MS as pwMS
don’t necessarily see themselves first as a pwMS
 Give them a persuasive argument for exercise
 Think of you’re your use of words exercise is a dirty
word for some people, how about a top tip to
manage a symptom
 Treat exercise like a prescription: CSP Love activity
campaign leaflets

Local Gym
Toning Suite
 Has 12 x Shapemaster
Power assisted exercise
machines

Recognize the
common
challenges for
pwMS
Overheating
Fatigue
Recovery
Mobility
Help them to start small and build on it.

Do not try to
eat the elephant
in one sitting,
take one bite at
a time.
Celebrate the
small activities
that you do
every day

Do what you Love
“Don’t ask yourself what the
the world needs. Ask yourself
what makes you come alive,
then go and do that.”
Howard Thurman

Video clip of PWMS
 Doing what they love!! And makes them come alive!
 https://www.youtube.com/watch?feature=youtu.be&v=pnGK4flkuUE&app=deskt
op

References / Hyperlinks
1.Effects of exercise and physical activity on anxiety. Anderson E, Shivakumar G.Front
Psychiatry. 2013 Apr 23;4:27. doi: 10.3389/fpsyt.2013.00027. eCollection 2013. No
abstract available. PMID: 23630504 Fr
2. Behav Ther. 2016 Jul;47(4):527-37. doi: 10.1016/j.beth.2016.04.003. Epub 2016 Apr
27.Influence of Exercise Intensity for Improving Depressed Mood in Depression:
A Dose-Response Study. Meyer JD1, Koltyn KF2, Stegner AJ3, Kim JS2, Cook DB3.


3. Razazian N, et al.Exercising Impacts on Fatigue, Depression, and Paresthesia in
Female Patients with Multiple Sclerosis.Med
Sci Sports Exerc. 2016 May;48(5):796-803Summary(link is external
4. Boneschi F et al.Lifetime and actual prevalence of pain and headache in
multiple sclerosis.Multiple Sclerosis 2008;14(4):514-21.Summary(link is external)
5. Rae-Grant AD et al.Sensory symptoms of multiple sclerosis: a hidden reservoir
of morbidity.Multiple Sclerosis 1999;5(3):179-83.Summary(link is external)

6. Afsharid D, et al.Evaluation of pulsing magnetic field effects on paresthesia in
multiple sclerosis patients, a randomized, double-blind, parallel-group clinical
trial.Clin Neurol Neurosurg. 2016 Oct;149:171-4SummaryCattaneo D, Jonsdottir J,
Regola A , et al.
7. J Neuroeng Rehabil. 2014; 11: 100.
Published online 2014 Jun 10. doi: 10.1186/1743-0003-11-100
PMCID: PMC4065075
PMID: 24912561
Stabilometric assessment of context dependent balance recovery in persons with
multiple sclerosis: a randomized controlled study
Davide Cattaneo, 1 Johanna Jonsdottir,1 Alberto Regola,1 and Roberta Carabalona1

8. Cochrane Database Syst Rev. 2012 Jan 18;1:CD008427. doi:
10.1002/14651858.CD008427.pub2.Interventions for fatigue and weight loss in
adults with advanced progressive illness. Payne C1, Wiffen PJ, Martin S.
9. Psychother Psychosom. 2008;77(3):167-74. doi: 10.1159/000116610. Epub 2008 Feb
A randomized controlled trial of the effect of aerobic exercise training on feelings of
energy and fatigue in sedentary young adults with persistent fatigue. Puetz
TW1, Flowers SS, O'Connor PJ.
10. https://www.msbrainhealth.org/

11. Association between objectively-measured physical activity and sleep,
NHANES 2005–2006
Author links open overlay panelPaul D.LoprinziaBradley J.Cardinalb
https://doi.org/10.1016/j.mhpa.2011.08.001
12. Sleep Med. 2010 Oct;11(9):934-40. doi: 10.1016/j.sleep.2010.04.014. Epub
2010 Sep 1.
 Aerobic exercise improves self-reported sleep and quality of life in older
adults with insomnia.
 Reid KJ1, Baron KG, Lu B, Naylor E, Wolfe L, Zee PC.

13. Health Qual Life Outcomes. 2006 May 10;4:29.
 Sexual activity and perceived health among Finnish middle-aged women.
 Ojanlatva A1, Mäkinen J, Helenius H, Korkeila K, Sundell J, Rautava P.
 A

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