Articles on Medical Diseases and Conditions

A physiotherapist would normally recommend a programme of management geared to the diagnosis of your mobility problems.
The main aim of exercising is to:

• try and keep as many muscles as possible in good working order;
• strengthen those that have become weak;
• help keep joints mobile;
• help prevent them from getting stiff;
• help your coordination and balance;
• improve your circulation – and in doing so help other body functions;
• help reduce spasticity in more advanced MS;
• help prevent pressure sores.

Types of exercise

A number of different types of exercise might be recommended depending on this diagnosis.

• For your overall fitness, general exercises may be recommended, not necessarily linked to any particular movement symptom of your MS.
• Exercises to improve your cardiovascular fitness will increase your heart rate, and are good for your circulation.
• Stretching exercises will decrease the risk of spasticity and contractures. These exercises work by stretching muscles and tendons to increase their flexibility and elasticity.
• Resistance exercises, with the use of weights or other devices, help increase the strength of muscles that have been weakened.
• Range of motion exercises focus on improving the degree of motion of joints in the body, and aim to overcome, as far as possible, difficulties caused by stiffness in joints or problems in tendons and ligaments.

There are several different ways in which exercises may be undertaken:

• What are called active exercises are those that you can undertake yourself without any help, and you may use weights or changes of position to give more resistance (to increase the value of the exercise).
• Self-assisted exercises are ones in which you can use one part of your body to assist another, e.g. by using a stronger arm to assist a weaker arm.
• Active assisted exercises are those in which another person is needed to help you from time to time, but in which you still do most of the exercising yourself.
• Passive exercises are those performed on you by others when you cannot easily move yourself, e.g. moving your arms or legs for you, to increase the range of motion.

As you can see from these different types of exercise, you will not always need to have the physiotherapist present. Even in relation to passive or active assisted exercises, other people, once they know how to help, can assist you. Indeed the normal pattern is for you to have an assessment and a small number of sessions with a physiotherapist initially – usually five or six over a period of a few weeks – and then for you to work on the agreed exercises on your own or with a member of
your family. You would probably return to the physiotherapist for periodic assessments thereafter to check how you are getting on.

Self-help exercises

Overall, one could say that exercise will help you maintain your maximum independence. Some floor and chair exercises are shown in Figures 8.1 and 8.2. Passive exercise is shown in Figure 8.3.

Regular sessions

Many people with MS find it puzzling, or even very disturbing, that physiotherapists will see them and assist them directly for several sessions, and then end regular consultations. This is for the following reasons:

• Pressures of time and resources mean that it is difficult for physiotherapists to continue to give regular (weekly or fortnightly) sessions beyond the initial phase of therapy.
• The training of physiotherapists emphasizes their evaluating role, in which the onus is on transferring responsibility as much as possible to the patient (client) for continuation of an agreed exercise programme.

An important feature of exercise is that it continues on a regular basis and that as much as possible is undertaken by the person with MS. Unfortunately, there is often a conflict between the view of physiotherapists, who consider that one of their main tasks is to ensure that people with MS undertake an agreed programme on their own or with family assistance, and the views of people with MS, who often feel that the support provided by regular and continuing visits to a physiotherapist is vital. It is often difficult to resolve this conflict, although some pattern of occasional consultations can often be agreed.

Caution

Be careful not to get overheated or exhausted, which may on occasion lead to a temporary increase in some MS symptoms (see Chapter 6). Your own commonsense will normally tell you when you are exerting yourself too much. Generally, if you exercise carefully and regularly, with periodic breaks, you should find that you can get the most reward from the exercise.

Figure 8.1 Floor exercises.

Figure 8.2 Chair exercises.

Figure 8.3 Passive exercise.

Having a helper

In general, the physiotherapist should have indicated how a friend or partner can help but, apart from following those instructions carefully, the following broad points may apply:

• Get them to encourage you to undertake as much movement as possible, but don’t let them impede your movements.
• They should allow you to perform a passive exercise (an exercise undertaken with/on a person by another person), as smoothly as possible.
• They shouldn’t apply increased pressure at the most extreme points of the movement and, if a spasm occurs when they touch a limb, wait to see whether the spasm ceases and then let them help for as long as the movement is comfortable.

Guidelines

Most of the guidelines are quite sensible if you think about them.

• Try and undertake those exercises that you have been recommended to do by a physiotherapist regularly, preferably every day – unless the physiotherapist indicates otherwise.
• Whether you have been given advice by a physiotherapist or not, it would be wise to try and move around as much as you can, and to sit and stand as erect as possible. Posture is very important. When
it is bad, it may produce muscle and joint strains, and secondary back problems. Furthermore, bad posture in a wheelchair or other chair may have more profound constrictive effects on your breathing and chest.
• Try to exercise within your own capacity, i.e. do not get overtired, and try not to worry if you perform less well on a bad day. Everybody’s performance varies from day to day.
• Also try and recognize when you need professional advice about problems that you are experiencing and that are not being helped by your current pattern of exercises.

Sports

The diagnosis of MS in itself should make no difference as to whether you continue to play sports or not. The key issues are whether you enjoy playing the sport, whether you feel that you can play the sport as well, or nearly as well, as you did before, and whether you feel that there are any inherent problems, e.g. a significant risk of injury, that might affect your life in other ways. People without MS have to consider these issues as well. You might be able to change your approach to sport later, perhaps by playing at a different level, if you feel that there may be problems for you at the highest competitive level. Nevertheless, sporting exercise is good for you, especially if you enjoy and benefit from it.

Fatigue and exercises

If you feel too tired to exercise, the key to solving this problem may be working out ways in which you can take advantage of the times when you feel less fatigued in order to do modest but well-targeted exercise. Look carefully at the day-to-day activities you undertake, to see whether they might be rearranged and result in less fatigue. Sometimes, introducing rest periods and using specific aids for certain activities will result in less fatigue, and the chance to undertake limited and helpful exercises. You may also need, perhaps in consultation with a physio- therapist, to review the exercises to make them less vigorous. After all, it is not only a question of getting your exercise regimen right, but of getting a good balance between exercise and relaxation.

Weakness and exercise

Physiotherapy, or exercise in general, cannot ‘mend’ the damaged nerve fibres that lead to less effective control of muscles. Weakness in the legs, and problems of balance, may be due directly to less effective nerve conduction, but exercise may help other causes of weakness. Devise a programme of exercise with your physiotherapist making sure that any special exercises that you do undertake, e.g. resistance exercises through using weights, are in fact likely to help you.
After an MS attack, some people find that they cannot walk. Whilst normally some recovery is usual from the symptoms experienced at the height of an attack, the extent of this recovery can vary a lot. If demyelination has been quite substantial, there is little you can do through an exercise programme to reduce this damage, but you should still do leg exercises in order to keep your muscles as strong as possible, and to maintain flexibility so that, if more spontaneous recovery occurs, you will be able to take advantage of this. In any case it is very important to continue undertaking leg exercises, so that you can sit more comfortably and avoid some of the problems that can come with prolonged sitting.

Spasticity and exercise

A regular programme of stretching and related exercises can help muscular development, or at the very least help prevent the muscles wasting away. Keep your joints, tendons and ligaments as flexible as possible. Avoid positions where spasticity is more likely. Keep your head as central as possible when doing exercises and, if spasticity does occur, do a passive exercise as smoothly as possible to relax your muscles. On occasion it has been found that towels dipped in iced water and applied to the relevant area for a few minutes at most may help the muscles to relax. Unfortunately, as MS progresses, even with the most helpful exercise programme, additional means – usually prescribed drugs – may be necessary to assist the spasticity. You should consult your neurologist or GP about these.

Swimming

Swimming is a good form of exercise for everyone, but especially for people with MS, because your body weight is supported by the water. Weakened muscles can operate in this environment and will strengthen from the resistance. In addition, as swimming involves many muscle systems in your body, it can help to increase coordination.
Your main practical problems may be issues such as where the changing rooms are in relation to the pool, and obtaining assistance to reach, and return from, the pool. There are now more and more swimming pools and leisure centres offering special sessions for people who need special help, and it might be worth trying one of these sessions at first. If such sessions are not available, try lobbying your local leisure centre/swimming pool for one. It may be worth asking whether there are quiet times of the day when the pool will be freer, and assistance is more likely to be available.
Functional electrical stimulation (FES) can help some people with
‘foot drop’. A small box sends electrical stimulation to muscles in the lower leg, so that you can regain useful movement. This is connected to a pressure pad in a shoe that enables the impulse to be triggered when you are walking, improving mobility. (See Appendix 1 for address of the FES Team.)
One point may prove to be important and that is the temperature of the water. The temperature that many people with MS find comfortable is about 30°C (86°F). Much lower temperatures appear to be too cold, although still tolerable, whereas much higher temperatures, often found in jacuzzis or spa baths, are sometimes associated with the onset of (temporary) MS symptoms. Also, in relation to your swimming activities, if you have troublesome bladder control, it may be worth discussing this with your neurologist or GP beforehand to try and ease your concerns.

Foot drop and exercise

‘Foot drop’ occurs when the muscles of the foot and ankle become weak, caused by poor nerve conduction, and either your ankle may just ‘turn over’ or, more commonly, your toes touch the ground before your heel – in contrast to the normal heel–toe action – and this might lead you to fall. This is quite a common problem in MS. There are two ways of dealing with it. One way is by exercising the relevant muscles as much as possible, through passive exercises if necessary. However, this may not be enough to prevent the problem once it has occurred. A special brace may be helpful, which supports the weakened ankle and allows you to walk again with the normal heel and toe action, if your leg muscles are strong enough to allow this (Figure 8.4). You may need to consider using a wheelchair or scooter, at least occasionally.
One of your feet ‘turning in’ is another problem that some people with MS have. In this situation the muscles turning the foot out have weakened, and the muscles and tendons on the inside of the foot have become shortened – largely due to disuse. In addition the ankle joint may be more rigid and stiff. Thus it is vital for people with MS to try and prevent such a situation occurring by exercising the muscles controlling the ankle as much as possible. It will be important to seek some help from a physiotherapist when the problem has arisen to ensure that you undertake the correct exercises and, if necessary, have a supporting brace.

Figure 8.4 Leg brace.

Wheelchairs and exercise

Although it may sound paradoxical, it is almost more important for someone confined to a wheelchair to undertake regular exercise than someone who can walk. You should try and undertake exercises that maintain the movement and flexibility in your joints as much as possible
– through the ‘range of motion’ and stretching exercises described earlier. As far as possible, try and maintain also your upper body strength – this is particularly important for good posture, which itself will help prevent some of the more problematic aspects of being in a wheelchair for a long time. Exercising your neck muscles will also help you to maintain a good posture. If possible, it is very helpful just to stand for a few minutes each day, with the help of someone else or with an increasing range of equipment now available for this purpose. It is known that bone density tends to decrease (causing ‘osteoporosis’) more quickly if weight is not borne by the legs and feet on a regular basis and low bone density is also one of the contributory factors of fractures. This is another reason why standing should, if possible, be undertaken – even if only for a very short period. As with sitting in a chair, you ought to learn specific exercises to be able to shift your weight on a regular basis, to prevent skin breakdown at the points where your body is in contact with the wheelchair, and ultimately to prevent pressure sores. (See Figure 8.2 for exercises that you can do sitting down.)

Pressure sores

As noted earlier, exercise can help prevent pressure sores. They are very dangerous once they arise, and yet they are entirely preventable. Basically, as the name suggests, they arise when the skin begins to break down from too much continuous pressure, from a chair or bed, for example, on key points of your body. Once this pressure has been applied for a long time, blood circulation to the area lessens or ceases, the tissues get starved of oxygen, and the skin and related tissues break down. Such pressure sores are particularly dangerous because, left untreated, they can lead to infection of the underlying bare tissue or to blood infection (‘septicaemia’), which can threaten your life. Most people do not get pressure sores because they move very frequently and thus pressure is never exerted on one point of their body for long enough for a pressure sore to develop.

Figure 8.5 Pressure sore areas.

Danger areas are the lower back, the shoulder blades, the insides of knees, hips, elbows, ankles, heels, toes, wrists, and even sometimes ears (Figure 8.5). Pressure sores are more likely if you are in a wheelchair, or are sitting or in bed for long periods of time.
Initially, a pressure sore may just look like an area of reddened skin, or even a small bruise. It can look like a blister or weal, which may break to reveal a small or even a large hole where the skin has been damaged more fundamentally. It is likely to be very painful but, if sensation has been lost, you may not be aware an ulcer is forming so visual checks are also necessary. It is important to act immediately and contact your doctor, for once the damage has occurred it is very unlikely to get better without considerable treatment.
Preventative therapy, i.e. regular movement every hour or two, is vital, especially for people in wheelchairs or in bed. If you can stand for even a short time, or shift your weight from time to time and from place to place, this is helpful. There are also a number of products that may help:

• ripple mattresses
• foam rings
• gel or air cushions
• water beds
• pads
• specific textures of clothing and bedding, especially sheepskin.

Sometimes the bedclothes can be lifted off the body by means of a cradle. You should wear nightdresses or pyjamas that chafe as little as possible.
The usual person to treat pressure sores is a District Nurse who will come in regularly to manage them. The treatment usually involves antibiotic cream or powder in and around the area. The aim is to prevent infection and to restore circulation, by keeping the skin clean and dry. The sore may be left exposed to the air during the day, but dressed with a sterile dressing at night. More serious sores may require substantial hospital treatment.
There is a great deal of development work currently underway on the management of pressure sores because, not only are they very painful, inconvenient and potentially dangerous for people with MS, but they are also very expensive to treat, at home or in hospital, and often involve very long-term nursing and medical care.