Exercise and Multiple Sclerosis

As a fitness instructor it is important to remember that each student you teach comes with a unique history of health, wellness & fitness.  Many fitness instructors are well versed in how to help a student modify for common temporary musculoskeletal aches and pains but may be left wondering what to do for students with a more complex systemic disease.  Multiple Sclerosis presents an even bigger challenge for fitness teachers since the disease presentation and progress is very unique for each individual with MS.  The good news is that studies have shown that exercise can help with symptom management and quality of life for those living with MS. 

What is MS?

MS is an autoimmune disease in which the immune system attacks the central nervous system (the brain and spinal cord). 

The nerve fibers in the central nervous system are called axons.  Surrounding each axon is a fatty sheath called myelin.  You can think of myelin as the insulation that surrounds an electrical wire.  In MS this myelin sheath is attacked, resulting in bare spots and scarring along the nerves.  

Smooth electrical conduction and communication between the central and peripheral nervous systems is important to everything we do as humans.  Our brain and spinal cord are constantly sending and receiving information from the peripheral nervous system to help us move, feel, see, even breathe.  When the myelin sheath is disrupted (called demyelination) the signals can get crossed or missed and the smooth conversation between our brain and our muscles can become choppy or silent.

There are four different types of MS:

• Relapsing-remitting MS (RRMS):  this is the most common type of MS (more than 80% of those with MS begin with relapsing-remitting MS).  With this type of MS symptoms come and go.  Symptom free periods (remission) can last from days to months.
•  Primary Progressive MS (PPMS):  this type of MS occurs in about 15% of people with MS.  Symptoms progress slowly and steadily for people with PPMS with no remission     
• Secondary Progressive MS (SPMS):  this type of MS often eventually develops in people with RRMS.  Periods of remission are replaced with periods of partial recovery.  Symptoms progressively get worse and result in greater disability over time.
• Progressive Relapsing MS (PRMS):  this type of MS is relatively rare.  People with PRMS experience a progressive worsening of symptoms and experience attacks or flare-ups during periods of remission.

Some common symptoms of MS are:

• Fatigue
• Numbness
• Problems with balance and coordination
•  Vision problems
• Dizziness
• Pain
• Spasticity (can be as mild as muscle tightness to severe pain and involuntary muscle spasms)
• Bowel and bladder dysfunction
• Emotional changes or depression

How can exercise help?

Exercise has been shown to decrease symptoms in MS including bowel and bladder dysfunction, muscle weakness, immobility and fatigue as well as improving mood and preventing secondary complications such as heart & lung disease.

What type of exercise is best?

Many different types of exercise have been shown to have a positive impact for those living with MS.

• Endurance activities improve cardiovascular health and help to reduce symptoms of fatigue in MS (walking, swimming etc.)
• Strength training activities improve muscle strength and bone density and help to reduce fatigue symptoms, improve mobility and prevent secondary complications such as bone fractures from falls (weight lifting and/or exercises that use your own body weight for strengthening such as planks, push ups, squats, lunges, etc.)
• Stretching helps to improve flexibility and mobility and prevent the muscle spasticity that can cause permanent shortening of the muscles in MS.

Perhaps most importantly a fitness routine should be something enjoyable.  Sticking to a fitness plan and being consistent is the key to long-term success. In those living with MS, exercise has been shown to reduce depression, increase participation in social activities and help people maintain and improve independence.

Are there any exercises that should be avoided for those with MS?

Choice of exercise should be based on each individual’s specific symptoms on a given day.  Exercise should be fun, challenging and safe.  It is imperative that those living with MS are encouraged to listen to their bodies and make small adjustments to their fitness routine as needed to ensure safety.

Heat has been shown to exacerbate the symptoms of MS.  When exercising outdoors, plan workouts to avoid the hottest times of the day.  Avoid activities performed in a heated room.

Consider the pros and cons of group fitness versus personal training.  For many, group fitness can be more motivating, uplifting and affordable.  Many group fitness studios will offer private instruction as well to get you started and give you the confidence you need to feel great in a group class.

www.msactivesource.com is a great online resource for more specific exercise tips and tricks include short videos as well as free exercise DVDs.

The most enjoyable and rewarding part of writing this particular post was having the opportunity to speak to some of the true MS experts -- the brave and strong men and women living with this disease every day.  I’m so fortunate as a The Dailey Method studio owner to have a worldwide community of owners and teachers to reach out to and learn from.  The testimonials, tips and tricks below come from the amazing students this community serves.  If you are a fitness teacher I hope you will be a student for the moment and allow these stories to guide and inspire you in serving your community.  If you are living with MS, I think these stories will serve as continued motivation to be in the present and live your best life.  I’d also love to hear any of your own personal tips & tricks in the comments section below.

Testimonials, tips & tricks:

Kris:

Kris is a 44-year old mother of two (ages 9 and 6) who has been living with MS for 9 years.  Previously a competitive gymnast and an active all around athlete, Kris seeks the emotional high of a great workout, but has sought and continues to seek a “new normal” for herself when it comes to fitness.  The number one MS symptom that has required an adjustment to her personal fitness routines is lack of balance.  Kris has found a home at The Dailey Method La Grange in La Grange, IL.  The low-impact yet results orientated nature of The Dailey Method has allowed Kris to stay fit while at the same time feeling safe in the environment and able to modify and adjust for her needs on any given day.  Here are Kris’s top tips for staying fit while listening to her body to ensure that her workouts leave her energized and inspired rather than frustrated and wiped out.

• Talk openly to your fitness teachers about MS.  It is an ongoing conversation as opposed to a one-time notification.
• Seek out less crowded class times or make sure to get to class early enough to find a spot in the room where you will have some space and something to hold on to when necessary
•  Know that if a certain exercise is not working for you on a given day it is OK to modify.  Frustration can set off a downward spiral and leave you feeling worn out and unsuccessful.  A great teacher will help you modify and listen to your body – ask for help.
• Set realistic goals for yourself.  It can be tempting to look around at other fit and healthy bodies and think, “I used to be that.  I want that.”  Look forward, not back – find your “new normal”.  
• Celebrate and be proud of little successes.  Feel good about yourself when you can let go of the barre for a few more seconds, can get deeper in a certain pose or hold a stretch a little longer.  It all means you are working towards your goal and it feels great!

Judith:

I have remitting-relapsing MS.; three years ago I was slammed with what was called a relapse, even though I didn’t know I had MS at the time.

Apparently I had had MS for many years, symptomatic at a low level.   But when my attack hit in 2010, I was devastated.   I could not walk across the campus where I taught. The disability cart carried me to and fro.  My husband drove me to the university and often I would pour myself into the car at the end of the day and sob.

I rehearse this story to provide a context for what I will say next:  I have slowly climbed back to a state in which most activities--physical, cognitive or spiritual--are not problematic.  And much of my recovery in the last year has been due to my regular participation in The Dailey Method classes at The Dailey Method Reno (Reno, NV).  Of this I feel sure.  Specifically, The Dailey Method has helped with many of the typical MS problems:  mood (I feel elevated by the mental and physical concentration the classes require – my anxieties are dispelled); neuropathy and limited movement  (my neuropathy and spasticity is often greatly improved by taking The Dailey Method classes and it is never made worse); my strength and balance are building “dailey”; and perhaps most interesting, I am now able to get muscles to fire that would not for the first year and a half after my attack – my brain and body connection has been reestablished.

I believe that the ways in which The Dailey Method targets small muscles, movement and awareness has been key for me.   Also, helpful are wonderful teachers who have encouraged me, a total type A person, to participate at 85% when necessary, recognizing that MS symptoms, including fatigue, come and go. In terms of my goals of maintaining strength, flexibility and endurance, I hope to be able to continue with The Dailey Method for a long time.  

Judith Rodby, Ph.D

Professor Emeritus, California State University

Reno, Nevada

Anne:

I started at The Dailey Method more than a year ago, soon after I wad diagnosed by the neurologist I was seeing at the time. I was scared and hesitant to try any kind of demanding exercise, especially anything involving heat (my doctor specifically warned me against hot yoga, which he felt could trigger a relapse of symptoms). However, I was also just tired of feeling bad all the time. I felt it was worth the risk.

Right away I could see that I was in good hands at the The Dailey Method Mission-Castro (San Francisco, CA). All the instructors were very sensitive to what I needed -- pointing out the "cool spots" in the room and helping me manage discomfort. They showed me how to adapt exercises to pain or numbness by working higher on the barre, and described how breathing could pull me through tough moments. In time, I figured out that neutral spine work helps me focus on everything else; I also use a towel to cushion my neck in floor work. 

I feel stronger and happier. I've also noticed less numbness in my extremities after and between workouts. More important, my primary care doctor noticed that the practice makes a huge difference in my stress level. My mood has improved over the 16 months I've been a member, and I can anticipate how I will feel the next day in a way I haven't been able to in years. I feel like I can actually make and keep commitments, because I can count on my body to work for me. That's priceless. 

I've had barely any symptoms at all for more than a year now. Very recently, my doctor told me about Clinically Isolated Syndrome, which he thinks might be a more accurate diagnosis. I am beyond thrilled, but not really surprised: I feel like this has been the year I got my body back. :)

I don't think that The Dailey Method can cure all that ails people, but it's done so much for me. The costs of a relapse can be really high, both financially and physically; I'm in better shape to fend them off thanks to The Dailey Method. It's the best choice I've made in years.

I want to give the biggest THANK YOU and giant virtual hugs to these amazing women for sharing their stories with me.  You are why I love what I do! Xoxo

Kerry

STAY CENTERED: your guide to a healthy spine

Your spine is your body’s axis, the central line about which the rest of your body moves.  The bony structure of the spine is also the vault that protects your spinal cord and the nerves that run from the spinal cord to communicate with the rest of your body.  If you think of your brain as “command central” for all of your body’s movement and function, the spinal cord is a super highway delivering all that the brain has to offer to the rest of your body.

THE SPINAL COLUMN

The spinal (or vertebral) column consists of 24 vertebrae stacked one atop the other in such a way to allow for even distribution of weight in upright posture. 

There are four sections of the spinal column: cervical (7 vertebrae), thoracic (12 vertebrae), lumbar (5 vertebrae), and the sacrum & coccyx.

The vertebrae differ slightly in each section depending upon the importance of mobility vs. stability in that particular section of the spine.  Each segment of the spine is dependent upon the health and strength of the other spinal segments to function properly.

The spinal curves are important to maintain structural balance & prevent pain and injury.  On a side view of the spine there are four normal curves:  cervical, thoracic, lumbar & sacral.  Each of these curves is either anterior (lordotic) or posterior (kyphotic).  Abnormal spinal curvature is referred to as hyper (too much curve) or hypo (not enough curve) lordosis or kyphosis.

 When viewing the spine from the front or back (coronal plane), the spine should be straight.  Scoliosis refers to an S-shaped or C-shaped curve of the spine in the coronal plane.  Scoliosis often has a rotational component as well affecting the appearance of the rib cage and shoulder blades.

A huge network of muscles, ligaments (connecting bone to bone), and tendons (connecting muscle to bone) supports the bony structure of the spine. This network holds the shape of the spine:  maintaining stability and allowing movement in multiple planes.  In addition, between each spinal segment is an intervertebral disc.  The discs are fibrocartilaginous cushions that act as shock absorbers and provide a small amount of movement between the vertebrae.

The transverse and spinous processes are important muscle attachment locations on each vertebra.  The vertebral foramen is the space in which the spinal cord is housed.

The back muscles can be divided into deep, intermediate and superficial muscle groups.

DEEP BACK MUSCLES

MUSCLE	LOCATION	ACTION
Intertransverse	runs from transverse process to transverse process	sidebending
Interspinalis	runs from spinous process to spinous process	extension
Transversospinalis	Runs from transverse process to spinous process.  Includes: semispinalis (spanning 5-6 vertebrae), multifidus (spanning 3 vertebrae), and rotatores (spanning 1 vertebral level)	Extension, sidebending & rotation

The INTERMEDIATE BACK MUSCLES are collectively referred to as the erector spinae (also known as sacrospinalis).  This is really a bundle of muscles and tendons that runs vertically along the full length of the spine.

The SUPERFICIAL BACK MUSCLES include the rhomboids, trapezius, and lattisimus dorsi.  These muscles are more involved in movement of the scapula.  You can read more detail about the superficial back muscles in my post "Mobility + Stability ... Finding Your Rhythm"

The DEEP and INTERMEDIATE back muscles work together in relay fashion to maintain upright posture, proper spinal curvature and space between the vertebral bodies.  These muscles are largely automatic and should not require conscious effort to activate.  In fact, the deep back muscles should activate automatically in anticipation of all movement.  However, studies have linked weakness and insufficient activation of the deep back muscles to back pain.

With such a huge network of bones and connective tissue, it is no wonder that back pain is so prevalent.  4 out of 5 adults will experience back pain at least once in their lifetime.  The National Institutes of Health (NIH) reports that Americans spend $50 billion each year on back pain.  Back pain is a primary contributor to missed work days and disability.

There are multiple potential causes for back pain including: muscular strains and ligament sprains, herniated discs, spinal stenosis, osteoarthritis, osteoporosis, and fibromyalgia.  The good news is that most back pain can be treated without surgical intervention.  In fact, the National Institutes of Health considers exercise the most effective way to speed up recovery from low back pain.  Exercise programs to heal and prevent back pain should focus on proper spinal alignment.

The most common postural / alignment changes associated with low back pain are loss of lumbar lordosis (“flattening” of the low back) and increase in thoracic kyphosis (“hunchback”).  Miyakoshi et.al. (2011) studied 630 Japanese men & women 50 -94 years old and evaluated the relationship between spinal alignment, mobility and chronic low back pain.  They found that people who had low back pain severe enough to affect their ability to walk had decreased lumber lordosis, increased thoracic kyphosis, as well as decreased range of motion and mobility in the thoracic and lumbar spine in both extension and flexion movements.  Abnormal posture was also associated with a decline in walking ability. 

Weakness and fatigability of the deep back muscles has been cited as a primary reason for low back pain.  Additionally, weakness of spinal extensor muscles is thought to be a primary cause for walking disturbances in people with increased lumbar kyphosis (“flattening” of the low back). (Arokoski, et.al (1999), Kamkaanpaa, et.al (1999), Mannion, et.al. (1999), Miyakoshi, et.al. (2011), Taimela, et.al. (1999)).

Exercise programs to support back health should educate students about proper spinal alignment and teach them to stretch and strengthen the muscles of the spine to allow for movement in flexion, extension, lateral bending and rotation. I will admit I have an obvious bias in promoting The Dailey Method as the best exercise program for back health, but my bias comes with good reason.  The Dailey Method provides in-depth education in a fun group format and teaches students how to access the deep stabilizing muscles of the spine in a way that allows them to carry that deep body knowledge with them into a large range of exercises including focused neutral spine work, extension, flexion, lateral bending and rotation. 

For a great neutral spine exercise, check out my earlier post “Your Abdominals from the Inside Out”.  This post shows an exercise called “dead bug”.  Dead bug is great for training not only the deep abdominal muscles, but also the deep spinal muscles that support the natural curves of the spine.

In this article from the ChicagoTribune Jill Dailey describes Spinal Extension exercises and Neutral Spine Plank; two fantastic Dailey Method exercises for strengthening the deep back muscles.

Exercises performed with the lumbar spine in flexion target the outer layer of abdominals.  There has been controversy about lumbar flexion exercises in the literature for a number of years.  This is due mainly to the lumping of all spinal flexion exercises into the category of large range of motion flexion exercises without the support of the deeper layers of abdominal muscles.  Here’s a link to a very comprehensive review of the literature outlining where the controversy with lumbar flexion began and highlighting how inconsistent the literature really is on the subject.  That said, if you are a fitness professional, it is surely essential to know your students and their bodies.  If you or your students have a history of back pain or find any particular spinal motion uncomfortable, your exercise program should be modified to accommodate. 

One more link … here are four great yoga poses to incorporate into your fitness regimen to improve your back flexibility and health.

Your spinal health is essential to your overall well being and comfort in your daily life.  Take the time to learn about the muscles that support your spine and you will reap the benefits of longer more comfortable life.  Not only will optimal spinal strength and flexibility keep you pain free -- it will keep you looking and feeling younger too!

References:

http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm

Arokoski,  J.P., Kankaanpää, M., Valta, T., Juvonen, I., Partanen, J., Taimela, S., et al. (1999). Back and hip extensor muscle function during therapeutic exercises. Archives of Physical Medicine and Rehabilitation, 80: 842‐850.

Contreras, B. & Schoenfeld, B. (2011). To Crunch or not to crunch: an evidence-based examination of spinal flexion exercises, their potential risks, and their applicability to program design. Strength & Conditioning Journal. 33:4: 8 -18.

Kankaanpää, M., Taimela, S., Airaksinen, O., Hänninen, O. (1999) The efficacy of active rehabilitation in chronic low back pain. Effect on pain intensity, self‐experienced disability and lumbar fatigability. Spine. 24: 1034‐1042.

Mannion, A.F., Muntener, M., Taimela, S., Dvorak, J. (1999) Volvo 1999 award: A randomized clinical trial of three active therapies for chronic low back pain. Spine. 24: 2435‐2448.

Miyakoshi, et.al (2011) Prevalence, spinal alignment, and mobility of lumbar spinal stenosis with or without chronic low back pain:  a community-dwelling study.  Pain Research and Treatment, 2011, 1-5.

Taimela, S., Kankaanpää, M., Luoto, S. (1999) The effect of lumbar fatigue on the ability to sense a change in lumbar position. A controlled study. Spine. 24: 1322‐1327. 

MOBILITY + STABILITY ... FINDING YOUR RHYTHM

The shoulder complex houses the most mobile joint in the human body allowing us the freedom to move and use our arms in a multitude of ways.

The shoulder complex is comprised of three joints:

sternoclavicular joint (where the sternum (breastbone) and clavicle (collarbone) meet)

·      Connects arm & shoulder to the rest of the skeleton

·      Saddle type joint that allows for movement of the clavicle

·      Supported by a strong network of ligaments

acromian clavicular joint (where the clavicle (collarbone) and scapula (shoulder blade) meet)

·      Allows us the ability to raise our arms overhead

·      Stabilized by a small network of ligaments

glenohumeral joint (where the head of the humerus (upper arm bone) meets with the glenoid fossa of the scapula (shoulder blade))

·      Most mobile joint in the body

·      Shallow ball & socket joint

·      Rotator cuff muscles help to hold the head of the humerus in the glenoid fossa (supraspinatus, infraspinatus, subscapularis, teres minor & major).

  

 ROTATOR CUFF MUSCLES:

In addition to these three joints, there is also a scapulothoracic articulation.  Although not a true joint, the articulation between the posterior thoracic cage and the anterior surface of the scapula is very important for the stability of the glenohumeral joint.

The coordinated movement of the glenohumeral joint and the movement of the scapula on the posterior thoracic cage are called scapulohumeral rhythm.

To understand how all the muscles involved in scapulohumeral rhythm work, let’s first look at the different ways in which the scapula can move:

http://www.pt.ntu.edu.tw/hmchai/Kinesiology/KINupper/Shoulder.files/ShoulderStructure.htm

The muscles that support the scapula throughout this range of motion include: serratus anterior, trapezius, rhomboids & levator scapulae

Action	Muscle(s)
Elevation	upper trapezius, rhomboids & levator scapulae
Depression	lower trapezius, lower serratus anterior
Protraction (abduction)	serratus anterior
Retraction (adduction)	mid trapezius and rhomboids
Upward rotation	serratus anterior, upper & lower trapezius
Downward rotation	rhomboids & levator scapulae

SCAPULAR STABILIZERS

credit: www.bandhayoga.com (Dr. Ray Long & Chris McIvor)

When all of the scapular stabilizers are working together in a synchronous way, the scapula and the arm bone will move together in a way that will keep the humerus securely seated in the glenoid fossa and will keep the scapula in even contact with the posterior thoracic cage.

When the scapular stabilizers are not working properly the scapula and the humerus move in a dysrhythmic way.  This scapular dysrhythmia can lead to pain, weakness and impairment of shoulder mobility.  The rotator cuff muscles often wind up overworked or injured as a result.

A physical sign that helps to indicate a problem with scapulohumeral rhythm is scapular winging.  True scapular winging is due to complete loss of function of the serratus anterior muscle and is very rare.  However, more subtle muscular imbalances, weaknesses or pain can also cause subtle scapular winging or scapula dyskinesis.  Noticing this sign early and learning to retrain your scapular stabilizers to work together in a synchronous way can help to increase stability & mobility of the shoulder complex and prevent injuries down the line.

Here is what scapular winging looks like and some suggestions for strengthening the scapular stabilizers to restore scapulothoracic rhythm.

Looking at the big picture:  The shoulder is a very complex joint.  Alignment of the thoracic spine, rib cage alignment, head carriage and neck alignment will all effect the position of the scapula and therefore the mobility of the joint and the ability of the scapular stabilizers to work in a synchronous way.  Understand your starting point before you begin any exercise routine.
 

• Do you tend to slouch or hunch your shoulders forward?
• Do you tend to jut your chin forward and carry your head forward of your chest?
• If you pull your shoulders down and in and open your chest does your ribcage thrust forward? 

If you answered yes to any of these questions you may need to begin by working on your thoracic spine alignment and mobility before being able to properly improve your shoulder strength and mobility (more on that in future posts!)

Improving strength & flexibility:  remember that you want to achieve a balance between mobility and stability in the shoulder complex.  Exercises that strengthen the scapular stabilizers such as the “push up plus” must be coupled with exercises to stretch the chest muscles and anterior shoulder. 

Improving motor control:  exercises that use resistance to lengthen muscles as they contract (eccentric contraction) can help to improve motor control.  Slowing the pace of exercises like push ups or lat pulls and using internal resistance throughout the full range of motion will help to make sure all the scapular stabilizers are working together throughout the full range of motion.

Here is a great simple article about cueing scapular motion during different exercises.  I particularly appreciate the mention of ribcage and neck alignment:  http://www.acefitness.org/certifiednewsarticle/2384/correct-cues-for-scapular-motion/

There is so much to think about when it comes to proper shoulder alignment.  Remembering to focus on alignment & stability first coupled by a balance between strength and flexibility will help you find your rhythm and keep you injury free for years to come!

References:

http://www.shoulderdoc.co.uk/article.asp?section=492

http://www.jaaos.org/content/11/2/142/F1.expansion

http://www.pt.ntu.edu.tw/hmchai/Kinesiology/KINupper/Shoulder.files/ShoulderStructure.htm