As the most common neurological disorder of the nervous system in adults under age 65, MS affects one in 1600 people. Sixty percent of those individuals affected are women. At the present time there is no known prevention for MS. Life expectancy can be 35 years or more after diagnosis. Many individuals have minor disabilities and can continue to walk and work for 20 years or more.
Multiple Sclerosis is a degenerating disease of the central nervous system (brain + spinal cord) that interferes with the quality of movement. A neurological disorder that traces its origins as an auto-immune response in which the body’s defensive system (macrophages) attack the myelin sheath that covers the nerves. Loss of myelin, which is the fatty substance that insulates nerves, decreases the speed of conduction and is associated with leaving areas of scar tissue on the covering of nerve cells (sclerosis).
Risk factors for MS are a family history of MS and living in a geographical area with higher record of reported cases of MS than other places around the world, such as northern Europe, northern United States, southern Australia, and New Zealand.
Multiple Sclerosis (MS) movement problems can be minimal or severe. Episodes of an individual experiencing symptoms for example, clumsiness, problems with walking or blurred vision, can last for a few weeks followed by months or years without any symptoms at all (state of remission). Recurrences of the disease are common. Some individuals however, may deteriorate more rapidly. Depending on their health status, clients may experience symptoms that can have an effect on the exercise session. These symptoms may include:
- Impaired balance, dizziness, vertigo
- Blurred or double vision, eye discomfort or rapid eye movements
- Fatigue and/or muscle weakness, or atrophy
- Sensory loss, numbness, tingling, and/or facial pain
- Partial paralysis or paralysis
- Heat sensitivity
- Cardiovascular dysautonomia (problem with speeding up of the cardiovascular system and decrease in blood pressure response due to improper functioning of the autonomic nervous system)
- Poor coordination, walking/gait abnormalities
- Muscle spasms (spasticity) especially in the legs
- Strong urge to urinate, incontinence
- Decreased memory, judgement, spontaneity and ability to think abstractly
- Decreased attention span
- Difficulty speaking or understanding speech or hearing loss
The goal of treatment is to maximize the quality of life of the individual and maintaining the body’s functions. Treatments such as Baclofen, dantrolene, and diazepam are examples of anti-spasmodic medications to reduce muscle spasms. Corticosteroid drugs can speed recovery and shorten the duration of exacerbations (times when clients are experiencing symptoms). Cholinergic medications can help to decrease urinary problems. Other medications may be given for depression and fatigue. Physical, speech, occupational and other therapies can relieve muscle spastic muscle contractions. There are other treatments that help to prolong the time between these symptomatic relapses. Some medications are helpful by suppressing the immune system. There is other research that suggests that this treatment may slow down the progression of the disease. Recent news (March 3, 2000) has shown Cannibus (marijuana) to have significant success in relieving symptoms, with efforts to legalize the usage of this drug for MS sufferers.
Benefits of Exercise for the MS Client
Exercise may improve the client’s ability to perform everyday activities. Individual living with MS may also improve their present fitness level of aerobic conditioning, muscular strength and endurance, and may increase or maintain flexibility. It should be stated again however, that there is no evidence that exercise training can change the nature or how the disease MS progresses.
A primary goal is to improve the function of daily activities such as stair climbing, opening door knobs or opening jars, and the ability to change the direction of walking and the reduction of muscle tension. Coronary risk factors such as a sedentary lifestyle, obesity and hypertension are common among this special population. Depression may also be an added burden and can cause poor program adherence. Constant motivation and support is needed with these individuals to help them face the challenges of exercise.
- Increase cardiovascular and muscular strength ability
- Provide function training to enhance client’s ability to accomplish the activities of their daily life
- Maintain or increase their range of motion
- Utilize PNF and Facilitated Stretching
- Increase or maintain gross as well as fine motor skills
- Offer stress management training to support a mind-body awareness
- Encourage good nutrition and adequate rest
Suggestions during Exercise Assessment
During exercise assessment, it may be better to use the upright or recumbent bike, since many symptoms such as impaired balance and spasticity make treadmill testing unsafe and inefficient. Ankle and foot stability is important while using the bike, so make sure heel straps or toe clips are available on the equipment chosen.
Guidelines for Exercise Programming
If the client is capable, the accepted fitness industry protocols regarding aerobic, strength, muscular endurance and flexibility can be applied when training MS clients. The special considerations below will help you to offer an interesting program that will encourage adherence, as well as promote an increased level of function in the individual’s daily life.
- MS can also affect the way your client is able to understand instructions and remember verbal cues. It is helpful to include written training instructions with pictures if possible. Written instructions with pictures will also be useful for individuals with hearing loss.
- Resting heart rate and blood pressure should be taken prior to the exercise session. During the aerobic section of the workout, monitor heart rate diligently to make sure the client stays in their target zone. RPE can also be utilized if the client has no cognitive deficit.
- Target heart rate may begin at 40-50% during aerobic conditioning; progressing to 60-75% target heart rate after the client has tested successfully at this level; Recumbent bike is recommended; elliptical cross trainers can also be successful provided there is attentive supervision at all times by the trainer.
- Contract and release forms of facilitated stretching; conscientiously maintain your focus on the client, as well as have the client remain focused on the task at hand; for optimum success perform stretching on a stretch table in a quiet space with few distractions.
- Encourage gross motor development by starting with simple skills and repeat these skills to encourage mastery. Examples of activities are: walking, stairclimbing, catching a ball (such as a physioball or very light medicine ball), simple yoga movements and positions, simplified karate katas, balance board/wobble board next to a bar for support.
- Encourage fine motor skills by starting with simple skills at first and progress to an adequate level of mastery. Activities such as exercises to develop strength of pinching of thumb to index finger, to improve handwriting and opening doors etc.
- Performing general calisthenics in chest high water, can be fun and effective, provided there is convenient access to a pool. Supervision when an individual with MS is in the pool should be attentive and constant.
- Practice "follow the leader" mirroring drills. This can be a fun activity which can bring a playfulness to the exercise session.
- Floorwork on a mat can very successful (ie. Pilates style exercises) In addition stretching, yoga, tai-chi or other forms of mindful exercise are helpful. It is recommended that the training session should begin and end with these type of mind-body exercises.
- Remember to not overlook functional exercises for enhancing grip strength. (bring in old jars and lids to practice opening, pliable grip balls etc.)
- Include joint isolation calisthenics/rhythmic limbering exercises. Keep exercises simple and easy to understand and follow.
- Ballroom dance or simplified ballet/jazz dance routines can offer practice with gross motor skill, balance and coordination and offer variety.
- With trainer supervision, heavy bag punching with gloves that are well padded (16oz.) can be safe for boxing lovers. Avoid the speed bag and teather bag unless the client has very good coordination.
- Improve life function by practicing everyday activities with your client. (ie. getting in and out of the car using proper biomechanics.)
Contraindications for Exercise
The progression of MS can be unique to each person. It is wise for MS individuals to avoid traditional aerobic, step and other high-energy classes with similar physical demands, need for quickness and sudden change of direction. In addition, avoid jumping rope for the same reasons. Swimming should always be an activity that is closely supervised. Remembering that some individuals can progress slowly and remain quite active, while others have more intense changes in their health status. Nevertheless all clients will experience incurable neurological degeneration. During times when the client experiences acute symptoms, exercise should be discontinued until the symptoms are gone and the client is in a state of remission once again. Despite the appearance that the client’s health has returned to normal, his or her neurologist should be contacted to confirm that the client is ready to exercise, and new fitness goals established.
Special Considerations which Affect the Training Session
It is important to be aware that your client may be spastic and fatigued at times and may be less energetic. Muscle weakness and inefficient or non-functional muscular tension in the legs, can also cause the client to fatigue before the workout is completed. Have client use the bathroom before the session, since incontinence is common among MS individuals.
Be ready to exercise your mental flexibility during personal training MS clients. Be prepared with amusing stories, jokes, and current events to keep the session lively. A "hopeful" attitude from a trainer is key when training an individual with a disease that is incurable. Constant sensitivity to the value of being emotionally hopeful, is vital for trainers working with individuals with serious medical concerns. In addition, changes in medication, sleep patterns and even a change of the weather, can change your client’s ability to fulfill the demands of the exercise program. As trainers we need to be ready in advance with alternative strategies for the exercise session if daily conditions limit the client’s performance.
For some individuals, MS can progress slowly, and while this is good news for the client’s overall life experience, it may make improvements with their exercise program less apparent. The client, and you the trainer, may be unable to easily notice improvements since the fitness benefits are gently overshadowed by the degeneration of the disease. This will require an attention to detail regarding documentation of the client’s fitness progress.
Suggestions for information that is helpful to record in addition to normal fitness measures are as follows:
- Minor and major symptoms present at the time of the workout
- Ability to perform functions of daily life
- Quality of rest/sleep
- Stress level
- Medication changes
- Motivational level
This information can give you the necessary comparative view you need to educate and inspire your client about the value of their exercise program. Remember to document your training sessions as specifically as possible, with follow-up assessments every 6 months.
Trainers also need to consider the daily climate conditions of the workout environment, since some MS clients have difficulty sweating, and dealing with the heat. Workout space whether it is indoors or outdoors, should be cool or comfortable, but not above 70-75 degrees Farenheit. Reminding your client to drink water before, during and after exercise is key to a successful session. Water exercise should be moderate intensity and the water no warmer than 90 degrees Fahrenheit.
Connecting with Physicians
When training individuals with special medical concerns, written consent, and periodic communication with physicians and allied healthcare professionals is necessary. Keep telephone conversations to a minimum, with most of the communication being sent in writing, using fax machine or by mail. Be sensitive to the fact that physicians have very little time to speak with you, due to the intensity of their schedule.
Since MS is a degenerating disease, it is inevitable that your client will need some physical help from their trainer such as getting in or out a wheelchair, or perhaps into a pool. If you are training this population, it is a wise idea to get training concerning how to transfer, lift and assist the body weight of disabled persons, prior to attempting to do it. Personal trainers are helpful, caring and strong people, yet receiving proper technique in carrying or supporting a disabled person can mean a safer experience for everyone.