Other Issues Related to Exercise for Persons with Multiple Sclerosis
Despite and depending on the severity of the multiple sclerosis, the unpredictability of exacerbations must be considered in an exercise program. The program must be sufficiently flexible to be suspended or modified (Benyas, 1999). Physical therapy is strongly recommended during an exacerbation to prevent deconditioning (Petajan & White, 1999). Depending on the severity of the exacerbation, slow gentle stretching, walking, or water exercises can be performed (Sherrill, 1998).
In order to continue with any exercise program, participants with multiple sclerosis must tune into the type and level of fatigue he/she is experiencing, such as normal muscle fatigue, substitution fatigue (strong muscles substituting for weak muscles), depression fatigue, and cardiovascular fatigue. It is important to isolate which symptoms indicate the onset of fatigue (i.e., feeling sleepy or tired, numbness, losing balance), and to manage energy appropriately. This could include a 15-30 minute rest, scheduling more strenuous exercises in the morning before body temperature increases (usually highest between 2-4 p.m.), and using appropriate equipment (i.e., cane, walker)("Exercise Your Options" website). It is critical that participants respect their body limitations and not compare themselves with other able-bodied persons (Harmon, 1998).
This is a malfunctioning of the ANS (autonomic nervous system), which can lead to problems with cardioacceleration and a decreased blood pressure (Mulcare, 1997). This is a key reason why heart rate, blood pressure, and RPE must be monitored continually during an exercise program. As with exacerbations and fatigue, the participant must not be pushed too hard.
Weakness/Paresis/Paralysis For spasticity, certain foot strapping mechanisms may help the participant utilize the exercise equipment. Additionally, one must be aware of possible hip adduction/abduction problems. Regarding paresis/paralysis, it must be determined what muscle groups still have function or partial function in order to adapt the exercise plan. Also, one must be watchful of a participant's limits and monitor exercise intensity and duration to avoid falls (Mulcare, 1997).
Balance and Coordination
As the disease progresses, balance and coordination can be a major problem and can lead to dangerous falls. Exercises with a Swiss Ball can help to increase flexibility and strength. T'ai Chi can help maintain or improve strength, balance, and ROM. Exercises in a pool are excellent for preventing injuries and falls. The water is supportive: flexibility, posture, muscle tone, and coordination can be improved (Petajan & White, 1999).
Because of an impaired autonomic system, participants with multiple sclerosis are overly prone to overheating. To counter these problems, exercise should exclusively be performed in cool environments (some leg ergometers with a fan mechanism, i.e., the Schwinn Air-Dyne, can be an excellent cooling device), proper clothing must be worn, and swimming or aqua exercises in a water temperature at or below 82° F are great. The participant must drink plenty of water and can also soak in a cooling bath 20-30 minutes before and after exercise (Petajan & White, 1999).
Participants should be encouraged to void their bladder before exercise, and the exercise instructor must inform the participant that he/she is aware that a bladder accident could occur, and that appropriate cleaning materials are available (Rimmer, 2000).
In the preliminary assessment, it is critical to review all medications the participant is taking, and consider this in the design of the exercise program, as these can affect qualities such as his/her energy level, coordination, and muscle strength, and exacerbate secondary conditions and comorbidities. For example, Baclofen helps to decrease spasms but may increase muscle weakness (Petajan & White, 1999); Prednisone may cause muscle weakness, decreased sweating, hypertension, diabetes, and/or osteoporosis (Mulcare, 1997).
Emotional State and Adherence
Because multiple sclerosis happens during early adulthood (Winnick, 1995), and because of the unpredictability of the exacerbations, the condition can be emotionally draining to some individuals. Subsequently, it is crucial that the participant's emotional state be considered in the design of the exercise program, as it can affect the participant's adherence to exercise (Texas Women's University Adapted Physical Education). For example, it must be determined whether a participant's fatigue is due to depression or a physiological state.
Regarding adherence, the exercise program and specific exercises which comprise this program must be fun, pleasurable, and meaningful. The social contact and peer support developed in an exercise should continue independently. Additionally, meditative body work such as Chi Qung, T'ai Chi, and breathing can inject a spiritual element into the program that will encourage the participant to adhere to the program (Petajan & White, 1999). Yoga can be used as a way to deal with stress, to feel more empowered, and to feel more in control of a situation both physically and emotionally (Benyas, 1999).