Expert Voices: Exercising Effectively, Safely With Multiple Sclerosis
In this installment of our “Expert Voices” series, Multiple Sclerosis News Today asked Mandy Rohrig to answer some of your questions about how to make exercise effective and safe for people with multiple sclerosis (MS).
Mandy Rohrig graduated from Nebraska Wesleyan University with a bachelor of science in exercise science and a minor in Spanish. Following her undergraduate education, she received her doctorate of physical therapy from the University of Nebraska Medical Center in Omaha.
Rohrig has had a multiple sclerosis certified specialist certification since 2017. She has more than 15 years of experience working with people with MS and their families in an outpatient physical therapy setting as well as a senior programs consultant with Can Do MS, a health and wellness nonprofit organization serving people with MS and their families. Additionally, she has participated in multiple multidisciplinary presentations at the Consortium of Multiple Sclerosis Centers, a conference for all professionals who help people with multiple sclerosis. She has also served as a presenter, volunteer, and committee member for the National MS Society and MSAA. Rohrig has worked as an associate director of patient advocacy at BridgeBio, a rare disease biotech company, since 2021.
What types of exercises are recommended for people with MS that might differ from those without the condition?
People with MS are often prescribed the same types of exercises as people without MS: flexibility or stretching exercises, strength or resistance training, balance/coordination activities, and aerobic or cardiorespiratory exercises.
What may be notably different is the approach to exercise. People with MS often experience MS-related fatigue. This fatigue is not fatigue as in sleepiness, but rather it is an overwhelming exhaustion that can limit exercise participation and daily activities. MS fatigue may also require the person with MS to take more frequent rest breaks or limit the duration of a workout. It is not uncommon for the fatigue to worsen with repeated movements or muscle contractions. This need to rest can be misinterpreted as lack of effort, which is simply not true.
In addition to fatigue, people with MS also often experience increased sensitivity to heat. Heat can come from the environment or from an increase in one’s core body temperature that naturally occurs with exercise. Research has suggested that as little as a 0.1 degree increase in core body temperature can have an impact on exercise performance as well as recovery. While this is certainly a barrier, it is also an opportunity to intervene. Use of cooling products around one’s trunk, wrists, or neck, as well as fans or cold drinks, are all strategies that could be considered to help someone to stay cool during exercise.
Do you have a favored exercise program or regimen for people with MS?
The best exercise program for people with or without MS is the exercise program in which they will consistently participate!
The challenges of MS are unique to each person so the exercise program each person participates in should meet the person’s needs. People should not waste their valuable energy on exercises that are not helping to improve or optimize their health or mobility. Exercising with a purpose also helps with adherence.
Functional exercises can be particularly helpful for people with MS. Functional exercises break down a task or function into single exercises that cumulatively contribute to improving the desired task. For example, if a person is challenged with getting on and off the toilet, exercises that emphasize strength of the gluteal and quadriceps muscles and flexibility of the calf muscles can help to improve, maintain, or optimize the ability to do that task.
Collaborating with a physical therapist or exercise specialist who understands MS can help to create an exercise program with exercises designed to target each person’s unique goals.
Where should a person with MS start when trying to get started in exercising?
I would suggest a person with MS begin with a thorough physical examination by the medical team and, if cleared safe for exercise, then the person should visit with a physical therapist who understand MS. The physical therapist can complete a comprehensive examination and evaluation that identifies the person’s physical strengths and potential areas to improve. This examination would include a discussion of symptoms, physical challenges, and an assessment of walking, balance, strength, flexibility, and breathing, among other areas of mobility.
Ideally, people with MS will see a physical therapist at diagnosis and frequently throughout the course of their disease, both during and after relapses as well as during periods of stability.
Checking in with a physical therapist for a “tune-up” visit or two allows the therapist to be attentive of changes that may be occurring, as well as ensures that the exercises are addressing the needs of the person with MS.
Is yoga safe and effective for people with MS?
Research suggests that yoga can be a safe and effective exercise approach for people with MS. Yoga can be completed using traditional poses or can be modified with props or performed entirely from a seated position. Bikram yoga or “hot” yoga may be discouraged for people with MS who have sensitivity to heat. The heat can temporarily exacerbate or worsen MS symptoms. Resources and information about yoga can be found at the National Multiple Sclerosis Society. To find a qualified yoga instructor, visit the Yoga Alliance.
How about aquatic exercise?
Aquatic exercise is another effective exercise option for people with MS. Research suggests that water exercises can improve flexibility, strength, balance, aerobic endurance, and help to minimize fatigue. The buoyancy or weightlessness water therapy offers can allow people with MS greater freedom of movement, while also offering a bit of resistance for strengthening opportunities. Additionally, cooler water can help people with MS with heat sensitivity the opportunity to do more without overheating.
While there are advantages to water exercise, there are a few disadvantages to consider. Often, because people have so much more freedom of movement in the water, there is a greater chance to overexert and cause excessive fatigue. Ideally, people should start slowly to minimize this fatigue. Another aspect to consider is the time and energy required to dress before and after pool exercise; the process around accessing the pool can often be more tiring than the pool activities themselves.
Check out this resource from the Multiple Sclerosis Association of America for more information.
What do you recommend for those fearful of falling while exercising?
Fear of falling during exercise is a common and reasonable concern for many people with MS and their support partners. In order for exercises to have the greatest effect, they must also be safe. A person, with or without MS, cannot experience all of the benefits of an exercise if a risk for falls exists.
If a risk for fall exists, a physical therapist needs to evaluate the symptoms and situations that are contributing to the fall risk and balance challenge. Knowing the circumstances (i.e., time of day, specific positions or movements, and environment) when balance is compromised can help to guide the physical therapist as to what exercises may help to improve balance. For example, a person who finds themself off balance when turning their head while walking in the grocery store may benefit from vestibular exercise.
If a fall risk exists, a few strategies can be used:
- Use mobility aids: Mobility aids, such as walkers or canes, can be valuable tools to keep people safe while allowing them to do more. For example, a person with MS who walks without a mobility aide may be able to walk for three minutes prior to fatigue and foot drop, but if that same person uses a walker, they may be able to walk for five or six minutes before symptoms limit their exercise. Mobility aids are tools to help people with MS do more safely.
- Consider seated exercise: A misconception exists that seated exercises are not as effective as standing exercises. This is not true. Seated exercise or exercises that use the arms more, such as arm bikes or rowing machines, can provide people another safe and effective approach to exercise.
What recommendations might you have for a person who finds they’re exhausted for days after exercise sessions?
I like to describe this as “exercise hangover.” A person either feels really good during exercise, so perhaps pushes more than they typically would, or the exercise combined with all of the daily activities impact fatigue for many days. Fatigue for many people with MS can have a cumulative effect, with days of activity and fatigue building on one another.
For people who experience exercise hangover, I suggest two primary strategies:
- Use of the RPE scale: The RPE, or the Rating of Perceived Exertion Scale, is a 0–10 scale that corresponds to a person’s level of exertion at rest or with activity. So, seated in a chair at rest a person may feel at a 0/10, but with riding a stationary bike, they may rate their effort at a 5/10. Quantifying fatigue or exertion before, during, and after exercise can guide a person of when may be appropriate to slow down or stop exercise so as to avoid exercise hangover.
- Two-hour rule: If you don’t feel as good two hours after exercise as you did at your baseline, you may have done too much. In other words, recovery from exercise should ideally occur within about two hours.
- Exercise snacks: If exercising in one single session (i.e., 30 minutes) results in fatigue that is lasting and interferes with daily activities, then that person may want to consider exercise snacks. Exercise snacks are bite-sized, short bouts of exercise that can be completed intermittently throughout the day. Approaching exercise intermittently can have the same positive effects as completing exercise in one session, but without the excessive fatigue.
With a progressive disease, it’s hard to find a reason to exercise when one may feel they can never reach their goals. Do you have advice for them?
This is a really good question. Living with a chronic, progressive disease and setting exercise goals can feel like working toward a finish line that keeps moving away from you.
People with MS can feel like their bodies change within the day, minute, and possibly within the hour. The fluctuating nature of the disease can make not only exercise challenging, but also setting goals for exercise challenging. For people living with MS, it is critically important to set realistic and achievable fitness goals.
A physical therapist with understanding of MS can help set these goals. I often encourage people to not only consider their exercise performance on a single day, but also their abilities over time. Often it can take two to three months of consistent exercise participation to experience change or improvement. Identification of key benchmark activities or exercises can be used as a guide for progress.
Because of the fluctuating nature of MS, I also highly encourage people with MS to have a variety of exercise options — a menu of exercises — that are appropriate for them and their goals, and that will be responsive to symptom fluctuations. For example, someone might ride a stationary bike for five minutes every day, but find on some days the fatigue is too overwhelming. Perhaps on those fatigue days, gentle stretching or deep breathing exercises are suitable and more manageable to do. This allows people to remain on target with their goals, but also be actively responsive to the inherent challenges of the disease.
Expert Voices is a monthly series involving a Q&A with an expert in the MS space about a specific topic. These topics and questions are curated from a survey in which we ask readers what they want to learn more about from experts. If you’d like to submit topics or questions for consideration in a future installment of the series, click here to take the survey.
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