by Mary Kay Hausladen Foley, PT, GCFP
Pilates instructors know well that the Reformer is an excellent tool to work on strength, flexibility, motor control and balance. For these reasons, the Reformer is also an extremely useful tool for working with people with multiple sclerosis. I have worked with a wide variety of MS patients over the last 23 years, as a physical therapist and as a Pilates Reformer instructor, in association with The Heuga Center for Multiple Sclerosis (the mission of which is to empower MS patients; its motto is “Can Do”). Some patients have such mild symptoms that an outsider would never guess that they have the disease, while others can be quite debilitated it. For the MS population, the Reformer can be invaluable for work on functional changes in areas where motor control or muscle function is compromised.
Multiple sclerosis is an autoimmune disease that affects the central nervous system. It is a chronic and usually progressive disease in which the immune system attacks the myelin—the layer of insulation around nerve fibers—in the brain and spinal cord. This leads to a decrease in nerve function, which causes symptoms that vary from patient to patient and in severity, such as weakness, fatigue, spasticity (a condition we’ll discuss later on in this article), bladder dysfunction, pain, vertigo, decreased balance, cognitive deficits and speech and swallowing difficulties. Because multiple sclerosis affects motor control, the majority of people diagnosed with the disease experience walking difficulty at some point. Research indicates that number is somewhere between 64 and 85 percent. In fact, 70 percent of MS patients report that walking is the most challenging aspect of their disease. Within 15 years of diagnosis, 50 percent of multiple sclerosis patients require assistance walking and, in later stages, up to a third of patients are completely unable to walk. More than 400,000 Americans have multliple sclerosis: most are between the ages of 20 and 50, and women are twice to three times as likely to be affected than men. Worldwide, MS may affect 2.5 million individuals.
Though Pilates exercise will not change the disease process, it can help people maintain strength and function longer than would otherwise be possible. There are, however, special considerations that a Pilates instructor should be aware of when working with someone with MS.
Avoid Heating Up
Heat sensitivity is common with multiple sclerosis. Heat slows nerve conduction—something that is true for everyone, whether you have MS or not. When you do not have a demyelinating disease such as MS, you are able to continue functioning without noticing much of a change. With MS, however, as little as a half-degree elevation in core body temperature can cause symptoms to flare up. When this happens, it is not a reason to panic—the disease process of MS is not progressing. Symptoms will decrease as body temperature lowers.
To keep cool, exercise in an air-conditioned room in the summer, or one that is not overheated in the winter. Wearing accessories such as a cooling scarf or vest can be helpful as well. Drinking cold water may also help, but some people with MS may have urinary incontinence and drinking water during exercise can lead to frequent restroom trips or accidents. If your client does feel as if their symptoms are worsening, they should stop exercising until their symptoms subside and their body temperature returns to normal.
Play It Safe
When beginning any exercise program, it is always better to err on the side of too little rather than too much. Deconditioning, which can occur with any population, can be compounded by the symptoms of a chronic illness. It is often not until later in the day, or even the following day, that people actually feel pain from inflammation or overuse. The excitement of using a new piece of equipment, i.e.the Reformer can easily lead you and your client to over-exercise. Be sure to make your initial sessions shorter than you would with another client. Focus on small movements initially in order to avoid exacerbating fatigue, another common symptom of MS. Concentrate on quality rather than quantity. As your sessions progress and you get to know your client and their abilities and limits, you will be better able to create a program that adequately challenges them, without wiping them out. For some, your sessions may always be shorter, even as brief as half the duration of a typical session.
Safety is a key consideration in working with people with MS. Because it’s common for patients to experience decreased strength and impaired balance, it can be difficult for some to get onto the carriage because of its mobility and low height. Locking the carriage, or attaching all of the springs while your patient is getting on, will give an MS patient the most stable base to move onto. A walker or a chair can be a stable prop and provide added assistance with the transfer to the carriage. Clinical reformers have a raised height that makes transfers onto them easier and safer.
For clients with more severe symptoms, exercises on the long or short box and exercises performed while standing on the carriage may not be an option. In standing, however, some props may give the necessary stability to make these exercises possible. Ski poles can serve as useful assistive devices, when they are available. If you do not have access to ski poles, similar substitutes can be used.
Working on Motor Control
Asymmetries, weaknesses, and general patterns of movement become more apparent when you begin working with a client on the Reformer. To improve motor control, breaking these patterns down into smaller component of movement can be aan extrememly useful technique. Specifically, when starting foot and leg work, using small ranges of motion can be helpful. Depending on the situation, just 30 degrees of knee movement might be an ideal way to start reeducating muscles and a nervous system that has lost the ability to differentiate refined movements. Instead of working through full extension and flexion cycles of the hip, knee and ankle with foot and leg series, try a small range of motion focusing the client’s attention on one joint initially. Small movements may make it possible for the person to find a compensatory strategy, when their normal movement may be compromised by the disease process. You can work your way toward full functional motions as a progression.
Breaking down complex exercises can also help to prevent clients from becoming overwhelmed. Cognitive symptoms of MS such as difficulty processing and remembering are common, yet not oftendiscussed symptoms of MS. Even if your client is physically able to do a complex series of movements such as short spine, realize that separating out the individual steps might make it easier for them if they are experiencing cognitive difficulties.
Decreased flexibility is another common symptom of MS. The beauty of Pilates is that it strengthens while working on flexibility. Depending on ability and spasticity (see below), leg circles with foot straps can be an excellent option. Some clients may require assistance with this exercise due to strength deficits. Performing this exercise with bent knees is one modification that can help with decreased strength, as well as if spasticity is an issue.
Working With Spasticity
Spasticity is a frequent symptom of multiple sclerosis that appears in up to 75 percent of patients. Spasticity is an involuntary increase in muscle tone, caused by demyelinization in parts of the central nervous system.
One would think that an increase in muscle tone is good. However, if tone is created involuntarily by a disease process in the central nervous system, it’s not always such a good thing. If someone has severe weakness, spasticity may help give them strength to stand or transfer. But the down side is that spasticity can render the legs stuck in extension. It can be hard to function with the toes pointed, and the knees and hips straight. With MS the legs are more typically affected than the arms in an extensor pattern. This increase in tone, particularly of the quadriceps in the legs, can be helpful for some clients in standing, walking or transferring. When exercising, however, we do not want to facilitate the extensor pattern, but rather work against it, in tone-inhibitory positions, i.e. not having knees, and hips extended, with toes pointed all at the same time. This allows us to work on true functional strength.
Neurologically, some positions and stimuli facilitate or increase spasticity. For example, lying supine with the legs fully extended can increase extensor tone in the muscles of the legs. Pressure on the ball of the foot can also facilitate the extensor pattern of the legs. Using the footboard will spread pressure over the entire foot, and maintain the ankle in a dorsiflexed position. Side-lying on the carriage, again using the footboard, is another option for leg work in a position that will not facilitate lower extremity spasticity. A pillow on the head cradle will aid in making this position comfortable. When this position is too difficult to achieve, avoiding full leg extension in supine, especially with the balls of the feet on the foot bar, is recommended. With the foot bar, heel contact can be utilized to facilitate contact of the back of the foot.
It’s likely that a person mildly affected by MS would seek out Pilates in a studio environment (these would be the people that you would not know by looking at them that they have multiple sclerosis). Knowing the key components of working with MS—avoiding overheating, how to work with spasticity and avoiding full extension of the legs—is very helpful for this poplulation. The guidelines outlined above can also be utilized with Pilates mat exercises. Patients who are more severely affected would more likely seek out Pilates as an adjunct to PT, and would typically have a rehab professional who could either provide the service or act as an interface with the Pilates instructor.
It is always a good idea for an instructor to contact a member of an MS client’s healthcare team. A physical therapist or occupational therapist would be able to give exercise and movement guidelines, limitations or precautions. A well-versed neuro PT would have more MS-specific knowledge. By gaining a better understanding of disease processes and the implications therein, Pilates instructors can offer more effective programs to a wide variety of populations. With a few simple modifications, the Pilates Reformer can greatly benefit people with MS.
About the Author
Mary Kay Foley, PT, GCFP, is a staff therapist at St. Luke’s Elks Rehab and coordinator for the Integrative Therapies Program at St. Luke’s Wood River Medical Center in Ketchum, Idaho. She is also a program staff member at The Heuga Center for Multiple Sclerosis, a nonprofit organization which provides lifestyle empowerment programs to people with MS and their support partners to transform and improve their quality of life. For more about Mary Kay’s work and The Heuga Center, please visit www.heuga.org.
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