Exercise and multiple sclerosis

Nicola: Welcome to the MS education podcast series. Thank you for joining me. I'm Nicola Graham and in each episode, we're going to be joined by an expert to discuss strategies for living well with MS.

Today we're talking about exercise and multiple sclerosis. My guest is Caitlin Ireland, MS exercise physiologist who works in the MS gym in Lidcombe, Sydney. Caitlin has been an exercise physiologist for five years, working exclusively with MS clients for the past three years. So welcome Caitlin.

Caitlin: Hi Nicola, thank you for inviting me here today.

So I'm really passionate about exercise and multiple sclerosis and hopefully by the end of this podcast our listeners are going to have a better understanding of why exercise is so important and how to exercise effectively so they can get the most out of their workout.

Nicola: That sounds fantastic Caitlin.

So let's start off with why is exercise so important with somebody with MS?

Caitlin: Yeah, so really good question. People with MS still get the same benefits as the general population. So, improved muscle strength, improved aerobic capacity or fitness levels, and also reducing the risk of developing conditions that are related to inactivity or leading a sedentary lifestyle and that's conditions like cardiovascular disease, type 2 diabetes and osteoporosis.

But then there's also further benefits specific to people with MS so that can be symptom management. So strengthening weakened muscles, improving balance and therefore reducing fall,s risk, improving fatigue and a lot of people will, are of the understanding that exercise may exacerbate their fatigue. But actually there's a lot of evidence to show that exercise has really beneficial long term effects on MS fatigue. Improving cognition and mood, functional capacity, helping manage spasticity and pain, improving mobility, so that's how far we can walk. Our ability to transfer and also the way in which we walk, so our gait patterns and, and the techniques we use, and then also quality of life. So, I guess on top of symptom management, we also get benefits such as social participation.

So, getting out of the house, meeting new people, especially if it's something like a group class or session, improving confidence and independence, especially in activities of daily living. And there are some disease modifying effects as well. And there's a lot of new research coming out. There's brain protection, slowing the progression of the disease and also slowing the progression of the disability, reduced relapses and exercise enhances the anti inflammatory mechanisms. That will improve symptom presentation as well.

Nicola: Okay, and there's a lot of good reasons for us to be exercising. I'm particularly interested as well in some of the things are quite obvious around balance and strength and energy, et cetera, but really important to note around that benefits for cognition and brain protection, which we often don't think about with respect to exercise.

So, it's good evidence there now. Okay. So, there's, there's many different types of exercise that we can do. Is there a standard prescription which is a good baseline for people with MS to do? So, I'm thinking, is it a mix of strength and cardio, how much do I do and how often? Because I'm lazy myself, I'm particularly interested in what's the minimum that I'm required to do to get a positive effect.

Caitlin: Ah yes. No, you're not alone there Nicola. And there is a really good guideline available. So, a few years ago there was a big body of research that came out and it's the Canadian Physical Activity Guidelines for Adults with MS. And they said that, I guess that minimum dose that we speak about, we want to be doing two, or people with MS, sorry I should say, want to be doing two 30 minute aerobic sessions at a moderate intensity and two 30 minute strength or resistance training sessions for those major muscle groups. Now those can be done on alternate days or you might find that if you, particularly if you go to a group session or a class, they might combine the aerobic and resistance session. So, you might do an hour class with 30 minutes of aerobic and 30 minutes of strength training within the one session.

I do recommend though if someone has quite a low cardiorespiratory fitness, maybe they haven't done exercise for quite a while, to start with a shorter duration. So maybe 10 to 15 minutes and then look to gradually increase to a 30 minute session.

Nicola: So, start gently, Caitlin sounds important.

Caitlin: Exactly right. Yes, definitely.

Nicola: What does that mean in practice in terms of moderate intensity exercise? What does that mean?

Caitlin: I guess when we're exercising, we really want to be doing purposeful exercise. So, you know, there is not just walking around the grocery store or walking from the car to into work, but really going out with the intention of getting that heart rate up and completing it say 30 minute session. So, what that might look like is that might look like can still be walking, but walking around the block or taking the dog for a walk or walking with friends, going for a run. A lot of the cardio equipment that we have, you see at the gym. So, things like exercise bikes, elliptical machines, treadmills, also can be propelling a wheelchair or something like boxing, a bit more dynamic. So, all of those count as aerobic exercise. And when I'm speaking about moderate intensity, so I guess moderate intensity is around about 60 to 70 percent of our max predicted heart rate. Although for people with MS, a lot of them will actually have something called autonomic dysfunction.

And what that means is that the heart rate is blunted so that the heart rate doesn't continue to increase with increased workload necessarily. And so it's not always a really accurate way to measure intensity. So, what I usually recommend and what we use here, what I use at the gym here, is an RPE scale.

And so that is a rate of perceived exertion. So, putting on a scale how difficult you found it. Now there's a few scales around, but there's a really easy one to remember is 0 to 10. And 0 being rest, nothing at all, really easy. And 10 being max effort, nearly impossible. And when we talk about moderate intensity, we really want to be getting between three and five.

But now if that's still a bit difficult to kind of get your head around, you can also try a talk test. And so really when you're exercising at a moderate intensity, you want to be able to talk. If I was saying next to you asking you how you were going, you should be able to answer me, but not sing. So, you are starting to get a little bit breathless.

Now, with resistance training, it's a little bit different, so what you want to be doing is working those major muscle groups, doing each exercise for 2 to 4 sets at 8 to 12 repetitions of each exercise. And I guess a good way to think about the intensity for the resistance training is that if you were to do 3 lots of 10 of an exercise.

On number 9 and 10, if I was to ask you after how many more you could do, you should only be able to do another 2 to 4 of that weight, and that would be working at a good moderate intensity.

Nicola: Okay, so if I've understood correctly, Caitlin, that's four purposeful 30 minute sessions a week, two of which would be moderate intensity sessions and two of which would be strength sessions.

Caitlin: So, two moderate intensity aerobic sessions and then two resistance sessions. Exactly.

Nicola: Okay, great. Also, Caitlin, I've heard about high intensity interval training and that it is particularly good for people with MS with regards to brain health.

Can you tell us a little bit more about this and what you might recommend in this area?

Caitlin: Definitely. I do a lot of high intensity interval training in the gym with my clients and there is a lot of evidence to show that it's a really safe and effective way to complete aerobic training for people with MS.

So, I know that there are a lot of people especially with MS who might express fear about pushing themselves into that high intensity range. There is a lot of evidence to show that is safe, completely safe and actually in fact recommended for people who might experience things like heat intolerance as well because you are only increasing that heart rate for a short periods of time.

So, the high intensity spurts, you really want to be having those go for 10 to 45 seconds and then either having a period of reduced intensity or complete rest. So, when you are at that high intensity, we're referring back to that RPE scale that I was talking about. The rate of perceived exertion, where zero is at rest, nothing at all, and ten is our maximum effort.

We want to be working at seven to eight. So, it should be quite hard. Rather than that talk test, you want to be getting that puffing and panting for that short period of time. And then what I would recommend is on that rest to be at least equal to the amount of the high intensity spurt and up to three times the work period. So, to make that a bit more clear if you were to go for a 15 second sprint then you would have at least 15 seconds off up to 45 seconds rest.

Nicola: Okay. So, you're working really hard for a super short interval and so it sounds like that's something that you could do in a gym, but you also mentioned sprinting.

So, is there any other types of exercise that you might do for high intensity training that gets your heart rate up?

Caitlin: Yeah, definitely. Look, I think, you can do that with almost any type of aerobic exercise. All you're trying to do is increase the intensity. So that might be if you're using a piece of gym equipment that has levels, you might increase the level to very high for a short period of time while you go on that interval or it might be that you increase your speed. So, if you were walking, you might do spurts of a faster pace and then slow down again, and then a faster pace again, where what we're trying to do is, is no matter what exercise you're doing, we're trying to get that huffing and puffing for a short amount of time, and then reduce it again.

Nicola: Great. So, I can still do this on my beach walk with the dog, for example? Yes. I can incorporate it in my daily life, but I can be a bit purposeful about it. I'd love to talk about barriers to exercising and what people can do to overcome these barriers. I know I struggle to exercise regularly and I'm wondering if you might have some top tips to help get us moving.

Caitlin: Yeah, definitely. So those benefits that we talk about, we know those benefits and despite them we still have almost 80 percent of people with MS that are not exercising. Some of the more general barriers that people might have, and I hear about are things like motivation, time, cost and uncertainty about what exercise they should be doing.

So, I'll just quickly go through those first, so motivation my recommendations would be to have a plan or schedule. So, you definitely know at the start of each week when you're going to be completing the exercise throughout the week. Also writing down some goals, what you want to achieve. That can be a vision for three months away and then you might have some smaller weekly goals to get there.

So, for example, if you wanted to walk two kilometres without a break, that might be a three or six month goal. And then what are you going to do this week to achieve that or make your way towards that goal? Well, you might do two 25 minute walks this week. Also for motivation group sessions are a really good way to be motivated or to make yourself accountable to complete the exercise.

Now time, you know, no one ever really has infinite amounts of time to exercise. And I understand that, but really just setting aside time in your day, addressing your priorities. If really, you really are very limited with the amount of time you have trying to do little and often. So you might break a session down into 10 minutes of strength training at home, and you might complete a few of those in a day. Cost - so there's lots of great ways that you can keep the cost down. Things like completing a home exercise program or doing things with friends, like having a walking group or community gyms can also be relatively low cost. And if you're not sure about the exercises that are suitable, probably my biggest recommendation would be to consult a professional.

So that can be a physio, an exercise physiologist, a personal trainer, ideally someone who has an understanding of multiple sclerosis, and not only can they give you some suitable exercises for yourself, but they're also going to be able to address your symptoms as well and give you a really beneficial exercise program.

Now those are some general barriers, but I know that there are some MS symptoms that can also act as barriers to exercise.

So, fatigue is one that I hear about a lot. So, my recommendations would be to exercise early in the day, making sure you have big rests, and that's during your exercise session, but also before and after your exercise session as well and during your strength training to alternate arm and leg exercises.

Balance. Try and set up a safe environment if you're exercising at home, so have stable pieces of furniture nearby that you can use if you need to, or making sure that you have someone at home that can either maybe assist you or just in the other room that knows you're completing your exercises for that confidence.

Pain. Now pain's an interesting one and probably my biggest recommendation if you're limited by pain, or that's your main barrier, is really again to maybe consult with a physiotherapist or a professional that can help you create a program that's going to be, you know, maybe relatively pain free. Also, to potentially manage that pain that you experience as well.

Temperature sensitivity. So, keeping a cool environment - making sure you have lots of breaks and lots of cold water as well. You know, a lot of people do go boom to bust. So, they'll start trying to do a lot to start with, and then they might find that that's not realistic. So really just doing anything you can and be kind to yourself.

So especially with MS, be aware that not every session is going to be better than the last and that, you know, each session you just do what you can and what you're up to that day.

Nicola: Can we talk a little bit more about motivation, Caitlin? You've mentioned some great tips. In your experience, if you had to pick two pieces of advice to help people get moving, what would they be?

Caitlin: Yes. Okay. So, my top two recommendations are to make it enjoyable and then to schedule it in like an appointment. So, if you make, if you pick an exercise that you find enjoyable, it's going to be more sustainable. So, find an exercise you enjoy. So, if you hate cycling, don't make yourself cycle twice a week. Each week you're going to dread it and you will, won't want to complete your exercise. If you enjoy walking or getting out in nature, then try and complete those exercises. If you don't have an exercise that you enjoy in particular, then try and combine it with something that you do enjoy. So, for example, find a friend that can go for a walk with you so you might be able to have a chat while you walk. Or you could try and reward yourself after the session. So, it could be sitting down and having a cup of coffee after your session or having a book that you enjoy reading after that. So that you know that once you finish your session, you get to have that reward and that'll be a good motivation for you.

And secondly, to schedule it into your day like an appointment. So I always say this to my clients who have home exercise programs and tell me that they're very busy. I say at the start of the week, schedule it into your week. And then if someone calls you and says that they want to pop over for coffee or one thing or another, you say, oh no, I can't, you know, I've got my exercise session that I need to do then how about another time? And that really keeps yourself accountable.

Nicola: That's great advice, Caitlin. I know when many people who exercise with MS, they can experience a mild exacerbation of symptoms due to their raised temperature and you, you've touched on that with around temperature sensitivity. Can you tell us what might happen when your temperature increases due to exercise: what's normal, when to be concerned, and maybe what you can do to manage your temperature when you exercise?

Caitlin: When anyone exercises, they will experience an increase in their core body temperature. But for people with MS, even an increase as little as half a degree of their core temperature can mean that they experience a rapid increase in their fatigue and / or sensory symptoms.

So, sensory symptoms are things like numbness, tingling, visual problems and muscle weakness. I think the main thing to be aware of is that this is normal, and that when your core temperature does decrease again, those symptoms will reduce. And you should see that decrease within 30 minutes to two hours after your session so that's important to be aware of. I guess when to be concerned. It's not necessarily a concern, but if you find that those symptoms don't decrease after two hours after your session, it might just be that you've overworked yourself, so it was a bit too high in intensity, which is okay.

I guess my biggest recommendation would be not to be scared off by exercise, to give yourself a bit of a break and on your next session just be a bit more conservative and reduce the intensity and slowly build yourself up again.

My tips for keeping yourself cool or during your exercise session is to take nice long rest breaks in between your exercise. Drink cold water, so, and when I say cold, icy water is best, so as cold as you can and this will enhance your exercise tolerance. Try avoiding hot environments, so not being outside and maybe picking a cooler part of the day in the morning or the afternoon.

Hydrotherapy pools can be a really good way for temperature sensitive clients to exercise, but there is an ideal temperature for the pool to be for someone with MS. So really, you want the pool to be 27 to 29 degrees. And what you can do is you can always call up and ask the administration at the hydrotherapy pool and they will be able to tell you what that temperature is. Having fans around you, wearing loose clothing, and also wearing things like cooling vests or scarves. They can be helpful as well.

Nicola: That's great, Caitlin. Thank you for those tips. And just finally, one last question. Are there any resources or apps or programs specific for people with MS that our listeners can tap into?

Caitlin: Yes, definitely. So, MS has some really great resources. There's some really good MS webinars and they're a bit longer than, well, they're much longer than the podcast. They're about an hour and they go into more detail on some topics. So, things like pain management, spasticity, getting active. I know that there's one coming up this year, if it's not already up there, on reducing falls risk through exercise programs.

That would be a great one. You can also contact MS Connect. That might be if you have more specific questions or you want access to more, find out where more resources are. They might be able to connect you with other allied health professionals as well. There's an MS Get Fit toolkit as well online which you can access.

Nicola: That's wonderful Caitlin. Lots of great information in there and I really hope it's inspired our listeners to get moving and that they really understand what to do and why they're doing it. Thanks Caitlin.

Caitlin: My pleasure. Thank you for having me, Nicola.

Nicola: For more information on anything we've covered today, please get in touch with MS connect on free call 1800 042 138 or email [email protected] and don't forget to find the MS Podcast on your favorite podcast player such as Apple, Google Play, Spotify, overcast, or you can access the podcast directly from our website, msplus.org.au.