Walking and Exercise
Exercise, medication and/or aids can help make life easier.
What could be more fundamental -and simple - than walking? But when Cheryl Botler, of Seattle, Washington goes out for a walk, she has to struggle to keep her balance, fight dizziness and keep from falling.
Betty Peterson of Albuquerque, New Mexico, complains mainly of weakness. "At some point the knees just give out and my legs flop," she explains.
A 36-year-old former carpenter who asked that we not use his name, has a combination of imbalance and weakness. "At the beginning I just had numb spots on my body, but would have moments when I kind of 'faded,'-couldn't walk right-for 20 or 30 seconds," he says. Then later the symptoms increased, and now I have trouble with balance most of the time."
Whether it's imbalance, weakness, numbness or spasticity, these are all symptoms of problems with walking "gait" problems. "Putting one foot in front of the other is a remarkable, technical feat we ordinarily take for granted," says George Kraft, M.D., professor of rehabilitation medicine at the University of Washington. "But when it comes to MS, your legs are the limbs most at risk. They move because of nerves that run the entire length of the spinal cord," he says. "So if there are MS lesions anywhere along the spinal cord, the legs are much more likely to be affected than the arms."
The act of walking (as well as other physical movements) results from a three step process: input of information or stimuli into the nervous system, a processing of that information, and finally output response to the stimuli. Everything in the process has to work correctly in order for you to walk normally. Disruptions of any of these three functions can distort the normal response and produce an abnormal gait.
Among the multiplicity of gait symptoms people with MS experience, weakness ranks as the number one cause, according to Dr. Randall Schapiro, director of rehabilitation and the MS Center at Fairview Hospital in Minneapolis. Poor balance runs a close second. Third, in his view, are sensory problems such as numbness and tingling in the legs. Fourth is spasticity which, it so happens, falls first in ability to treat.
The first step toward better control of spasticity is for the person with MS to understand what it is," says Dr. Norman Bass, chief of the Division of Rehabilitation Medicine at the University of Maryland. "Spasticity is exaggerated responses to stimuli to the nervous system because of MS lesions found anywhere from the spinal cord to the cerebral hemispheres." The result is increased muscle tone, which the individual experiences as a tight or stiff sensation in the affected muscles.
"Proper stretching, under the direction of a physical therapist,'' says Dr. Bass, ''is one of the most important ways to decrease spasticity. Stretching exercises typically should be done once or twice each day."
"Spastic muscles tend to get tight," Dr. Kraff agrees, "and physical therapy can stretch them out. Spasticity is an impulse for a muscle to contract, and when stretching lengthens the muscle and tendon mechanism, that spastic impulse doesn't occur as frequently."
A relatively new technique in the treatment of spasticity is electrical stimulation applied directly to spastic muscles, according to Jan Jacobs, a physical therapist. The technique was known for being somewhat effective in selected cases of spinal cord injury. Ms. Jacobs, who is at the Mellen Center for Multiple Sclerosis Treatment and Research in Cleveland, says, "I decided to try it for MS as well. In our therapy, we are experimenting with a high-intensity, low-frequency electrical stimulus. Although it is not exactly clear how it works, to date, we seem to be finding it beneficial."
Electrical stimulation is used by Dr. Kraft to help correct another gait problem - foot-drop. He uses a special type of brace that has a switch in the heel which turns on at certain gait intervals to help the toe pick up correctly. "It's a kind of physiologic toe pickup device."
A variation on that device is one that switches on the electrical current after the wearer has attempted to move the muscle. The switch activates when muscle activity reaches a certain level.
On the whole, however, the use of electrical stimulation to correct any gait problem is still largely experimental and not in general use.
Interestingly enough, spasticity isn't always bad, according to Dr. Bass. Contrary to what many people - and some physicians - think, some spasticity can be beneficial, at least compared with the alternative of having legs that are overly weak and rubbery.
"Some spasticity actually works as a kind of isometric exercise, keeping tone in your muscles and retaining your ability to walk and stand for longer periods, and perform other movements such as swinging your legs over the edge of your bed. It can actually result in less fatigue."
"We contend," Dr. Bass stresses, "that spasticity should be reduced only if it is getting in the way of the patient's optimum lifestyle, not just because it's there."
On the other hand, an active approach is almost always recommended for dealing with other gait symptoms. Exercise, in particular, can be helpful, although it should never be undertaken coordinated to exercise, you may be pleasantly surprised. Justin Alexander, Ph.D. and the late Arthur S. Abramson, M.D., writing in the first edition of Multiple Sclerosis: A Guide for Patients and Their Families, caution against the tendency known as "anticipation of disability...those who are getting weaker tend to function below their actual capacity. None of us ever works up to our full capacity, a capacity determined by the fact that the human being possesses large, untapped reserves of energy."
In practical terms, this means almost everyone, no matter what the level of disability, can push a little. How much depends on what your doctor recommends and your own good common sense. Andrew Chandler, of St. Paul, Minnesota, has pushed a lot. He was diagnosed only two years ago, although he is 60 years old, and is still very active as a salesman at a large printing plant in the area. "Muscle-tone exercises have worked wonders for me," he says. "Every morning I get up about 5:30 and do 20 minutes of leg exercises with 5-pound weights on each foot. I also have been swimrning and lifting weights a couple of times a week."
However, he has recently tempered this regimen to avoid getting too fatigued. "I try to balance things out now." Cindy Holmes, 36, wisely has never pushed as hard as Chandler. She does mild stretching exercises every morning, even before rising, to help the flexibility of her arms and legs. But she is careful to plan her day so she will have adequate strength to walk when she needs to. "I usually plan my active periods for mornings and evenings," she says, "and don't do much in the afternoon. That's when I'll often lie down to relieve a kind of heavy feeling that comes over me when I get fatigued." Ms. Jacobs would say that Cindy Holmes is "listening to her body," something we all should do. "It's necessary to treat your entire physical system with respect," Ms. Jacobs says. "When fatigue tells us to take it easy, we should obey that signal, although it's important to push on as soon as one feels up to it."
When symptoms are not excessive, gait exercises can actually help a person relearn the art of walking, according to many therapists. As with any other skill, practice makes perfect. Dr. Schapiro says he often recommends that his patients start walking exercises in a therapeutic pool, because "moving in the water is so much easier than on dry land." He also uses parallel bars as a guide when walking is being relearned. Both these exercises are beneficial for balance problems, too, he says. And for those whose feet are numb, a cane can be used as a means to "feel the ground" with one's hands instead.
Jan Jacobs says she does a lot of gait and balance retraining at the Mellen Center through a system known as NeuroDevelopmental Training, or NUf. "We divide gait into different components such as the stance and swing phases of each leg. The people who come here get a movement analysis to identify what exactly is abnormal about their walking pattern. We then design exercises specifically for each individual. It's a process of retraining the neuromuscular system."
Strengthening exercises can keep muscles from atrophying from disuse," Dr. Schapiro says. He cautions that if you exercise too hard, you can fatigue your good muscles and not strengthen those affected by MS, but it is important to keep on using your legs. Betty Peterson, despite the chronic fatigue she suffers, agrees. She is determined to strengthen her muscles and improve her endurance. Just about every morning she walks a mile up and down her street, and every week goes to an exercise class led by Cecilia Muntz, who has been teaching therapeutic exercises for 15 years.
"We try to include a number of practical tips on walking," she says. "In compensating for weakness and stiffness, people learn a lot of bad walking habits and patterns that we must undo. "We practice walking a lot while holding onto chairs and leaning against the wall," she explains. "We not only go forward but backwards and sideways. It requires more concentration, but the correct techniques are learned better." "This exercise class has been invaluable to me," Betty Peterson says. "I feel lOO% better, since coming here."
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