REHABILITATION

Health Promotion

These suggestions promote good general health. They are particularly useful in MS since feelings of uncertainty and loss of control contribute to anxiety and depression. Any activity you can do which will give you an improved sense of control will promote an improved sense of well-being. Many patients find this to be the case with diets and regular exercise programs. Feel free to discuss these options with your care providers at the Center.

Exercise Over the years, the thinking about exercise and MS has changed. It is now believed that exercise promotes cardiovascular fitness, a sense of well-being, and may prevent complications from disuse or inactivity. Exercise also helps to regulate appetite, bowel movements, and sleep patterns. Jogging, walking, and aerobic exercises are helpful when strength and coordination are not affected. Stationary bicycle riding may be more practical if walking or balance are impaired. Swimming is particularly helpful for stretching and cardiovascular fitness. Yoga and Tai Chi are most useful for stretching and a sense of well-being. Your physical and occupational therapists will assist you in selecting the best exercise program for you to follow. Exercise has long been proven to be of benefit to health and longevity.

Stress Reduction Although stress cannot be totally eliminated from our lives, we can learn to manage it more effectively. Any reduction in stress will be associated with an improved sense of well-being and increased energy. A psychologist or social worker may be helpful in developing a stress management program that is tailored to your needs. The following are some useful stress reduction techniques:

Identify causes of stress in your life and share your thoughts and feelings.
Simplify your responsibilities by setting priorities.
Relaxation and meditation exercises are often helpful.
Manage your time and conserve your energy.
Ask for help when needed.
Set short-term and life goals for yourself.
Keep as active as possible both physically and mentally.
Recognize the things that you cannot change and don't waste.
Make time for fun and maintain your sense of humor.

Nutrition Good nutrition maximizes your energy, general sense of well-being, and healing capacities. A dietary routine also contributes to regular bowel habits. Although no specific diet has been demonstrated to conclusively improve the natural history of MS, most people do report an improved sense of well-being when following a carefully planned diet. Several published diets are healthful and easy to follow. Others are more restrictive and less practical. We provide you with a list of references in the reading materials section.

Vitamin and Mineral Supplements Unless there is a specific vitamin deficiency found by your doctor there is no scientific proof that supplementary doses of vitamins or minerals, alone or in combination, favorably affect the course of the disease. Be careful not to take excessive doses of vitamin B6 because excessive doses of this vitamin can produce sensory symptoms similar to those seen in MS. High doses of vitamin A and D are toxic.

Oleic and Linoleic Acids These fatty acids have been reported to be deficient in MS patients. There is an unconfirmed suggestion that supplementary feeding of these fatty acids may slightly reduce the frequency of attacks of MS. These fatty acids are contained in sunflower seed oil and primrose oil. The former is much cheaper and readily available in grocery stores. Two tablespoons of sunflower seed oil each day will provide you with these fatty acids and give you the added benefit of a laxative.

Skin Care If you have problems with mobility, muscle contractures, or are confined to a wheelchair you should check your skin regularly for sores, pressure spots, infections, or abrasions. Regular skin care will minimize the chances of skin breakdown and help you to avoid complications such as a decubitus ulcer. Be sure to check the pressure points on your body including your heels, knees, hips, buttocks, and elbows. Remember to protect against skin cancer by wearing sunscreen and protective clothing when outdoors, whether it is sunny or not. Get familiar with your skin and examine it frequently.

Urinary Tract Infections Vitamin C helps to acidify the urine and prevent the growth of bacteria. Orange juice or vitamin C tablets are both useful. Cranberry juice will also acidify the urine and is available as a sugar free juice for those who count calories. If you develop new urinary frequency, burning when you urinate, or have difficulty passing your urine, you should call your doctor and be seen for the possibility of a urinary tract infection.

Vaccinations There has traditionally been a concern that immunizations could worsen MS by stimulating the immune system. With the exception of transient worsening associated with fever or rare neurological complications known to be associated with certain vaccines, there is no convincing evidence that immunizations make MS patients worse. If immunizations are recommended by a physician, they can probably be undertaken safely. In general, immunizations should be delayed if the person is experiencing an acute attack of MS. In some circumstances (e.g., urgent vaccinations for tetanus or rabies), however, immunizations should be given immediately. If questions arise, you should discuss them further with your neurologist.

Physical Therapy

PT focuses on ways to preserve or improve safety and independence with functional mobility. This may be accomplished through a variety of approaches including: mobility technique training, home exercise programs, caregiver training, and effective use of adaptive equipment. The following are examples of PT therapeutic strategies toward the everyday management of mobility-related symptoms.

Exercise Categories

You and a physical therapist should develop an individualized exercise program that is based your on current needs and future goals. This may include yoga, exercises in a gym, tai chi, or Feldenkrais, as well as traditional forms of exercise such as running, walking, biking, swimming, or water aerobics. In some cases, exercises can be carried out independently, with or without modification. In other instances, certain more challenging exercises may require some assistance.

Stretching Frequently, persons with MS have spasticity, especially in their lower extremities. This can cause the legs to stiffen if a regular stretching program is not incorporated into the daily routine of activities. Stretching exercises help to maintain or improve muscle length to allow greater flexibility.

Coordination Coordination exercises are done to improve balance and ease of purposeful movement. The degree of skill required to perform the exercises varies. An appropriate program will be discussed with the individual MS patient.

Strengthening Strengthening exercises are designed to build weakened muscles to aid in moving and walking. While being beneficial, discretion is advised when carrying out a strengthening program. For instance, if one has undergone a vigorous session of exercising but is too tired to prepare dinner or do chores that ordinarily can be done without difficulty, it may be necessary to modify the program (such as fewer repetitions) or space the activity more evenly throughout the day.

Upper Body Exercises

These simple exercises are designed to promote flexibility, muscle balance, and to enhance upper extremity function. If done correctly, they are appropriate for all stages of MS. Stretches are to be done slowly, generally being held for approximately five to ten seconds. These exercises can be performed either seated or lying on your back. Repeat each exercise five to ten times on each side as tolerated. You can do one side at a time or both sides at the same time.

Back and Neck

Shrug
- Shrug your shoulders up towards your ears.
- Hold for 10 seconds then relax.

Tilt
- Tilt your head slowly to the right shoulder.
- Hold for 5-10 seconds.
- Tilt your head slowly to the left shoulder.
- Hold for 5-10 seconds.

Turn
- Turn your head slowly to the right.
- Hold for 5-10 seconds.
- Turn your head slowly to the left.
- Hold for 5-10 seconds.

Arms and Hands

Arm Raise
- Place your arm(s) at your side and turn your palm(s) down or toward your body.
- Keeping your elbow straight, bring your arm(s) up toward your head and ear.
- Hold this position for 5-10 seconds. (Stretch can be done one or both arms at a time.

Arm Side Swing
- Place your arm(s) at your side, palm up.
- Keeping your elbow straight, slide your arm out to the side and up toward your ear.
- Hold this position for 5-10 seconds.

Arm Crossover
- Place your arm out at shoulder level, with the elbow straight.
- Bending your elbow, bring your arm across your chest.
- Hold for 5-10 seconds.
- Repeat with opposite arm.

Arm Curl
- Bend your elbow(s).
- Completely straighten your elbow(s), holding your arm out straight for 5-10 seconds.

Wrist Stretch
- Holding your hand in the air, bend your wrist up 90 degrees to a straight position.
- Then move your wrist backward as far as possible.
- Straighten your wrist again.

Fight the Power
- Make a tight fist.
- Straighten all your fingers.
- Relax.

Adaptive Equipment Various types of devices are available to allow greater mobility and increased independence. A type of walking aid (walker, crutches, cane, AFO or Ankle Foot Orthosis) can assist one in becoming or remaining ambulatory. A wheelchair may provide new opportunities to go shopping, attend social functions, and promotes conservation of limited energy.

Mobility

Ambulation Each person will be taught a specific gait pattern based on current condition. The following are a few tips to keep in mind when walking:

Walk at a comfortable, safe speed.
Take equal length steps.
Maintain good posture by standing erect with the chin up.
Keep a little weight forward on the hands if using an assistive device.
When stair climbing, always use a railing, if available, and remember to step up with the stronger leg first and to step down with the weaker leg first.
Avoid high heels that may cause you to trip, turn your ankle, and/or lose your balance.
Wear shoes that give adequate support at the ankles to avoid twisting at the ankle and consequent injury or loss of balance.
When stepping through, remember that your heel should strike the ground ahead of you before the rest of your foot makes contact.

Transfers Transfers mean moving from one place to another. Transfers may be done alone or with help. To do a stand pivot transfer:

Position the strong side closest to the surface to which one is transferring.
Prepare to stand by moving the buttocks forward to the edge of the chair.
Place the feet under and slightly behind the knees.
Lean forward with hands on the arm rests.
Push off with the arms, while straightening the knees and body.
Pivot on the strong leg and reach for the chair or bed.
Sit by lowering the body slowly.

If unable to come to a standing position, do a sliding board transfer. Remove armrests and/or footrests to make transfers safer & easier.

Occupational Therapy

Occupational therapy places an emphasis on improving and maintaining functional independence in activities of daily living (ADL's) and improving quality of life. The therapeutic program is tailored to an individual's needs. The following are examples of OT therapeutic strategies.

Activities of Daily Living

Dressing

Select loose fitting clothing such as pullover tops and elastic waist slacks.
While dressing, sit as much as possible.
Lay out clothing the night before.
Dress the weaker side of your body first.
When undressing, undress the stronger side first.
Use assistive equipment such as a long handled shoehorn, Velcro closure shoes, long-handled reacher, dressing sticks, sock aid, or button hook.

Eating

Eliminate distractions such as TV or conversation to avoid choking on food.
Cut your food into small bite-size pieces.
Use a commuter-type mug with a lid or a sport bottle with a built-in straw to avoid spillage.
Use built-up handles on utensils.
Notify your physician if swallowing becomes increasingly difficult.

Bathing

Transfer into a dry shower or bath tub. Turn on the water after you are situated. Always have a nonslip bath mat or nonslip strips on the tub floor.
Avoid hot water while bathing as it may increase fatigue.
Use a bath stool/chair and a hand-held shower.
Use grab bars for safety in the bathroom.
Use liquid soap.

Communication

Use a built-up pen grip or felt tip pen for writing.
Get a telephone with enlarged numbers and a redial button.
Use a speaker phone.
Use a magnifying glass for reading small text.
Use a voice-activated tape recorder for messages.
Become part of a computer network.

Energy Conservation and Work Simplification

Individuals with MS often become efficiency experts through simplification of tasks. Here are a few suggestions to simplify daily tasks and avoid fatigue.

Plan ahead and organize. Alternate light and heavy tasks throughout the day, doing heavier tasks in steps, with rest periods.
Do as much physical activity as you can.
Allow adequate time for each task and stop before fatigued.
Use a daily, weekly, and monthly schedule to plan your activities and appointments.
Alternate sitting and standing tasks.
Eliminate the unnecessary (such as allowing the dishes to drip dry).
Ask for help. Enlist the support of family and friends.
Plan your most active hours for early in the day when you have the most energy.

Kitchen Tasks

Set up a simple working area. Store items used most often on the counter or areas where they are within easy reach.
For easy access, use wall hooks to hang utensils and tools.
Slide instead of lifting cooking containers over surfaces.
Use a cart for moving food and dishes.
Sit while preparing meals.
Create simple meals.
Use electrical appliances when possible.
Use jar opening jaws or place jar under running warm water before opening.

Home Management

Evaluate your safety and independence in the home.
Begin thinking of ways to simplify tasks such as budgeting finances, laundry, vacuuming, bed making, and cleaning.
Limit ironing by using wash and wear clothing.
Create an accessible work station or desk for your personal finances and correspondence.
Use motion detector lights.
Use remote control devices for the TV and stereo.
Sit when possible for housekeeping and cleaning chores.

Heat Related Fatigue or Weakness If you must be physically active in the heat, taking a few simple measures can help to reduce the effects of the heat:

Plan heavier activity for the cooler part of the day.
Use the air conditioner whenever possible, at home or in the car.
Use fans.
Have ice chips, cold drinks handy.
Cool off with a spray mist bottle or a wet towel.
Consider a cooling vest.

If you are especially heat sensitive, ask the PT about a portable personal cooling device.