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YOGA AND MULTIPLE SCLEROSISSUSAN KUSHNER, MS, PT

SUSAN.KUSHNER@SRU.EDU

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OUTLINE•Intro to Multiple Sclerosis

•Overview of yoga

•How yoga can be useful with persons with Multiple Sclerosis (PwMS)

•Postures to assist with flexibility and range of motion

•Postures to assist with strengthening

•Postures to assist with balance and coordination

•Mindfulness

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Multiple Sclerosis Defined•Chronic neurological disease in which immune system attacks CNS

•Oligodendrocytes produce fatty substance called myelin

•“Multiple scarring”-results in demyelination and axonal damage to myelin

•Neurotransmission is impaired

Demographics of MS•Affects most people in the prime of their lives:20-50 years old

•More prevalent in temperate climates

•Incidence about 1:750

•Recent statistics from the National MS Society state that 1,000,000 persons in the US have MS. Up from the previous estimate of 400,000

•Women are 2-3x more likely to have MS

US Prevalence

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Demographics

•Slight hereditary component

•Where you live prior to age 15 matters geographically

•More pediatric cases being diagnosed

•Men are likely to have a more aggressive type of the disease

•Over 2.5 million worldwide with MS

•Most wide spread disease in the world among young adults

MS: Challenging AND Rewarding for the therapist

•Knowledge of the disease is crucial to successfully treating this patient population

•Patient needs to be “captain of their ship”, or the “cog in their wheel”

•A comprehensive medical team is needed for management of the patient

•Team members must communicate-this includes the support partner(s)

Patient must be educated!!

•Many symptom management choices: rehab, medications, equipment etc…•All members of the team must be invested in MS

•Physician(neurologist, urologist, GI, Ophthalmologist, Psychiatrist, Physiatrist, etc)

•PT Dietician

•OT Psychologist

•SLP Exercise Physiologist

•Vocation counselor

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Therapists must:•Understand the disease and the nuances of the disease

•Evaluate and establish baselines

•Educate the patient and support partners

•Be in communication with all team members

•Be an advocate for the patient

•Look at the patient as a whole

•Be prepared for changes in status as the disease changes

•Expect patients to “boomerang” back to you over time

•Be familiar with the Disease Modifying Therapies (medications)…(DMTs)

Common Symptoms

•Fatigue: # 1 patient complaint

•Spasticity

•Impaired mobility

•Bowel/Bladder issues

•Decreased strength

•Decreased range of motion

•Sensory deficits

•Pain-reported in at least 1/3 of patients-used to be ignored

•Balance and coordination problems

Symptoms

•Cognitive challenges

•Speech, swallowing difficulties

•Sexual dysfunction

•Heat intolerance

•Depression

•Optic neuritis

•Ataxia

•PATIENT SYMPTOMS ARE HIGHLY VARIABLE! NO TWO PwMS ARE ALIKE!!

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Types of MS

•Commonly classified in 3 categories:

•RRMS: Relapsing Remitting MS-most common (80%) Relapses (exacerbations), varying lengths of time, followed by remission. Often recovery is NOT back to baseline.

•SPMS: Secondary Progressive MS-most patients with relapsing remitting MS transition to SPMS. Disability increases.

•PPMS: Primary progressive MS-least common but most aggressive form of MS. Steady disease progression with no clear relapses or remissions

Diagnosis

•Used to be a disease of “exclusion”

•Patient history/medical history-symptoms

•MRI

•Evoked potential

•CSF-bands

•2 separate areas of CNS involvement

•2 separate recorded events

Treatment•Disease modifying therapies-22 year proven history of decreasing the progression of the disease

•DMT to be prescribed by MD in conjunction with patient input

•May have side effects

•Varies in type of administration: infusion, pills, injections

•Rehabilitation-ongoing lifelong process

•Be certain that patient has appropriate assistive devices, braces, electrical stimulators, etc, along with appropriate equipment for ADLs

•PwMS should exercise in a cool setting-use fans, cooling vest, cool neck wrap, cool drinking water, cool swimming pool water if doing aquatics; small bouts of exercise

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Treatment•EXERCISE!!

•Since mid 90s, exercise has been proven to be beneficial

•Should be supervised!

•Strengthening

•Stretching

•Balance and Coordination

•Cardiovascular exercise

Cause

•UNKNOWN!!!

•Most likely a combination of genetic and environmental factors

•Immune system attacked…autoimmune?

•Many theories, few definitive facts

•Highly researched disease

Moving on to YOGA……

•In general, exercise may have a neuroprotective effect….Insulin growth factor-1 acts as a protective agent. Studies suggest that exercise could promote this factor in MS

•Brain derived neurotrophic factor (BDNF)-increases in hippocampus with physical activity, may lessen decline in cognitive function in MS

•Higher physical fitness levels enhance cognitive and neural plasticity in patients with MS

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Mind-Body approach to movement

•Definition: to join…mind and body

•Origin: Ancient India…branch of Ayurveda “study of life” Mind/body approach to movement and awareness. Breath, posture, meditation

•Yoga is a mode of exercise therefore guidelines for intensity, frequency and safety clearances are applicable

•It is NOT A RELIGION!!!

•Not highly regulated….certification

Research shows:

Improvements in areas of:

•Strength

•Flexibility

•Body awareness

•Self-efficacy

•Fatigue

•Perception of stress

•Quality of sleep

•Lung capacity

•Mental health

•Relaxation

Yoga integrates:

•Breathing

•Posture

•Cardio fitness

•Strength

•Flexibility

•Relaxation

•Meditation

•Visualization

•MIND AND BODY!!!!

•RECREATION….Game of LIFE!!!

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Styles of Yoga

•Hatha-general term for all physical poses or postures. A physical practice

• Iyengar-alignment, detailed and precise movement. May hold postures, adjust them and use breathing. Use of props. Safe practice

•Ashtanga-very aggressive, very active. Not for beginners, nor persons with MS. Sun salutations.

•Vinyasa-”to place in a special way” Most athletic. Not for persons with MS. Many types of yoga can be considered vinyasa flows…ashtanga, power, prana

•Bikram-hot yoga…NOT for persons with MS!

•Restorative-does NOT mean adaptive! Relaxing, winding down, uses props

•Prenatal

•Anusara

•Etc. (“goat yoga, streaming yoga)

•DO NOT GET CAUGHT UP IN CLASSIFYING THE TYPE OF YOGA!

What YOU need to know!

•Very important to experience yoga yourself!!! …attend classes, beginner training courses, study videos, online info, etc.

•Use props! Very helpful. Blocks, straps/belts, mirrors, music, walls, partners, pillows, Swiss ball, small “mushy” balls, tennis/racquet balls, blankets, foam rollers

•Incorporate YOGA and MS!!

•Use your training as a PT/OT, etc to help with yoga and use yoga to help with your professional training!!! TEACH your patients!

Need to know

•Use a mix of static and dynamic poses

•Keep cool! Use water bottle, fan, light clothing, cooling neck compresses

•Remember strengthening and dynamic poses increase heat

•Wheelchair or chair if needed

•Gentle, slow, especially to start

•Know medical history, co-morbidities

•Keep it PRACTICAL! FUNCTIONAL!

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Avoid:

•Bouncing stretches

•HOT YOGA!!!

•Difficult balance poses if risk of injury

•Poses that cause dizziness

•Movements that will increase spasticity

•Neck flexion-may initiate “L’hermittes phenomenon”-pain, tingling, shock feeling along spine

•Aggravating any pre-existing orthopedic injuries

•Neck extension

Incorporate components of:

•Flexibility/stretching

•Strengthening

•Balance and coordination

•May include a small amount of cardiovascular work

•Emphasize posture and AWARENESS of posture/alignment

•Awareness of breath

•Mindfulness

Challenges presented by MS

•As previously mentioned, symptoms of MS may present challenges to a yoga practice or to incorporating yoga into treatment (BUT may present opportunities for BETTER movement, increased awareness, decreased energy expenditure with movement)

•Spasticity, weakness, tightness and poor posture will cause asymmetry in the body

•Patient may not be able to do some postures independently. May need props, may need to modify or may need assistance

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Poses to assist with flexibility and improve range of motion (ROM)

•This is inherent in yoga-STRETCHING is occurring

•Keep in mind that most poses in yoga will assist: FLEXIBILITY, STRENGTH AND BALANCE!!

•Ideally involve the entire body but concentrate on the patient’s needs

•Try to balance a mix of flexion and extension/twists

•Perform SLOWLY with steady stretching to avoid increasing spasticity

•Can be done actively by patient or passively with assist of another person, or use of band/strap

Spine

Cat/Cow:

•CAT-on all 4s, arch back, shoulder blades towards ceiling, belly button tucked towards spine, long exaggerated exhalation, gaze towards mat

•COW-belly sags, gaze stays straight ahead, long exaggerated inhalation

•Do not sink into shoulders…”push” out of shoulders

•Use visual of pelvic tilt. Spine “undulating”

•Can be modified to sitting, standing, supine

Cat-Cow

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Spine

Child’s Pose:

•From all 4s, big toes together, open knees, slide hips back over heels-ONLY if knees can tolerate the flexion!

•Arms relaxed either along side of body, on floor in front of body, supporting forehead

•Emphasize deep breathing (belly breaths), ribs expanding, sternum relaxed, shoulders relaxed

Child’s Pose

Lumbar/Thoracic Extension

•Amount of extension….as tolerated

•Standing, prone

•Caution against hyperextending the neck

•Helpful to brace hands posteriorly on hips

•Extend from the lumbar spine, NOT from pushing the hips forward

•Difficult to isolate thoracic spine-use a mushy ball (about 6 inches in diameter)-supine, place between shoulder blades, allow for thoracic extension to occur. Complement it with pectoral stretches.

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Prone on elbows

Cobra-more active upper back extension

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Lumbar Flexion

•Seated or standing…depends on balance

•Differentiate between lumbar stretches and hamstring stretches-remember your anatomy

•May assist with spinal stenosis, (may be contraindicated for certain disc problems)

•May allow for some cervical traction when in forward fold

Flexion

Flexion

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Flexion with ankle/inner thigh stretch

Downward Dog

Spinal Twists

•Excellent for spinal mobility

•Aids in digestion

•Increases circulation

•Stimulates liver and kidneys

•Detox

•Opens up chest, increase space between vertebra

•Very little twisting done in daily life

•Encourages focus on breath

•Can be done supine, seated, standing

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Seated Spinal Twist

Lying Spinal Twist

Inner thigh-adductors

•Commonly a tight muscle group in persons with MS

•Can interfere with ambulation/hygiene/ADLs

•Try: seated or reclining butterfly, seated adductor stretch, “happy baby”

•Can use strap to wrap around feet to pull in

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Seated Butterfly

Reclining Butterfly with blocks

Inner thigh stretch using wall

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Happy Baby

Hip Flexors

•SO important with persons with MS due to prolonged periods of sitting; LBP

•May need to be modified-can be done in a chair; side-lying, prone

•Challenges balance

•Caution: knees! Keep knee over ankle. Use extra padding on supporting knee in low lunge

Low Lunge with blocks

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High Lunge with blocks

Hip flexor stretch with foam roller

Hamstrings

•SO important in patients with MS due to prolonged periods of sitting; LBP

•Can be done in a variety of ways: seated, supine, chair, standing

•Can use strap, wall

•Caution with spasticity

•Make sure to differentiate LB versus hamstring stretching (flat lower back versus rounded)

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Chest, Shoulders, Neck and Back

•Again, very important due to much sitting-forward head, forward shoulders, weak upper back, tight pectoral muscles

•Need to augment with back strengthening, particularly upper/mid back (especially women)

•Seated spinal twist helpful for chest opening

•Chin tucks; scalene stretches

•Avoid cervical flexion and extension

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This stretch opens many areas

Shoulders, chest, back

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Back, shoulders, rotator cuff

Threading the Needle-shoulders, back

Shoulders, back with foam roller

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#4 stretch-hips, gluteals, piriformis, deep hip rotators

#4 stretch seated (can be done sitting upright)

Poses to assist with strengthening

•As previously mentioned, there is great overlap in the benefit of poses for stretching, strengthening and balance

•Be aware of balance issues

•Can use blocks, swiss ball, chair, barre, wall

•Lunges are strengthening poses. Make sure weight is mostly in legs versus blocks

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Plank

•Strengthens core, arms, shoulders, legs

•Full or modified(knees down)

•Arms extended or forearm plank

•Can also be done in side plank position

•Be very aware of position of trunk and shoulders to prevent injuries

•Can be difficult-build up strength

Full Plank

Side Plank

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Forearm Plank

Correct forms

Modified

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Modified Side Plank

Bridge Pose

Poses to assist with balance

•Poses that involve standing, kneeling, lunging, bridging, sitting will challenge balance

•Identify if balance deficits are from proprioception, vestibular system, vision problems, weakness, muscle imbalance, lack of appropriate assistive devices or DMEs, etc

•Caution against injuries from losing balance

•Use Swiss Ball, barre, walls, blocks, foam cushion, pillow, blanket, chair, wheelchair, etc to assist with balance during a pose or to challenge balance

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Spinal Balance

Tree Pose

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Mindfulness-what is it?•An attribute of consciousness that can be developed effectively through practice of mindfulness and meditation.

•An awareness of and attention to the present-the here and now

•Involves thoughts, emotions and somatosensory experiences

•Can augment benefits of yoga

•A way of being actively aware of what you’re doing while you’re doing it

•Not the same as meditation, though overlapping

See this in your patients? Yourself?

Mindfulness: where to start?

•If the concept of mindfulness seems too daunting, begin by paying attention to everyday tasks…maybe skip the work “mindfulness”•Ask PwMS to start by be aware of brushing their teeth, foot placement, noticing the DETAILS of normal tasks

•Train one’s attention!!!

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Components of Mindfulness

Encourage:

•Slowing down

•Ceasing to multi-task

•Focus on breathing, not just with yoga or treatment sessions, but throughout their daily routine

•Simplify!! In many ways

Focused mode:•Immersed in the experience (no matter how mundane)

•Experience IT…what ever IT is

•Be fully engaged

•See things as novel and meaningful…a child-like approach

•Encouragement to stop worry about and focusing on self….begin awareness of external environment: sunset, a friend, a pet

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Default mode:•What patients (and we) resort back to naturally

•A wandering mind/auto pilot

•Rumination of the past, current problems, future concerns

•Automatic, undirected thoughts consume ½ of each day!

•GOAL: increased time in “focused” mode

BREATHING: important part of yoga

•Be aware of qualities of breath:

•Length

•Smoothness

•Depth

•Where in body

•What is happening head to toe: sensations, vibrations, warmth, tension, pain, discomfort versus relaxed areas

•Emphasize abdomino-diaphragmatic breathing. Belly rises. Use hand placement to critque

MS/Yoga References:

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References:

Mind-Body Connection: Never underestimate its power!

Mindfulness references:•The underlying anatomical correlates of long-term meditation: larger hippocampal and frontal volumes of gray matter-Luders, 2009

•Neuroprotective effects of yoga practice: age, experience, and frequency-dependent plasticity - Villemure, 2015

•Mindfulness based interventions in MS: Burschka, J. BMC Neuro, 2014: 14: 165

•Bogosian A, et al. Distress improves after mindfulness training for progressive MS: a pilot study MS: 2015: 21:1184-1194

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References•Garner, G, et al (2016). Medical therapeutic yoga: biopsychosocialrehabilitation and wellness care. Edinburgh: Handspring Publishing.

•Remati K, et al. Are Mindfulness and Meditation the Same? From https:// yogainternational.com/article/view/are-mindfulness-and-meditation-the-same.

Resources:• National Multiple Sclerosis Society :

www.nmss.org

• Consortium of MS Centers: www.cmsc.org

• CanDo MS educational Webinars: www.cando-ms.org

• MS World:www.msworld.org

• Yoga websites: NUMEROUS! Many encourage joining theirs, or taking their training courses, but LOADS of free pictures, advice, etc

THANK YOU!