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MS information for health and social care professionals Mobility

Mobility can be defined as the ability to move freely. In MS, altered movement is one of the more common symptoms and may be due to weakness or tightness in a particular muscle group or limb.

Although this section considers a physiotherapeutic approach to these problems, it must be remembered that mobility can be adversely affected by altered sensation, fatigue, visual disturbance, ataxia, pain or depression. These symptoms and effects are dealt with elsewhere in this book, as is spasticity, which can be a major contributory factor to mobility problems.

Other factors with a major impact on mobility and which may need to be considered include:

  • Wheelchairs and seating
  • Walking aids: sticks, rolators, crutches, tripods
  • Splinting and orthotics
  • Appropriate home adaptations: hoists, stair lifts, bath aids

This section describes the physiotherapeutic approach, considers group exercise, the importance of good positioning and individual exercises to encourage this, and describes the use of FES (Functional Electrical Stimulation).

A physiotherapeutic approach

Physiotherapy aims to prevent unnecessary complications such as contractures, poor gait patterns, pressure sores, and muscle imbalance. With the right help, the physical abilities of each person can be maximized. The goal of an exercise programme at any stage of MS is to improve quality of life by allowing the individual to do as much as they can with what they have.

Physical problems can be divided into

  • primary problems which arise as a direct result of neurological damage
  • secondary problems which arise as complications of altered movement and which are preventable

It is important to distinguish between maintenance and restoration. The former enables the individual to continue with their present lifestyle, whilst the latter enables them to return to the best level possible following a relapse or period of inactivity.

The regime needs to be realistic and relevant in order to lead to change. One of the challenges in MS is patient compliance to a routine. It is difficult for fit people to persevere with exercises without becoming bored and disheartened; if you add the problems of pain, fatigue and disability then motivation can be a challenge. This is why group sessions in a proactive atmosphere can be useful at all stages.

Group physiotherapy

Groups need to meet in a venue which is local, easily accessible, with ramps, good transport and parking, and with disabled toilets.

Groups have many advantages including:

  • The opportunity to educate and teach preventative strategies to more than one person. Groups are more economical than one to one so can often continue to provide support by running for longer periods. Ongoing individual physiotherapy for people with MS is not a reality in most areas
  • Improved attendance
  • A positive way of monitoring progress, and picking up any problems before complications arise
  • Social interaction leading to friendships, mutual support and sharing ideas

Each person should be assessed individually before entering a class, and be given a home exercise regime. Each week at the class a goal should be set for every attendee to work on before the following class.

The goals of a group exercises routine include:

  • Maintaining good posture - looking at positioning in chairs, cars or at work
  • Maintaining correct balance mechanisms
  • Maintaining standing to encourage weightbearing
  • Avoiding muscle imbalance - maintaining muscle strength and length, so a good daily stretching regime needs to be established
  • Discussion on pacing to reduce fatigue
  • Reducing complications
  • A healthy self image

Education plays a vital role at all stages of MS. The person with MS needs to be involved in the treatment plan as an active participant, as well as learning about the condition and how to minimise complications. He/she needs to take responsibility for daily regimes and be aware that exercise needs to be for more than 20 minutes once a week. Management is a 24 hours a day, seven days a week challenge. In order to achieve maximum benefit, long term care and support are needed, involvement of family, carers and friends, and forward planning of activities to ensure pacing and maximum enjoyment of life.

Group activities can be beneficial for those who are newly diagnosed and / or have minimal disability. If groups are kept small then the moderate handicap group can also benefit but they may need some individual input from carers / physiotherapists. If appropriate, partners or carers may be involved and shown how to help with basic stretching routines, positioning and handling. Those with severe disability need ongoing support, long term care facilities and realistic input from physiotherapy. Carers should be educated about correct handling, stretching routines and positioning to prevent complications. A multidisciplinary approach is vital with adequate support for both the person with MS and the carer.

Exercise can be made more attractive by variety:

  • Hydrotherapy - individually and in groups
  • Equipment - treadmills, Swiss balls, poles, weights, cycles
  • Games - from simple throwing and catching to competitive work
  • T'ai Chi, Yoga, Chi Qung and other classes could be encouraged
  • Attendance at a local gym if appropriate

Posture and positioning

It is all too common for people with MS to adopt a compensatory posture, which, in the longer term, can exacerbate mobility problems. Posture should be assessed

in a chair:

does the person slump?
are they one-sided?
have they got diminished breath control/quiet voice?

and in bed:

do they lie in the 'windswept position'?
do they hold their head to one side?
do they go into spasm?

When people adopt such changes in positioning, the changes become habitual, leading to further problems of poor circulation, increased risk of infections, pressure sores, shortening of tendons and so on.

Many people are unaware of postures that they adopt because of the brain's ability to adapt when its equilibrium is compromised. For example, if one leg does not 'work' or 'feel right', the body will adopt a one-sided stance to take the responsibility for standing up away from the problem side. If that stance is not corrected, then the change in posture becomes permanent.

Individual exercises to improve posture

All of these exercises can be done in a chair; some can also be done in bed

Breathing exercises

These can take the form of whistling, singing or even blow-football. All these activities will encourage diaphragmatic control, increased air entry and some facial exercise, and in practice people will usually sit up straighter and improve their posture automatically.

Exercises using a stick (or umbrella or rolling pin)

Holding the stick with two hands and raising it above the head will elongate the trunk and help to improve balance. Holding the stick vertically and walking hand over hand will help shoulder control, grip and release of the hands.

Stretching exercises

Sitting at a table, using a duster or towel with both hands, stretch forward across the table. This again will elongate the trunk, work the arms and improve postural control but with the advantage that because of the table there is no fear of falling.

Using a regular trigger of daily activity, such as exercising whilst waiting for the kettle to boil or checking posture when looking in the mirror to comb hair can encourage compliance with an exercise regime. General advice on maintaining posture and introducing exercise is available in the Exercises for people with MS, the DVD Move it for MS and int he book Are you sitting comfortably..?.

Functional Electrical Stimulation (FES) is a simple neuromusculator stimulator which elicits a muscle contraction. For people with MS, it is most commonly used to produce dorsiflexion at the ankle to prevent/control footdrop. Stimulators can work on several muscle groups or bilaterally.

Bibliography

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  • Betts L. Exercises for people with MS. Letchworth:MS Trust;2004.
  • DeSouza L, Bates D, Moran G. Multiple sclerosis. In: Stokes M. Neurological physiotherapy. London: Mosby International Ltd; 1998. p133-148.
  • Edwards S. Neurological rehabilitation. Edinburgh: Churchill Livingstone; 2001.
  • Lord SE, Wade DT, Halligan PW. A comparison of two physiotherapy treatment approaches to improve walking in multiple sclerosis: a pilot randomized controlled study. Clin Rehabil 1998;12(6):477-486.
  • MS Trust. Move it for MS. [DVD] Letchworth Garden City:MS Trust;2007.
  • Pope P. Nigh-time postural support for people with multiple sclerosis. Way Ahead 2007;11(4):6-8.
  • Solari A, Filippini G, Gasco P et al. Physical rehabilitation has a positive effect on disability in multiple sclerosis patients. Neurology 1999;52:57-62.
  • Wiles CM, Newcombe RG, Fuller KJ, et al. Controlled randomised crossover trial of the effects of physiotherapy on mobility in chronic multiple sclerosis. J Neurol Neurosurg Psychiatry 2001;70(2):174-179