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Living Well with Multiple Sclerosis
Bonus from the Archives: Using exercise to build neuroplasticity with Dr Gretchen Hawley | S8 Bonus
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- [00:00]
Dr. Gretchen Hawley
Several years ago, research was showing that it was best to do all of your exercises at one point during the day. But now research is actually proving that it's just as effective to do your exercises throughout the day. I prefer my clients to do some of their exercises maybe late morning, some in the afternoon, some in the late afternoon before dinner, and you're just separating it up so that you're getting yourself moving throughout the day.
- [00:30]
Podcast Producer / Announcer
Welcome to Living well with Ms. This show comes to you from Overcoming ms, the world's leading multiple sclerosis healthy lifestyle charity, which helps people live a full and healthy life. Through the Overcoming Ms. Program, we interview a range of experts and people with multiple sclerosis. Please remember, all opinions expressed are their own. Receive monthly tips and ideas about living well with Ms. By signing up for our newsletter@overcomingms.org Newsletter and now let's meet our guest. Today's episode is a replay from the Living well with Ms. Archives. We are revisiting some of our favorite episodes that break down the Overcoming Ms. Program and feature doctors, facilitators and community members with top tips and personal stories about living well with Ms. All the advice and information were accurate at the time of recording. You can listen to the entire back catalog@overcomingms.org podcast or wherever you listen to podcasts.
- [01:41]
Jeff Alex
Joining us this week is Dr. Gretchen Hawley. Gretchen Hawley is a Doctor of Physical Therapy and Multiple Sclerosis Certified Specialist. After graduating from Simmons University in Boston, she developed a multiple sclerosis program alongside two of the city's top Ms. Neurologists. Dr. Hawley utilizes the concept of neuroplastic elasticity to improve strength, balance and walking in those with Ms. By using specific functional exercises. She has been a keynote speaker at several National Ms. Society events and other Ms. Focused conferences and presents frequently to Ms. Groups. Dr. Hawley brings a keen understanding of the challenges faced by people living with Ms. And has developed a virtual physical therapy program to help people improve their Ms. Symptoms while in the comfort of their own home and guided by an Ms. Specialist. Welcome to the Living well with Ms. Podcast. Dr. Gretchen Hawley yes, thank you so much for having me and thank you for attending. Firstly, so we're talking about the exercise and physical aspects of Ms. So I wanted to ask, how is Ms. Physical therapy different from regular or orthopedic physical therapy?
- [02:48]
Dr. Gretchen Hawley
So I have a lot of clients who have been to orthopedic physical therapists and felt that they did not improve in the way that they were hoping to, and there's several different things that set Ms. Physical Therapy Apart from orthopedic physical therapy, Ms. Physical therapy focuses on neuroplasticity based exercises as well as functional exercises. One of the most important things to understand when working with multiple sclerosis is that the carryover is not the same. So if you're doing a classic orthopedic exercise like straight leg raises or clamshells, where you're either maybe lying on the ground or lying on your side, you might have full strength in those positions. But then you go to stand up and use those muscles while walking and those muscles are shot. They don't have the same strength in a standing position. So a lot of the exercises are very functional. Meaning if you have difficulty climbing stairs, we're going to break down the activity of stair climbing into maybe five different exercises and focus on strengthening those exercises. Or similarly, if you have a difficult time standing up from the ground, that can be broken down also into maybe five to eight exercises. So it's breaking down those tasks and activities that are hard for you to do and improving each of those steps along the way and then putting the activity back to together with your improved strength. And there's also a lot of different ways to get neuroplasticity to work more for you. So it's implementing those strategies.
- [04:25]
Jeff Alex
So you've mentioned neuroplasticity there. What, what is neuroplasticity?
- [04:29]
Dr. Gretchen Hawley
Yes, neuroplasticity is really exciting because it is the ability of your brain to create new pathways for a movement to occur. So it works all the way from if you have no strength to good strength. So if there is a movement, let's just say lifting your toes up. Because I know a lot of people with Ms. Suffer from drop foot. So if you have drop foot and you have a difficult time lifting your ankles up and you either can't do it at all. Let's start with that. First, let's say you cannot lift your ankle up if you practice over and over and over again. Even though no movement is happening every single time you're practicing, your brain is trying to find a new pathway to go from your brain to that muscle. So if you only practice twice, then give up. Your brain only tried to find two pathways and neither worked. But if you try 10 times, 10 times a day, your brain just tried a hundred times to find a pathway that works. And if you do have strength, let's say you have a little bit of strength, but it's not your best with lifting your toes up, that means that you do have a pathway that's working, there's some halfway from your brain down to that muscle that is working, it's just not strong enough. So in that case, neuroplasticity has the ability to strengthen that current pathway that is there. But the only way to get neuroplasticity to work is to have high repetition and perfect quality. If you are training a movement incorrectly and it looks a little wonky, well, that's the movement you're going to get over time. So you want to make sure it's perfect quality. Quality, which often requires lots and lots of rest breaks.
- [06:13]
Jeff Alex
And so if someone's just doing regular exercise, whether they've seen things online or they've just going through exercise they did before in the gym, what's. What's the downsides? Potentially, with someone with ms, the biggest
- [06:26]
Dr. Gretchen Hawley
downside would be if there is a movement that's happening that's not supposed to be there. One of the best examples that I see is if someone's practicing walking, which is a great thing to do, it's very functional. But if when you're walking, your knee slightly goes out to the side and therefore your foot slightly comes in, over time, that's going to keep happening, and that could cause a trip to happen. Or if you are biking, a lot of people like to bike when they're at the gym or just for regular exercise. If you're biking and both of your knees are collapsing in, which is very common, you might not know you're doing it, but if you. Next time you do it, if you're looking down, check out your knees. And if your knees are collapsing in, you're training your brain that when my legs move like this, my knees are supposed to collapse in. So then sometimes when you go to stand up and walk, walking is somewhat of a similar MO motion to biking, just less exaggerated. Your knees might collapse in. And again, that can cause a trip or weakness. And it's those tiny little movements that you have to be looking for to make sure you're doing it well and therefore will have good quality once you're able to improve the strength.
- [07:39]
Jeff Alex
So what you're saying about doing something perfectly, you want to really make sure everything you do is exactly right. Rather than just going for the biggest weights, you want to go for the perfect motion.
- [07:51]
Dr. Gretchen Hawley
Yes, perfect motion and high repetition. And I also want to point out it's very typical that one side of your body or one leg is weaker than the other side. So for your strong side, you might be able to do 10 repetitions. 10 times, 10 sets on your strong leg, but on your weaker side. Maybe your first set of the exercise is 10 and then your second set is 6 and then the third set is 3 and that is perfectly fine. Again, it needs to be perfect quality. So taking those rest breaks and noticing when your quality starts to get poor, stop, take a break and then continue. So you're still getting repetitions in, but it's not going to look the same as on your strong side.
- [08:39]
Jeff Alex
So that's absolutely a case with me. My, my right side is pretty much as good as it always was. My left side is, is, is the one that's affected by Ms. Would you suggest that I do work my same, my, my right leg to maximum, which is a good one, and then my left leg to what it can achieve or do I want to keep it the same. So my concern is that my, my right leg will get much stronger because it's doing more exercise, because it can do more exercise. And then it kind of might exaggerate the difference between the two.
- [09:11]
Dr. Gretchen Hawley
Right, Great question. I would say with your right leg, since that's your stronger leg, I would exercise it as much as you can. You don't have to push yourself to feeling like this is the most I can do on that side. But you still do wanna strengthen the strong side because that is your strong side. It needs to stay strong. A lot of people will do very little or nothing on their strong side because they don't want that imbalance. However, with ms, we can actually use that to our advantage every now and then where you use your strong side to help you get by throughout your day to day activities and your, your weaker leg. Again you want to do as many repetitions as you can, like go all out, but they have to be perfect. So one day your total count of repetitions for one specific exercise on the weak leg might be 15, while the right leg was 50, and then another day it might be 30 and 50. But I would say for your strong leg, maybe get to about 40 to 50 perfect repetitions and that's typically good enough.
- [10:17]
Jeff Alex
Okay. And so one of the other things again I personally have is fatigue. I, I've, like prior to ms, I exercised a lot, I ran, I ran a marathon, surfed rock climbed, snowboarded, all sorts of things. And I, I used to push myself a lot. I, I could get quite good at things because I would really prepared to push myself really hard. Now I definitely find that um, the limitation is fatigue which kicks in so, so much earlier than it ever would before and is, and is so Much more extreme, really. I, I mean, fatigue before, I would be completely worn out. Now I won't be able to stand up straight. I'll, it'll, it will affect my balance and all sorts of things. So how do you manage that side of fatigue?
- [11:07]
Dr. Gretchen Hawley
Great question. Again, if it's specifically with exercise, one thing that might be causing the fatigue is that your core temperature is rising. So everyone, whether you have Ms. Or not, when we exercise, our core temperature rises because our muscles are moving, our blood is pumping, everything's up and moving. And when you have ms, if your core temperature rises more than half of a degree, then you could have heat intolerant. And heat intolerance can cause any of your symptoms to worsen. So if you have fatigue as one of your symptoms, then when you're exercising and you're not being cognizant of keeping your core temperature down, then that could be one reason that fatigue is kicking in to the intensity that it is. So one tip for that would be to make sure even before you exercise, you're sipping ice cold water, just really, really cold, because you want to keep your core temperature down. Or if you have any cooling products, maybe a neck wrap, a hat, a vest, something like that again before you start exercising. So that once you start exercising, hopefully your core temperature will stay neutral. So that's one thing. But a lot of people might even have fatigue before they exercise, so they don't exercise for that reason. But research has proven time and time again that doing the right type of exercise can actually improve your fatigue. And you're never pushing into or beyond your fatigue, that when you have Ms. Is not going to do you any good. Like you said before ms, you used to be able to push yourself really hard, but when you have ms, that's just going to result in poor quality of movement and your brain's going to start remembering that. So again, we don't want to push into fatigue or bad quality, but being aware of when that fatigue is about to set in and stop and rest
- [13:05]
Jeff Alex
and exercise can actually help with fatigue.
- [13:07]
Dr. Gretchen Hawley
Yes, and there's two different types of fatigue. Primary fatigue is when there is no reason for it. You did not have a late night, you had a great night's sleep, you did not exercise, there's no reason you should be tired, yet you are exhausted. And then secondary fatigue, it means that there is a reason for it. You did exercise and maybe you overdid it, or you had a late night out, or you didn't get a good night's sleep or whatever the Reason There is a reason for your fatigue. And research proves that exercise in the right way, in the right dosing, can improve both types of fatigue.
- [13:47]
Podcast Producer / Announcer
Living well with Ms. Is listener supported. To help us create more episodes, please visit donate.overcomingms.org to make a donation.
- [13:56]
Jeff Alex
Aaron Boster posted recently. He's been on the podcast.
- [14:02]
Dr. Gretchen Hawley
Yeah, he's great.
- [14:04]
Jeff Alex
And it was that doing regular active, just just small amounts of regular activity really helps. And I, I personally find that if I sit down all day, then when I get up then my balance is much worse. My. Yeah, well, everything's worse basically. But if I do a regular, I mean I have a Fitbit. I mean I'm sure other fitness trackers will do this, but it will tell me every hour. It will prompt me to have done 200 steps an hour. And I actually find that's more important than the 10,000 steps a day everyone talks about. If I do the 200 an hour, then I'm quite mobile. But actually in that lack of activity can actually make things worse. So it's yeah, there is a trade off between doing too much will make things worse, but equally doing nothing.
- [14:51]
Dr. Gretchen Hawley
Yeah, there's two things I want to mention about that. The first thing is several years ago research was showing that it was best to do all of your exercises at one point during the day. So lunchtime you're going to sit down and do your exercises for an hour or 30 minutes, whatever it is. But now research is actually proving that it's just as effective to do your exercises throughout the day. And I actually prefer that for reasons that you just stated. I prefer my clients to do some of their exercises and maybe late morning, some in the afternoon, some the late afternoon before dinner and you're just separating it up so that you're getting yourself moving throughout the day. And the second point I wanted to make is exercise means something different for everyone. I might be saying exercise right now and someone is picturing sprinting on a treadmill and another person might be picturing walking, another person might be picturing squats and lunges and weights. And I think it's important to note that exercise can simply be sitting up tall in your chair and marching your legs or kicking your legs or just squats of standing up and then sitting down. There are so many forms of simple, which is not the same as easy, but simple movements that you can do throughout the day that can really help improve your fatigue and just improve your overall wellness and strength. When you have ms, it doesn't need
- [16:16]
Jeff Alex
to be intense and so Bearing in mind you were saying about everything needs to be absolutely as perfect as it can be, or the movements, how would you handle setting goals and targets?
- [16:29]
Dr. Gretchen Hawley
So that's a great question. First time you do. So let's pick just standing up and sitting down as an exercise. I would say set a new goal and target for each exercise and maybe even for each leg. So for squats and standing up, sitting down, you use both of your legs at the same time. However, maybe your weaker leg caves in. That's typically what happens when the leg is weak. So maybe a goal would be to do it 10 times perfectly without the leg caving in for five sets. But see where you're at. If at first you can only do it five times two sets, then maybe aim for five times three sets. And I would say to a set very small goals at first because you'll feel like you're winning. And our brains do positive things. They send out endorphins when we feel like we're winning. So make the goals small at first and set a different goal for each leg if it's something like marching or leg kicks or any type of single leg or arm exercise, because it won't be the same. Your strong side is going to be stronger. So it would be unfair to set the same goal for your weaker side.
- [17:43]
Jeff Alex
And you were saying as well. I just want to sort of reiterate that even if you can't do something, it's worth trying it repeatedly, because then the neuroplasticity might kick in and eventually you'll be able to.
- [17:53]
Dr. Gretchen Hawley
Absolutely. And that's really hard for people to do over time because you lose motivation. You can't. One difficult thing about neuroplasticity is as amazing as it is, you can't see it, you can't hear it, you can't feel it. You really don't know it's happening. You really have to trust the process that your brain, according to research, is actually trying to find these pathways. Even if you have no movement, you still should be doing the basic exercises for your muscles that are weak over and over and over again, which can be discouraging when there's no movement. But absolutely you still should be doing them.
- [18:35]
Jeff Alex
Okay. And so you have your own program. Missing link. S I N G Missing link. So can you tell us a bit about your program and what that involves?
- [18:46]
Dr. Gretchen Hawley
Yes. So there, as you know, Ms. Is called the snowflake disease. There is no one person that is the same. There are so many different symptoms. However, I have found through my experience working with people who have Ms. That there are specific muscle groups that tend to get weakest first. And I also had noticed I've been working with people who have ms, treating them for about six years and at the physical therapy clinics I was working for, I was a physical therapist who typically had the highest no show and cancellation rate. And it's because my clients with Ms. Couldn't come to physical therapy regularly and it may have been because of weather or they were having just a bad day or a lot of fatigue or they weren't able to get transportation to come to physical therapy because they weren't driving themselves. So there's so many reasons that they couldn't come. And I decided that I wanted to create some type of platform that anyone with Ms. Could do in their own home and therefore do it more regularly and start seeing improvements quickly, quicker. So that's why I created the Missing Link. It's an online Ms. Wellness program and it includes all of the exercises that would be giving my clients in person. It's just online. I have categories for strengthening, stretching, balance and walking and I show modified levels as well as advanced levels. A lot of them are seated, which I love because you can do it throughout the day, whether you're still working or if you're watching TV or eating a meal. You can always do some type of exercise while you're sitting. And then I also bring in guest speakers like Dr. Aaron Boster and other Ms. Neurologists, occupational therapists and really experts that are in other fields where I am not an expert. That way my members can still learn from the different members in the Ms. Community on how they can best conquer their life with Ms. And then lastly there's also research updates, symptom management videos for things that aren't necessarily physical like heat intolerance, a cognitive exercise, energy conservation and fatigue management as well as task specific exercises. So I actually review how to climb stairs, how to get into a car or out of a car, how to stand up from the ground, how to get into bed. So more of those activities that we have to do with on a day to day basis.
- [21:17]
Jeff Alex
I've had a look at your program and you do offer an awful lot for the subscription, but it is quite expensive for a lot of people. Particularly some people with Ms. Aren't working because they can't work anymore, particularly if they've got a physical job. So what about if someone can't afford a subscription to to Missing Link or similar resources?
- [21:39]
Dr. Gretchen Hawley
Yes, I'm glad you asked that. So I am very active on YouTube, I post a new video every week. As well as social media, I have a Facebook page and an Instagram page and I am constantly posting videos or tips and strategies or motivation. So any of those outlets are completely free and still gives you access to my knowledge and my expertise.
- [22:03]
Jeff Alex
Okay, that's excellent. So to wrap up then, I'd like to ask, is there some key takeaways that people should aim for? Things that they should do, things that they should look out for when we're talking about exercise for people with ms?
- [22:17]
Dr. Gretchen Hawley
So the first thing I would say is, if you haven't already, either make a mental note or a handwritten list of things that you feel are challenging for you throughout your day. Even if you can do it. If there's something that's hard for you to do and you want to be easier or better, jot that down. And then if you are seeing a physiotherapist near you or a personal trainer, anyone, see if the exercises you're currently doing line up with what that activity is. If not, you need to make changes to include more exercises that will help you with those specific goals, because general exercise does not always help improve your walking or your balance or stair climbing or anything that you might want to do throughout the day. So that's the first thing. And the second thing is, as we've already stated, do something is shocking how much our bodies can actually either maintain or improve simply just from standing. Standing requires balance. It requires all of your muscles to work evenly. If the muscles on the front of your body, like your quads or your core, are working more than the muscles on the back of your body, you're going to fall forward or vice versa. If the muscles on the back of your body, like your hamstrings or your glutes, are working more than the fundamental you'll tip backwards. So if you're standing and you're not falling, you're just staying upright, you are actually working a lot of muscles. So just doing something throughout the day often is so helpful compared to doing nothing at all. So don't underestimate the power of just simple movements.
- [23:57]
Jeff Alex
Thank you very much for that. And thank you very much for joining us, Dr. Hawley. Those of you listening, if you've enjoyed the podcast, please leave us a rating or review and I hope to join you next time.
- [24:11]
Podcast Producer / Announcer
Thank you for listening to this episode of Living well with Ms. Please check out this episode's show notes@overcomingms.org podcast. You'll find useful links and bonus information there. Don't forget to subscribe to the podcast so you never miss an episode and please rate and review the show to help others find us. This show is made possible by the Overcoming Ms. Community. Our theme music is by Claire and Mab Dean. Our host is Jeff Alex. Our videos are edited by Lorna Greenwood and I'm the producer, Regina Beach. Have questions or ideas to share, email us@podcastovercomingms.org we'd love to hear from you. The Living Room with Ms. Podcast is for private, non commercial use and experience exists to educate and inspire our community of listeners. We do not offer medical advice. For medical advice, please contact your doctor or other licensed healthcare professional.