Dr. Gretchen Holley (0:00)

Hello. Hello. Welcome back. I have been so excited to talk about this topic today because it is a specific question that I, as a physical therapist that specializes in ms, I am asked this question quite frequently, but it's usually also with questions about walking strength or walking endurance and just walking as a whole. But today, today I'm going to be answering one specific question, which is why am I getting stronger indoors? And why can I walk better indoors but not outdoors when I have multiple sclerosis? This is something that is so, so common. So if you are also experiencing this, please know that you are not alone. And there's actually lots of reasons why this might be happening. So you might be feeling like it doesn't make sense. Maybe you have been focusing on strengthening exercises and balance exercises and maybe you are getting stronger indoors or your walking is improving indoors and it's just not clicking of why. If I'm stronger indoors, I should be stronger outdoors. If my walking is better indoors, it should be outdoors. And unfortunately, especially, especially with a condition like multiple sclerosis that affects us in lots of different ways, more times than not, that carryover doesn't happen. So it is very likely that you could be getting stronger, improving walking or balance, whatever it is, indoors or in the place that you are exercising in. Maybe it's in your home, maybe it's at a gym, maybe it's at a class location, if you take classes wherever. But then you get outdoors and it just, it doesn't exist. So we're going to talk about why that's happening and then at the end, I'm going to share what you can actually do about it so that you do start noticing those same improvements that you're seeing from exercising indoors while you are outdoors.

Podcast Host / Narrator (2:11)

The big question is, how does someone with Ms. Actually improve their mobility, strength, energy independence, the list goes on. My name is Dr. Gretchen Holley, physical therapist and multiple sclerosis specialist. Welcome to the Missing Link podcast. Tune in as I share the top strategies and exercises to help you gain control over your life with Ms. Using research driven insights and advice from top industry experts. Whether you're newly diagnosed or have had Ms. For over 30 years, whether you have relapsing Ms. Or progressive MS, this podcast is for you. You're sure to feel empowered and inspired after each episode.

Dr. Gretchen Holley (3:01)

Ready?

Podcast Host / Narrator (3:02)

Let's dive in.

Dr. Gretchen Holley (3:11)

There are three main components, in my opinion, that are contributing to this challenge that you are experiencing. First and foremost is the temperature and weather. Now this might feel like a hard pass for you. Like immediately you might be thinking, nope, that's not me. What's the second one? But I just want to share that temperature and weather can play a big role in your movement, even if it has never played a role in your life before. So when it comes to temperature, it's our internal temperature that we're talking about. So it doesn't mean that it needs to be hot outside for heat intolerance or cold outside. If you have cold intolerance, it's what your internal temperature is doing. So even if the temperature and the weather outside feels fine to you, it can actually affect your body. Because as you are moving indoors or outdoors, it more likely than not is going to increase your core temperature. But adding on to that, when we are outdoors, the barometric pressure can affect us even more than when we are indoors. And oftentimes that can translate to more weakness or muscle tightness or stiffness, wobbliness. There's so many symptoms of Ms. That can worsen due to barometric pressure changes or our internal temperature. And to take it one step further, the seasonal changes, even if you are someone who normally does fine in the warm weather, sometimes when the temperature is changing from cold to warm. So here in the US especially on the east coast, if we're going from winter to spring and we randomly have a really hot day in spring and it was really cold yesterday, even if you normally do fine when it's hot, that change can really affect your mobility and other symptoms as well. Similarly, if we're going from summer to fall where it's normally hot, and then we have a really cold day out of nowhere, if you're normally fine in the cold, that change can really affect you. So just considering what's the temperature like, what is the barometric pressure, what is my internal temperature, how might that be affecting my mobility indoors and outdoors? Because if you're going outdoors and you know, okay, the season's changing right now and it's going to be colder today, even though I'm normally fine in the cold, maybe I'm going to wear an extra sweater or put a jacket on if I wouldn't. Normally you can prepare for that. Or if it's going to be a little bit warmer than usual, even if you're someone who doesn't normally have heat intolerance, maybe you sip some ice cold water or as cold as you can tolerate before going outside, or wear a neck fan or put on cooling wristbands so you're giving your body a proactive tool so that ideally you don't notice any symptom changes from the temperature, the weather, the barometric pressure. The second component that contributes to making your strength and your walking improvements not carry over to the outdoor environment is the strength and mobility needed to. In the outdoor environment, it is often very different than what is needed indoors. Indoors is typically pretty predictable. Most of us, when we are indoors, whether it's our home, an Ms. Clinic, the gym, the grocery store, it's level ground. You know, we don't have to worry that we might be tripping over a thing. You might trip over your feet or your shoe might stick to the ground, but that's something different indoors. It's a pretty predictable environment, and we know what to expect. And when you exercise indoors, not only can that be easier due to the predictability, but when you're exercising indoors, your strength and mobility is learned in an indoor environment. And your brain does not automatically transfer those improvements and those strength gains to other environments, like outside. Sometimes, and I've seen this quite often, if you're always exercising in one specific room or even just in your house or in the gym, you might even notice that your strength and mobility improvements don't carry over to other indoor environments. So you might, if you go to a physical therapy clinic, your PT might be saying, great job, Linda. You're getting so much stronger. You're passing these tests with flying colors. You're ready to be discharged. But you go home and you feel like, what the heck is she talking about? Because I'm not walking fine here. My strength isn't fine here. So even though the indoor environment can be more predictable, each indoor environment is different. And I do have a strategy for that. But just wanted to share that perspective with you. And when we are thinking of outdoor environments, we often are running into uneven surfaces or inclines or declines. Like if there's a ramp that you have to go up or down, or if you're walking on different textures like grass or cobblestone or brick or even sidewalk that might have a crack in it. These uneven surfaces that are unpredictable require more strength. It requires more balance. It requires more weight shifting. So typically, walking outdoors does require more effort, more strength, more balance. And the last component I want to talk about here with strength and mobility being different for indoor versus outdoor is the sensation that we have or don't have in our feet. Our feet are so important for lots of reasons, but one reason is sensation. If we are able to feel our feet, feel our shoes, feel the ground, then those messages of feeling those sensations transfer up to our brain. And our brain says, oh, okay, we are on Grass right now, let me pick up my feet a little bit more or we're on uneven surface. Let me make sure my balance is kicking into high gear. It gives our brain those messages of what we are feeling. So if you are walking outdoors with shoes on, and when you're exercising indoors, your shoes are off, you're more likely to feel sensation with your shoes off. So just the fact of putting sneakers on or shoes on is going to limit the amount of sensation you can feel in your feet from the environment that you're in, AKA the grass, the cobblestone, the sidewalk that you're on. And even if you do normally wear shoes when you are exercising indoors, if you're also wearing shoes outdoors, we now need to ask the question of, okay, but can you feel the sensation of unevenness when the ground that you are on is uneven or changing to a slope up or a slope down? So to recap this section, when we're talking about the strength needed to walk and the balance and flexibility and mobility needed to walk indoors versus outdoors, when we're outdoors, it does require that you're able to adapt to the environment, that maybe you lift your leg higher, which requires more strength, or that you are able to weight shift or balance better because of the environment that you're in, or feel the ground more so that your brain gets that message. So it does actually require more physical effort than when we are indoors. The third component, and to be honest, this is my favorite component to talk about because it's not discussed enough. And if we were to stop here, and we only reviewed the first two, the first component or contributor was the environmental factors, the temperature and the weather. And then the second was the strength and mobility that's needed outdoors. If we were to stop there and you were to implement things to help, such as cooling devices or something to keep you warmer and doing more effort with your exercises. Because you now know that, okay, I might need to lift my leg more outdoors, so let me practice really lifting my leg and trying to get more out of it. If you were to stop there, you likely would still not be able to walk better outdoors as you do indoors. This third component, in my opinion, is the most important. And the third component and contributor is our mind, our brains. Our brains, especially if you have ms, does not have the same carryover, which is why we run into this problem of exercising, moving, just daily activities indoors doesn't carry over to outdoors. And one of the number one reasons is because your brain doesn't feel safe or comfortable outdoors, because you don't practice that thing outdoors, your brain, all of our brains, needs to feel safe and confident outdoors. And if we don't feel safe and confident outdoors, then more likely than not our minds are going to freak out a little bit. And if our minds freak out, it can produce more fear of falling, it can produce more anxiety, more nerves. And when our body feels anxiety and nerves and overwhelm and fear, it physically doesn't move as well. So the thing here for our mind is that we need to practice our exercises and our walking outdoors in order for our mind to understand that we can do this. We've been here before. I've done this before. This is not the first time. And the more regularly you practice exercises outdoors or walking outdoors, the more your mind will feel confident. It's just practice like anything else. A great example of this is I just started gymnastics classes for my daughter, and my daughter is not even two years old yet, but we started last week. It was the first week and we went. Now this is an environment where she or I have never been in before. We've never been around these people. She's never taken a gymnastics class before. And mind you, gymnastics at this age is like running and jumping and swinging and bouncing. It's not, you know, what we typically think of for gymnastics anyways. She hasn't been in this environment and she did not feel comfortable. Her mind did not want to participate. And for 95% of the class, I had to hold her. She didn't even feel comfortable standing on her own. Can she stand on her own? Absolutely. Can she run? Yes. Can she do all the things that they were doing there? Yes. But she didn't feel safe or confident to do that. Now, this week, today actually was our second class. And even after just one week of seeing and observing, she felt safer and more confident to move. And she only wanted me to hold her for, I would even say less than half the class, maybe even 25%. And she started participating. She was running in some of the activities, she was bouncing in some of the activities. And it's because she felt safer and more confident. That's how our brains work, regardless of our age. So our brain needs to feel comfortable standing outside, moving outside. So we need to practice our exercises outside. I'll get to specifics on that in a second. But another component of our brain being a contributing factor is that there's other things around when we are outside. There might be people around. And for a lot of my missing link members and patients and clients that I worked with, people being around Changes things. You might notice that your walking is different simply because there's people around and you might be feeling like they are watching you and their eyes are on you, and maybe they actually are, and that freaks your brain out. Similarly, the visual processing that's required outdoors is typically more than indoors. So when you're exercising indoors, maybe it's in a gym, maybe it's in your home, you typically know what's around you. But when you're outdoors, there's moving cars, there's changing lights. Even if it's just a sunny day and there's trees and the sun's going in and out of the trees, that's changing light. The depth perception for curves or cracks or ramps is going to be different. So visual processing outdoors is often much more challenging than visual processing indoors. So that plays a contributing role as well. Okay, so now we get to the fun part, which is great. We have this knowledge now. What can we do with it? So let's recap the three contributing factors and then we're going to talk about what to do with it. Number one is the temperature and weather. So what is the solution there? Cooling strategies or warming strategies, depending on what the temperature or weather or barometric pressure is, giving your body time to adjust, taking proactive measures, like sipping cold water before you even get outside in the warm weather, or sipping hot water before you get outside in the warm weather. Also maybe picking cooler or warmer parts of the day, depending on where and when your body moves best. The second contributing factor is the strength and mobility that's needed for outdoors, which is more strength, more balance, more mobility. And then the third component is our mind. And the second and third components go so closely together because what it requires, what the solution is, is to practice your exercises, your individual exercises, as well as practice movement and walking outdoors. So let's break that down a little bit more, just so you're super clear on what I mean and how you can possibly implement this. So you can practice your individual exercises, if you follow me on pretty much any social media platform or especially if you are inside the Missing Link membership, you know that some exercises that I am a huge advocate for, that I suggest everyone with Ms. Do to improve strength. Walking and just ease in. Our daily movements are marching. So lifting your leg up and down, up and down, practicing knee bending. So bend your knee, straighten your knee, bend your knee, straighten your knee, maybe even some heel raises. So you lift your heels up, then lower them down. So if you normally do those exercises indoors, you now want to practice them outdoors. And because we now know of all the changes and all the things and factors that make movement and exercise outdoors more challenging, use assistance. Use a rollator, use a cane, use a trekking pole. If you have stairs going to the outdoors, hold on to the railing. Even if you don't normally need that level of assistance indoors, use it outdoors so that you can do this successfully. So you're literally going to practice the same exercises that you do inside, indoors, outside, maybe with more assistance so that you have the correct balance and support and guidance to actually do it. But that is going to do such goodness for your brain because now not only are you physically going to be practicing and therefore getting stronger, but with lifting your legs outdoors, but your brain understands, oh, okay, this movement that I do inside, I can also do it outside and I'm safe and I'm not falling over and I'm building confidence. And if that's too challenging to go right from, okay, practicing these exercises indoors to now practicing outdoors, think about what is outdoor, ish. So not literally outdoors, but it makes you feel like you're getting closer to being outdoors. If you have a garage, this is a great example because you're still indoors, it's still more predictable. But if your garage door is open, your mind, your eyes can see the outdoors. So you might feel like you're outdoors while you're still in a safe, confined environment. So that can be a great middle ground as you're working your way up to building more confidence doing exercises outdoors. Now, in addition to those individual exercises, it's also going to be important that you are practicing movement and walking outdoors as well. So some exercises that we have in the missing link that are specific to walking are ones called the single step or exaggerated walk or the bridesmaid walk. These are great exercises to practice indoors, but I also recommend practicing them outdoors again with a mobility aid. Even if you don't normally use a mobility aid indoors, use one outdoors, at least until you feel safe and comfortable and confident doing those exercises without a mobility aid, if you don't normally use one. And again, this is doing two things. It's strengthening your muscles in a different way because you are practicing lifting your leg on uneven surfaces, maybe with the wind blowing and seeing cars going by. So it's targeting lots of different things physically for you and requires that you put more effort in so that you don't trip and fall. But it's also showing your brain that you can do this, that you've done this before. So tomorrow, when you need to go out of your house to go get groceries or to go to the doctor's appointment. Your brain won't be as likely to freak out because you were just out outside today, moving around and exercising. Now, you don't need to have great quality with all of these things, but it's just the fact of trying, of getting out there, of doing what you can. And again, it's both components. It's that strength component, but it's also that mindset and getting your brain to be confident and reduce that anxiety and fear of falling and overwhelm that can often happen when we're outdoors. It's really about training our nervous system for outdoor environments. And as always, remember that small, consistent practice is what will bridge that gap. It's not like you need to practice exercising outdoors every single day. And also, what time of year is it right now for you? If that's not feasible right now, now might not be the time to practice this, but save this for later. And when it's a nicer day outside or season, bring this back up, relisten, and then practice these things outdoors a few times a week or honestly, even once a week. Something is better than Nothing.