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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.
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Ready? Let's dive in foreign. So let's dive into the specifics here. So there's lots of ways to activate neuroplasticity. We are going to be focusing today more on the exercise and physical therapy component. So I'll just mention that quickly right there. But other ways include thought process and mindset. Sleep, getting great sleep. It is going to help our brain recover and work better. Nutrition, generally a healthy diet. There is some research right now in the Ms. World that is pointing to the Mediterranean diet or the mind diet as possibly being the best for people with multiple sclerosis. Again, learning a new skill, participating in a hobby, reducing stress, not smoking. These are all things that can help with neuroplasticity. And I actually just interviewed someone on my podcast, Dr. Kelly Rich, and she is a researcher for brain health and specifically brain aging. And it was a really insightful conversation because she basically was sharing that anything that we can do for brain health, all the typical things that we know are helpful for our brain, like these things that I just mentioned, is going to be helpful for neuroplasticity as well. So it's not always as hard as we make it out to be. You know, sometimes sleep is going to be hard because you're of your Ms. Symptoms, you're waking up to go to the bathroom. So that might be a really challenging one. But can we work on pelvic floor physical therapy to help with that? Can we work on reducing stress? Can we work on staying hydrated? Hydration is great for our brain. What can we do to help our brain be in its optimal self? That is going to help with neuroplasticity? So what type of physical therapy and what type of exercise is most likely to promote neuroplasticity? According to research, it's one that focuses on strengthening your muscles and your neural pathways. And the best way to do that is through functional exercise. So what that means is you're going to pick a goal that you have, you probably have tons of goals, I would hope. Think about your day from the moment that you wake up to the moment you go to bed. What things within that span do you want to feel easier? In my mind, each of the things that you say are goals. So it might be walking, it might be getting out of bed, it might be brushing your teeth, it might be showering, going to get the mail, getting in and out of your car, whatever it might be. Those can all be goals. But for the point of what we're trying to discuss right now, just pick one of them. But list all those goals and then think for that one that we're focusing on right now, what movements or activities are challenging for that specific goal, and then we turn those into exercises. So the example that I want to share is the majority of people with Ms. That I work with want to improve their walking. So I like to share the example of walking and what this means for functional exercise. So we take the goal of walking and we break it down into. However, many components are required in order to take a single step forward. Okay, so if I want to take a step forward, what I need to be able to do is shift my body weight forward. That's the first thing. If I can't shift my weight forward and it's going to be really challenging for me to lift my back leg and bring it forward, I need to be able to shift my weight forward. Then I need to bend my knee, then lift my ankle, then bring my knee up, straighten my knee, put my heel down. And all while that leg was moving and doing those things, I was standing on one leg. So that's seven different movements. Let me say that again. I'll list those seven. Shifting your weight forward, bending your knee, lifting your ankle, bringing your knee up, straightening your leg, putting your heel down, standing on one leg. And sometimes what I hear when I say this is, well, I know I use a mobility aid. I'm never standing on one leg. Even if you're using a mobility aid, you still are standing on one leg. As your other leg is coming through, you might have support, which is great. There's nothing wrong with that at all. But you still have to be able to stand on one leg for some amount of time as your other leg comes forward. So mobility aid or not, those seven things are non negotiables. So what functional exercise means is pick one or several of those seven movements and do them as your exercises. So if that first movement of shifting your weight forward is really hard, if that front knee locks or buckles, it Just doesn't feel steady, and you can't put all of your weight on that leg. Well, then, guess what a great functional exercise is Shifting your weight forward and backwards, forward, back, backwards. A big one that's really challenging for 99% of my missing Link members is bending the knee. So you could practice standing or sitting or lying down. Find a position that works for you, but practice bending your knee. Can you get your heel closer to your butt, even if it's a centimeter? That is a very functional exercise, because in order for you to safely bring your leg forward without overcompensating in other ways, we need to be able to bend our knee. That was one of the seven movements. So that's what functional exercise means. You take a goal that you have, you break down the movements that are needed in order to do that goal, and then you do those movements as exercises. Do 10 repetitions, do five repetitions, however many you can do. But that is one. We're going to get into several. That's one of the ways that you can get neuroplasticity to activate and work through your exercises. So when we're talking about functional exercise, what else? Like, how else can we make those individual exercises even more likely to strengthen our neural pathways? So, first and foremost is good quality. I used to say perfect quality. If you've been following me or a patient of mine from 10 years ago or more, you likely heard me say perfect quality. But perfect quality is likely not even possible. But my point was, if you have poor quality, like you're practicing bending your knee, but every time you bend your knee, it falls out to the side then, and you keep doing that, and you're doing lots of repetitions of that quality, you're going to retrain your brain to do that. Your brain is going to strengthen the neural pathways for whatever you continue doing. So if you have poor form or poor quality, you're going to get stronger with that poor quality, meaning you're just going to keep doing it over and over and over again. And more often than not, when it comes to our legs, those poor form movements can result in tripping or falling. So we really want to be aiming for good quality, everything staying in the right alignment. I would rather see very little or no movement, but the right muscles are activating in the right way than lots of movement, but the leg is flailing out to the side or falling inward. So it's more about quality than quantity. That's the number one reason why I say success with exercise is not how much movement you see, it's how much effort you're putting in. The amount of effort you're putting in is what will translate to better neuroplasticity with better form. Another thing that you can do. So we've got our functional exercise, we're aiming for good quality. Another thing, and this is really, really important, is high repetitions cumulatively. So if you attempt to lift your leg once and then you're done for the day, maybe it didn't go so well, so you just scratch it, that you gave your brain one opportunity to find a neural pathway or strengthen the neural pathway, one opportunity versus if you tried five times, and maybe you did five times before breakfast, five times before lunch, five times after lunch, and maybe five times before dinner, that's 20 times total. So in that one day, you just gave your brain 20 times to try to find or strengthen the neural pathways that will help with getting that muscle stronger. So the number of repetitions that you do with good quality directly translates to how much you're setting your brain up for success. It's almost like if you never study for a test, the likelihood that you're going to get an A is not very high. But if you study consistently, you're much more likely to get that A. Same thing with neuroplasticity. So high repetitions is hugely important. It does not need to be all at once. It can just be cumulatively throughout the day, lots of rest breaks. So again, the reason this rest breaks is so important is because we're going for good quality and high repetitions most of the time. If you're aiming for high repetitions and good quality, that is going to require rest breaks. It's unlikely that you'll be able to do tons of repetitions, maybe 30, maybe 50, all with good quality, without resting. So don't think of rest breaks as a bad thing. They are great. They can help you have better quality. Additionally, doing exercises throughout the day can be really helpful compared to doing them all at once. As a physical therapist who specializes in Ms. And who has been treating people with Ms. Almost exclusively for 10 or 11 years now, I can say that if you exercise all at once, it's very likely that you might actually get stronger, but just at that one time. If you always exercise at 9am, you might notice improved strength and mobility at 9am, but not at noon. Noon, not at 3pm it can be really helpful for our brain to acknowledge and understand that we want to use these neural pathways at any time throughout the day, not just at one time. So exercising throughout the day, even if it's just a few repetitions here and there can be very important. And research shows this to be true as well. Not just my anecdotal stories. Additionally, doing your exercises in a different order, you don't want to always start with the same exercise and then the second exercise is always the same and the third is always the same. Switch it up, alternate the order of the exercises, and then last but not least, exercising in different locations can be really helpful. Similar to what I just mentioned with exercising all at once at 9:00am versus throughout the day. It is very possible. And I've seen this happen where if you always exercise in the same room or in the same chair, it's possible that you can get stronger and better mobility in that room, but not other rooms, or when you're on that chair, but not on the toilet or not on the couch. So doing your exercises in different rooms, different locations, different environments, is more likely to get neuroplasticity to occur throughout the day in all these different places versus just at that one time or just in that one location. I hear this quite often where after you exercise, the weak leg feels weaker or is weaker and you might need to take a few hours before it recovers or drink water in order for it to feel better. And there's a few different scenarios here. I once had a patient who loved the recumbent bicycle and he would really push himself on it and he would turn up the intensity. He, I think he would go for an hour, it was quite a long time. And he would tell me that when he's done, his legs are so fatigued that he has to stay sitting on the bike for up to two hours before he can get off and move. And so my brain immediately was like, okay, how can we modify this so that your legs aren't weak? Or we could do less. Less intensity, less duration. So instead of an hour, let's do 45 minutes or 30. I'm brainstorming all these ways and I asked him, I was like, what do you think about those? And his response was, but then I wouldn't get my hour in, or then I wouldn't feel like I was successful with that. And what it actually boiled down to for him was that he didn't mind that he had to sit there for up to two hours after because that form of exercise made him feel strong. So if that is the case for you, where you do feel weaker after, but you're okay with it, you don't really want to change that, then that's totally okay. But if exercising with good quality and high repetitions and these things that we're talking about leaves you feeling weaker and you don't enjoy that because maybe you have to get up and go to work, or maybe you just have to move around your home the rest of the day, then I always recommend modifying. And there's so many different ways to modify. You could modify by doing the same exact exercises, but fewer repetitions, or choose an easier position. So if you're exercising in a standing position, maybe you choose seated, or maybe you choose seated and reclined, or maybe lying on your side, just choosing a different position. Or if you normally do six different exercises, maybe only do three or four. So lessen what you're doing in some way, shape or form until you find a routine that doesn't make you feel weaker after. I will also share that there's Ms. Research saying that fatigue is normal after an exercise routine. But normal fatigue should start to disappear within two hours of you stopping your exercise routine. So if it's lasting more than that, that is a sign that you may have overdone it, even if you felt fine during your exercises. There's just a lot that we can do to promote neuroplasticity. So I like to call these bonus points. We already have so many ways that we can activate neuroplasticity, but in addition to those things, there's other things. There's six. One, two, three, four. Yes. There's six things that we can do. So we know from research that doing cardio or aerobic exercise first before our functional strengthening exercises can actually prime your brain for neuroplasticity. So it's going to set you up for success. And what we know from newest research is that we want to be looking for a higher cadence. So basically, moving quickly, quicker is going to be better. We don't yet have a specific protocol of how intense your aerobic exercise needs to be or for how many minutes. There's no specifics like that. We just know that if it's a higher cadence, if you're able to move a little bit quicker, if your target heart rate can be between 60 and 80% and it feels like a higher intensity for you, that's what we're aiming for. So in the classes that I teach, we aim for about three to five minutes of aerobic or cardio exercise. And one trick of the trade that I'll share with you is that 99% of the time that I'm teaching aerobic exercise before strengthening, we use our Upper body. Because again, the majority of the people that I work with, we're looking to strengthen our legs, improve our walking, you know, a lot of lower leg mobility things. So we don't want to fatigue our legs first if we're then going to need them to do the strengthening exercises. So we do a lot of upper body cardio based exercises to get our high aerobic intensity, higher cadence target, heart rate up. And the last thing I want to say about higher intensity is that some people see that word and they just feel like, oh, I can't do high intensity. But I want you to keep in mind that high intensity is different for every person. It just needs to feel high intensity for, for you, even if you're only able to sustain that for 20 seconds. 10 seconds. Great. We don't know yet exactly what protocol is needed, so anything truly does count. Another thing that you can do for neuroplasticity in these bonus points is focused attention. So while you are exercising and doing these functional exercises, ideally your attention is focused on the specific movement that you're doing. This kind of goes hand in hand with another bonus point, which is alertness. You want to be alert to what you're doing and focused on the specific muscle, not thinking about what are you going to have for dinner later tonight or what are you going to wear tomorrow or oh, I need to call Susan. Before I forget, you're not thinking about your to do list. You're thinking about which muscle am I supposed to be feeling right now and can I feel that muscle working? And you're really focused and alert on what you're doing. Another bonus point to activate neuroplasticity is urgency. So this can be fun by adding a challenge. One that I've had a lot of fun with and my patients tend to really like, is to play a stage, play one of your favorite songs and have a goal of how many repetitions you'll do with good quality of a specific exercise for the duration of the chorus of the song. I had a patient not too long ago who said she loved the Miley Cyrus Wrecking Ball song. And for the whole chorus of Wrecking Ball, she would practice walking back and forth in her hallway with exaggerated good quality form. And then she would let herself rest. And then as soon as that chorus hit again, she'd do it again. So you're adding a challenge, you're adding urgency. This could also mean that maybe we're adding in balance into the equation and you're doing an exercise on a slightly uneven surface to challenge Your balance and strength at the same time, as long as you can do so safely. Another one is novelty. So doing new things don't always do the same exercise, don't always do that exercise in the same position in the same room. We touched on this a bit earlier. You know, doing things in different environments, at different times, in a different order. There's different positions that you can exercise in. So even just with the same muscle group, think about how can I change this up from what I've been doing? And then last but not least, saliency. How can you make this exercise that seems so mundane and so boring mean something? One of my favorite exercises is marching. So you could be sitting, you could be standing, you could be lying on your side or lying on your back, but you're just going to bring one leg up, try to get that foot off the ground, the knee comes up towards the ceiling and then lower it back down. That is such a boring exercise. But that is one of the functional exercises that we need to walk better, to walk longer distances, to climb stairs. And what would those things mean for you? 1. I won't share the full story because we don't have too much time here, but I, I was working with someone on trying to make these exercises mean something for her and initially she just said that these exercises would be great because they'd help her get stronger. But after we worked through it, we really honed in on the reason that these exercises would be great if she could get stronger at them would be because it would mean that she could go trick or treating with her 10 year old son, walking around the neighborhood with him. So like make it mean that that's meaningful. Being able to go outside and go trick or treating with your son, or going walking around the park with a friend or a family member and getting yourself out, going to a restaurant, all those things could be more possible because you're doing these mundane exercises. So thinking about what can this mean for you can in your life, what would paint that picture? And that can help with neuroplasticity as well. So other strategies, again, I know I'm throwing a lot at you, but visuomotor strategies. So once you've gotten exercise down, can you combine other types of visuomotor components, meaning cognition or vision and movement at the same time? So walking while purposely trying to step on the cracks, or doing your marching exercise while you're thinking about all the words that you can think of that start with the letter S or looking in the room that you're in and just naming things that you see around the room while doing that marching exercise. So we're combining cognition, what you're seeing visually and movement at the same time. That can help with neuroplasticity constraint therapy. This isn't used as often more recently, but it has been used in the past where constraining or blocking, the use of one limb, usually your stronger limb, in order to force the weaker one to work harder, has been shown to be effective. And what I mean by constraining or blocking would mean, like, if we're trying to improve the strength in our right arm, then maybe you sit on your left hand, so your left arm can't really help out at all. Assistance from robotics, and this is becoming more and more common. There seems to be a lot of innovation lately with exoskeletons and products and tools that are more robotic. So exoskeleton gait training has been found to help people with Ms. Improve walking velocity, the 6 minute walk test and quad strength. And then another strategy that could help is electrical stimulation. Things like the newbie pons, possibly psionic neural sleeve. These are things we don't have a ton of research yet of the long term effects, but definitely in the short term. It can help you have good form. It can help you get more repetitions. So that could be another strategy that you use as well. Kind of quick faq. How long does neuroplasticity take? It's different for everyone. I have seen improvements, truly, in as little as a few days. And if that's the case for you, I just want to point out that more likely than not, it's not that your brain completely rewired itself in two days or three days, or even that you truly strengthen the full neural pathway in two or three days. But more likely than not, you were overcompensating in other ways. And by doing these specific exercises, you woke up the neural pathway that had fallen asleep. And it's not that it was super weak, it's just that your body found a different way that felt easier. So if you're able to wake up those neural pathways, you truly can see progress within just a few days. But when we're talking about true neuroplasticity of strengthening the neural pathway, then that could take anywhere from, I would usually say maybe one to five months. If we're talking about the type of neuroplasticity where we are rewiring, that does take longer. That usually takes anywhere from six months to two years. So it does require consistency. Does it matter how old I am? No. Does it matter how long I've had ms? No. Doesn't matter what type of Ms. I have? No. Does it matter how disabled I am? No. All of these questions, the answer is no. With that said, even if you didn't have ms, as we age, as we have other comorbidities, if we're healthy or unhealthy, those things do slow down neuroplasticity. So it's not that being older means neuroplasticity won't work for you, or if you've had Ms. For over 40 years, that it won't work for you, or if you have progressive versus relapsing that it won't work work for you, or if you're in a wheelchair that it won't work for you. It will work, but those are factors that might make it take a little bit longer, so we need to stay even more consistent. Okay, that concludes I know that's a ton of information all at once, but hopefully you now have a better understanding of what neuroplasticity is, how it works, and a ton of different strategies to get it to work for you and to implement it. The last thing that I will share is please remember you do not need to do all of these. You could pick one of the several things that we learned today and just focus on that one thing and then eventually if you want to add a second one, go for it. You don't need to do all of these at once. Truly, just one thing is better than nothing and it's going to be more easy to stay consistent with that one thing. So keep it up. Hopefully this gives you the guidance that you need and the motivation that it is actually possible to to strengthen those neural pathways.
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Thank you for listening to today's show.
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I am so grateful to have you as a listener.
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If you'd like extra resources such as a video of one of my seated exercise classes, my favorite core exercises, and the opportunity to ask me your questions, head to missinglink.com insider. That link will be shared in the show notes along with links to my social media handles. If you loved this episode and think a friend or family member with Ms. Would benefit from listening, please go ahead and text or email this podcast to them right now. Sharing this podcast will help me educate and empower as many Ms. Warriors as possible. Thanks again for joining and be sure to tune in next week for another episode of the Missing Link podcast.