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Staying WellStretching for People with MSAn Illustrated ManualFor Information: 1-800-FIGHT-MSnationalmssociety.org

Beth E. Gibson, PT, has a certificate in physical therapyfrom the Mayo School of Health Related Science inRochester, Minnesota. She has been working with peoplewith MS for 11 years.Special thanks to Susan Kushner, MS, PT, and CindaHugos, MS, PT, for their valuable assistance.Drawings by iMageWorx. Some of these drawings originallyappeared in Multiple Sclerosis: A Self-Care Guide toWellness, published in 1998 by Paralyzed Veterans ofAmerica, Inc. They are reproduced here with the kindpermission of PVA, Inc.Reviewed by members of the Client Education Committee ofthe National Multiple Sclerosis Society’s Medical AdvisoryBoard. 2004 National Multiple Sclerosis Society

Stretching for People with MSAn Illustrated Manualby Beth E. Gibson, PT

TABLE OF CONTENTSGENERAL INTRODUCTION.3SOME PRECAUTIONS, BOTH OBVIOUS AND NOT SO OBVIOUS .5HEAD AND NECK EXERCISES .6SHOULDER EXERCISESBASIC .7AS A FLOW.9ELBOW AND FOREARM EXERCISES .10HAND AND WRIST EXERCISES .11TRUNK AND HIP EXERCISES .14ANKLE AND FOOT EXERCISES.17SITTING COORDINATION AND BALANCE .19POSITIONING FOR SPASTICITY .20INDEX OF SPECIAL TERMS .242Stretching for People with MS

GENERAL INTRODUCTIONEveryone with MS, regardless of his or her degree of ability or disability,needs regular physical activity. Lack of exercise has serious health consequences, ranging from constipation to increasing the risk of heart disease.Just as important, good exercise programs not only prevent problems,they promote a sense of achievement and well-being.This booklet focuses on basics to move and gently stretch muscles andtendons, on your own, at your own pace. For the purposes of this book,the familiar term “stretching” is used, though most of these exercises are,technically, range of motion activities. Exercise can be broken down intofive categories, one of which is relaxation. All are important to peoplewith MS.Flexibility—stretching the muscle and tendon to its full length andmoving the joint through its full range. These activities decrease muscletightness and prevent loss of full range of motion which may occur withdecreased activity, weakness, or spasticity. Unaddressed, such loss canlead to joint contractures that painfully “freeze” joints into a singleposition.Strengthening—increasing the force or power of the muscle. Strengthcan be increased by lifting a limb up against gravity, lifting weights, or byworking against resistance such as walls, weights, or rubber tubing.Strengthening exercises can help reduce fatigue.Endurance—improving heart and lung function. Aerobic exercisemakes the heart and lungs work harder and builds endurance, reducesthe risk of heart disease, and helps manage weight and cholesterollevels. Walking, swimming, or using a stationary bike are forms ofendurance activities.Balance and coordination—improving quality and safety of movement. Rhythmic hand or foot exercises and specific standing activities,usually with directions from a physical therapist, can improve balanceand coordination.3

GENERAL INTRODUCTIONRelaxation—reducing physical and mental tension. Relaxation can justmean stopping and taking a deep breath or sitting while listening to softmusic. Structured relaxation techniques can reduce fatigue from an exercise session or help manage a stressful day. The National MS Society’sbooklet “Taming Stress in MS” contains directions for several kinds ofstructured relaxation exercises.4Stretching for People with MS

SOME PRECAUTIONS, BOTH OBVIOUS AND NOT SO OBVIOUS1. Wear clothing that doesn’t restrict movement.2. Be sure the room temperature is comfortably cool. Consider a fan, airconditioner, or open window. If you are especially heat-sensitive, consider a 10-minute soak in a cool tub before exercising. (Start withlukewarm water, slowly adding cooler water until the tub feels like acool swimming pool.) Or experiment with cooling headbands, vests, orneck wraps.3. Don’t force any part of the body. If pain occurs, stop. Check with yourhealth-care professional before trying that move again. If discomfortoccurs, cut back to a motion that’s easier.4. Go slowly. All movements should be done evenly, allowing the musclestime to respond to the stretch by relaxing. Moving quickly canincrease spasticity or stiffness. Try to hold each stretch for 60 secondsat the comfortable far end of your range. It may help to count outloud. Then gently return to the starting position.5. Feel your way to more challenge. The idea is to increase the range ofpain-free motion. Therefore, it’s important to distinguish between painand the feeling of stretch. Stretch is okay; pain is not.6. If one side is weaker, use the stronger side to move the weaker side. Aphysician or physical therapist should be able to help you with this.7. Remember to breathe evenly and relax the face throughout eachmovement. There’s a tendency to grimace or hold the breath duringan unusual movement.8. Avoid overexertion. Include rest periods, and sip cool water to preventoverheating or dehydration.9. Experiment with times of day. Some people find early morning best;some find it helpful to break exercise sessions into two parts: one inthe morning, and the other in the afternoon or evening.5

HEAD AND NECK EXERCISESExercise 1Bend head back (looking up).Do slowly; do not thrust headback quickly. Shoulders shouldbe lowered and relaxed.Bend head forward (lookingdown). See CAUTION below.Exercise 2Bend head so that ear is movedtoward shoulder.Exercise 3Turn head to look overshoulder.CAUTIONVertigo: This is dizziness or a “spinning of the room” sensation. If thismovement makes you dizzy, light-headed, or nauseated, stop immediatelyand check with your physician.Lhermitte’s sign: This is a tingling or electric shock–like sensation in thespine or limbs upon bending the neck, which sometimes occurs in MS. If youfeel this sensation, discontinue this exercise and check with your physician.6Stretching for People with MS

SHOULDER EXERCISES—BASICExercise 1Starting position: Lie on yourback with arms at your sides,palms up.Raise one arm up over yourhead (as if raising your hand inclass), keeping elbow and forearm straight. Hold for one deepin-and-out breath.Return arm to starting positionand repeat 2–3 times.Repeat exercise with otherarm.Exercise 2Starting position: Lie on yourback with arms at your sides.Turn your palms up.Bring one arm out to the sideand smoothly up to the side ofyour head (as if doing a onearmed jumping jack).Return arm to starting positionand repeat 2–3 times.Repeat exercise with otherarm.7

SHOULDER EXERCISES—BASICExercise 3Starting position: Lie on yourback with arm out at your sideand your elbow bent at a 90degree angle. Turn your palmdown.Raise your forearm up and overuntil the back of your palmtouches the bed.Gently return forearm to starting position, palm down on thebed. Repeat 2–3 times.Repeat exercise with otherarm.Exercise 4Starting position: Stand orsit in a chair.Move arm straight back, as ifreaching for something in yourrear pocket. Allow forearm todangle.Return arm to starting position. Repeat 2–3 times.Repeat exercise with otherarm.8Stretching for People with MS

SHOULDER EXERCISES—AS A FLOWExercise 1Step 1: Start by lying downwith arms at sides, close to theedge of the bed. Move arm overhead, as shown.Step 2: Return arm to startposition (arm straight).Step 1Step 2Step 3Step 4Step 5Step 6Step 7Step 8Step 3: With arm at shoulderheight, reach for the ceiling,lifting the shoulder off the bed.Step 4: Draw arm and shoulder back until shoulder is flaton the bed.Step 5: Move arm outwardfrom the body to above thehead.Step 6: Return arm to startposition (arm straight).Step 7: With arm extendedoutward at shoulder height,move arm down toward thefloor as far as possible. Returnarm to start position.Step 8: Extend arm outward atshoulder height. Move armacross body, lifting shoulder offthe bed. Return to startingposition, with both armsstraight.Repeat all the above with otherarm.9

ELBOW AND FOREARM EXERCISESExercise 1Starting position: Lie on bedor mat, arms at side, palms up.Keeping elbow on bed or mat,bring hand as close to theshoulder as possible. Hold.Return to start position.Repeat 3 times on each side.Exercise 2Starting position: Lie onback with arms at your sides,palms turned toward body. Orsit at a table, with forearmresting on the table.Raise forearm straight up. Iflying down, keep elbow andupper arm on the bed.Gently rotate hand, palmtoward your face, palm awayfrom your face. Repeat 2–3times.Repeat exercise with otherarm.10Stretching for People with MS

HAND AND WRIST EXERCISESExercise 1Step 1: Bend fingers towardpalm (make a fist).Step 2: Straighten fingers.Step 1Step 2Exercise 2Step 1: Bend thumb at alljoints.Step 2: Straighten thumb.Step 1Step 2Exercise 3Step 1: Move fingers apart(spread fingers).Step 2: Move fingers together.Step 1Step 211

HAND AND WRIST EXERCISESExercise 4Step 1: With palm up, movethumb up and away from palm.Step 1Step 2Step 2: Return thumb to position along side of first finger.Step 3Step 3: Move thumb out andaround to touch little finger.Exercise 5With hand out flat, keepingarm still, move hand first tothe left, then to the right.SUGGESTIONTo improve finger coordination, try playing board games, building models,or doing crafts.12Stretching for People with MS

HAND AND WRIST EXERCISESExercise 6Step 1: Bend wrist so thatpalm is toward forearm.Step 2: Straighten from bentposition to neutral position.Step 1Step 3: Move hand so thatback of hand is moved towardforearm.Step 2Step 3Exercise 7Step 1: Start with arm andwrist in a comfortable position,fingers pointing to the ceiling.Step 2: Bend the fingers at thelarge knuckles, making a tabletop. Then straighten. Try tokeep the wrist relaxed.Step 1Step 213

TRUNK AND HIP EXERCISESExercise 1Starting position: Sit onchair or edge of bed, with feettouching floor.Bend hip by lifting kneetoward chest.Hold, then lower foot to floor.Repeat.Exercise 2Straighten knee while liftingfoot up. Return slowly to a bentknee position.Exercise 3Lie on stomach, bend knee.Return to original position.14Stretching for People with MS

TRUNK AND HIP EXERCISESExercise 4Step 1: Lying on your back,turn your leg out so that toespoint away from your other leg.Step 2: Turn your leg so thattoes point toward your otherleg.Step 1Step 2Exercise 5With legs together and straight,move legs apart from eachother and return to the neutralposition. Or move one leg at atime out and then back to thestarting position.Exercise 6Bend one leg at the knee, keeping the foot flat on the mat.Slowly move the other leg up6–10 inches off the mat without bending the knee. Lowerslowly and repeat.(Note: If lower back is veryweak, slide hands, palms down,under the small of the backbefore lifting the leg.)15

TRUNK AND HIP EXERCISESExercise 7Lying on back, pull one knee upand hug toward chest. Keep theother leg flat on floor or bed.If this stretch is too hard, holdthe thigh behind the knee withboth hands. If this is too hard,stand one leg on the floor andslide the heel toward the buttock. Do each side.Exercise 8Lying on back with knees bentand feet flat, slowly lowerknees from side to side. Thegoal is to stretch the trunk andhips, not to touch the knees tothe floor or bed.Exercise 9Pull one knee up and then theother to hug them to chest for alow back stretch. After thestretch, set one foot down andthen the other to prevent anystrain to the low back.16Stretching for People with MS