rehabyoga
Several symptoms of MS are amenable to rehabilitation treatment employing the physical aspect of yoga, which includes various poses postures and exercises. Symptoms of MS that potentially respond well to this approach include fatigue 1, muscle weakness, spasticity, and pain. With MS, muscle weakness results from damage to the central nervous system, which is inflicted on the myelin sheath surrounding the nerve fibers 2. This damage disrupts electrical impulses from the nerve producing weakness and other deficits depending on the pathway involved e.g., motor, sensory, coordination, autonomic 3.
The muscle weakness associated with myelin damage is aggravated by atrophy in neighboring healthy muscle fibers associated with disuse 4. This weakness is also the primary cause for secondary disability such as soft tissue contractures 5. Traditionally, the rehabilitation approach targets muscle weakness, contractures and spasticity, and can alleviate some of these symptoms. However, in my clinical experience as a physical therapist, I have found that yoga may be productively modified for people with MS and integrated into rehabilitation with considerable benefit. In particular, yoga postures may be employed with great success to decrease fatigue, abnormally high muscle tone, spasticity, promote muscle relaxation, elongate soft tissues and improve muscle strength.
Particularly appropriate for this purpose is the therapeutic approach of the Iyengar School of yoga 6. These teachings emphasize precision and symmetry in exercises, which may be both static and dynamic 7. In static variations, muscle activity is either isometric or relaxed, with poses held for approximately 5 to 10 breaths, or about 30 to 60 seconds. When static yoga poses (also called restorative poses) are employed with patients who have MS-related muscle weakness, spasticity and soft tissue tightness, the patients may be assisted into the yoga pose, and they stay in each pose longer. They are then passively supported in maintaining the poses through the use of props such as yoga mats, bolsters, chairs or ropes. In dynamic variations, muscle activity may be either isotonic or isometric and may or may not employ gravity as resistance. Therapists provide instructions or assistance to movement into and out of the pose in synchrony with the breath.
The use of yoga postures with symptoms of MS is illustrated in my work with SK. SK is a 40 year-old woman whose EDSS score is 8.0-8.5 8. Her symptoms include severe fatigue after staying seated in her wheelchair even for a short period of 10-20 minutes. She also demonstrated weakness in the upper extremities and trunk muscles (3-/4 MMT). Her lower extremities demonstrated spasticity (3/4 Ashworth Scale 11) with no volitional motor control. SK had severe limitation of end range of motion in all major joints with muscle tightness, particularly in the regions of shoulders and hips, knees and ankles. Her breathing appeared shallow due to soft tissue tightness and weakness of intercostal muscles. SK also had severe discomfort while sitting, due to abnormally high and asymmetric trunk muscle tone. As a result of this, SK had a poor sitting posture, even in a custom-fitted wheelchair with her knees held in severe adduction, and her pelvis and trunk misaligned. When starting treatment, SK's goal was to reduce the discomfort caused by the tightness and tone in her trunk and extremities. She also expressed a desire to improve her stamina and reduce her fatigue. Standing, which is considered the most important yoga posture 6, did not seem to be a realistic goal because of contractures, spasticity and weakness of her lower extremities and trunk.
Fig. 1
Fig. 2
The modified Inverted pose (Fig 1) and Paschimottanasana (Fig 2) are some modified sitting poses used in the sessions. SK was helped and supported to stay sitting in extended legs, then she was helped to reach with her arms toward her feet. This pose is aimed at elongating the hamstrings by moving the pelvis into anterior tilt and flexing at the hips with knees held in full extension. This treatment resulted in temporary reduction in spasticity and greater flexibility, which typically lasted for a few days. The long term effects of this flexibility at the lower extremities and lumbosacral region eventually resulted in allowing the rehabilitation program to explore standing poses with SK.
SK's EDSS score did not change following this rehabilitation with yoga approach. However, following the treatments SK has better sitting posture, and she reported improved stamina and greater comfort sitting for a longer period of time. In addition, she demonstrated increases in range of motion at the hips, knees and ankles that were sufficiently large that now she can be helped into a standing position and remain standing for more than one hour. SK stands on a tilt table, with good postural alignment when in therapy, and is able to stand with knee-ankle-foot orthoses and stall bars at home. While standing, SK is able to practice breathing exercises, coordinated with upper extremities exercises, thus assisting improved oxygenation of the blood. This has greatly reduced her risk of secondary disability of osteoporosis and improved her psychological outlook. Thus it appears that patients like SK can benefit from the integration of yoga postures into physical therapy.
Guidance is important, because yoga exercises are numerous, and most often individuals with severe disabilities cannot perform these exercises without professional assistance. However, it does appear that people with MS may benefit from yoga as a therapeutic approach when they are assisted by a professional who can match the unique symptoms of the patient with the appropriate exercises. There is a need for formal empirical research regarding the effectiveness of yoga when included in the MS patient's physical therapy treatment intervention. Some practitioners have begun to apply yoga techniques routinely 9, but the field would benefit from more formal research regarding the techniques which may be most effective in different situations.
Appendix:
Treatment Rationale Summary:
Goal : To be able to stand upright for weight bearing and other benefits:
What are the modifiable factors that limit the goal?
Abnormal Muscle tone such as Spasticity LE tightness and contractures
How should these factors be modified to meet the activity goal?
Yoga type poses and exercises by therapist, patient, care giver to maintain or regain length in musculature;
These stretches can be done actively or passively with and without another person. Restorative Yoga postures have elements of stretch and relaxation with gravity assistance.
Theoretical Rationale with the PST the abnormal muscle tone causes undue stress on the body 10
Intervention Yoga poses
Outcome:
Improved trunk, pelvis, hips, knees and ankle ROM and muscle length so that patient will be able to participate in daily program of standing.
References
B. S. Oken, S. Kishiyama, D. Zajdel, D. Bourdette, J. Carlsen, M. Haas, C. Hugos, D. F. Kraemer, J. Lawrence, and M. Mass Randomized controlled trial of yoga and exercise in multiple sclerosis Neurology, Jun 2004; 62: 2058 - 2064.
Vollmer,T.L., Hadjimichael, O., Preiningerova, J., Ni, W., & Buenconsejo, A (2002). Disability and treatment patterns of multiple sclerosis patients in United States: A comparison of veterans and nonveterans. Journal of Rehabilitation Research and Development, 39(2), 163174.
A.B. DiBernado. (2002). Multiple Sclerosis Primer. Boston: Cure Project.
D. D. Kilmer. (1998). The role of exercise in neuromuscular disease. Physical Medicine and Rehabilitations Clinic of North America, 9(1), 115-125.
Royale College of Physicians of London. (2004). National clinical guideline for diagnosis and management in primary and secondary care. London: The National Collaborating Centre for Chronic Conditions.
Iyengar, B.K.S. (1966). Light on Yoga. New York: Schocken Books.
Yoga and Multiple Sclerosis Rehabilitation
Dalia Zwick PT, PhD
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