Exercise testing and training guidelines for clients with multiple sclerosis

• Complex skill-oriented exercises should be avoided in most persons with MS, partly because of the loss of proprioception, or ability to perceive muscle and joint position in space.
• The energy cost of walking may be two to three times higher than normal for people with MS, particularly those with advanced disease; thus adjustments in workloads to maintain a 60% to 75% maximal heart rate are necessary.
• Persons with MS are thermosensitive and therefore at increased risk for both heat- and cold-related injuries; this emphasizes the need to ensure adequate hydration and to have persons with MS exercise in thermoneutral environments. In addition, dehydration during exercise could be exacerbated in persons with MS who have bladder dysfunction (incontinence or sense of urgent need to urinate or both) and sometimes limit their fluid intake.
• It is important to be cautious with large muscle lower limb exercise, since muscle spasticity may be particularly predominant in the hip abductor and adductors.
• Sensory loss may preclude certain exercises such as free weights because of a client's inability to grasp the bars effectively, and may necessitate modification in other forms of exercise.
• Strapping may be necessary if more severe spasticity is present.
• Some evidence suggests that morning, when circadian body temperature is at its lowest, may be the preferred time for exercise.
• Recumbent bicycling may be preferred over upright cycling in clients with balance problems.
• Imbalances between agonist and antagonist muscles are common.
• Muscle weakness tends to be greatest in the lower limb and trunk muscles.
• Neuromuscular problems such as foot drop may be present in more advanced cases.
• Some clients may have cognitive deficits and are prone to depression; caution is warranted in education of these individuals, and constant reinforcement to enhance compliance is generally needed in clients with MS.
• The variable nature of MS symptoms and progression requires that the personal trainer adjust the exercise program on a daily basis.
• It is advisable to monitor heart rate before, during, and after aerobic exercise to ensure the appropriate metabolic intensity and stimulus.
• Regular follow-ups to monitor progress are highly recommended with persons who have MS in order to facilitate compliance and to adjust the exercise prescription appropriately.
• In the case of an exacerbation, exercise should be discontinued until complete remission.
• Since some individuals with MS have cognitive impairments, it may be necessary to provide information and instruction in both written and diagram formats. Frequent reminders of exercises, technique, and proper use of equipment may be necessary.
• If the client has incoordination in either the upper or the lower limbs, the use of a synchronized leg and arm ergometer may improve exercise performance by allowing the arms or legs to assist the weaker limbs.
• Resistance training should be performed on nonendurance training days to avoid fatigue.
• Resistance training should be done in the seated position initially if balance is impaired.
• Flexibility exercises should be performed from either a seated or a lying position (16, 41, 56).

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