'Improving core strength' has been the latest trend/buzz-term in fitness and gym circles for what seems like years (so much so that it can't really be termed the 'latest trend' anymore) so you would be forgiven for thinking that a strong core can solve anything!  It can't unfortunately, but a strong core is important to maintain posture and balance in everyone, not just those of us with MS (I'll cover posture in a future post). 
The importance to us though, is that MS can mean that balance can become problematic; research shows that as many as seven out of ten people with MS (PwMS) experience balance problems at some point during the course of the condition, with around one in five people reporting balance problems as one of their first symptoms of MS. 
​

In pre-MS days whilst studying for my MSc I wrote a piece on osteoporosis and the importance of maintaining bone strength.  Much of this research focussed on preventing falls causing breaks at high-risk sites like the hip, wrist and spine and the importance of  balance training in helping to prevent potential falls.  I carried on to learn much more about functional training for improving balance through my PT qualifications and understood that balance is definitely something we can train for regardless of age or ability.
Balance is important primarily to prevent falls, but also (as we all probably already know!) in day to day living; no-one wants to trip down the stairs (or up as I did recently) or to fall over nothing.
​                 
How can MS be responsible for balance issues?Do you remember the 'tangled wires' analogy from the site? This is where messages sent from the brain to the  muscle to perform a specific action get jumbled up and don't necessarily reach the desired destination, get misinterpreted along the way or are too weak to elicit the required action; it maybe that the brain orders the foot to be lifted in order to clear a kerb, but if the message doesn't get through, you'll trip up the step.
Many of our MS symptoms can bring about unsteadiness and balance problems, increasing the chance of tripping or falling, including:

• Muscle stiffness/weakness causing unsteadiness
• Muscle spasms/spasticity/tremor putting us off-balance  
• Numbness interfering with how we walk
• Vertigo affecting perception
• Pain affecting mobility
• Visual problems affecting how we perceive obstacles 
• Fatigue  

First cautionary note...
...not all balance problems are a result of your MS, if things change or are different to your 'normal' consult your medical team for advice.  

​The core is considered the main trunk of the body once the arms and legs have been removed.  A strong core (or core stability) allows us to maintain balance when moving a limb away from the body eg reaching for something on a table or walking; muscles working around the core allow for and correct this imbalance to keep us upright.
The core musculature can be visualised as a non-compressible cylinder with the diaphragm at the top, the pelvic floor at the bottom; the transverse abdominis (which compresses the abdominal contents and maintains pressure to protect the spine) wrapped around the sides, all zipped up by the intricate muscles surrounding the spine.   

Layers of the coreMuscles which support the trunk are arranged in three layers - deep, middle and superficial (outer) - and work together to maintain spinal stability and balance.  Often when talking about the core people mistakenly assume we are talking about a visible 'six-pack' or sculpted oblique muscles to pull in and define our tummies.  These muscles are an important part of the core but as large (outer) muscles, they are primarily responsible for gross movements such as bending and twisting while other smaller, deeper muscles such as those surrounding the spine play a larger role in subtle movement to maintain balance.  The main goal of core stability is keeping the spine supported and protected; without this musculature the spine is inherently unstable putting us at risk of injury.  The three layers of muscles surrounding the trunk work together to wrap around the body to allow stability when we move limbs when walking, stretching, leaning etc; any movement which puts the body out of balance.      
There are many muscles involved in core stability, some major ones include:   

Deep muscle layer

• Series of intricate muscles surrounding the spine

Middle muscle layer

• cylinder image above

​Outer muscle layer 

• Abdominal ,muscles 
• Oblique muscles (internal and external) which allow spinal rotation and a degree of forwards and backward bending
• Gross spinal muscles 
• Gluteals

...among others
The core's function is primarily to support and protect the spine while we do activities with the attached limbs eg walking etc in an attempt to throw it off balance!

What can I do to strengthen my core?Now we've covered what the core actually is and the importance of using movements which work on all three muscle layers, you can hopefully see that a core training plan isn't just a load of abdominal crunches/sit-ups each day - although, with proper form these can play a role...
...and this is always the challenge of writing about exercise but not providing a training plan for you to follow; it is very difficult to provide personalised training through a blog post or even through an online video (remember my rotator cuff injury of a few years ago?!).  Personal Training is by nature 'personalised'; what works for me isn't necessarily suitable for anyone else.  I could provide links to a video of core exercises but without knowing you personally I can't find out if they are suitable or whether they will aggravate existing conditions; some core exercises are tricky and need coaching into position, difficult from behind an email.  For example, the plank is a traditional core exercise, but unless you have been shown the correct way to perform it, it can give you dreadful back-pain and provide little benefit.
What I can do though is add a link to core and balance exercises provided by the MS Trust; these have been shown helpful for many abilities and are promoted within their site.  If I can work out how to create the little moving figures perhaps next time I can add some of my own!     
Exercises for core stability
​

There is a large part of PT-ing which focusses on improving your functional ability in order to perform your daily activities with less energy and effort.  Many of our daily activities eg walking, wheeling, carrying groceries, reaching for items on a table or shelf etc will automatically use your core strength already; there is a 'principle of training' around specificity ie train at performing specific tasks in order to be better at them or to make them easier; so rather than setting out to have the 'strongest core ever' why not focus on specifically making daily tasks easier - the more you do something the easier it becomes.  Practice intentionally reaching up to pick something off a high shelf, practice balancing to walk along a line at home (a floorboard in the kitchen is my favourite) practice standing on one leg (if you do that a lot!) etc; rehearsing daily activities may provide more benefit than worrying about specific exercises. 
​    ​

Core strength isn't the only thing responsible for improving balance; exercises such as Tai Chi, yoga and pilates are also suggested (which arguably rely on training a degree of core strength too)
Please consult a physiotherapist or book a session with a PT to assess which exercises are most suitable and give you a step-by-step guide.  As always, safety when exercising is paramount.  

References:Active IQ (2016) Fitness instructing manual: gym.  London: Active IQ

Active IQ (2016) Personal training manual. London: Active IQ

Cash M (1999) Pocket atlas of the moving body.  London: Ebury press

Freeman, J.A Et al., (2010) ‘The effect of core stability training on balance and mobility in ambulant individuals with multiple sclerosis: a multi-centre series of single case-studies’, Multiple Sclerosis 0(00): 1-8.  Doi: 10.1177/1352458510378126

Kanis, J. A., McCloskey, E. V., Johansson, H., Cooper, C., Rizzoli, R. and Reginster, J. Y. (2013) 'European guidance for the diagnosis and management of osteoporosis in postmenopausal women', Osteoporosis International, 24(1), pp. 23-57. doi: 10.1007/s00198-012-2074-y.

MS Society (2016) Balance and MS (booklet).  Available online at: https://www.mssociety.org.uk/ms-resources/balance-and-ms-booklet

​MS Trust (2016) A-Z of MS: Balance.  Available online at: https://www.mstrust.org.uk/a-z/balance

Water is essential to maintain life
and health. At birth the human
body is made up of around 70%
water which decreases with age; in
the elderly water comprises around
55%. The balance also differs
between the sexes with males generally holding more water, and females holding
more body fat. Water has functions both within and outside of the body's cells
providing a host-environment to maintain vital chemical processes.
To remain adequately hydrated - and to prevent dehydration - it is important that
water lost through essential bodily processes including breathing, sweating and
urination, is replaced. The frequently cited first signs of dehydration are a feeling
of thirst and a dry, sticky mouth; but by the time the body had noticed a reduction
in water, processed the deficit and sensed the need to respond with a 'feeling of
thirst' response the body is already dehydrated.
Other symptoms of dehydration include:

• feeling lightheaded
• headache
• lack of energy
• dark coloured urine
• poor concentration

​
Water plays a key role in vital processes within the body, including:

• formation and maintenance of blood plasma, tissue fluids and lymph
• effective passage of substrates into and out of cells (including circulation of
• nutrients via the blood and removal of waste)
• providing a suitable environment for chemical cellular processes
• provides lubrication to our joints and protection for our organs
• transportation and filtration of waste products for excretion
• maintenance of consistent body temperature and subsequent a cooling

function through sweating
​

How can dehydration affect my symptoms?
One of the first pieces of advice my neurologist gave me was to make sure I made
a point of staying hydrated, especially when exercising.  When I did some digging
around the research on this I realised how valuable it was. Dehydration had been
shown to make many of our MS symptoms worse, notably:

Fatigue
Much of the recent research on fatigue has looked at hydration status; not an
unexpected jump given that in people without MS a small drop in hydration can
bring on tiredness and confusion. This work is still ongoing but it seems it could
be a promising part of the fatigue-puzzle,

​Urinary tract infections (UTI)
We know that some medications used to treat MS can irritate the bladder and
cause UTIs; but UTIs and bladder difficulties are a symptom and complication of
MS themselves. Some people with MS (PwMS) choose to limit their fluid intake to
try to avoid bladder difficulties, but this in itself can lead to development of UTIs
and subsequent dehydration.

Constipation
Adequate fluid intake is important to help to prevent constipation and bowel
difficulties; constipation has been shown - in some cases - to affect spasm and
spasticity and also aggravate bladder symptoms although specific mechanisms
remain unclear.

Heat-related exacerbations (Uhthoff's phenomenon)
Heat (and in some cases cold) has been shown to being about a temporary
worsening of symptoms; adequate hydration can help to maintain a consistent
body temperature to help to manage this.

How much fluid do I need?
The amount of fluid required depends on various external/environmental factors,
including:

• Environmental temperature
• Body temperature
• Humidity
• Physical activity
• Respiration rate

In the UK, drinks provide around 70-80% of our water needs with the remaining 20-30%
coming from foods such as soup, fruits and vegetables,
The guideline amount of fluid to consume per day for adults and the elderly is
2,000ml for males and 1,600ml for females. Guidelines for pregnant and lactating
women are slightly different (BDA, 2017). If you are interested in the guidelines
for children and infants drop me a note and I can send on separately.
​
Water helps to regulate body temperature which can be important when
exercising with MS. It is important to increase fluid intake whilst exercising in
order to replace fluid lost through increased respiration and sweating.

​Common household
measures include:
1 medium sized glass = c.200ml
1 can of fizzy drink = 330ml
1 mug = c.250ml
1 cup = c.200ml

​What types of fluid count?
Ultimately the type of fluid you consume is up to
you, however water (either tap, filtered or
bottled) is a healthy option. Tea and coffee
count too and can be a useful way of helping
elderly family and friends to drink more, but be
mindful of the caffeine content. Fizzy drinks
contain a lot of sugar as do fruit juices so should
be limited. Fizzy drinks can contain a lot of
chemicals, sweeteners and sugar which make
them a less-healthy option; they also contain
caffeine which can prove dehydrating and
counteract any benefit of fluid intake.

How can I tell if I'm drinking enough?
It can be tricky to know how hydrated you are; generally as soon as you feel the
first symptoms of dehydration (ie thirst and dry, sticky mouth) you will find a drink
which makes you feel better but you will generally stop drinking before you are
fully re-hydrated. The colour of your urine is the best indicator; if you are drinking
enough your urine should be straw-coloured or pale yellow in appearance.

Some lifestyle factors can affect how much fluid
you need...
Regardless of your fluid intake, some additional lifestyle factors can complicate
the body's absorption and use of water and bring about dehydration, Some of
these can include:

• caffeine
• salt
• sugar
• alcohol

Caffeine (often found in fizzy drinks and coffee) and alcohol can both irritate the
bladder and affect symptoms which can further impact dehydration.
​

Some practical tips to
increase your fluid
intake
My husband calls me a camel (a bit rude
I feel) as I carry water everywhere; in my
handbag, in the car, gym bag etc and I
drink a lot of water. I suppose I'm lucky
as I don't dislike the taste of plain water, but said husband finds it 'boring' and
prefers it with some flavour.

Some easy/fun ways I've found to make it more interesting include:

• sliced fruit in a big jug in the fridge topped up with water. Favourites are:
• sliced lemon, lime, basil & cucumber, ginger and orange.
• sometimes I quickly squeeze half a lemon or lime into a water bottle to take
• out with us
• occasionally I freeze homemade smoothie into ice-cubes to pup into a large
• jug/bottle of water
• a friend uses the 'ten-glug rule' taken from a favourite US fitness couple,
• where every time you go to have a drink you must take 'ten-glugs' before
• putting it down
• to make water more interesting for children I have sometimes frozen
• blueberries, raspberries or chunks of strawberry into ice-cubes which can be
• fun when they melt (provided they like the fruit in the cubes!

​​References:
Active IQ (2016) ‘Hydration’ in Personal Training. London: Active IQ Ltd
Active IQ (2016) ‘The importance of adequate hydration’ in Fitness instructing
(gym) manual. London: Active IQ Ltd
British Dietetic Association (2017) Food fact sheet: fluid. Available online at:
https://www.bda.uk.com/foodfacts/fluid.pdf
Department of Health (2012) Manual of nutrition, Twelfth Edition. London: The
Stationary Office
MS Trust (2016) A-Z of MS: diet. Available online at:
https://www.mstrust.org.uk/a-z/diet

​Why is flexibility important in MS?
Clearly we're not all gymnasts aiming to effortlessly do the splits (or perhaps you are?  Jolly well done if so; I was part of a gymnastics club when I was little and never managed to do the splits).
Splits aside, maintaining flexibility is important in MS to help reduce the day-to-day demands placed on the body through daily activities (themselves often made more difficult whilst dealing with MS), and also to help manage symptoms like muscle stiffness, spasticity and muscle tightness and help improve posture and balance.
​
​What do we mean by flexibility?
As we went on to understand, flexibility doesn't only mean cartwheel-spinning and back-flipping gymnasts it refers to the range of movement possible around each joint or series of joints.  The level of movement ('range of motion' or ROM) is determined by the shape of surrounding bones and cartilage, the length of the muscles around the joint and the ligaments and tendons crossing over the joint to allow movement.

How/why is flexibility relevant to MS?
The nervous system plays an important role in flexibility; it is responsible for determining muscle tone (tension) which allows movement.  Some of the diagnostic tests that neurologists perform look for the level of muscle tone ie level of tension or resistance specific muscles can provide when force is applied.  Muscle tone is the tension which allows us to move limbs and hold a limb in position.  An increase in muscle tone is responsible for symptoms of spasm and spasticity.

• Spasticity in MS can cause your muscles to feel stiff, heavy and difficult to move.
• Spasm in MS is a sudden stiffening of a muscle which can cause a limb to kick out or jerk towards your body.  

Nerve pathways connecting the brain, spinal cord and muscles work together to coordinate smooth movement; if the signals are jumbled and the message is interrupted between the brain and muscle by damage caused by MS the muscle can remain in its shortened state making the affected limb feel tight and heavy.  These jumbled and disrupted messages can also cause loss of coordination which can lead to spasm.   ​

Methods of stretching
1. Maintenance stretching
Involves short stretches in muscles which aren't particularly tight; often carried out during warm-up and cool-down phases of activity.
Muscle taken to the point of mild tension and held for 10-15 seconds to maintain flexibility. 

2. Developmental stretching 
Used to increase flexibility; the muscle is stretched in the normal range of motion then when it relaxes in position it is taken a little further and held near the end of the range of motion for 30-60 seconds to increase flexibility.  This is not recommended during the warm-up phase as the muscle needs to be warm.  ​

​Long-term benefits of improving flexibility
General benefits of working to improve your flexibility - outside of specific benefits to our MS include:

• Improved physical relaxation
• More effective and efficient movements
• Improved posture
• Reduced risk of low back pain
• Decreased DOMS (Delayed Onset Muscle Soreness) after exercising
• Improved coordination
• Improved development of body awareness

​A word of caution...
​This wouldn't be a post from me without a few words of caution;
1. Always make sure your muscles are warmed up before stretching: stretching cold muscles can result in injury.
2. Only stretch your muscles to a point of mild tension.
3. Be careful not to jerk or force you muscles into a stretch position which can cause jarring and injury
4. Be careful not to over-stretch a muscle: working at the furthest end of a muscle's range of movement can cause injury.
5. Stop if you feel pain; I know I've said it before, but 'no pain, no gain' doesn't apply when exercising with MS.
6.  Please consult a PT for clarification and example exercises if symptoms of spasticity and spasm are a challenge for you. 
OK, sorry, six words of caution but it's important to stay safe when doing any form of exercise.

​Cardiovascular (CV) fitness is the ability of our heart, lungs and muscles to take in, transport and utilise oxygen during exercise or any daily activities which make you breathe a little harder and pump your blood a little faster (you may have heard it referred to as cardio-respiratory fitness, stamina and aerobic fitness too).
CV activities do not refer exclusively to traditional, structured 'exercise'; any activity where your heart rate is raised for a prolonged period and you start to feel out of breath counts too.  My friends and I giggled during the personal training course when 'gardening' was used as an example of an activity which raises heart-rate and gives you a good workout; I live in the centre of a town where my gardening is limited to a couple of hanging baskets and a stone courtyard, but on mentioning this to my parents who live in the countryside they agreed wholeheartedly that it definitely provides them with a good form of exercise!   
CV activities increase the heart rate and breathing rate with the aim of increasing blood flow and delivering more oxygen to the body to produce energy.  When the pulse quickens and breathing gets deeper the cardiovascular system is working.  
Activities that will improve the efficiency of the heart, lungs and circulatory system- thereby improving CV fitness are those which use the large muscles within the body in a continuous and rhythmic way and include activities such as walking, running, swimming, cycling, rowing, dancing and aerobics classes.
​

​Alongside the general population health benefits of CV activity (available to all regardless of MS status), research has shown specific benefits to people with MS (PwMS) in terms of symptom management and improved ability to complete daily activities (known as ADLs: Activities for Daily Living).   
Regular CV activity has been shown to improve:

• Balance
• Coordination
• Mobility (specifically related to walking)
• Fatigue 
• Low mood
• Anxiety
• Depression

The guidelines below were published for the general population (ie those without MS) by the UK Department for Health in 2011 but it has become accepted that as far as is reasonable these apply to PwMS too (full reference below).  It is understood that the nature of the disease and the varied symptom patterns may make any level of activity challenging, however the benefits of CV activities to health outside of our MS are huge (as detailed earlier in this blog). 
As I mentioned in the previous resistance-training blog (and labour a little on the site!) the popular adage 'no pain, no gain' simply doesn't apply when exercising with MS; you should only do what is realistic for you and only you know that: not a personal trainer, training buddy or the distance of a run or bike ride you signed up to... just YOU.     ​

​If you are a gym-goer there are lots of adaptations available for using machines like the rowing machine or arm-cycling machines - both are great CV activities.  At home - a suggestion from the MS Trust's neuro-physiotherapist Liz Betts is arm-jogging whilst watching the TV or working on balance whilst waiting for the kettle to boil.  Small consistent actions can really make a difference to your fitness.   ​

​Please don't be afraid to ask for help if you're trying to work out how to start exercising; part of the PT course discusses MS so a qualified personal trainer can help put together a plan for you - in or out of the gym.  It is important that you explain about your MS and don't be embarrassed about admitting there are things you find difficult, the emphasis here is on 'personal' training so they can put together a bespoke plan which works for you and keeps you safe: safety whilst exercising is paramount.  For specific mobility-related queries it may be best to consult a physiotherapist too.
On that note, be careful about following YouTube videos by fitness bloggers; they are qualified in their own areas but they don't know you personally: one size does not fit all in terms of exercising with a condition like MS.  From personal experience pre-diagnosis and pre- PT qualification it can be costly in terms of physio appointments to repair any damage caused by following videos with no-one to correct possible poor form.  This is part of why I keep focussing on safety with anything to do with exercise.
If you haven't exercised for some time be sure to get agreement from your GP before you start to make sure there are no other factors you need to consider first.     

The idea for this post came from a study published at the beginning of August in the Multiple Sclerosis Journal exploring whether resistance exercise can show improvements in MRI and other clinical markers of MS disease progression. The article was quickly picked up and reported by the popular press- albeit with a rather sensationalist and misleading headline - screaming:

‘Resistance training SLOWS the progression of multiple sclerosis and even REVERSES brain shrinkage, study shows for the first time’.

Not quite so accurate once you read the full study (reference below) but it got me thinking about how resistance exercise can be beneficial in the management of MS. 
 
​
What do we mean by resistance exercise?
Resistance exercise (or strength/weight training) improves the strength of the muscle and its ability to resist force. 
Whilst this sounds frighteningly 'personal trainer-y' it can be as straightforward as lifting and carrying a bag of shopping (although that's not always as easy as it sounds).

Why might resistance training help with my MS?​
The premise behind study into the role of resistance training to help in MS is based on research indicating that PwMS often show loss of muscle mass over time (muscle atrophy).  This muscle atrophy is the result of decreased activity (eg walking and standing etc) and is not restricted to PwMS; muscle atrophy happens to anyone who is not active - or as active as they have been previously - for a period of time.  This loss of muscle mass further results in loss of muscular strength making functional tasks such as walking and standing, lifting and carrying even more difficult.    
In MS there is uncertainty around the origins of atrophy-based impairment; is it as a result of the disease activity per se (ie demyelination and axonal degradation in the central nervous system) and/or the consequence of reduced physical activity levels, in itself driven by effects of the disease? It’s a vicious cycle. 
A recent systematic review [consensus of results from a number of studies] revealed that despite the suggestion of muscular weakness as a result of disease activity it is evident that MS does not impede the ability of muscles  to increase in strength through training, thereby potentially improving ability to complete strength-related functional tasks (eg lifting and carrying).  It is worth emphasising that any improvements in strength are task-specific to the individual muscles trained.  
It is crucial here that you consult a physiotherapist or qualified personal trainer to pinpoint any specific weaknesses so that they can develop a bespoke programme for you; I can't reiterate enough the need to consult a professional on this, exercise can definitely do more harm than good if performed incorrectly.

​
Specific ways in which resistance training can help in MS         
Since it was established in the last few decades that exercise is beneficial to PwMS (contrary to early advice to avoid exercise altogether for fear of worsening symptoms of fatigue) many studies have attempted to quantify the optimal type and amount of exercise for PwMS.
Much of this research has been focussed on resistance training to address the evidence discussed above around muscle atrophy and associated weaknesses; after earlier studies established that aerobic exercise (eg running and cycling) can raise body temperature to levels which may exacerbate symptoms (Uhthoff's phenomenon).  More recent studies have shown that resistance exercise may be better tolerated by PwMS due to the shorter bursts of activity/effort required, and frequent rest periods naturally programmed between sets
Resistance exercise has been shown to improve:
​

Some ideas for resistance exercise...
Resistance exercise can come from many different sources including:body weight exercises (eg yoga and pilates poses, sit-ups, press ups or squats)

• Exercises using dumbbells, a barbell, kettlebell or resistance bands  (Before I invested in some weights for home I used filled water bottles as dumbbells!)
• Free weights (gym and with a spotter for safety)
• Water-based resistance in the swimming pool (usually as a class with floating resistance-devices)

Although on the surface resistance activity is not seen to be as 'social' or 'enjoyable' as going for a run or cycle with a friend if you are able (benefits of aerobic activity to be discussed in a later post) it has clear specific benefits for PwMS with regard to improving muscular weakness and maintaining muscle strength to complete functional tasks.  
That said, if you enjoy swimming and aren't affected by the temperature of the water, the classes which have foam 'noodles'/ 'water woggles'/ or whatever look great fun and seem to be enjoyed by people of all ages. Maybe take a friend and give it a try!      
 
What is the recommended amount of resistance activity?
The guidelines for resistance training for PwMS do not seem to differ from that of the population as a whole.  My website shows the general population guidelines for physical activity which includes two sessions per week for adults aged 18-65+.
As with any activity you should only do what feels achievable and can be completed safely.  Your ability is yours alone so only you know what is best for you.
 
Some notes on safety; it is paramount that you keep yourself safe while exercising.  Always use a 'spotter' when lifting weights, you never know when you may not be able to complete a planned exercise, so they are there to step in and help.  The same advice goes for anyone lifting weights, it is not exclusive to PwMS so always workout with a buddy when using weights; the weights really do hurt if you drop them.
See my page on tips for exercising with MS on the website; both from me and the MS trust.
    
And the final words from me...
Have a look at my website to understand more about how exercise can help us manage some of our specific MS symptoms.
Do let me know if you have enjoyed this post and found it useful.  Send me an email (address below); send me a tweet (@healthylifems) or send me a message through the contact page on the website, I'd love to know what you think.