Physical Therapist Dr. Mark Mañago’s work is focused on advancing clinical research in the field of rehabilitation in people living with MS. He recently joined the MS Center for an Empower Educational Series webinar titled “Living an Active Lifestyle with MS: Physical Therapy and Beyond.”
InforMS: How do you see your role as a Physical Therapist (PT) in a care team?
Mark Mañago, PT: When working with an MS care team, the PT is important in a variety of ways. Early in diagnosis and disability, a PT can help prescribe exercise programs that help people stay fit and prevent progression associated with lack of activity. A PT can be important when new symptoms present, such as difficulty walking, balance problems, falls, weakness, fatigue, or pain. If a person has more advanced disability, a PT can also be important to prescribe assistive devices and maximize function and independence.
InforMS: How is physical therapy different from personal training?
Mañago: PTs have graduate-level professional training and are experts in diagnosing and treating movement problems. Personal trainers have a scope of expertise limited to improving strength, flexibility, and fitness. In addition to being able to prescribe exercise programs and treat injury, some physical therapists have specific training in how to work with people who have neurological conditions such as MS.
However, I’ve often worked together with personal trainers. For example, if I identified a movement problem in a patient like a foot drop and designed an exercise program to address that, a personal trainer can supervise and manage the exercise program. You can get general exercise ideas and workouts from personal trainers and online videos, but I wouldn’t recommend trying to diagnose a problem or getting a specific treatment plan from a non-physical therapist.
InforMS: What are the benefits of a one-off visit to a PT before you’re having major troubles?
Mañago: Early in a diagnosis I think it is important to find a PT you are comfortable working with and review your overall activity level, assess your balance and walking, and make sure you have a specific, safe plan to stay active and fit.
Your PT should work with you to decide on an individualized plan of care that considers your schedule and specific needs.
InforMS: Are there different levels of support provided by PTs?
Mañago: Yes, early on we might be primarily focused on preventing disability and deconditioning. This typically involves periodic check-ins with a PT. In the middle stages of disability, a PT may be working on prevention strategies but also what we call “remediation.” That is, we are helping people to fix or improve problems they have related to MS, such as weakness or balance problems. Finally, we look to help people compensate for what they can no longer improve. This could mean anything from resting more throughout the day to manage fatigue, to using a cane or walker when walking becomes more difficult.
InforMS: Should people with MS exercise? How much? Are there specific exercises? What all does physical activity encompass? How hard does it have to be?
Mañago: Yes. Absolutely. Around 80% of people with MS don’t get enough physical activity and that can lead to deconditioning and worse health. There is no specific set of exercises, but people should strongly consider doing some exercise that is aerobic and some that is focused on strengthening. The general guidelines for exercise and physical activity are at least 150 minutes per week at least at a moderate intensity, and people with MS are no exception to that rule. However, it doesn’t matter as much if people complete all their exercise in long bouts, like 30 minutes or more, or in short bouts of, say, 10-15 minutes (or whatever works) as long as the total time adds up. Finally, physical activity is exercise too, so if you’re very active that can be therapeutic. However, this is sometimes hard to measure so that’s one reason to check in with your PT.
InforMS: What are some reasons why people with MS might not be as active as they want to be?
Mañago: People with MS have to overcome the same barriers as anyone: time and lack of motivation. But MS also presents its own barriers like fatigue, weakness, bladder issues, and heat sensitivity, among others. People with MS may also have a lack of knowledge about what types of exercises they should do or can do safely. A physical therapist can help with gaining the knowledge and confidence for what you can do safely. And a PT can talk through possible solutions for the various MS symptoms that are barriers for you.
InforMS: In your webinar, you discuss the difference between self-reported fatigue and performance fatigue. Why does this distinction matter?
Mañago: Knowing which type of fatigue you are experiencing is good to know when you’re deciding how to treat it or overcome it. Performance fatigue or fatiguability is sometimes easier to treat because you can use intervals or periods of rest to break up activity to allow you to exercise for longer. Self-reported fatigue is more complicated and what works varies from person to person. This is where it can be helpful to have a team approach to working on it. Your physical therapist may give you exercise adaptations. A neurologist can prescribe the appropriate DMT or other medications. An occupational therapist can help make your daily movement more efficient and suggest pacing for your day. A dietician can make sure you’re properly fueling your body with nutritious foods. A psychologist can help improve your motivation with cognitive behavioral therapy or mindfulness-based stress reduction techniques. These solutions each might help your fatigue a little here and there, but when several techniques are layered, the effect can be quite meaningful.
One thing that really works for some people is to keep a log of what they’re doing and how it makes them feel, particularly their fatigue level. This can be really insightful and can help you identify cycles. If you are overdoing it on days that you feel good and then experience several days of higher levels of fatigue, you can figure out the right pacing so that you have a more balanced day-to-day experience. Since so much of improving fatigue is trial and error, a log can help you see what works and what doesn’t.
InforMS: There are lots of reasons why MS can make physical activity harder, can you tell us a little more about the many ways to chip away at these barriers?
Mañago: Having good social support has been shown to be very beneficial to many people. It can help with both motivation and accountability. Signing up for a group class or sessions with a physical therapist can also add a layer of accountability because you’re paying money for it. You may not continue paying for these forever, but they can help set up the routine and habit that you want to build.
Manageable goals are also really important. If you’re living a very sedentary lifestyle, 150 minutes a week might be out of reach. So you can start with 10 minutes a week, then 20, and so on until you’ve reached your ultimate goal. If you’re starting at zero, anything is better than nothing. Even small changes can be important and create meaningful improvement.
You can also try reframing the goal from “getting in more movement” to “decreasing sedentary time or time spent sitting.” It’s a bit harder to track your sedentary time yourself, so think about how long you’re sitting for at a time. You can set an alarm to go off every 20 minutes and then you get up and walk around or stretch for 5 minutes. Some everyday activities can count toward your physical activity if they’re moderate intensity: household cleaning, yardwork, even some errands.
Because MS is so variable in its symptoms and the ways that it affects people, it’s difficult to have an “MS Workout Class” but that’s why it’s important to explore and try different activities to see what works for you. If you have mild or no disability, there’s not really a limit to what you can try. At higher levels of disability you can meet first with a physical therapist to get their recommendations and then consider community classes that are supervised with someone that you can talk to about modifications and safety concerns.
InforMS: Any tips for how to find a physical therapist?
Mañago: Some PTs have a specialist certification in neurology from the American Board of Physical Therapy Specialties (ABPTS). You can go to ABPTS.org and click on “Find a Specialist” to see if there are physical therapists with this certification in your area. If there are no neurological specialists available to you, going to a physical therapist of any kind can still be beneficial because of their advanced level training. When you are researching, it’s important to mention that you have an MS diagnosis and ask if they have experience with that.
At your first meeting, you should learn about their treatment philosophy and recommendations. You want to be comfortable and confident in your provider, so it’s important to find a PT that meets your needs and style. There are many different styles and types of physical therapists out there. Always remember that you are in charge of your care team.