Interview Conducted by Kerri Cechovic | Dr. Jeffrey Hebert’s clinical and research expertise includes examining, treating and investigating balance, fall risk, mobility, fatigue and other related negative symptomatic outcomes, muscle and brain function, and the efficacy and effectiveness of exercise approaches in patients with neurological diagnoses, including persons with MS and mild traumatic brain injury. Dr. Hebert developed a novel conceptual framework of the complex interrelationships of balance, dizziness and fatigue. Based on this framework, he has constructed an innovative, multi-faceted vestibular rehabilitation program, the Balance and Eye-movement Exercises for persons with MS (BEEMS) program, which is the focus of much of his clinical and research efforts.
InforMS: Many people feel overwhelmed by the idea of incorporating an exercise program. Are there helpful ways for people to think about exercise to help overcome that feeling?
Dr. Jeffrey Hebert: Exercise has historically been defined in very specific and rigid ways. For most people, that isn’t a helpful approach. And, in reality, exercise doesn’t have to be 30 minutes on a stationary bike or 30 minutes exactly on some kind of equipment, and then you’re off to do three sets of this and two sets of that.
What it’s really about is reducing your sedentary time, and I find that shift in thinking is very helpful for people. I counsel people that 30 minutes is the amount of time where you can be completely sedentary, not moving at all. Beyond that time, you start to chip away at your general health. The most important thing is to reduce the amount of time that you’re inactive, and to spread out your physical activity throughout the entire day.
InforMS: Let’s talk about that idea. People are hearing all of the time about the importance of exercise and specific guidelines to achieve. Are there any misconceptions people have around those guidelines?
Dr. Hebert: The guidelines for physical activity from the American College of Sports Medicine, American Heart Association, and Medical Associations are 150 minutes of activity per week. Most people assume that that means it must be 30 or 45 minutes of exercise all at one time every day. In fact, it’s a cumulative total time for that week.
People may be surprised to learn that research shows us that if you vigorously work out for an hour in the morning, but you then go to work and you’re not moving from your desk at all throughout the day, you’ve almost erased the benefit of what you did at your workout that morning. It’s important to try your best to pull yourself away and move around every hour of the day. Walk around, walk up and down the stairs a little bit and then go back. If you use a wheelchair, see if you can scoot yourself away form the back of the chair and sit unsupported for a little while. Then see if you can move your arms and just move for the next five minutes. Any part of your body that moves is activity and exercise.
I also think it’s important to point out that you don’t have to love exercise or being more physically active. But, you do have to love the benefits of what that brings. Believe me, every time I’m about to go for a run, I’d rather be sleeping, or surfing the web, or playing with the dogs. When you’re feeling that way, it’s so helpful to acknowledge that feeling and then give yourself a moment to remember the benefits that will result from that movement.
InforMS: And what are the most important benefits of exercise especially for people living with MS?
Dr. Hebert: There are two main pillars of potential functional impairment in MS: First, immobility or impaired gait; and second, cognitive decline. Exercise has been shown to improve gait, balance, and possible cognitive function.
In a patient with MS, it’s even more important to protect the brain and make it healthier. Research shows us that exercise leads to not only brain protection and enhancement, but also neurogenesis — which is growing actual new brain cells.
We also know there’s a direct correlation between increased activity and increased brain volume. In individuals who have more physical activity, important areas for cognition in the brain, including the hippocampus, have been shown to be larger. A major factor of this cause and effect relationship is that a brain-derived growth hormone is released when you are exercising – it’s like fertilizer for your brain.
In addition, there are anti-inflammatory components of exercise. It helps protect and reduces the degenerative process that naturally happens in all our brains, whether we have MS or not.
InforMS: How do you address the challenges of changing behaviors and habits with your clients?
Dr. Hebert: When I’m working with an individual, I’ll discuss the progressive steps involved in making behavioral change with them. These steps are: contemplate, adopt, start and maintain.
I make sure they know it’s going to take time for them to go through these steps. I assure them it’s okay, and it is human nature to fall back down those steps. But where we can’t let you stay is back at the lowest step.
People drop exercise all the time, but if they drop it for long periods of time and stay on the lower step, then we’ve got a bigger challenge to restart the positive changes again.
When some people are diagnosed with MS, they unfortunately think “there’s nothing I can do about it.” That’s not at all true. But the thing you can do does take some effort: maximizing your physical activity throughout the day.
Other challenges may be common physical and symptomatic hurdles for people living with MS. Of particular regularity are impaired balance and mobility and fatigue. Thus, it’s important to take action to eliminate or reduce these barriers in order to optimize your ability to initiate exercise-related behavioral change and succeed in your journey to maintain these positive behaviors.
[/su_column] [/su_row]In my research with the BEEMS program, the balance and eye movement exercises patients practice lead to improved effectiveness and efficiency of daily activity performance, helping to reduce the effort it takes to stand and walk and in essence how much energy it takes people to focus mentally. I theorize, by improving balance – mastering ones “place in space” and control of their eyes even a little bit better people are not using up as many cognitive resources mainly due to lessening the load on conscious and subconscious processing. This concept may also be a reason for the reduction of fatigue in patients that participate in the BEEMS program. Collectively then, improved balance and fatigue results in improved capacity and ability to engage in physical activities safely and effectively.
InforMS: Are there any particular strategies and tools that people you work with have found helpful to maintaining an exercise program?
Dr. Hebert: Monitoring can be a very effective strategy for some people. It helps maintain accountability, gives you an understanding of where you’re at, and the progress you’re making. It’s all about meeting that particular individual’s needs.
For some people it’s very helpful to have the answers to the questions, “Where am I right now?” and “Am I maintaining this?” So, if someone is visually or technology oriented, activity monitors like FitBits can be very helpful. (On the subject of FitBits and other step-counters, it’s important to note that the well-known step count of 10,000 has not been validated as the optimal step count for heart health or general health, especially as it relates to people with MS).
InforMS: Do you have any specific examples of adaptation strategies people have used to help adopt or maintain an exercise program?
Dr. Hebert: A couple of different clients come to mind who are reflective of two fairly common scenarios.
The first is a gentleman who recently asked me, “How am I going to get more steps in if I can barely walk?” The number one barrier to your physical activity is falling, and the inability to walk for longer distances. With muscle fatigue and MS, it’s important to make sure we don’t get to the point where you fatigue muscles so much you can’t lift your legs anymore. That is when you start to diminish muscle function often leading to moving slower and you are no longer benefiting from the activity because you are just working on survival.
For this individual, we focused on incorporating an assistive device, a four-wheeled walker that would enable him to be more physically active. This device can then be utilized for two reasons. First, I have emphasized with my patients that this device needs to be considered as your “portable treadmill.” You have both of your hands on it and you’ve got mobility underneath you just like a regular treadmill. Second, it gives you a level of safety required for you to capitalize on your efforts to exercise. These factors offer you increased flexibility – you can use it for intermittent walking or interval training, using the seat to provide that complete rest between the active intervals which is essential for muscle recovery. The seat can lock down. You then turn around and sit down for a couple minutes, then get back up and walk, repeating this sequence that best matches your desired accumulative exercise.
It’s important to help people understand that assistive devices aren’t limitations to activity, they are enabling more physical activity for those that require them.
The second person that comes to mind is a fully-ambulatory young woman in her thirties. When she came to see me, she explained that she had recently started tripping, was running long distances at her normal pace, and wasn’t able to do marathon running any more. With her, we focused on a balance program (BEEMS program) and then on improving her training so she was focused on intervals. These adaptions to her training program would help ensure she wouldn’t get to the point of fatigue, particularly in her muscles and by reducing the added efforts of maintaining her balance while running.
It was also important for her to incorporate these interval training methods into a marathon. Initially, she responded to that idea with a level of disbelief: “Wait, you want me to stop, rest, and sit down at a water break? That’s not possible, I have to keep going!” I explained that without taking some breaks, she’d start to get slower and slower throughout her run, and her tripping would likely increase.
She agreed to try this approach. She ran her marathon and reported back to me. Not only did she run and complete the marathon, and did not trip… but she also ran her personal best. She did all those breaks, and it was really hard, because she was thinking she needed to keep pushing to get to that finish line as fast as she could. But in fact, it was like running a series of smaller races, much like longer versions of interval training, that allowed her to perform at a higher level during each “mini race” and when added together, resulting in the optimized accumulative effect on her full marathon performance and completion.
So, the fundamental lesson here is that when you are trying to increase your physical activity, respect the fact that you can’t keep pushing until your leg starts to drag or you start to get really fatigued. For many people, it’s helpful to think about it as little bouts of exercise throughout the day.
And running is just one example. If you’re not currently active and spend a lot of time at home, it might be focusing on walking from one room to the next room in the house. Take that walk multiple times throughout the day – start with five times per day and build to twenty times per day. It’s important to build slowly and safely.
For many patients with MS, each day is a “marathon”, but if you organize your resting/sedentary time and your exercise/physical activity time in intervals or “mini races” you are more likely to reach your very own “personal best.”
InforMS: Could you talk a bit more about the importance of safety when beginning an exercise program?
Dr. Hebert: Everything has to err on the side of safety. It’s problematic to advise someone, “Well, you should walk more,” and not take into account the possibility of unsafe behavior. But again, then you appropriately compensate for it, whether it be a brace for the ankle on the foot that’s dropping, or a possible walking stick, or rolling walker with a seat. It doesn’t mean that you can’t be physically active, those devices will allow you to be just that, active. You’re never too disabled to benefit from activity.
If you can move anything, if you’re in a wheelchair and all you can move is your head, then you can move that head up and down, pressing against the back rest and that will create some activity in your spine. It’s something. Because the more inactive you are, not only does your heart get unhealthy, but also your muscles can be quite deconditioned too, leading to the acceleration of disability and a vicious, negative cycle.
InforMS: What is your number one piece of advice for someone who feels overwhelmed by what feels like a daunting proposition?
Dr. Hebert: We’ve talked about it a little bit, but we need to continue to change the paradigm or the operational naming of exercise. Just that name — “exercise” — is going to bring to mind someone that is running or biking or doing something strenuous. The number one take home message is to make sure you understand that your activity throughout the day — and limiting your sedentary time during the day — is what we are really talking about.
It’s about changing those ratios: less sitting and not being active, because if you’re not sitting as much, you automatically have to be moving more. You’ll benefit from that, without ever jumping out of the chair and getting on a treadmill. Just being less stationary is going to equate to overall activity.
You don’t necessarily need to monitor your heartrate to know you’re exercising, the one data point you want and have at the ready, is how long you’ve been sitting. If you measure that and chip away at your sitting count — that’s the metric we want to be looking at. When we think like this, it’s not so daunting. I’ve had clients come back to their second session and say, “it’s revolutionary and it’s not high tech.” Low tech is going to be more adoptable for many people as well.
If you are going to log anything, log your sitting time. As you get a little more into the “this is feeling pretty good,” then you want to take that next step. Do you want to talk about if you get into a certain heart rate zone, what that’s going to do to your heart and in turn, what that’s going to do for your brain, because we already know you have been decreasing your sedentary time. You are already capitalizing on that, your brain is already getting more healthy; you might not be able to measure it, but it’s happening, now do you want to continue on that route?
So, very often your first session is that first step of behavioral change, contemplation. It’s not successful to leap over that first step. You have to think about it, contemplate it; and that’s where we start.
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