Posted - September 2009 in Living with HSP - Management & Treatment News
Fitness – a key to maintaining mobility for HSPers
by Lea McQuade, Physiotherapist*
Part 2 of a 2 part series(read Part 1)
Pilates & Yoga
Boxing style fitness sessions
Aerobic Classes / Circuit training / Boot camps
Gym and weights based resistance programs
Other Forms of Exercise
3 Final Tips
Let’s talk about different forms of exercise.While variety in exercise is good, every form of exercise does not suit everyone equally. HSPers vary in age and level of symptoms, and what suits one person will not be practical for another. Always seek individual advice from a qualified professional such as a physiotherapist.
The most common form of regular exercise, requiring no special equipment is adaptable to almost any situation. Many HSPers describe walking as something they have to pay attention to, step by step, to avoid tripping. For those HSPers who can manage walking, it is a good mainstay of fitness.
Here are 3 things to help make it easier for you to transfer the weight from one leg to the other with more control.
1. “Walk Tall’ as the old song says, and find your natural rhythm. Think of lifting your body weight up off the legs, to make it easier for them to move under you. Get more ‘up and over’ your feet with your body weight.
2. Keep your stance narrower, feet closer together – less shifting side-to-side as you walk.
3. Keep step length fairly small, rather than long striding.
The stronger the large muscles are in the centre of the body (core stability) the more ‘held together’ the trunk is, and the more easily the legs can be used to propel efficiently. This is the focus of much Physiotherapy research in recent years.The popular Pilates approach focuses on core stability and is discussed in a section later on in this article.
Many HSPers lock their knees during the ‘Stance’ phase of walking. To counter-act this, concentrate on getting the front of the hip/groin area forwards (bottom under) as your body advances over your planted foot, rather than let the hip slump and bend which pushes your bottom behind you and makes your lower back over-arch inwards.
Visualise an elastic strap making a connection between the backs of both legs at the very top, and between the tops of the legs and the underside of your buttocks. Try not to completely release that connection from the moment you prepare to stand up and whilst walking, etc. When walking, consider a leg moving forward as a preparation stage, stretching the elastic bands so that the leg recoils back underneath you with some momentum, pulling the ground under your foot with it – so driving your body upwards and forwards over that ground.
When going up slopes or steps – tuck your bottom under you, point your chest and groin up to the top & consider your legs making a cycling motion underneath to drive you forwards and up the whole rise. As you raise each leg, consider how you are stretching the elastic band that will drive the leg back down again. It is normal and efficient to use rising up and down on the toes for stairs.
Coming down, again tuck your bottom under and consider your trunk and pelvis moving upwards, whilst your legs control the bending for the descent. This keeps your weight back over the heel of the rear foot until the toes of the leg moving forward find the lower ground without you leaning back. Again use whatever your ankles can do to assist you.
Shoes & Aids
Well fitting shoes will help the efficiency of rolling from heel to toe along the length of the foot and increase confidence on more uneven ground. There are some shoes on the market specifically designed to assist with the front to back roll of the foot, which may assist with propulsion. You could seek advice from a podiatrist if these are suitable for you.
The greatest overall health benefits are gained by moving at a moderate to faster tempo. However, for many HSPers, walking at any pace can be quite a workout. Strive to push yourself along within your comfortable tolerance, and as spasticity allows. Walking at a slower speed generally requires much more control and effort.
If you feel an aid is sensible for balance or just to assist with the ‘push along’ technique then try ‘walking poles’ (also called Nordic Poles) such as a ‘Happy Hiker’. Walking sticks on the other hand encourage leaning down on them, whereas the longer poles are gripped vertically. Try one or two walking poles used like ski poles – helping to drive you forward over the terrain. The correct length (they are telescopic) is with the forearm at 90° when your arms are by your sides.
To use them effectively – keep your shoulders wide, your lower back tucked in, your elbows fairly close into your sides and the poles at an angle slightly backwards from the vertical. It’s a short ‘push-back, press down’ action as part of normal arm swing. They are available from $50 each (& upwards) at outdoor retailers, and adjust in length to suit each person. Several colleagues and I have observed that when someone has already developed an altered walking pattern, focusing on how they use their arms as described above, may allow the body to find a different and improved pattern for the affected legs.
HSPers who are experienced runners can have a highly automated pattern of activity that can often be maintained well despite greater difficulties with walking. Fast manoeuvring can often present the greatest problem for game playing. However, if you are a ‘jogger’ – beware! because at slower speeds patterns of muscle activity vary greatly, postural stability is readily lost and the additional pounding on hips and knees can quickly result in joint problems and worsen spasm. Running training for people with Neurological conditions is a new area, with few experienced professionals to guide you, as yet.
A substitute for normal walking especially in inclement weather – HOWEVER – the rolling belt action detracts from the normal drive back of the legs under the body which we use to propel us forward, meaning there is less use of some of the most important muscles of walking. Also because of the ‘ground’ movement, many people feel that they need to hold on to the machine rail, and often lean back to counterbalance, and so hang on by pulling themselves forward with their arms rather than propelling with their legs. This alteration in alignment often results in more ‘pick up’ leg action, especially if there is concern of catching the toes on the belt. This is likely to exaggerate abnormal muscle activity and is to be avoided.
From my observations I would suggest that using a treadmill is NOT a recommended option for HSPers, UNLESS they are familiar and comfortable walking without holding on and can push back with the belt at a reasonable pace. If one side of the body is considerably less affected than the other, then the treadmill could be a reasonable option, with the above considerations.
Like many of the other activities, this can be difficult if there is already established toes-down spasticity. The focus should be on keeping the heel down, driving down underneath you from the top of the stroke, so lengthening the back of the leg.
In cycling one uses the inner thigh muscles (hip adductors) often, especially when pushing up hills or rising out of the saddle – in both cases the focus should be on the rear adductors underneath, squeezing you up off the saddle or shifting weight from pedal to pedal. Even without toe clips or shoe cleats there can be a tendency to ‘pull up’ especially at the top of the pedal rise – this is best avoided as it can affect the hip muscles needed for walking and climbing stairs.
If balance, or getting on and off become an issue for a seasoned cyclist, attaching ‘stabilising wheels’ or converting to a tricycle could be a good option to continue a favourite activity. If terrain is a problem, the recent advent of powered bicycles, where assistance from a small motor can be added when needed to normal leg power, may make cycling more feasible for an HSPer.
This can be an excellent form of exercise for HSPers. Whether on the road or in the gym, Bike Seats are frequently too wide and too far back from the pedals for efficient ‘press back and down’, especially for taller people, so experiment to find your best position. In all cases, advice on best seat height and position is paramount. The pedal crank should be close to vertically underneath the point of the hip and the knee still slightly bent when the heel is pushed well down at the bottom of the pedal stroke.
Aim to keep the pelvis level and stationary on the saddle, separating the leg action from the body. If you prefer to bend forward and rest on the handlebars, try to keep the chest pushed out forwards and the shoulder blades stabilised down your back, with elbows close together to support the neck.
I would advise against the recumbent versions of exercise bikes, as it appears much harder for many to use the rear push ‘down & back’ muscles in this position.
Ballet, classical, salsa, line dancing – all dance is excellent for balance, body alignment, lightness on feet, fluidity and co-ordination with superb CV benefits.
Start early. Close partnered dancing has a significant effect on enhancing excellent posture. Dance around the house.
(For every up on the toes, ensure smooth lengthening of the calves to lower heels again, not fall backwards down onto heels or stick bottom out)
Not so sure about ‘break dancing’!!!
Swimming is often advocated for those with ‘joint wear’ issues especially osteoarthritis of knees, feet or hips, because there is minimal joint loading with movement in swimming. It also has the benefit of whole body use, involving many muscles at once, which is why it places a workload on the heart and breathing. You need to be fairly efficient to get reasonable cardiovascular benefits from swimming. Many people fatigue and stop before that point, mostly because of breathing inefficiency. A snorkel could help that initially. I recommend inexperienced swimmers get good coaching for efficient technique.
Many HSPers report swimming or other aquatic activity as their exercise of choice and with which they have the least problems. I would imagine that crawl/freestyle’s controlled rotatory action of the body around the spine would limit spastic effects whereas breaststroke kick may be more difficult in someone with established spasm. Core stability of the trunk is essential to allow the limbs freedom to work, so work on that ‘saggy’ belly if you currently have one!
Many forms of aquatic exercise are potentially excellent as a long-term, enjoyable and central part of an HSPer’s physical activity and fitness regime. However there are pros and cons of different forms of aquatic exercise for someone with HSP. Buoyancy makes some exercises easier; the resistance of the water makes others harder.
Walking faster in waist depth water requires push back against the ‘drag’ resistance and could be a beneficial activity; however, walking slowly in waist depth water has little benefit and could worsen spasm.
Balancing sitting on a ‘pool noodle’ (a flexible, cylindrical polythene float device) under the buttocks or between the legs can be an effective core stability exercise. Similarly ‘water running’ in deeper water with a float waist belt could also have value, while working on standing in deeper water tends to lift people up onto their toes and makes lengthening the calves even harder than normal. A lot of aqua-aerobic classes encourage people to ‘pick the knees up’ or do half-squats to involve the arms under the water a lot of the time – I would not recommend this for HSPers as again, it can affect the hip muscles needed for walking and climbing stairs.
For HSPers, or anyone with a neurological condition, I suggest personal, professional advice by a Physiotherapist experienced in Aquatic Therapy about how to do your preferred water exercise safely and effectively.
Pilates & Yoga
Both of these activities focus on core body stability, control, strength and balance, through smooth and specific exercises designed to keep muscles long and lean. They focus on achieving stability of the pelvis, trunk and shoulder girdles in preparation for separate movements of the limbs. This is very similar in approach to the current thinking of Physiotherapists.
Both are excellent activities for HSPers provided they are done well. HSPers would be advised to pick small group sessions where the instructor can analyse your abilities and difficulties throughout the class to ensure you are achieving the desired techniques and getting results. Some people are put off because many exercises occur on a mat on the floor, which is difficult for them, but this problem can generally be overcome in a small group through discussions with the instructor. Pilates can also be performed on specific machines, but this usually requires one-on-one or one-on-two instruction.
There are many types of Yoga approaches, and anyone interested should discuss the appropriateness or goals with the tutor. A class where the flow of exercises is maintained can also have some cardiovascular benefits.
Boxing style fitness sessions
Increasingly popular with many age groups, and works on balance, reflexes, coordination, strength and stamina. Good coaching is essential for HSPers!
Aerobic Classes / Circuit training / Boot camps
Many have a fast-paced focus for the cardiovascular benefits.This can be difficult for someone with deteriorating coordination and increasing spasm. They often have large participant numbers and are not as focused on the individual. Rarely is there a second instructor who gives ‘on the floor’ guidance. The frequent change of movement also requires fast responses and challenges the very systems most damaged in HSP. For those HSPers inspired by this type of activity – class choice is paramount!
Similarly, home exercise videos do not allow interaction and feedback on your technique, but they do often frequently repeat the key coaching points of each exercise and you can take it at a more personal pace and repeat sections as you wish.
Gym and weights based resistance programs
Consider that if you are taking ‘Baclofen’ or other anti-spasmodic drugs, they work by inhibiting the conduction of some nerve impulses, therefore many people with neurological conditions taking these medications report feeling generally weaker. They report that these drugs can seem to exaggerate the difference between the strength of affected muscles and unaffected muscles.
Therefore, regular consultation with an experienced trainer should be a must and probably in consultation with an experienced Physiotherapist to ensure that the balance of muscles trained is appropriate in someone affected by HSP.
A mix of both strength and endurance is ideal and will be different for each individual.
Progressive resistance exercises generally involve ‘free weights’ e.g. dumbbells, or machines, and often both. Free weights and pulleys have some advantages – they require greater postural stabilising; also greater concentration on, and consideration of, technique for both effectiveness and safety compared to resistance machines. The movements on most resistance machines are isolated and somewhat divorced from the normal functional use of the strength, but they can have their place if targeting of specific muscles is desired.
Developing specific strength in individual muscles can be beneficial providing it is then trained into functional movements. Recent studies with the Stroke population have demonstrated that progressive resistance training does not increase spasticity, however this may not be the case for everyone.
Poor and possibly harmful technique is evident in many people who attend gyms and do resistance training.Get professional advice and guidance, at least until you really know what you are doing.
The strong ‘leg press’ action and need for considerable flexibility required in the legs and low back for sitting with legs outstretched can be a problem with spasticity. As can the timely co-ordination of upper body and legs as power is required which needs faster movements. This is a demanding exercise both in terms of co-ordination for desired technique as well as the physical stress. However balance requirements are minimal, but getting up from the low machine (similar to out of the boat) can be difficult when fatigued. Good initial technique coaching is essential.
There are machines around in fitness centres that simulate the action well, with the ability to vary the resistance. Good paddling technique relies on developing good body control around the pelvis and lower trunk to allow the smooth spinal rotation required for the arm action, otherwise there can be considerable strain at shoulders and forearms. This is likely to be a more suitable activity for HSPers but is much less available than rowing machines. Good initial technique coaching is essential.
Other Forms of Exercise
Horse riding – many similarities to cycling with less effort.
Surfing / body surfing – just being challenged in the waves can be excellent strengthening, CV and balance training. Beware of too much sand walking as there can be a tendency to overuse less desirable muscles and a sideways slope can be difficult.
Sailing – (being in the crew that is, not just lazing back under the canvas).
Tennis – if tennis is beyond you then try ‘Swingball’ or ‘totem tennis’ in the backyard or park. Great for CV, coordination, balance and some strengthening.
Golf – often too much standing around, and slower speed walking – using a ‘driving range’ and ‘putting green’ is probably a better option as you dictate the pace. You need good core stability and efficient muscle use to be effective.
Bowls/Bowling – specifically good for balance and weight shifting – very difficult to do well unless most leg muscles are working as a team. No CV benefit.
Basketball – shoot basketball hoops with the kids. You might want to stay off their scooters and skateboards though!!!
Whole body vibration (WBV) – 2 types. This is a new concept beginning to appear in Fitness and medical specialist centres. Purports to give overall workout just through standing on a vibrating platform for a few minutes. Claims to improve strength and coordination and bone strength. Many of these claims have some evidence behind them, but use with people with neurological conditions requires more consideration of the individual than will generally be found in a fitness centre. Such units are now turning up in Physio practices, but experience with this treatment is still in it’s infancy.
This is a difficult topic because there is little scientific evidence regarding the efficacy of stretching regimes in those with neurological conditions. There is also little guidance on the most effective way to stretch, e.g. prolonged or short duration. Muscles generally become shortened or tight if overactive especially if other muscles around the same joint or nearby joints are weak or inhibited for some reason. This could just be the habit of the individual to ‘favour’ some muscles over others because they have ‘learned‘ to move that way or because of neurological changes or injury. Other muscles become short or tight because the joint over which they act is never taken to it’s full range to lengthen them out, often for the same reason as above.
Aggressive stretching of muscles that have not been warmed up by gentle activity pumping blood through them can easily cause damage within the muscle tissue. This can then lead to further restriction of range of movement and ease of lengthening.
Aggressive stretching of a muscle that is short for a reason, as above, can also cause problems with joint control and stability and lead to injury if the muscle relaxes or is stretched so that it no longer contributes to control of the joint motion.
As stated before, incorporating a mixture of activities using different body parts in different activities that include opposite movements, e.g. pushing and pulling, taking them to as full a range of movement as feels safe and controlled is probably the best management strategy. Considering what postures and positions the body is experiencing throughout the day or week, especially those that are prolonged can give clues as to why some muscles seem tight or movement restricted.
Where possible, stretching should be through active use of opposite muscles, e.g. stretch the upper front area of the shoulder by contracting the rear lower shoulder blade muscles, and vice versa.
3 Final Tips
1. ‘No Pain – No Gain’ does not apply to any of the above! Exercise within your limits and back off if experiencing pain.
2. The greatest benefit of these and all activities is when the principles and the gains are carried over into all daily movements!
3. Frequent use maintains the skills. “Use it or lose it” or should that be ‘Use it well or lose it’.
Lea has many years experience as a practising physiotherapist. She has patients with HSP and works to manage their symptoms, maintain their mobility and keep them fit.