Being active with CMS
HAYLEY RAMJATTAN
NEUROMUSCULAR PHYSIOTHERAPIST
APRIL 2016
Objectives

Role of the NM Physiotherapist

Understanding Myasthenia

Benefits of exercise & National Guidelines to exercise

The impact of exercise in CMS

Types of exercise & activity

Pacing & Goal Setting

Case Study

Workshop
Neuromuscular Physiotherapist

Assessments in clinic – objective and QMG

Advice and guidance on exercise

Specific exercises

Links with community therapists
Benefits of exercise

Improves cardiovascular fitness and
endurance

Helps develop and maintain joint flexibility,
muscular strength, and balance

Reduces the risk of diabetes and some
cancers

Helps control weight

Improves bone density
Government Guidelines to exercise
Physical Activity Guidelines for adults (19-64 years)

Aim to be active daily

Over a week activity should add up to 2 ½ hours moderate
intensity exercise or 75 minutes vigorous exercise
…. 30 mins of activity 5 days a week

Moderate – brisk walk, gardening, cycling

Vigorous – running, swimming, football
http://www.nhs.uk/Livewell/fitness/Documents/adults-19-64-years.pdf
The impact of exercise in CMS
Negatives

Muscle fatigability with repetitive
movements

Post exercise fatigue

Impact on ADLs

Exercise induced myalgia

Ocular and speech difficulties
Positives

Improved balance

Easier ADLs

Reduced fatigue?

Strength training can be beneficial?
The impact of exercise in Myasthenia
Types of exercise & activity

Aerobic activity

Strength training

Stretching
FITT guidelines for strength resistance training in Multiple Sclerosis

Frequency = 2 days a week

Intensity = 60%-80% of 1-RM

Time = 1-2 sets of 8-10 repetitions
ACSM guidelines (2014)
Pacing

Battery power

Watch for signs of fatigue

Diary

Managing exercise induced myalgia

Specialist support
Setting Goals

Functional goals

Keep you focused

SMART

Discuss with physiotherapist
Case Study - History

28 year old male

confirmed diagnosis of Congenital Myasthenia, GFPT1

Mobility difficulties at early age – delayed in attaining motor skills

Predominant wheelchair user

Medication:

3.4 DAP (15mg 3-4x/day)

Pyridostigmine (60mg morning, 30mg every 3-4 hours PRN)

Ephedrine Hydrochloride (15mg once a day).
Case Study - History

Volunteers twice a week (4 hours)

Physically active – gym and swimming (weekly)

Functional abilities and challenges:

Predominant wheelchair user

Stand max. 30 seconds before rest needed – anxious about mobility and falling

Vision limited (~20%)
Case Study - Intervention

8 week programme

MS guidelines (ACSM)

Adapted to suit individual with CMS

Reduced repetitions

Increased sets

FITT guidelines for strength resistance training in Multiple Sclerosis

Frequency = 2 days a week

Intensity = 60%-80% of 1-RM

Time = 1-2 sets of 8-10 repetitions
Worked opposing muscle groups

Resistance programme 2 days a week

Separate Upper Limb & Lower Limb programmes
ACSM guidelines (2014)
Case Study - Intervention

Stretches daily – knee extension
FITT guidelines for stretching in Multiple Sclerosis
•
Frequency = 5 days per week
•
Intensity = 3 x each leg
•
Time = minimum of 30 seconds
ACSM guidelines (2014)

Aerobic activity added at week 4

3 minutes, 50-60 RPM, 60-80% HRR, recumbent bike or hand bike
Case Study - Results

Goals achieved:

Holding a front support pose for 30
seconds

Completing three inclined ¾ pressups dips in a row, with >10 degrees of
elbow flexion.

5 x Sit to Stand = 10.76 seconds
(baseline 13.25 seconds)

Standing Long Jump = 40cm
(baseline 25cm) 60% improvement!

Muscle strength improvements –
Knee extension increased by 40%
Case Study - Summary

Resistance training programme can be beneficial in individuals with CMS

Importance of pacing activities

Noticing signs of fatigue important in progressing programme

Attaining 1-RM challenging in CMS

Benefits of Aerobic activity in CMS remain unclear
Key Messages

Specific graded exercise is safe

Know how to pace yourself

Remember your triggers and tell-tale signs of fatigue

Consider strength training over aerobic activity

Set functional goals
Workshop

Questionnaire

Exercise - what works for you?

Nutrition

Give it a go!
Hayley Ramjattan
Neuromuscular Physiotherapist
Hayley.ramjattan@ouh.nhs.uk