S2E4 Using exercise to build neuroplasticity with Dr Gretchen Hawley

Geoff Allix  00:00 

Support for the Living Well with MS podcast is provided by Overcoming MS. The global charity registered in the United States, United Kingdom and Australia, whose mission is to educate, support and empower people with MS in evidence based lifestyle and medication choices that can improve their health outcomes. Please visit our website at www.overcomingms.org to learn more about our work and hear directly from people around the world, about the positive impact Overcoming MS has made on their lives. Now on to today’s episode. Joining us this week is Dr. Gretchen Hawley. Gretchen Hawley is a doctor of physical therapy and Multiple Sclerosis certified specialist. After graduating from Simmons University in Boston, she developed a Multiple Sclerosis program alongside two of the city’s top MS Neurologists. Dr. Hawley utilises the concept of neuroplasticity to improve strength, balance and walking in those with MS by using specific functional exercises. She has been a keynote speaker at several National MS Society events and other MS focused conferences in 2018 and 2019, and presents frequently to MS groups. Dr. Hawley brings a keen understanding of the challenges faced by people living with MS and has developed a virtual physical therapy programme to help people improve their MS symptoms while in the comfort of their own home and guided by an MS specialist. Dr. Hawley resides in Buffalo with her dog Fin. So welcome to the Living Well with MS podcast Dr. Gretchen Hawley. Firstly, so we’re talking about the exercise and physical aspects of MS, so I wanted to ask how is MS physical therapy different from regular orthopedic physical therapy. 

 
 

Dr Gretchen Hawley  01:58 

So I have a lot of client’s who have been to orthopedic physical therapist and felt that they did not improve in the way that they were hoping to and there’s several different things that sets MS physical therapy apart from orthopedic physical therapy. MS physical therapy focuses on neuroplasticity based exercises, as well as functional exercises. One of the most important things to understand when working with Multiple Sclerosis is that the carryover is not the same. So if you’re doing a classic orthopedic exercise, like straight leg raises or clamshells, where you’re either maybe lying on the ground or lying on your side, you might have full strength in those positions, but then you go to stand up and use those muscles while walking and those muscles are shot, they don’t have the same strength in a standing position. So a lot of the exercises are very functional, meaning if you have difficulty climbing stairs, we’re gonna break down the activity of stair climbing into maybe five different exercises and focus on strengthening those exercises. Or similarly if you have a difficult time standing up from the ground, that can be broken down also into maybe five to eight exercises. So it’s breaking down those tasks and activities that are hard for you to do and improving each of those steps along the way and then putting the activity back together with your improved strength and there’s also a lot of different ways to get neuroplasticity to work more for you so it’s implementing those strategies. 

 
 

Geoff Allix  03:42 

So you’ve mentioned neuroplasticity, what is neuroplasticity? 

 
 

Dr Gretchen Hawley  03:46 

Yes, neuroplasticity is really exciting because it is the ability of your brain to create new pathways for a movement to occur. So it works all the way from if you have no strength to good strength. So if there is a movement, let’s just say, lifting your toes up, because I know a lot of people with MS suffer from drop foot. So if you have dropped foot and you have a difficult time lifting your ankles up, and you either can’t do it at all, let’s start with that first, let’s say you cannot lift your ankle up. If you practice over and over and over again, even though no movement is happening. Every single time you’re practicing, your brain is trying to find a new pathway to go from your brain to that muscle. So if you only practice twice, then give up, your brain only tried to find two pathways and neither worked. But if you try 10 times 10 times a day, your brain just tried 100 times to find a pathway that works and if you do have strength, let’s say you have a little bit of strength but it’s not your best when lifting your toes up, that means that you do have a pathway that’s working, there’s some pathway from your brain down to that muscle that is working it’s just not strong enough. So in that case, neuroplasticity has the ability to strengthen that current pathway that is there. But the only way to get neuroplasticity to work is to have high repetition and perfect quality. If you are training a movement incorrectly, and it looks a little wonky, well, that’s the movement you’re going to get over time. So you want to make sure it’s perfect quality, which often requires lots and lots of rest breaks. 

 
 

Geoff Allix  05:37 

And so if someone’s just doing regular exercise, whether they’ve seen things online, or they’re just going through exercise they did before in the gym, what’s the downside, potentially for someone with MS? 

 
 

Dr Gretchen Hawley  05:52 

The biggest downside would be, if there is a movement that’s happening, that’s not supposed to be there, one of the best examples that I see is, if someone’s practicing walking, which is a great thing to do, it’s very functional. But if when you’re walking, your knee slightly goes out to the side, and therefore your foot slightly comes in, over time that’s going to keep happening and that could cause a trip to happen. Or if you are biking, a lot of people like to bike when they’re at the gym or just for regular exercise. If you’re biking and both of your knees are collapsing in which is very common, you might not know you’re doing it, but next time you do it, if you’re looking down, check out your knees. And if your knees are collapsing in, you’re training your brain that when my legs move like this, my knees are supposed to collapse in. So then sometimes when you go to stand up and walk, walking is somewhat of a similar motion to biking just less exaggerated, your knees might collapse in and again, that can cause a trip or weakness and it’s those tiny little movements that you have to be looking for, to make sure you’re doing it well. And therefore will have good quality once you’re able to improve the strength. 

 
 

Geoff Allix  07:11 

So what you’re saying about doing something perfectly, you want to really make sure everything you do is exactly right, rather than just going for the biggest weights, you want to go for the perfect motion. 

 
 

Dr Gretchen Hawley  07:25 

Absolutely. Yes, perfect motion and high repetition and I also want to point out, it’s very typical that one side of your body or one leg is weaker than the other side. So for your strong side, you might be able to do ten repetitions, ten times, ten sets on your strong leg but on your weaker side, maybe your first set of the exercise is ten and then your second set is six and then the third set is three and that is perfectly fine. Again, it needs to be perfect quality, so taking those rest breaks and noticing when your quality starts to get poor, stop, take a break, and then continue, so you’re still getting repetitions in, but it’s not going to look the same as on your strong side. 

 
 

Geoff Allix  08:17 

So that’s absolutely the case with me. My right side is pretty much as good as it always was, my left side is the one that’s affected by MS. So would you suggest that I do work my right leg to maximum, which is a good one and then my left leg to what it can achieve? Or do I want to keep it the same? So my concern is that my right leg will get much stronger, because it’s doing more exercise, because it can do more exercise and then it kind of might exaggerate the difference between the two. 

 
 

Dr Gretchen Hawley  08:53 

Right, great question, I would say with your right leg, since that’s your stronger leg, I would exercise it as much as you can, you don’t have to push yourself to feeling like this is the most I can do on that side, but you still do want to strengthen the strong side because that is your strong side it needs to stay strong. A lot of people will do very little or nothing on their strong side because they don’t want that imbalance. However, with MS we can actually use that to our advantage every now and then, where you use your strong side to help you get by throughout your day to day activities and your weaker leg again, you want to do as many repetitions as you can, like go all out but they have to be perfect. So one day your total count of repetitions for one specific exercise on the weak leg might be 15 while the right leg was 50 and then another day it might be 30 and 50. But I would say for your strong long leg, maybe get to about 40 to 50 perfect repetitions and that’s typically good enough. 

 
 

Geoff Allix  10:05 

Okay. And so one of the other things I personally have is fatigue. So prior to MS, I exercised a lot, I ran, I ran a marathon, I surfed, rock climbed, snowboard, all sorts of things. And I used to push myself a lot so I could get quite good at things because I was really prepared to push myself really hard. Now, I definitely find that the limitation is fatigue, which kicks in so so much earlier than it ever would before. And it’s so much more extreme, really, I mean, as fatigue before I would be completely worn out now, I won’t be able to stand up straight, or it will affect my balance and all sorts of things. So how do you manage that side of fatigue? And especially if you’re doing a lot of exercise, and then that’s affecting things like balance, how would you manage fatigue with exercise? 

 
 

Dr Gretchen Hawley  11:11 

Great question again. So if it’s specifically with exercise, one thing that might be causing the fatigue is that your core temperature is rising. So everyone, whether you have MS or not, when we exercise our core temperature rises, because our muscles are moving, our blood is pumping, everything’s up and moving and when you have MS if your core temperature rises more than half of a degree, then you could have heat intolerance and heat intolerance can cause any of your symptoms to worsen. So if you have fatigue as one of your symptoms than when you’re exercising, and you’re not being cognisant of keeping your core temperature down, then that could be one reason that fatigue is kicking in to the intensity that it is. So one tip for that would be to make sure, even before you exercise, you’re sipping ice cold water just really, really cold because you want to keep your core temperature down. Or if you have any cooling products, maybe a neck wrap, a hat, a vest, something like that, again, before you start exercising so that once you start exercising, hopefully your core temperature will stay neutral. So that’s one thing, but a lot of people might even have fatigue before they exercise, so they don’t exercise for that reason. But research has proven time and time again that doing the right type of exercise can actually improve your fatigue and you’re never pushing into or beyond your fatigue that when you have MS is not going to do you any good. Like you said before MS you used to be able to push yourself really hard but when you have MS, that’s just going to result in poor quality of movement, and your brain is going to start remembering that. So again, we don’t want to push into fatigue or bad quality, but being aware of when that fatigue is about to set in and stop and rest. 

 
 

Geoff Allix  13:16 

And then exercise can actually help with fatigue. 

 
 

Dr Gretchen Hawley  13:19 

Yes, and there’s two different types of fatigue. Primary fatigue is when there is no reason for it, you did not have a late night, you had a great night’s sleep, you did not exercise, there’s no reason you should be tired, yet you are exhausted. And then secondary fatigue, it means that there is a reason for it, you did exercise and maybe you overdid it, or you had a late night out or you didn’t get a good night’s sleep, whatever the reason, there is a reason for your fatigue and research proves that exercise in the right way in the right dosing can improve both types of fatigue. 

 
 

Geoff Allix  14:00 

Okay, there was actually something that Aaron Boster posted recently, he’s been on the podcast, i dont know if you’ve come across Aaron Boster? And it was that doing regular active,  just small amounts of regular activity really helps and I personally find that if I sit down all day, then when I get up, then my balance is much worse, well everything’s worse basically. But if I do a regular, I mean I have a Fitbit, I’m sure other fitness trackers will do this, but it will tell me every hour it will prompt me to have done 200 steps an hour and I actually find that’s more important than the 10,000 steps a day everyone talks about. If I do the 200 an hour, then I’m quite mobile. But actually, lack of activity can actually make things worse. So there is a trade off between doing too much can make things worse, but equally doing nothing. There was certainly some research he posted this week about that that can be in effect that doing something even a small amount regularly and not being too sedentary?  

 
 

Dr Gretchen Hawley  15:19 

Yeah, there’s two things I want to mention about that. The first thing is, several years ago, I would say maybe five years ago or so, research was showing that it was best to do all of your exercises at one point during the day. So lunchtime, you’re going to sit down and do your exercises for an hour or 30 minutes, whatever it is. But now, research is actually proving that it’s just as effective to do your exercises throughout the day and I actually prefer that for reasons that you just stated. I prefer my clients to do some of their exercises, maybe late morning, some in the afternoon, some in the late afternoon before dinner, and you’re just separating it up so that you’re getting yourself moving throughout the day. And the second point I wanted to make is, exercise means something different for everyone, I might be saying exercise right now, and someone is picturing sprinting on a treadmill and another person might be picturing walking, another person might be picturing squats and lunges and weights and I think it’s important to note that exercise can simply be sitting up tall in your chair and marching your legs, or kicking your legs or just squats and standing up and then sitting down. There are so many forms of simple, which is not the same as easy but simple movements that you can do throughout the day, that can really help improve your fatigue and just improve your overall wellness and strength when you have MS. It doesn’t need to be intense. 

 
 

Geoff Allix  16:56 

And so bearing in mind, you were saying everything needs to be as perfect as it can be on the movements. How would you handle setting goals and targets? 

 
 

Dr Gretchen Hawley  17:10 

So that’s a great question, the first time you do so let’s pick, just standing up and sitting down as an exercise, I would say set a new goal and target for each exercise, and maybe even for each leg. So for squats and standing up sitting down, you use both of your legs at the same time. However, maybe your weaker leg caves in, that’s typically what happens when the leg is weak. So maybe a goal would be to do it 10 times perfectly without the leg caving in for five sets. But see where you’re at if at first, you can only do it five times, two sets, then maybe aim for five times three sets. And I would say to set very small goals at first, because you’ll feel like you’re winning. And our brains do positive things, they send out endorphins when we feel like we’re winning. So make the goal small at first and set a different goal for each leg. If it’s something like marching or leg kicks, or any type of single leg or arm exercise, because it won’t be the same, your strong side is going to be stronger. So it’d be unfair to set the same goal for your weaker side. 

 
 

Geoff Allix  18:31 

And you were saying as well, I just want to sort of reiterate, that even if you can’t do something, it’s worth trying it repeatedly. Because then the neuroplasticity might kick in and eventually you’ll be able to? 

 
 

Dr Gretchen Hawley  18:42 

Absolutely, and that’s really hard for people to do over time because you lose motivation. You can’t the one difficult thing about neuroplasticity, as amazing as it is, you can’t see it, you can’t hear it, you can’t feel it, you really don’t know it’s happening. You really have to trust the process that your brain according to research is actually trying to find these pathways. So even if you have no movement, you still should be doing the basic exercises for your muscles that are weak over and over and over again, which can be discouraging when there’s no movement, but absolutely, you still should be doing them. 

 
 

Geoff Allix  19:27 

Okay. And so you have your own programme; MSing Link, which it’s linked to in the show notes. So can you tell us a bit about your programme and what that involves? 

 
 

Dr Gretchen Hawley  19:43 

Yes. So as you know MS is called the snowflake disease. There is no one person that is the same there are so many different symptoms. However, I have found through my experience working with people who have MS, that there are specific muscle groups that tend to get weakest first. And I also had noticed, I’ve been working with people who have MS treating them for about six years and at the physical therapy clinics I was working for, I was a physical therapist who typically had the highest no show and cancellation rate. And it’s because my clients with MS couldn’t come to physical therapy regularly and it may have been because of weather, or they were having just a bad day or a lot of fatigue, or they weren’t able to get transportation to come to physical therapy because they weren’t driving themselves. So there’s so many reasons that they couldn’t come. And I decided that I wanted to create some type of platform that anyone with MS could do in their own home, and therefore do it more regularly and start seeing improvements quicker. So that’s why I created the MSing Link. It’s an online MS wellness programme and it includes all of the exercises that I would be giving my clients in person, it’s just online. So I have categories for strengthening, stretching, balance, and walking. And I show modified levels as well as advanced levels, a lot of them are seated, which I love, because you can do it throughout the day, whether you’re still working, or if you’re watching TV or eating a meal, you can always do some type of exercise while you’re sitting. And then I also bring in guest speakers like Dr. Aaron Boster, and other MS Neurologists, Occupational therapists, and really experts that are in other fields where I am not an expert. That way, my members can still learn from the different members in the MS community, on how they can best conquer their life with MS. And then lastly, there’s also research updates, symptom management videos for things that aren’t necessarily physical like heat intolerance, a cognitive exercise, energy conservation and fatigue management, as well as task specific exercises. So I actually review how to climb stairs, how to get into a car out of a car, how to stand up from the ground, how to get into bed, so more of those activities that we have to do on a day to day basis. 

 
 

Geoff Allix  22:24 

I’ve had a look at your programme, and you do often an awful lot for the subscription, there’s one to one counseling and so on and, you know, there’s a lot of resources. But it is quite expensive for a lot of people particularly some people with MS aren’t working because they can’t work any more, particularly if they’ve got a physical job. So what about if someone can’t afford a subscription to MSing Link or similar resources? What can they do if they just can’t afford it? 

 
 

Dr Gretchen Hawley  23:00 

Yes, I’m glad you asked that. So I am very active on YouTube, I post a new video every week, as well as social media. I have a Facebook page and an Instagram page and I’m constantly posting videos or tips and strategies or motivation. So any of those outlets are completely free, and still gives you access to my knowledge and my expertise. 

 
 

Geoff Allix  23:27 

Okay, that’s excellent. So, to wrap up, then, I’d like to ask, is there some key takeaways that people should aim for things that they should do, things that they should look out for when we’re talking about exercise for people with MS? 

 
 

Dr Gretchen Hawley  23:45 

So the first thing I would say is, if you haven’t already, either make a mental note or a mental list, or a handwritten list of things that you feel are challenging for you throughout your day. Even if you can do it, if there’s something that’s hard for you to do, and you want to be easier or better, jot that down. And then if you are seeing a physiotherapist near you or a personal trainer, anyone, see if the exercises you’re currently doing line up with what that activity is. If not, you need to make changes to include more exercises that will help you with those specific goals. Because general exercise does not always help improve your walking or your balance or stair climbing or anything that you might want to do throughout the day. So that’s the first thing and the second thing is, as we’ve already stated, do something, it is shocking how much our bodies can actually either maintain or improve simply just from standing. Standing requires balance, It requires all of your muscles to work evenly if the muscles on the front of your body, like your quads or your core are working more than the muscles on the back of your body, you’re going to fall forward, or vice versa. If the muscles on the back of your body like your hamstrings or your glutes are working more than the front, you’ll tip backwards. So if you’re standing and you’re not falling, you’re just staying upright, you are actually working a lot of muscles. So just doing something throughout the day often is so helpful compared to doing nothing at all. So don’t underestimate the power of just simple movements. 

 
 

Geoff Allix  25:34 

Thank you very much for that. And thank you very much for joining us, Dr. Hawley. Those of you listening if you’ve enjoyed the podcast, please leave us a rating or review, and I hope to join you next time. With that, I would like to thank you all for listening to this episode of Living Well with MS. Remember that there is a wealth of information at overcomingms.org including show notes, and an archive of all Living Well with MS episodes. Once again, that’s overcomingms.org there you can also find OMS friendly recipes and exercise tips, connect with other OMSers in your local area through our OMS circles programme, and learn about the latest research going on in the MS world generally and related to OMS. Specifically, I encourage you to register on the site and stay informed about the latest news and updates. I also encourage you to subscribe to this podcast, so you never miss an episode and please feel free to share it with others who might find it of value. Let us know what you think about the podcast by leaving a review and if you have ideas for future episodes, we’d love to hear from you. So please contact us via our website; overcomingms.org. Thanks again for listening, and for joining me on this journey to Overcoming MS and Living Well with Multiple Sclerosis, I’m Geoff Allix and I’ll see you next time