Active living with MS
Living With/Living Well is a free public education series offered by Toronto Rehab. It features events and resource materials to help people learn to overcome or prevent serious injury and illness so they can live life to the fullest. For more information about Living With/Living Well, visit www.torontorehab.com/livingwithlivingwell.
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Table of Contents
Introduction Why exercise? Exercise and physical activity Barriers to increasing activity The four components of fitness Making exercise safe and suitable for you Monitoring your response to physical activity Fatigue management Principles of energy conservation Activity analysis Self-monitoring Recharging energy Additional resources Notes
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Introduction
An estimated 55,000-75,000 Canadians have multiple sclerosis (MS). Every day, three more people in Canada are diagnosed with MS, making it the most common neurological disease affecting younger adults. While it is usually diagnosed between the ages of 15 to 40, MS can occur at any age. Approximately 1,000 new Canadian cases of MS are diagnosed each year. MS is a disease that attacks the protective myelin covering of the central nervous system, causing inflammation and destruction. This disrupts communication between the brain and other parts of the body causing problems with vision, balance, coordination problems, muscle stiffness, fatigue, speech, and memory, and even paralysis. MS can range from being relatively benign to totally disabling. At its most extreme, MS can drastically reduce quality of life. The cause of MS is not known and there is no cure. Through its Neuro Rehabilitation Program, Toronto Rehab offers a Multiple Sclerosis Service that provides specialized interprofessional rehabilitation for adults living with the many challenges of multiple sclerosis. Rehabilitation can improve quality of life for people with MS by helping them improve their balance and mobility, communication skills, cognitive functioning and ability to perform daily activities. A critical component of MS rehabilitation is physical activity. Engaging in regular physical activity in safe, fun and effective ways helps people with MS: • improve mood and energy level • promote health and well-being • maintain functional independence Toronto Rehab is pleased to provide this resource booklet to help you become more physically active in safe, fun and effective ways and to manage your energy and fatigue levels. This booklet is adapted from material created as part of the “Life with MS” group wellness program in the Multiple Sclerosis Service of Toronto Rehab’s Neuro Rehabilitation Program. For more information about the MS Service, visit www.torontorehab.com.
Why exercise?
While physical activity and exercise cannot reverse or stop the progression of MS, they can provide many positive effects and help to reach your best physical potential and retain function over a longer period of time. The benefits of physical activity and exercise for people with MS include: • reducing the risk of heart disease and stroke • reducing the risk of acquiring adult-onset diabetes • increasing or maintaining strength and muscle mass • stimulating metabolism and decreasing body fat • reducing blood pressure • improving sleep patterns 2
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decreasing fatigue decreasing anxiety, tension, and depression promoting relaxation and management of stress promoting vitality and increasing energy reserves improving bowel & bladder control decreasing the risk of osteoporosis (with weight-bearing exercise) promoting better posture increasing confidence with everyday activities increasing self-image, self-esteem, and general mood
To enjoy the benefits of physical activity or exercise, it is important to maintain a mild to moderate exercise intensity. Avoid exercising muscles to the point of exhaustion: “No Pain, No Gain” is not the message for people with MS. Fatigue management will be discussed later in this booklet.
Exercise and physical activity
The concept of exercise is changing to include a very broad range of physical activities. The amount of physical activity you engage in has been shown to be more important than the specific type of activity. What you do is not important. Instead, it is important that you do something! The following behaviours all help to increase your activity level: • exercise, such as stretching and lifting weights for strength • recreation, such as gardening and evening strolls • housework, such as dishwashing and dusting, There are benefits to even short bursts of physical activity. For example, 10-minute activity intervals can accumulate to the duration recommended by rehabilitation research and Canada’s Physical Activity Guide. These both recommend that every adult should accumulate the following on most days of the week, if not every day: • 30 minutes or more of moderate intensity physical activity or • 60 minutes of light intensity activity A traditional exercise program of strength and aerobic training is still the preferred method for achieving maximal fitness benefits, but every bit of physical activity helps.
Barriers to increasing activity
Research has identified a variety of barriers to becoming more physically active that are common for people with MS, including: • fatigue • lack of time • lack of accessible facilities • lack of transportation • decreased motivation • cost • safety concerns • effects of MS 3
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self-esteem issues heat other responsibilities
While these barriers are valid and important concerns, you must not let them dissuade you from being active. Prolonged inactivity and a sedentary lifestyle result in a state known as “deconditioning.” Deconditioning results in a long list of secondary symptoms, including weakness, fatigue, sleep disturbances, and a low mood. Prolonged inactivity has the potential to lead to greater disability and secondary symptoms, and— ultimately—reduced participation. The following diagram illustrates the impact of inactivity on participation.
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The four components of fitness
There are four components of fitness: strength, flexibility, endurance and balance. All four components of fitness are addressed in a well-balanced exercise and physical activity program. The next section will present an overview and some suggested activities for people with MS from each of the four components of fitness. Strength Strength is the ability of a muscle to exert force. Muscle weakness is a common symptom in MS. However, you may be able to increase or maintain muscle strength within reasonable expectations. (Your personal MS history must be taken into consideration here.) Improvement is possible because some of the weakness can be a "secondary effect" caused by inactivity. Strengthening can also occur due to increased growth (called “hypertrophy”) of remaining muscle fibers, and through motor learning (which occurs when an activity improves through repeated practice). Suggested activities to build strength: To improve strength, you must work against resistance or gravity. Exercises include lifting weights, moving against the water in a pool, standing up and sitting down, or performing activities like housework or yoga. As the exercise becomes easier, increase the resistance and/or number of sets (e.g. 10 reps x 2 sets). When possible, make exercises functional (e.g. repeatedly standing up from a chair is great for strengthening your hips and knees). Strengthening programs do not have to cost anything. Use common household items for your weight lifting routines, such as soup cans. Flexibility Flexibility is the ability to move a joint through its full range of motion. Flexibility plays a very important role in allowing you to maintain your desired activities and remain painfree and comfortable in all the moving parts of your neck, trunk, arms and legs. For some people with MS, it is more challenging to maintain flexibility because of increased muscle tone or stiffness. Tone (called spasticity) is an abnormal hyper-excitability of muscle that can lead to a disabling stiffness. Suggested activities to build flexibility: Stretching is a very important way for everyone to decrease muscle tone and prevent shortening of muscles and other connective tissues. Stretching is especially important for people who have increased tone or spasms and for wheelchair users who stay in the same position for long periods of time. Stretching can be done in different positions (including while seated), so find a position that is best for you. To loosen tight muscles, stretch just until you feel tension and hold stretches for 10 to 30 seconds, depending on your tolerance. Breathe throughout and stretch a little more on each exhale. Repeat each stretch three times, if able. You can also consider yoga or tai chi as an option for increasing flexibility. Endurance Endurance is the ability to last, continue or remain. There are two main types of endurance: aerobic endurance and muscle endurance.
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Aerobic endurance refers to the ability of your heart, lungs and muscle systems to efficiently extract and use oxygen during repeated exercise or activity. People with good aerobic endurance have much more energy, less fatigue and the ability to keep active for longer periods during the day. Suggested activities to build aerobic endurance: There are several ways to increase aerobic fitness. Possibilities include stationary bicycles (leg or arm), brisk walking, treadmills, and swimming or walking in water. You can even complete your aerobic exercise while seated in a chair or wheelchair, using: • arm bikes and restorators • videos of seated aerobic exercises Muscle endurance is the ability of a muscle to keep repeating, maintaining, or holding a position or exercise. Both types of endurance are usually decreased in people with MS and both can be improved with a training program at the right level for you. Suggested activities to build muscle endurance: You can build muscular endurance either with or without weights, depending on your strength. The key for building endurance is to repeat an exercise many times (for example 3 sets of 10-15 repetitions) but at light to moderate resistance. You can also use the resistance of your own body weight, for example, by stepping up on low stools or moving from sitting to standing. Everyday activities will feel much easier with improved muscle and aerobic endurance! Balance Control of balance underlies all of our activities. Balance is affected in people with MS because of weakness, stiffness, increased tone, ataxia (reduction of coordination) and decreased sensation and vision. Suggested activities to improve balance: Balance is a learned skill and should be practiced regularly. Control of balance will be improved by all of the exercises discussed in this booklet. Balance training should also include a variety of activities, such as yoga, tai chi, “walking the line”, lunging in all directions and dancing. To help you adhere to your exercise program, group exercise may be more fun and motivating. Talk to your team of health professionals to help you fit appropriate activities into your daily life!
Making exercise safe and suitable for you
Everyone with MS can enjoy some type of exercise—you just have to fit the right exercise at the right time! Keep in mind that exercise programs can include many different forms of physical activity, and should be based on individual needs and abilities. Talk with your physiotherapist and occupational therapist to determine the best program for you. Consider these things when determining your program: Self evaluation Assess your present level and type of activity: 6
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Are you already exercising or are you starting for the first time? Consider the times of day when you have more energy. Avoid periods of higher body and environmental temperatures.
Muscle tone If increased muscle tone (or stiffness) is a problem, you may have to include more stretching exercises. Stretching will keep your joints and muscles more flexible, comfortable and reduce spasms (if you have them). You can stretch as many times a day as you like, but you should stretch any “problem” muscle groups at least twice each day. Another way to maintain muscle flexibility and increase comfort is getting a massage. In addition, you may want to consult your doctor or about medications that may help. Balance issues If balance is a problem, you can modify most exercises to obtain the support that you need while performing the exercise. For example, you can take the following steps to compensate for your balance: • Sit instead of standing while exercising. • Stand holding onto a stable support. • Pedal on a stationary bike with a back support (called a recumbent bike) or while sitting on a chair or wheelchair (called a restorator). Coordination The amount of coordination in your trunk and limbs will guide your choice of exercise. If you have a tremor, it is still possible to exercise and you will still enjoy the benefits even if the movement is not perfectly smooth. There are several ways to compensate for decreased coordination (called ataxia) in your exercises: • Support your limbs on a stable surface. • Glide objects along a surface instead of lifting them. • Try using weights to decrease tremor, e.g. on the wrist, ankle or hips. • Use relaxation techniques and mental rehearsal. Practice good core stability (in your lower back and mid section) to improve ease of movement. Try to maintain good posture at the beginning and throughout the movement as this may give you more control over your arms and legs. Keeping cool Exercise can increase the body’s core temperature. For some, this increase makes nerve transmission more difficult and symptoms may temporarily become worse. This is a short-term increase in symptoms and does not represent an exacerbation of MS. If the increased symptoms last more than one hour after exercising, you need to adjust your program of exercise (e.g. perform fewer repetitions or eliminate part of the program). Here are some tips for keeping cool: • Exercise in a cool environment. • Wear comfortable, loose fitting clothing. • Drink plenty of cool fluids even before you are thirsty. • Choose the best time of day to exercise: body temperature tends to increase in the afternoon, so exercise may be most comfortable for you in the morning or early evening. 7
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Build in a “cool down” period at the end of your exercise session. Treat yourself to a cool shower after exercising. Explore the cooling accessories on the market (e.g. neck collars, vests with pockets for cold packs)
Monitoring your response to physical activity: How hard should you work?
Maintaining a mild to moderate exercise intensity is recommended. It is useful and important to monitor your response to exercise and physical activity. The symptoms of MS may require adjustments of the type, intensity and pattern of your activity. Fatigue is normal after exercise, but you should adjust your exercise program if your fatigue lasts much more than an hour. When having an active day, take rest periods regularly before you get over-tired. Self-monitoring of body symptoms (e.g. heat and fatigue) is essential to achieving the delicate balance of exertion that promotes health, but avoids discomfort. There are two methods you can use to monitor your exercise intensity: • target heart rate range • Rating of Perceived Exertion (RPE) Target heart rate range Heart rate is used to monitor the intensity of aerobic exercise. You should take your heart rate at different times while you exercise (usually before, during and after). You can then determine if you are reaching your target range and obtaining a training benefit. The formula to find a target training heart rate is: (220 – Age) x % exercise intensity. For example, if you are 40 years old: Your minimum intensity target heart rate is 108 beats per minute (bpm): (220-40) x 60% = (180 x 60) ÷ 100 = 108 Your maximum intensity target heart rate is 126 bpm: (220-40) x 70% = (180 x 70) ÷ 100 = 126 Therefore, your target heart rate range is 108 to 126 bpm. (Note: Intensity targets should be less, e.g. 40–50%, if you have not exercised for a long time.) Because some people may not have enough sensation in their fingertips to feel their pulse, the Rating of Perceived Exertion (RPE) is often the preferred method. There are alternatives such as having someone else take your pulse or using a heart rate monitor. Rating of Perceived Exertion The Rating of Perceived Exertion (RPE) scale is used to quantify subjective exercise intensity. The scale has been shown to relate to the degree of actual physical exertion. RPE can be used as a guide to safely adjust exercise intensity to meet your 8
requirements. RPE is especially useful if you are unable to meet the target heart rate ranges or if your pulse is difficult to monitor, both of which could be impairments for people with MS. When applying this scale to your exercise routine, consider your total feeling of exertion, including all sensations of breathlessness, effort and fatigue. Use the scale by selecting a target range of 3 to 4. This range will assist you to achieve an appropriate level of exercise intensity. Description Nothing at All Very Light Light Moderate: Comfortable but slightly elevated breathing. You should be able to talk during the activity. 4 Somewhat Strong: Exercising briskly. Aware breathing is deeper and slight feeling of fatigue. 5 Strong 6 More Strong 7 Very Strong 8 Very, Very Strong 9 Very, Very, Very Strong 10 Maximal (Adapted from http://cme.medicine.dal.ca/online/demo_ecp/exertion.html) What if you just don’t feel like exercising today? Exercise can definitely be stopped for one day or even two, but try not to go three days without exercising. Exercising regularly is better. Remember that your program of physical activity will vary depending on other demands in your life, e.g. family, work. If you have had a recent exacerbation, your exercise program may require modifications or be temporarily discontinued. Consult with your doctor before resuming exercise. RPE Value 0 1 2 3
Fatigue management
A common and limiting symptom of MS is fatigue. People with MS report fatigue— which may be experienced in the form of physical and/or mental exhaustion—as one of the top three disabling symptoms. Fatigue may prevent you from doing the amount, variety and intensity of activities that you want to do. Just as we have only a limited amount of money to spend, we have only a limited amount of energy to spend. To manage your fatigue and ensure that you have enough energy to participate in your most valued activities, you must budget your energy the same way that you budget your money.
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Key fatigue management strategies include: • Enhancing resistance to fatigue: A major part of this strategy is regular physical activity and exercise, as has been described so far in this booklet. The remainder of this booklet focuses on the next two strategies: • Energy conservation: This strategy reduces energy consumption, which, consequently, delays the disabling effects of fatigue. Energy conservation entails doing less, getting help from others and working more efficiently. • Recharging energy: This strategy includes finding ways to recharge your batteries, such as rest and relaxation, yoga, meditation, light exercise and other pleasurable activities.
Principles of energy conservation
Energy conservation is a formal technique that people use to make wise choices about how they spend their energy. Consider the following six principles of energy conservation. Pacing It is important to take frequent breaks. It is better to take short breaks at frequent intervals than one long break at the end of the activity. Learn to monitor your body and take breaks before you get tired. Planning Keep organized. Make a list of activities you need to do, and plan ahead so that you have time to take breaks. Look at your activities carefully and try to break them into smaller steps. This approach will help you to pace yourself. Prioritizing Once you have planned the things that you need to do, prioritize them and complete the high priority items first. Do not feel guilty for saying “no” to people (including yourself!) who try to place extra demands on you. Only you can make decisions about how to spend your energy. Patience Be patient with yourself. Appreciate that you may not be able to accomplish as much in a day as you used to. Be realistic about what you can accomplish given the amount of energy that you have on any given day. Posture Avoid staying in the same posture for too long. Shift your weight so that the same muscles aren’t always working. Keep things within easy reach so that you do not have to strain or bend too much. Plan your activities so that you have everything you need nearby. Try to sit instead of stand for most activities and use proper work heights to avoid strain. Efficiency Look carefully at the activities that you have planned and prioritized. Try to simplify them by eliminating steps that are not essential. Consider using adaptive equipment or 10
other time saving products on the market. These tools will make it easier for you to perform your daily activities and help you save more time and energy. Be open to new ways of doing things and to new ideas. Do not be afraid to ask for assistance.
Activity analysis
Choose an activity that you expect to take 20 minutes or longer to complete and that is likely to be stressful or fatiguing and then apply the principles of energy conservation to it. Consider whether any and/or all of the following things can be changed, and if so, whether the change(s) would reduce the possible stress and make the activity more manageable. Activity: ____________________________________________________ Things to consider Number of rest breaks Time of day activity is done Energy-draining body positions Proper work heights Location of supplies Break down activity Get help Do activity less frequently Eliminate parts or whole activity Temperature control Use adaptive equipment Can’t be changed Can be How can it be changed? changed
Self-monitoring
Self-monitoring involves paying attention to your body and mind and respecting the signals that they send to say, “We need a break.” To successfully self-monitor, you must learn your unique warning signs of impending fatigue, which may include irritability, headaches, fatigue, legs feeling heavy, difficulty concentrating, feeling warm, or feeling overwhelmed. By paying greater attention, you may notice a pattern between your activities and your energy levels so you can better plan how to spend your energy. The following exercise provides you with an opportunity to take an objective look at your self-monitoring and energy management skills. The purpose of the exercise is to learn to spread your energy throughout the week so that you will be able to do more overall and eliminate the really bad days. Spending energy effectively activity Complete the two charts that follow by responding to the following questions and statements. 11
1. Think of a very difficult day from which you required several hours or a day to recover, and list each activity you performed on that day, including things like getting dressed or climbing stairs. 2. Think of a great day when you were satisfied with what you accomplished yet were not exhausted at the end of the day, and list each of your activities. 3. For each activity, assign a numerical value representing the number of units of energy you used. For example, taking a shower used 10 units of energy, but climbing the stairs required twice as much energy, 20 units. 4. Total the values for the activities performed on both days and take the total from the “great” day as the target number for each day. 5. Plan for your week using the weekly schedule. Plan exercise and rest periods first, and then try to schedule some fun things. 6. Try to keep your daily energy units on target for the week. 7. Think about how you can modify your activities using some of the strategies discussed in the activity analysis so that you can meet your energy targets. (This exercise is adapted from the work of Karen Dickinson, Occupational Therapist in Fredericton, New Brunswick.) Difficult Day Great Day
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Recharging energy
Meditation Meditation, focusing on your breathing, mindfulness and progressive muscular relaxation are other tools to rejuvenate your energy. You may want to learn some meditative breathing and/or progressive muscular relaxation techniques. Here is a sample of a script that may be used in a meditation exercise: Find a comfortable position. Close your eyes or stare at a particular object in space. For the next few minutes, give yourself permission to let your mind and body completely relax. Take a deep breath in and say the word “relax” out loud. Start to pay attention to your breathing. Become aware of the rhythm of your breath. Pay attention to your breath in, and your breath out. Focus on the rhythm. Pay attention to your surroundings. Focus on the environment around you. In your mind’s eye, imagine the room that you’re in, the furniture in it, the temperature, the sounds, the smells. Allow yourself to be in the moment. Take another breath in and imagine the number ‘3’. As you breathe out, allow your muscles to completely give away. People often hold tension in their neck and shoulders and as you breathe out, allow that tension to melt away. Take another breath in and imagine the number ‘2’. Now as you breathe out, let your mind be calm. Our mind often thinks of many different things at once. During this relaxation, you may notice that your 13
thoughts are wandering. Acknowledge these thoughts but then return to the relaxation. Take another breath in and imagine the number ‘1’. As you breathe out let your emotions be peaceful and calm. Earlier today you may have experienced different emotions. For now, set that aside and let your emotions be calm. Now go back to your breathing and focus on breathing slowly and deeply (pause). With relaxation your breathing is natural. Don’t force yourself to breathe really deeply and slowly. Let your body breathe itself. Become aware that as you breathe in, your stomach goes out slightly, and as you breathe out, your stomach comes in slightly. Breathe in—your stomach goes out. Breathe out—your stomach comes in. Take some time now to enjoy the relaxation that has come to your body and mind. Give yourself credit for taking time to rejuvenate your mind and body. Soon we will leave the relaxation and return to our group. Know that as you relax your blood pressure decreases slightly, your heart rate slows down, your rate of breathing slows and your physical and mental energy resources are improved. Slowly start to come back. As you feel ready, start to move your arms and legs. Whenever you’re ready, open your eyes and come back to the group. Sleep habits Sleep is essential to a healthy life. Most adults need six to eight hours of sleep each night to stay healthy. For people with MS, there may be specific difficulties that interfere with sleep – for example, pain, muscle spasms, and/or the need to empty the bladder, etc. What is more, the diagnosis of a sleep disorder is more common in people with MS than in the general public. The tips can help you improve your sleep habits: Keep a regular sleep schedule and a bedtime routine. Try to wake up at the same time even on nights when you go to bed later than usual. This regular routine can help to condition your brain to your sleep schedule. Maintaining a routine helps condition your brain to fall asleep afterwards. Keep the bedroom for sleep and intimacy only. Rest, read and watch TV in another area to help condition your brain to perceive the bedroom as the room for sleep. Get up if you wake up in the night and can’t fall back asleep. Don’t try too hard. Sleep will come if you establish the right conditions. The more effort you put into sleep, the less likely you are to achieve it. Eat before sleeping if hunger keeps you awake. Something light (like crackers or cereal) is better than a full meal or large snack. It is easier to condition your brain to this pattern if you have your snack regularly, not occasionally. 14
Avoid alcohol, caffeine and nicotine at night. These substances can all interrupt your deep sleep Get some exercise each day. Exercise or physical activity of any kind will relax you and prepare you mentally and physically for sleep. But don’t exercise too close to bedtime. Don’t take long daytime naps. For most people, daytime sleep will interfere with the ability to sleep in the evening. However, brief napping (no more than one hour in total) on a regular basis probably isn’t harmful. Practice relaxing, calming activities before bedtime. Calming activities, including deep breathing, meditation music and massage, can help calm the body and quiet the mind as preparation for sleep. Perform gentle stretching before bed. Be careful not to stimulate the body while stretching before bed. Move very slowly and focus on your breathing. Consider warming yourself. Raising the body’s temperature slightly with a bath or an electric blanket on a low setting before bedtime can help some people to relax and feel tired. Make sure your sleep environment encourages sleep. Your sleep environment should be dark, quiet, and neither too warm nor too cold. Do not have a bedside clock visible when you sleep to avoid lying awake and watching the time, and getting angry or worrying about not being asleep. Adjust your sleeping position. If you sleep on your back, try sleeping with a pillow under your knees. If you sleep on your side, try sleeping with a “body” pillow between your knees and supporting your upper arm. Sleeping position is particularly important for spasticity. Consider medications and/or herbal remedies. You may want to talk to your doctor or naturopath about medications or herbs that can enhance or hinder your sleep.
Additional resources
Prepared by Toronto Rehab Library Services Canadian Canadian Network of Multiple Sclerosis Clinics http://cnmsc.org Clinical Trials (US, Canada) http://clinicaltrials.gov/ct2/?ui=D009103&recruiting=true 15
Consumer Health Information Service http://www.torontopubliclibrary.ca/uni_chi_index.jsp Healthy Ontario (search “Multiple Sclerosis”) http://www.healthyontario.com/Home.aspx MS Canada Magazine http://www.mssociety.ca/en/information/msnewsletter.htm Multiple Sclerosis Society of Canada www.mssociety.ca/ Multiple Sclerosis Society of Canada. Reading List http://www.mssociety.ca/en/help/msreadinglist.htm Women’s College Hospital. Women’s Health Matters (search “Multiple Sclerosis” under Health A-Z) http://www.womenshealthmatters.ca/index.cfm
International Consortium of Multiple Sclerosis Centers www.mscare.org/ eMedicineHealth http://www.emedicinehealth.com/multiple_sclerosis/article_em.htm eMedicineHealth : FAQs http://www.emedicinehealth.com/multiple_sclerosis_ms_faqs/article_em.htm EverydayHealth : Multiple Sclerosis http://www.everydayhealth.com/multiple-sclerosis-basics.aspx Healthfinder.gov : Multiple Sclerosis http://www.healthfinder.gov/scripts/SearchContext.asp?topic=563 Mayo Clinic. Multiple Sclerosis http://www.mayoclinic.com/health/multiple-sclerosis/DS00188 MedlinePlus : Multiple Sclerosis http://www.nlm.nih.gov/medlineplus/multiplesclerosis.html Medlineplus Patient Education Institute. Interactive tutorial http://www.nlm.nih.gov/medlineplus/tutorials/multiplesclerosis/htm/index.htm Momentum Magazine http://www.nationalmssociety.org/multimedia-library/momentum-magazine/index.aspx
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MS in focus http://www.msif.org/en/resources/msif_resources/msif_publications/ms_in_focus/inde x.html Multiple Sclerosis Association of America www.msaa.com/ Multiple Sclerosis International Federation www.msif.org/en/ Multiple Sclerosis Resource Centre (UK) http://www.msrc.co.uk National Institute of Neurological Disorders & Stroke http://www.ninds.nih.gov/disorders/multiple_sclerosis/multiple_sclerosis.htm National Multiple Sclerosis Society http://www.nationalmssociety.org/index.aspx NOAH : New York Online Access to Health http://www.noah-health.org/en/bjm/ms Rehabilitation in Multiple Sclerosis (European) http://www.rims.be
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Notes
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About Toronto Rehab Toronto Rehab is Canada’s largest teaching and research hospital specializing in adult rehabilitation, complex continuing care and long-term care. At Toronto Rehab, our goal is to advance rehabilitation and enhance quality of life by pushing the frontiers of rehabilitation science. As a fully affiliated and specialized teaching and research hospital of the University of Toronto, we do everything humanly possible to generate new knowledge, put it into practice and share our discoveries with others. Each year, Toronto Rehab’s patient care, research and education programs make a difference in the lives of more than 15,000 people who experience disabling injury, illness and conditions associated with aging. More information is available at www.torontorehab.com. If you would like to support Toronto Rehab’s work, please contact the Toronto Rehab Foundation at 416-597-3040 or foundation@torontorehab.on.ca. Toronto Rehabilitation Institute University Centre 550 University Ave Toronto, Ontario M5G 2A2 416-597-3422
Toronto Rehabilitation Institute A University of Toronto Teaching and Research Hospital
2009