Exercise Can Help!
By Jane Brandenstein, P.T., University of Pittsburgh Medical
Center (originally published in "Scleroderma Foundation
Newsline," vol. 2, no. 3, Summer/Fall 1999)
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Jane
Brandenstein, P.T., speaking at the Scleroderma Foundation's
2001 National Conference in Washington, D.C. |
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As physical therapists, there are some things that we have
learned over the years about scleroderma, and there are even
more things we wish we understood better and could share with
you. But, the information is just not there at this point
in time, so as health professionals, we experience a certain
amount of frustration, just like you do. What we would like
to pass on to you are some of the things that we have found
to be helpful and important.
One thing we do know is that exercise is imperative in order
to maintain the highest level of functional independence possible.
We find that you can and should do different things on different
days. There are several types of exercise and any or all can
be beneficial for you, depending upon your particular needs.
These can be range of motion, stretching, strengthening, and/or
conditioning/aerobic exercises. Our suggestion is to do range-of-motion
exercises to all joints after a warm shower, first thing in
the morning to "get things going." Then, later in
the day, set aside another period for exercise. It may be
helpful to take a pain relieving medication, such as an extrastrength
Tyienol one hour before you do your exercise program. Depending
on how you feel, you can really stretch those tight areas,
strengthen the weaker ones, or do something aerobic, like
walking, hiking or even swimming. Basically, the second workout
should target the areas that need work.
We have found that warm applications are beneficial prior
to stretching exercises. Some examples of heat include paraffin
baths for hands or feet, electric moist heating pad (for example,
the thermophore), microwaveable hot packs, and warm showers
or baths. These heat applications should be warm, but not
hot as you could bum your skin. Use these for 15 to 20 minutes,
no longer than half an hour. If you are having joint aching
or stiffness, you can use the heat several times followed
by the stretching exercises.
When doing range-of-motion and stretching exercises it is
very important to go as far as you can, even to the point
of pain and hold at this end of the range point for at least
ten seconds. Do not bounce with the exercises; a sustained
stretch is more beneficial. Sometimes it is helpful to have
someone else help by giving some additional pressure at the
end range position to get a better stretch. Common areas that
experience tightness are the hands, mouth opening, and neck
areas, but many other areas can be involved. There are many
instances where the skin tightening eases off, but if you
have not been stretching you will not be able to take advantage
of this. You must seriously think, "use it or lose it"
for each motion. It is really important to take each joint
through the full range-of-motion each day and to note any
changes from the day before. If an area is stiffer, then be
a bit more vigorous to get that last degree of motion.
Strengthening is another important part of a general exercise
routine. Lifting your arm or leg against gravity is actually
strengthening and may be the beginning of the program. You
could then move to elastic loops (Therabands), cuff weights,
or machines for resistance. We do not normally recommend the
use ofbarbells this is too much stress on the tiny hand joints.
Therabands are available in any Physical Therapy (PT) clinic
and work well for strengthening. The best thing when using
a Theraband is to make loops in the end to go around your
wrist or ankle and tie the other end to something strong.
A visit to a physical therapist may be beneficial for instructions.
We suggest you do strengthening on an every-otherday schedule.
This gives the muscles a chance to recuperate from the activity.
Conditioning exercises help with endurance. These exercises
can be in the form of walking, riding a bike, or swimming
in a heated pool. These activities are good unless you have
been told by your doctor to avoid them. The best exercise
is something that you want to do. There is no competition;
do what you can, but DO IT! If you are unable to tolerate
twenty minutes, start with a few minutes and gradually increase.
Be pleased with what you are able to accomplish. These types
of exercises increase your cardiovascular fitness, which helps
combat the fatigue, and also help you to feel better about
yourself. If you are going to be swimming, it is important
to maintain skin health with moisturizing creams. Those with
a high glycerine content seem to be helpful to many folks.
Physical Therapists are real fans of group exercise programs,
as you derive encouragement from each other and it is not
quite as boring. You make a commitment to yourself and your
friend that you are not likely to break. There are two programs
that are designed for people with any or all types of arthritis.
The Arthritis Foundation and health professionals specializing
in inflammatory diseases approve both. PACE is People with
Arthritis Can Exercise, a land-based group program, and the
AFYAP (Arthritis Foundation/YMCA Aquatics Program) is a program
of warm water swimming exercises. Both are taught by people
specifically trained in the programs and who are aware of
the limitations or cautions important to you.
The following exercise suggestions may be helpful. They are
a good start, but they are not all inclusive. It may be helpful
to see a physical therapist for evaluation and recommendations
to help with your exercise program. Many times it is helpful
to have a professional to ensure that you are working hard
enough. There are many therapists who can be very helpful
to you, but may not have worked with a patient with scleroderma
before.
Again, we would like to reinforce the importance of doing
some exercises every day. The stretching may be painful, but
it is imperative. We would also like to stress that you not
start any exercise program without the full approval of your
physician(s).
Range-of-Motion Exercises
General Instructions
These exercises are to be done daily, preferably early in
the morning after heating your stiff joints. Each exercise
should be repeated five times. After several days of performing
the exercises, try to establish an estimate of your range
of motion and the level of pain you have for each joint. On
those days that you find either decreased motion or increased
pain in any joint or muscle area, you should continue to use
heat and repeat exercises three additional times for those
areas. In this manner, you should be able to detect limitations
and prevent the loss of motion of a joint. You should decrease
the number of exercises temporarily for only I those areas
where an acute flare-up has occurred (hot, painful, swollen
joint), and increase them when the flare subsides.
All exercises are designed to limber up muscle and joint
stiffness as well as maintain maximal joint motion. These
exercises are to be performed in your bed, if firm enough,
or on any other flat surface while lying on your back, and
without pillows.
General Warm-up
- Gluteal Setting
Pinch or tighten your buttock muscles together tightly,
holding for five seconds and relaxing 10 seconds.
- Quadriceps Setting
Place a rolled-up towel under each knee. Tighten the muscles
on tops of thighs and hold for five seconds, and then rest
10 seconds. This exercise will pull the kneecaps up toward
your hips while you are attempting to straighten the knees
and lift your heels off the bed. Your buttocks must remain
resting on the bed.
Arm and Hand Exercises
- Forward Elevations
Arms at sides, elbows straight, hips and knees bent. Palms
turned toward body, raise both arms back over your head,
leading with your thumbs as far as possible in a slow, wide
arc of motion. Slowly return to starting position and relax
10 seconds.
- Sideward Elevation (Abduction/Adduction)
Arms at sides, elbows straight, palms upward, hips and knees
bent. Slowly slide arms out to the sides and up over your
head as far as possible, leading with the thumb. Slowly
return to starting position and relax 10 seconds before
repeating. Be sure to keep the elbows as straight as possible.
- Shoulder Rotations
Elbows away from body as far as possible, up to level of
shoulders with elbows bent 90 degrees and resting on bed
with fingers pointing to the ceiling and palms toward the
body. Hips and knees bent. Rotate your shoulder while attempting
to touch little finger to mattress at hip level.
- Elbow Flexion and Extension
Start with arms straight at your side, with palm resting
on bed, and hips and knees bent. Start by turning palm up
and bending elbow in an attempt to touch your shoulder Then
turn your palm away from your face and attempt to touch
your opposite knee while attempting to straighten the elbow
as much as possible. Repeat with your other arm.
- Finger and Wrist Flexion and Extension
Arms at sides, fingers pointed toward toes with palms facing
body. Start by curling or bending fingers and attempt to
touch tips of fingers to palms. Then bend wrist as far as
possible away from hips. Slowly straighten fingers as much
as possible and bend wrist toward hips as far as possible.
Return to start and relax.
Leg and
Foot Exercises
- Hip and Knee Flexion and Extension
Legs flat on bed with toes and kneecaps pointing straight
up to ceiling and heels four to six inches apart. Start
by bending your hip and knee. Slide your foot straight toward
your buttocks as far as you can, still keeping some part
of the foot resting on the bed. Hold, and then slide back
down to the starting point and relax. Repeat same exercise
with the other leg.
- Hip Abduction and Adduction
One leg lying flat with toes and kneecap pointing straight
toward the ceiling, and the other leg with the hip and knee
bent 45 degrees or approximately halfway with foot resting
flat on the bed. The exercise consists of sliding the straight
leg out to the side as far as possible while keeping the
toes and kneecaps pointing straight to the ceiling, and
then sliding back to the same starting position. Reverse
leg positions and perform the same exercise with the other
leg.
- Internal and External Rotation of Legs
Legs out straight with heels four to six inches apart.
Roll knees in toward each other. Then roll outward, and
then relax.
- Foot and Ankle Range of Motion
Legs flat on bed and heels resting on the bed at all times,
start by pointing feet down with toes bent. Then point feet
up with toes bent up. Then point feet in with toes relaxed;
next point feet out with toes relaxed.
Final Reminder
These exercises should be done daily, slowly, and without
causing increased pain.
Facial Exercises
The following list of facial exercises has been prepared
by the Physical Therapy Department of PresbyterianUniversity
Hospital of Pittsburgh. The exercises are designed to:
- maintain or improve mouth and jaw opening
- improve movement and tone of the face
- prevent further stiffness
Do the stretches gently but firmly. Hold each position five
to ten seconds before relaxing.
Stretching
Exercises
- Raise your eyebrows as high as possible, then relax.
- Frown as hard as possible, wrinkle your nose, and bring
your eyebrows together.
- Open your mouth as wide as you can, and stretch it as
much as possible.
- Smile as widely as you can while keeping your lips closed.
- Puff out your cheeks and stretch them as much as possible.
- While keeping your mouth closed, tilt your head back as
far as you can to stretch your throat area.
- Pucker up your lips as if giving a kiss.
- Make exaggerated vowel sounds (aaaaaaa, eeeeeee, iiiiiii,
ooooooo, uuuuuuu), stretching as much as possible.
- Stick your tongue out as far as possible. Then, move your
tongue to the right, to the left, up toward your nose, and
down toward your chin.
Augmentation
Insert a stack of tongue depressors, bound by a rubber band,
into your mouth from your front middle teeth to your back
molars on one side. Use only as many tongue depressors as
necessary to stretch your jaw. Repeat to the opposite molars.
Manual Stretch
- Place your right thumb into your left cheek and push outward
firmly.
- Place your left thumb into your right cheek and push outward
firmly.
- With both thumbs, push outward firmly on opposite cheeks
at the same time.
Exercises for the
Lips
- Open your mouth as wide as possible and hold it for two
seconds; close mouth, making sure your lips are closed.
Practice slowly 10 times.
- Pucker your lips and hold for two seconds, then relax.
Practice slowly 10 times.
- Spread your lips into a smile and hold for two seconds,
then relax. Practice slowly 10 times.
- Alternately pucker lips then spread lips as though saying,
oooo-eeee-oooo-eeee. Practice slowly, repeating each series
10 times.
- Open your mouth wide, then try to pucker lips as though
saying "oh" for two seconds, then relax. Practice
slowly 10 times.
- Pucker your lips and make a kissing sound. Practice slowly
10 times.
- Suck your lips into your mouth, then release in a loud
smacking noise. Practice slowly 10 times.
- Keeping teeth together, say these sounds: "ba bi
bu," exaggerating the lip movements. Practice slowly
10 times.
Exercises for
the Tongue
- Open your mouth and protrude your tongue. Be sure your
tongue is straight out, not resting on your lips or pointing
to one side. Maintain this position for two seconds. Practice
slowly 10 times.
- Protrude your tongue and move it slowly from corner to
corner of your lips.
- Repeat step 2, as rapidly as possible, still touching
each corner of your lips. Practice repeating each series
10 times.
- Protrude tongue and point it downward toward chin; hold
for two seconds, then relax. Practice slowly 10 times.
- Protrude tongue and point it upward toward nose; hold
for two seconds, then relax. Practice slowly 10 times.
- Protrude and point your tongue to touch the top, bottom,
and corners of your lips. Practice slowly 10 times.
- Repeat step 4, as rapidly as possible. Practice repeating
each series 10 times.
- Protrude tongue and move it down then up as though licking
an ice cream cone; relax. Practice slowly 10 times.
- Move tongue around your lips in a circle, touching all
of upper lip, corners, and lower lip; relax. Practice slowly
10 times.
- Raise the tip of the tongue and touch the upper lip, the
upper teeth, and the ridge behind the teeth and the hard
palate. Practice slowly 10 times.
- With your mouth open, suck up hard on your tongue, drawing
in the sides of the tongue as hard as possible to the hard
palate. Hold for five seconds and relax. Practice slowly
10 times.
Exercises for
the Palate
- Puff out the cheeks and press the fingers against one
cheek without allowing the air to escape through the mouth
or nose. Practice slowly 10 times.
- Blow on a straw keeping a finger on one end and maintain
the air in the straw for 5 to 10 seconds. Practice five
times.
- Say the (s) sound "ssss" without allowing the
air to come through the nose. Practice slowly 10 times.
- Repeat "ka" 20 times, "ga" 20 times,
and "sss" 20 times.
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