Ardra Shephard: I'm Ardra Shephard and this is Tripping on Air. A place to talk shit about what it's like to have MS. Normally I like to make everything about me, but MS also affects the people we love. So weighing in from the partner perspective is Alex Hajjar, my friend whose wife also has MS. Join us monthly as we dish about everything from symptoms to stigma. If you have MS or you love someone who does, we want to connect with you. Exercise is a powerful DMT, or Disease Modifying Therapy. How we move our bodies has the potential to positively impact MS symptoms. And for me, that's a good news, bad news story. I've had success with physiotherapy in the past, but I'm also prone to extended PT slumps. MS means I don't have as many available hours as I used to. When a shower can take two hours, by the time I've recovered from blow-drying my hair and putting my legs into leg holes, the choice to do anything resembling a workout can feel overwhelming. And saying yes to exercise often means saying no to something else. Our guest today, you know her, you love her, Dr. Gretchen Hawley is a fixture in the MS community. She's the author of the recently released book, The MSing Link. She's here to talk about the benefits of neuroplasticity and maybe talk some sense into me. Basically, I'm hosting my own intervention. Dr. Gretchen, welcome to the show. We're so happy that you can join us. Dr. Gretchen Hawley: Yes, I'm happy to be here. Thank you so much for having me. Alex Hajjar: Yes, welcome Dr. Gretchen. Thank you. I think we're going to have to put all of the burden of the MSer and the partner on you this episode. I mean, I know I can be a supremely lazy procrastinating magpie who will always find a non-movement based thing to do rather than go to the gym. This year, I'm trying a little bit harder, but the motivation is hard. It's a sunny day today, but it's usually quite gray, so I mean, I'm just letting you know so you're prepped. Ardra Shephard: Yeah. You had to bring the energy for both Alex and I, but I think that's an important point, Alex, because the people in our worlds, the people we hang out with, are partners in a lot of cases, can impact and influence how active we are or aren't. So I think there is room to explore that here. Dr. Gretchen, what do you think? Dr. Gretchen Hawley: Oh my gosh, absolutely. I think when we think of exercise, so often we think of maybe just going to the gym or these things that we were taught growing up, but it's so much more than that and we can think of it as just movement and who else is around and who can be there with us and maybe keep us accountable or at the very least encourage us or even just let us know it's okay to not do anything. Ardra Shephard: Yeah, I'm really good at that. And so is my husband. Dr. Gretchen, you're a certified MS specialist. What does that mean? What is neuro therapy and why is it important? Why is it a distinction that people with MS should be aware of? Dr. Gretchen Hawley: Yes, I think this is such an important distinction because so often people with multiple sclerosis will go to physiotherapy and they won't really focus on what type of physiotherapy it is, they just kind of have this thought that all physiotherapy is equal and the same. And unfortunately that's not the case. Most physiotherapists that work for outpatient clinics are what I would call traditional or orthopedic typical physiotherapy, and that's where you would go if you feel like you are having low back pain or shoulder pain or post-surgery, these normal orthopedic things that a lot of us experience day to day. And the difficulty there is that they focus more on strengthening muscles, and when you have MS, it's very likely that you do have some level of muscle weakness, but the reason that you have that muscle weakness is due to weak neural pathway. So the pathway from your brain all the way down to those muscles. So when you have multiple sclerosis and when that is the reason for your weakness, it's important that you're working with a physiotherapist that knows how to strengthen the neural pathways because when you skip that step, if you just focus on the muscles, you're likely not going to notice the same level or any level of improvement. So MS-specialized physiotherapists need to prioritize focusing on the neural pathways and muscles, not just the muscles. Ardra Shephard: That's so interesting. It's almost like the muscle weakness is secondary, does that make sense? Dr. Gretchen Hawley: It is. It's a great way to think about it. Sometimes I'll give these presentations and I have three pictures explaining how a muscle works. The first picture is a picture of our brain because the first thing that needs to happen in order for our bodies to move is we first have to have the thought of let me move my leg or let me pick up my leg, or whatever it is, so it has to be a thought or a reflex. Then the second picture is a picture of a nerve because once you have that thought or reflex, it doesn't just go straight to the muscle, it travels down all these neural pathways. And then the third picture is a picture of the Hulk indicating that's when your muscles actually work. So there's these three steps of what has to happen for a muscle to move, but so often we forget about the first two steps and with MS, that's where the focus has to be. Ardra Shephard: So that's the takeaway. For people who are looking for physiotherapy, make sure you're looking for someone who is an MS specialist or who has a designation in neurophysiotherapy, is that right? Dr. Gretchen Hawley: Right. And you might know what type of physiotherapy you've experienced so far, if you feel like you were doing certain exercises, and maybe you did feel a little bit stronger, but your day-to-day activities didn't feel easier, that's a huge sign that you didn't have that carry over. So you may have done typical physiotherapy exercises like the clam shell, or straight leg raise, side lying leg raise, a lot of these lying down exercises and maybe you even got full strength in them, but you went to stand up and walk and that strength is nonexistent. It didn't carry over from the exercises that you are doing. So that's another way to be able to tell if you're doing the right type of physiotherapy for what your goals are and what your diagnosis is. Ardra Shephard: Would you say that's a case of working smarter, maybe not harder? Dr. Gretchen Hawley: Yes, absolutely. So often we think we have to have 10 to 20 exercises that we're doing, or exercise for an hour. But if you know what your goals are and you know what muscles are weak, which would be up to the physiotherapist to help you determine, then you can get really specific. And there's certain people that I work with who have MS, and I only give them three to five exercises, but those are going to be the biggest bang for their buck. They will notice way more improvement doing those three to five exercises than they would doing a full hour of maybe, I don't know, 15 exercises or three or four rounds of the exercises. Alex Hajjar: Actually, that's really interesting. And I had a question about I guess the wording that's getting used. So is there a difference between exercise and physiotherapy, and do you find that people with MS who might have reduced mobility are bumping on the word exercise as if there were a negative connotation? Dr. Gretchen Hawley: That's a really good question. I do think there is a difference between physiotherapy and exercise in this sense that in my mind, physiotherapy specifically focuses on the weakest areas so that we can build up the strength, whereas exercise can be anything. I like to think of exercise as the same definition as movement and just moving around, we think of exercise, well, I don't know about you guys, but myself and most people that I know, we think of exercise as what we were taught it meant back in kindergarten and it's jumping rope, going for a run, squats and lunges and going for a mile-long walk. And yes, that is exercise, but we forget what else is exercise too and what else counts as movement and exercise. And if we don't switch that definition in our brain, it's so easy to feel like, "Well, I can't exercise, I can't move." Or, "I can't exercise because I can't go for a run." And that's just simply not the case. But physiotherapy does focus more on specific muscle groups, even specific muscles and the neural pathways, whereas exercise is just move, as Ardra said in the beginning. Showering, I count as exercise, I count as movement, going to get the mail- Ardra Shephard: I count brushing my teeth as exercise. Dr. Gretchen Hawley: Yeah, absolutely. Alex Hajjar: Yeah, that's an active repetition of work. Dr. Gretchen Hawley: Yeah. Absolutely. Ardra Shephard: Even I thought the electric toothbrush was going to save me some strength, but it's heavy. So I feel like I've traded- Alex Hajjar: It's a weightlifting thing. Ardra Shephard: ... the motion for the weightlifting part of it. So yeah, I'm pretty good at rationalizing. Dr. Gretchen, this is a really important question for me, what do you say to people with progressive MS who are maybe, who are almost certainly, me for sure, feeling guilty or their MS could be better if they just tried harder? We already have to give so much of our time, our attention, our effort and energy to MS, what do you say to someone who is really struggling and feeling like it's not fair that we have to use so many of our resources just to function? Dr. Gretchen Hawley: Yeah. Well, one thing I would say is to, again, change your mindset a bit to realize how much you are doing. Because even just the example of brushing your teeth and the toothbrush being heavy, you could think of that as, this is something that's really heavy and hard for me to do, or you could think of it as, this is a hand strengthening exercise and an arm strengthening exercise to keep my arm up there to brush my teeth. And I think having that mindset will allow you to feel differently about what you're doing. Yes, it's still challenging, we're not taking that away, but viewing it as you doing an exercise and you actually putting effort in. Which leads me to my second point, which is so often, as you said, we think, if we could just do more. But it's not always about doing more, I think it's about what effort you are putting in, whatever that looks like for you. So one thing that I... I Had this experience with one of my patients about a year or so ago, and she was so bummed because she felt like she didn't do any of her exercises for a full week. Her daughter was sick, so she was taking care of her daughter. And I was like, "Well, okay, so what did you do throughout the day?" And she was like, "Well, my daughter was staying upstairs, so I was constantly going up and down stairs. I had to make her food. I was bringing her Kleenexes." And so we took a pause and I pointed out all of what she did do, even though she wasn't viewing it as exercise or movement, and I pointed out to her, "That absolutely counts." Every movement you do throughout your day counts. And it's more about, how do you feel you did with what effort you put in? If you feel, even if it was brushing your teeth and you feel like I put a hundred percent effort into that, that counts. The only time it doesn't count and you aren't doing enough is if you truly can say, "I put 0% effort into my day today," which is pretty rare. A lot of people can't say that they put 0% effort in. Alex Hajjar: Sorry, I'm only laughing because some days, even as a partner or just as a human being, if I tell myself I've put zero effort in today, sometimes I'm actually proud of that. Ardra Shephard: Alex, you're an enabler. Alex Hajjar: It's only because I feel like other days are happier days. Ardra Shephard: There is this feeling, though I know when I do put a lot of effort in, where it feels like I've earned rest, which I know is a super toxic way to think, but rest does feel different when I'm tired because I did a lot of stuff versus the feeling I have of needing to rest and being really tired, but I actually haven't done anything. So I think that's a big struggle when we're talking about how to stay motivated with MS when a lot of us remember what it was like to exercise before our diagnosis, what it was like to feel our muscles get stronger, to feel our run times get faster, and then now feeling like you have to be satisfied with just getting worse, slower. It's hard to measure that. It's hard to... Sometimes I just feel like I'm just telling myself, I'm rationalizing, like, oh, giving myself a pat on the back for brushing my teeth feels kind of like a cheat. Alex Hajjar: So actually I think one of my favorite parts of Dr. Gretchen's book is when, Gretchen, when you talk about resting without guilt, can you expand on this and- Ardra Shephard: It's, how much of your job as a physiotherapist is also just a psychoanalyst? Dr. Gretchen Hawley: A lot of my job actually. Alex Hajjar: ... and maybe what our bodies are doing while we're resting? Dr. Gretchen Hawley: Yeah, so that is something that I'm so passionate about talking about is this guilt-free rest, which I do understand that that's way easier said than done, but it feels different when we are resting and with it and not feeling guilty versus but thinking, "I should be doing XYZ, I shouldn't be resting right now." It just feels more like a burden and our body physically doesn't rest as much as it does when we have that guilt and those ruminating thoughts. And so if we can get to a place where we're resting guilt-free and rest is productive, you have earned it in most cases, even if it was just brushing your teeth, if that requires rest afterwards, great, have that guilt-free rest. Because if you're feeling guilty, if we're having those ruminating thoughts, our literal cells in our body don't fully calm down. We're still in fight or flight mode, and being in fight or flight mode can cause more inflammation. So yes, we might be in bed or on a couch or anywhere just resting, but our body is not actually resting. It's just a place that we're sitting or a place that we're lying down. So if you can get to a point where understanding, this is helpful for me, this is productive for me to not do anything right now, you likely, and of course MS is different for each person, but you will likely feel more rested afterwards and ready to do the next thing. Ardra Shephard: I love this advice and I think it's also a really important piece for partners to hear because sometimes our guilt is compounded when we are the ones lying on the couch and our partners are doing all the housework, making dinner, looking after the dog, looking after the kids, all of these things. And so, it's about not having guilt ourselves, but also kind of releasing ourselves from that from our partners and having that understanding. Dr. Gretchen Hawley: Absolutely. And having that conversation with them because partners often don't understand MS specific fatigue and just what happens in a body when MS is involved. So often during initial evaluation, so that very first time I'm working with a person who has MS, their spouse or significant other will come in with them and they'll say things like, the patient will say that fatigue is one of their symptoms. And the spouse will say, "Yeah, but we all have fatigue, tell her about X, Y, Z." And it's like, "No, it's different. Their fatigue is not the same as your fatigue." And so- Ardra Shephard: Oh, I can speak to this. I can speak to this. I did an interview with my husband for the blog and I asked him, "If you could take one of my symptoms, what would it be?" And he said, "Fatigue." And he said, "Because I don't get a lot of sleep during the week anyway." And I was like, - Dr. Gretchen Hawley: Oh, wow. Ardra Shephard: "Hold up, hit pause. We need to have a big fight. And you think you could handle fatigue better than me?" It is hard when you don't feel it. I think it's always, my advice is when your partner has the flu, tell them to imprint that feeling because that's the kind of fatigue, sickness behavior that MS fatigue, I think, can feel like. And it's hard... You forget when you're feeling better, but it is a good reminder. Let's say Dr. Gretchen that your Fitbit thinks you're dead, that's how little you've been moving, active, asking for a friend. How do you start? What's enough? What do you prioritize? Dr. Gretchen Hawley: I love this question, I love how you worded it. So one thing that I really prioritize with everyone that I'm working with is really, really, really small wins. And so for example, the first thing that you can do is just pick one goal, one thing in life that you want to just be a little bit easier. And for most of the people that I work with, it might be standing up with better strength without having to plop down five times before you actually stand up and stay up. Or it might mean walking 10 steps to get from your couch to the kitchen or to the bathroom. So just pick one thing that you would like to be easier. Let's go with the example of standing up with better strength, and then break that down into as many movements as possible so you're not just successful when you stand up and stay up, but part of having to stand up means scooting forward in your chair. It's impossible for anyone, MS or not, to stand up and stay up if our butt is all the way back in the chair, we have to be able to scoot forward. And so oftentimes I'm working with a patient and they'll say, "Ugh, I still can't stand up, but I'm working on it, but I am able to scoot forward." And they're saying it in this depressive tone, and I'm like, "Um, that's amazing, you can scoot forward." It sounds so simple, but that's part of the process. If you couldn't scoot forward, you're not going to be able to stand up. Let's take that as a win. And so being that specific, picking really, really, really small wins. Another part of standing up is having the strength and flexibility to open your feet and your knees a little bit wider so that you can be more balanced once you're standing. So if you're able to move your leg slightly further out to the side, again, that's a huge win. So taking a goal, but really break it down and see, "Okay, what can I do today? It might take you a week or a month or six months to be able to forward out of a chair better, but that's still a win even though you're not yet at that point where you're standing up fully. Ardra Shephard: Okay, I accept that. I like the idea of refocusing on the things that we can do and being able to identify those because it's so much easier to focus on the frustrations that are getting in our way. Alex Hajjar: Yeah, and I like the idea of the little wins. Every little sort of accomplishment, yeah, it should feel like you've rewarded yourself, you're rewarding your body with this next step activity. Ardra Shephard: I wouldn't have thought, "Yay me. I can move this foot over a little bit," but I think I will think of that now. Dr. Gretchen Hawley: Well, and you're definitely in the majority there, because I will say, usually I do my client calls on Zoom, and so we can see each other and they're explaining this to me, again, they're usually in this like, "Ugh, this is all I can do." And I've got this huge smile on my face, and I'm like, "Uh, that's great. That's amazing. [inaudible 00:21:35]." And they're looking at me like I have five heads because they weren't thinking of it in that way. And so it really is training your mind to look for the small wins, because We're not trained for that. Especially when you have MS, we're often focusing on how hard the movement is and what the end goal is, but training yourself to think about all the little steps that are required, you literally have to scoot forward in order to stand up. So let's celebrate that because that's part of the steps. Alex Hajjar: Yeah, that's so interesting. I feel like, because I mean without MS you would just do it and you wouldn't even think about it. So when you do have to think about it maybe becomes a little bit more of a weight on your shoulders, but once you can, then it becomes a really big accomplishment. I really like that. Ardra Shephard: Well, that's the thing for people with MS, we remember when we didn't have to think about things. Now if I see somebody on TV or in a movie who bolts upright in bed without using their hands and shimming, I'm like, "How do they do that?" Dr. Gretchen Hawley: Well, and that's the thing. It can be a little depressing as well, because on the other side of things, we are thinking, "Great, now I'm rewarding myself for being able to scoot forward. I didn't use to have to do that." So it really is how you're choosing to look at it because the same situation can feel very defeating and depressing instead of rewarding and exciting and motivating. So making sure you're focusing on how you're looking at things. Ardra Shephard: Because all that's valid too. I mean, it's also incumbent on us to recognize changes, whether positive or negative. We have to be aware of them so we can report those to our doctors. But yeah, reframing and working with what we have and strengthening the things that are working for us, right? Alex Hajjar: I think one thing I wanted to sort of touch on that might be related to this in terms of training yourself and just building up new connections, I guess in a way. But in the book, I guess you talk about four ways to activate neuroplasticity. So can you tell us what they are and maybe is this an opportunity for partners to engage and support their person? And maybe speak directly to my wife Nicole and tell her that playing Fortnite and/or other games with me will benefit her MS? Dr. Gretchen Hawley: Yeah, absolutely. So going back to what we were talking about in the beginning, which was when you have MS and when you're exercising... How do I even want to phrase this? The deeper meaning behind exercising isn't just to get stronger. Yes, that's a great goal and it's absolutely something to work towards. But the reason that exercise, MS specific exercise is so important is because we need to strengthen those neural pathways, those pathways from our brain all the way down to our muscles. Without that, our muscles will not get stronger. Standing up will not feel easier. Brushing our teeth will not feel easier. So we have to focus on that. And there's two ways to do that. One is through functional exercise and one is through neuroplasticity based exercises. And as you're mentioning, there's many ways to activate neuroplasticity, so you're more likely to strengthen those neural pathways. So one of those ways, one of those things that you can do is focused attention. And what that means is as you're exercising, and when I say exercising, what I'm imagining is practicing sitting or standing or even lying in bed and lifting one leg up, even just a little bit and then lowering it down. So I'm not talking about going for a walk or anything crazy, but just even it could be opening your hand and then closing your hand. So that's what I mean when I say exercise. When you're exercising, focus on the exercise that you are doing. Don't be thinking about, what's my grocery list today? What do I need to add to it? Or what am I going to have for lunch? Or how am I going to shower tomorrow? Or when is my appointment? Focused attention is one of those ways where you can actually strengthen your neural pathways just by focusing wholeheartedly on that specific movement. Ardra Shephard: I love that you're saying this, but at the same time it's like, man, not only do I have to exercise, I have to think about it. It does feel like another mentally taxing thing, but maybe I could be sold on it if I really think about it. Do I have to do fewer repetitions? Could that be a thing? I'm always looking for a loophole. Dr. Gretchen Hawley: You could do fewer repetitions. Yeah. Well, and the thing too, there's multiple ways to activate neuroplasticity. So if that one in particular is like, "Yeah, I'm not going to do that, I'm immediately crossing that off," that's fine. There's other things that you can do, you don't have to do all of them. Alex Hajjar: Are things like video games or board games or some other games something that you can focus on and build that neuroplasticity, or is this strictly from a- Ardra Shephard: Do you see how lazy we are, Dr. Gretchen? Alex Hajjar: I'm just trying to get my wife to play games with me. Ardra Shephard: We just want to do fun things. Alex Hajjar: I need some backup here. Dr. Gretchen Hawley: Yeah, another way that you can activate neuroplasticity is through adding a challenge and urgency and games are a great way to do that. One game that I actually just learned about this year, even though this is a kid's game and I feel like I should have known this, is the Bop It. Do you guys know what the Bop It is? Alex Hajjar: You have to press different buttons or pull or- Ardra Shephard: I have no idea. Alex Hajjar: Is that what you're talking about? Dr. Gretchen Hawley: Yeah. So it's this handheld game it, and you listen to what the directions tell you. And it will say, "Bop it, pull it, twist it, spin it," I don't know, a bunch of different things. And you just follow along. And the better you do, the quicker it tells you what to do next. And there's this music in the background that of course also gets quicker the better you do. And so it really adds this layer of fun, but also urgency and challenge because you don't want to screw it up. And so that's more of a handheld game, but any type of game that you find urgent, fun and challenging can absolutely be something you incorporate. And not only that, you can choose to do that with your exercise. So maybe you're playing the Bop It while you're standing, so you're working on your standing balance, your standing endurance, or you can implement the challenge, the game, the fun, the urgency between your exercises. So maybe you're practicing your leg lifting, and then during your break you're playing one round of your game with your wife and then you go back to the next exercise and then you add a different challenge in between the next one. So it can either be part of the exercise or between your exercise. Ardra Shephard: Dr. Gretchen, in your book you identify gaps in what you consider to be patient knowledge that you thought would've been obvious in terms of little things, hacks, I guess that you would've expected us to know. Can you talk about how you use social media as a platform to reach patients and to fill in some of those gaps? Dr. Gretchen Hawley: Absolutely. Yeah, this was such an eye-opening experience that I will never forget. I can imagine it vividly, and I believe it was eight or nine years ago now, where early, early on into becoming an MS specialist, I was giving a presentation to a support group and there were about 15 people or so there, all had multiple sclerosis. And I honestly felt so silly talking to them and giving them these strategies. Because in my mind, they were very simple strategies, almost like no-brainers, "Yeah, of course that's going to help me." And I gave this presentation. It was about 45 minutes long, so it was long. And everyone was frantically writing down notes the entire time, and there were so many questions at the end. And honestly, I was really taken aback. And I don't even know how to explain how surprised I was that they didn't know this information. And I truly felt disappointed in our healthcare system and the people that we're working with, how has no one told them this before? If you have heat intolerance, so one or multiple symptoms worsen when your core temperature rises, how has no one told them that it's not just from the temperature outside, but it can also be from stress or movement and exercise or a warm shower and what to do about it. I was just- Ardra Shephard: Or a fever. Dr. Gretchen Hawley: A fever, yeah. There were so many things. And I'm like, everyone with MS needs to know this, this simple trick of cooling your core temperature down can literally change your day if you are having a day where your core temperature is high for whatever reason. Or if you have drop foot, the simple act, not that it's easy, so I don't mean easy when I say simple, but this simple act of practicing lifting your toes. Even if it doesn't move, that's a no-brainer, of course you would practice that exercise if you have that symptom, and they just didn't know. So that was the first experience where I was like, "Whoa, okay. People with MS don't know these simple tricks, hacks, exercises and they need to." And so pretty shortly after that, I started a social media account where I educated on this stuff and it was me demonstrating exactly what to do. And it was again, just really eyeopening how many people had no idea what I was talking about. And I found it just really fun. Ardra Shephard: You talk about spasticity in the book, what tips do you have for someone who has intermittent vocal spasticity and maybe hosts a podcast? And what do you do when your voice starts to crap out or get a little bit of too much fry and you need to stop it quickly? Dr. Gretchen Hawley: Yeah, so that's the thing about spasticity that some people might not realize is that it can affect any muscle in our body, including your vocal cords, those are muscles too. And one thing that might help in the moment is, in this specific case, is talking slower. Because generally speaking, speed is something that can make spasticity worse. So if we're talking about spasticity in the legs, the quicker you're trying to move, a great example is if you really need to go to the bathroom, you're going to run to the bathroom or obviously not run, but as quickly as you can, and that can make the spasticity even worse and then we're in a whole situation. But for vocal cords, it's the same thing. If you're trying to talk really fast and explain something or get the question out, that can make spasticity worse. So slowing down can be one thing that you can do to help out. And then another thing to think about could be, is there a reason that this is worsening right now? That's my favorite question to ask when any symptom is worsening. And the first question that I like to go to is, could there be the possibility that my core temperature is increasing right now? And I don't know about you guys, but anytime I'm being interviewed or if I'm interviewing someone else, I sweat. When I'm done, I can literally see sweat marks under my arms- Ardra Shephard: Are you sweaty right now, Dr. Gretchen? True confessions. Dr. Gretchen Hawley: I absolutely am. And so my core temperature right now, anytime. Again, if someone's interviewing me or vice versa, my core temperature rises. If I had MS, that could make one or multiple symptoms worse. And so having ice-cold water nearby and taking small sips to reduce your core temperature, or it doesn't have to be ice-cold, but as cold as you can tolerate, that might be something that could help as well, if you do feel like your core temperature could potentially be rising. If that's not it, what else could be causing the spasticity? Ardra Shephard: It's the opposite for me, I am baseline reptilian. I am so cold, I'm freezing right now. But I also can hear this fry and I should try to slow down. It's hard. I think we all have a natural tempo to our voices, but I will try to apply that slow speaking. Dr. Gretchen Hawley: Yeah. Well also if it's the opposite where you're more cold, I just posted about this on social media and it's also in my book, cold intolerance is a thing as well. It's when your core temperature drops by at least half of a degree and causes one or more symptoms to worsen. And so what you would do is instead of having cold water, have hot water next to you and take small sips this entire time that we're talking in hopes of bringing your core temperature up to more of a neutral. Because if you are getting colder and colder, that could be making your spasticity even worse. Ardra Shephard: I think this is an interesting point because I know I'm not the only one that suffers from being cold and improper temperature regulation. It's funny because, it's not funny, haha, but it's worth noting that I run cold. It's hard for me to regulate my body temperature. At the same time, I am impacted by heat. My legs will turn to spaghetti if my core temperature raises. And I am feverish at a lower temperature than the average person because my body temperature just naturally runs colder, so that's something to be aware of too. Dr. Gretchen Hawley: Absolutely. And I'll even take it a step further and say that I have some clients who don't have heat or cold intolerance per se, but they have more sunlight intolerance. It could be the dead of winter, but if the sun is shining on them, their symptoms will get worse. And so the sunlight can also play a big role as well. Alex Hajjar: We're big shade chasers. Wherever we go, if there's sun, we just constantly look for the shade. But I wanted to ask because a lot of physiotherapy and exercise is about measuring success. And you talk about measuring success by how much effort is expended versus measuring success by the actual results themselves, so I wanted to know why is this approach important? Dr. Gretchen Hawley: That's such a good question. So most of the time when we're exercising, what we are looking for is movement, and that's how we measure success. If I am trying to lift my leg up right now, I would likely think success is if my leg lifts up off of the ground because the goal that I'm going for. And if it doesn't lift off the ground, I'm likely to think, "Okay, well this isn't working. And in that case, more times than not, if I'm giving them the exercise, they'll say, "Well, it doesn't work. What's next? I'm not going to do it. Give me the next thing to do." Because what we're looking for is movement and is the thing that I'm trying to do happening. But when it comes to neuroplasticity, the reason... So let's say you go to lift your leg and nothing happens. The reason that that's happening is due to your neural pathways. If you have MS, the reason is because your neural pathways aren't strong enough and/or they're just too demyelinated where there is no connection from your brain down to that muscle. But there is a way to get that neural pathway working or to find a brand new neural pathway, which if this is the first time you're hearing this, it sounds too good to be true, I totally understand that. But that's the definition of neuroplasticity, it's the ability of our brain to find a way to get from point A, being our brain, to point B, being our muscle. But the only way to find or strengthen a neural pathway so that you can eventually lift your leg is to actually do the movement that you're hoping to improve. And we can move things around a bit to make it a bit easier, maybe we change your position, we can use resistance bands to help, to actually assist. So there's things we can do to make it easier, but regardless, you have to do that movement. And the way that I like to think of this is when you're doing an exercise, view success as how much effort you're putting in regardless of how much movement you're seeing. If you are trying to lift your leg and there's no movement, but you feel like, "Holy cow, this is a hundred percent of my effort. I cannot put any more effort into this." That's success. Awesome. You just did one round or one repetition. And viewing success in that way in terms of effort can keep you doing it, versus if you feel unsuccessful because there's no movement, realistically, you're not going to do it long term and then you won't see results from it. Alex Hajjar: Honestly, I think this has been completely enlightening because even for me, who is a seasoned procrastinator, a seasoned lazy person, I think these little wins and the effort, just calling the effort itself a win is really going to boost my own morale, let alone everybody elses I think. But this has been amazing. I think Dr. Gretchen, I mean, where can our audience find you, other than everywhere? Tell us where we can get your book and talk about online access to The MSing Link, please. Dr. Gretchen Hawley: Absolutely. Yeah, so my book, The MSing Link is available on Amazon as well as in Barnes & Noble and some of the bigger bookstores. And if you have local bookstores, I have found that they are very open to getting the books that you want. So even just going to your local bookstore, calling them and asking them for it, they would be able to get it as well. Same with libraries. So that's for the book, The MSing Link. And then online, I have social media, of course. So Instagram is doctor.gretchen. If you're more of a long form video type person, I do have a YouTube channel, which is Dr. Gretchen Hawley. And if you're looking to work with me, I do have my online MS wellness program, which is also called The MSing link, and that is where we get to work together in group settings and you get to see all of my favorite MS specific exercises with calendars that tell you what exercises to do each day. You get to ask questions if you need modifications or advancements. We have experts come in like MS neurologists, so it's more of a more well-rounded program for someone looking for that level of support versus just random exercises here and there. And then I also have my podcast also called The MSing Link. Ardra Shephard: I will also add that if you are one of the 10,000 MS patients at the BARLO Centre here in Toronto, Dr. Gretchen's book is available in our resource libraries. So you can ask for that. Dr. Gretchen, thank you for joining us. You've given us a lot to think about. Dr. Gretchen, thank you for joining us. You've given us a lot to think about. A dedicated movement practice is an investment in yourself and in your future. Start small, start wherever you're at. I have done six toe raises at least during the course of this interview. Remember that all activity counts and that rest is as essential as exercise. Be gentle with yourself and keep moving. Trippers, what are your favorite physical activities? Are you part of a PT community? We want to hear from you. Thanks for listening to Tripping on Air. Don't forget to visit us at trippingonair.com.