Background information on multiple sclerosis
Multiple sclerosis is a chronic disease that affects the nervous system. The disease
affects the normal functioning of nerve cells in the central nervous system by
damaging the myelin. Myelin is a fatty material that insulates the nerve fibers, also
called axons. In a healthy state, the myelin helps transmit electric currents between
nerve cells. This damage to the myelin impedes the transference of electric currents
to the brain, and thus impairs the brain’s proper, smooth functioning, which affects
the entire body. This process causes damage to various organs, most commonly the
spinal cord, brain and optic nerve. The damage to the nerve is so significant, that the nervous system cannot transmit electrical messages properly.
The disease manifests itself in different ways, and there are two main types. One
type is characterized by periodic seizures. During a seizure, the body loses its ability
to function, but after the attack function returns, at least partially. The second type is
characterized by constant deterioration. In both types the damage accumulates over
time. The phenomenon in which the first type of the disease turns into the second
type with time is common, and this causes increasing disability. Most patients are
diagnosed between the ages of 20 to 40. It is estimated that multiple sclerosis
shortens life expectancy by 10 years, so on average, sufferers are living with the
disease for about 30 years.
Multiple Sclerosis can strike anywhere in the body, and patients live in a state of
uncertainty and anxiety about which part of the body will get hurt next and when, and
whether the damage will be permanent or temporary. Such constant uncertainty
causes a chronic state of anxiety and tension. Every phenomenon in the body or
mind, even a small or normal one, may be the start of a new attack or a new
deterioration, which will result in a growing disability. The disease attacks the somatic
(voluntary) nervous system and the autonomic (involuntary) nervous system, the
motor and sensory systems. It develops differently in each, but has classic
symptoms, which I review below.
The classic symptoms of MS
Visual problems – Blurred vision, loss of vision, usually in one eye. Involuntary
movements of the eyes. It is very common for the disease to begin in a sudden fit
that affects the vision. People may wake up in the morning unable to see out of one eye.
Fatigue – Very intense fatigue making it impossible to get out of bed. Bouts of
fatigue can last for one day or for several days or even weeks.
Muscle problems – Difficulty standing and walking. Shaking and cramping.
Weakness and muscle atrophy. Pain. Pins and needles. A burning feeling in various
organs of the body. Numbness in other organs. Loss of fine motor skills. Lack of
balance between the two sides of the body. Loss of balance and dizziness.
Problems controlling the excretory system: urine and feces – Constipation. Loss
of sphincter control. Difficulty controlling excretions.
Effect on the brain – Depression, memory loss, confusion, concentration disorders,
Principles of working with MS patients
a. Uncertainty is what most characterizes multiple sclerosis: uncertainty about the
development of the disease; anxiety about which part of the body might be
affected; and uncertainty about how the patient will feel from one day to the next,
and even from one hour to the following one. I emphasize to my students the
importance of perseverance in the practice, but still try to help them develop the
ability to look inward and explore whether it is right for them to practice on a
certain day and if so, how to practice. The challenge for the student is to keep
practicing, even when in an unstable and unpredictable state, and to match the
exercises and postures to her current needs. In every yoga class there is a need
to listen to the students and adapt the lesson to them, but in the case of multiple
sclerosis and other medical problems, this is paramount.
b. Transitions in the class – for many MS patients there is a physical and
emotional difficulty in transitioning between standing, sitting and lying down, to
the point that it can be difficult for them even to turn over while lying down. These
transitions take a lot of time and effort, so it is better to restrict them during the
Therefore, I always try to limit the class to two states only, for example:
- Lying down and sitting on the floor or
- Sitting in a chair and standing or
- Lying on the floor or on a reclining chair.
I use the transition itself to practice the principles of Vijnana Yoga and guide the
students toward breathing and relaxation of effort, observing and listening,
rooting as leverage to get up, intent before and during action. I use transitions as
an opportunity to draw attention and awareness to the use of the principles of
yoga for daily physical challenges.
c. Precautions In addition to the usual precautions needed in yoga classes, there
are three additional ones:
- Do not tire the student. You do not know how her body will respond to the current class, even if she did the same in last week’s class.
- Do not warm up the body too much. Heat worsens MS patients’ condition and in extreme cases can even cause seizures. Therefore, any exercise that creates internal or external heat is not recommended.
- The student should always feel safe and always be in a position, so that if loss of control or sudden contraction of a muscle occurs she will not be injured.
d. Student independence – Despite the temptation to assist the student, it is very
important to let her do things on her own, as far as possible, in order to empower
her and to keep all options open, even when the desire to help comes from good
intentions. For example, allow her to organize for class on her own. The teacher’s
intervention should be minimal, yet supportive and reinforcing, to allow her to
face herself as much as possible, even when she loses balance or a muscle
contracts. Let her try to go from sitting to standing with guidance but without
physical support, as much as possible. In many cases, I give verbal guidance and
stand close to the student with a hand in the air in front of her and behind her, so
that she will feel emotionally supported, but physically she will cope by herself
and yet, if necessary, I am right there to give more help and support.
e. Our job in yoga is to improve the quality of life – We cannot make sick people
healthy, but we can help improve their quality of life. We endeavor to reduce their
symptoms and help the process of empowerment, and to work on healing at
physical, mental, spiritual and energetic levels.
f. Contract with the student: coordinate expectations – When working with MS
patients it is important for the teacher to be aware of problems that may arise,
and decide for his or herself how to deal with them. A common problem is last
minute cancellation. Or the teacher can arrive and find the student is not ready
and it takes her a long time to get organized.
a. The importance of a process – The persistent experience of MS patients is that
they are faced with a growing list of things they can no longer do. Through yoga
we change this experience by focusing on the process itself and not the results.
An orientation to the process removes the emotional weight associated with
success and failure. When we break each action and asana into small portions
and concentrate on them, MS patients can see that there are many actions they
can actually perform, and eventually, when the emotional weight falls away, in
many cases the scope of movement is increased.
b. The emphasis on attentiveness to the body – MS patients are faced with
uncertainty, a tendency to fatigue and changes in their condition and therefore, it
is very important to help them develop skills of internal attentiveness, in order to
adapt the training to their needs. Attentiveness to oneself and working from
within, that are the heart of Vijnana Yoga, are very significant in this process.
c. The principles of yoga: Intent, Breathing and Relaxation – We work with a
distinct mental intent to encourage the body to do physical actions, despite the
damage in the nervous system, and to strengthen the existing neurological
pathways and even foster new ones. Every action starts with intent and imagery.
When we work from a place of “sending a command” directly to a resistant
muscle, it often causes a forceful movement with struggle, tension, strain, muscle
contraction and resultant anger or frustration for the student. In Vijnana Yoga the
student learns to send mental intent, letting the muscles perform the movement
from a state of release and “relaxation of effort”. Instead of an inner attitude of
struggle against the body, she develops an inner attitude of curiosity and
openness, observing what the body can do. This is a much pleasanter
experience for body and soul that often brings a more successful movement.
I reinforce this work with an emphasis on breathing and relaxation. Breathing is a
tool of relaxation and concentration when we build asanas and hold them, relax
and stay within them, and then come out of them. I teach many exercises that are
a combination of length of movement and length of breath. In each exercise and
each asana I teach the student to begin each one of them with breathing, and
imagine that the body relaxes and floats on a wave of breath into the pose.
In many cases, this means very small movements, yet, these small movements
are very important because the MS body loses its physical abilities slowly,
gradually and incrementally, one movement after another, step by step, one by
one. Therefore actions and movements in the margins are very significant for MS
Planning a yoga class
In the initial stages of the disease, when the symptoms are minor or disappear
between seizures, many patients can lead a more or less normal life, and participate
in a regular yoga class, with a teacher’s supervision and adaptation of the exercises
to their needs. The challenge in this situation is to make them feel part of the group
even when they do individually tailored exercises. I like to do a number of individual
sessions before an MS student joins a group. At more advanced stages of the
illness’s development, a framework of private lessons is more appropriate. Most of
my students are now at the stage when it is better for them to attend private lessons,
and they can still work lying down and standing up, at least some of the time.
1. Meditation is usually done at the beginning of the class, as an opportunity for the
student to practice introspection, listen to her body and find out how she feels.
The goal is that after the meditation and contemplation the student and teacher
will build the lesson plan together. Therefore, each class begins with a short
meditation in which the student looks inwardly, physically and emotionally, and
evaluates her needs and her physical abilities on this specific day. After
meditation, we discuss it together and decide on the structure of the lesson, so
the class begins with an agreed contract between teacher and student. For
example, on a particular day we may decide that “Today we will start the lesson
with stretches on a chair, and then if you feel strong enough we will do standing
poses.” On another day we can agree that “Today we will try to lie on the back on
the floor in order to stretch the back and hips, and then try to do some
lengthening poses on your belly”.
2. Observation – Sitting on a chair or wheelchair, lying down on the floor and so
on. The aim is to foster listening and an inner attitude of love and acceptance,
building a quiet and stable mood, and an energetic field of peace and tranquility
instead of frustration and struggle against the body. Remember that multiple
sclerosis causes a tendency to depression, so do not let the student “sink” too
much. I do guided meditations to lead the student towards a positive experience
such as talking to different places in the body; expelling out of them stress,
fatigue and pain, and inserting strength, energy and healthy color; sending love
and healing to different organs of the body.
3. Pranayama (breathing exercises) – Their purpose is to develop lung capacity,
fill the body with energy and strengthen the immune system. Pranayama is
practiced lying down or sitting.
- Breathing softly. Breathing into the stomach.
- Placing hands on different parts of the chest and breathing into them.
- Soft Ujjayi, working on the extension and lengthening of exhalation with different rates.
- Anuloma Viloma, gently.
- Nadi Shodhana, with simulation and using the hands.
NB: Avoid pranayama that creates heat in the body.
4. Asanas – The key is to find a balance between the need to reinforce and
challenge the student, and the need not to heat up her body and not tire her. In a
group lesson, I give personal versions of asanas and emphasize the need to do
resting poses throughout the lesson to gain strength. In private classes, the
lesson includes postures of all kinds, with an emphasis on elongation, expansion
and backbends, because MS patients do not usually move in these ways in
everyday life. The class includes straight elongation, back arching, twisting,
forward bends and stretching sidewise. In addition, we work on releasing the
joints, fine motor skills, the Vayus for stimulating energy, strengthening the body’s
core and connecting to the center.
Relaxation – Each lesson ends with a guided relaxation, for example:
- Go through the muscles and organs in the body and imagine them resting and sinking downward.
- Breathe into different places in the body and imagine the breath and the energy relaxing and strengthening these places.
- Breathe and fill your body with healthy energy.
- Work with imagining colors.
Relaxation is important for MS sufferers for several reasons:
- They live with anxiety and tension, and relaxation gives them tools to deal with these feelings.
- Studies indicate that high levels of stress hormones (adrenaline) aggravate the disease and may even cause seizures.
- The ability to relax the body and muscles can be helpful for symptoms such as muscle spasms and tremors, which characterize the disease.
Various symptoms and suggestions for postures and exercises that can help them
I do a lot of eye exercises with the students:
- The Vayus of the eyes.
- Exercises to strengthen the muscles around the eyes such as drawing circles with the eyes, clock exercise, short and long-focus.
- Relaxing the eyes.
Vision deteriorates with time and the exercises aim to preserve existing vision.
Some days rest is needed, and it is important to respect the body at these times. I
encourage students to do the breathing exercises and relaxation if they have the
strength. However, there are days when despite fatigue, working on building energy
will help, using, for example, the external Vayus, pranayama or gentle stretching
combined with deep breathing. I try to help students look inward and cultivate the
listening and sensitivity that will enable them to differentiate between these two types
Difficulty walking, standing and maintaining equilibrium
Standing upright is unstable, keeping balanced and being able to lift the legs are all
impaired so it is difficult to walk. For this reason I work on standing with an emphasis
on rooting. Yet it has to be borne in mind that not all patients are able to work
standing up, and even those who can, cannot manage it in every lesson .The
muscles have a tendency to contract or collapse unexpectedly, so it is important for
the student to stand near something she can hold on to for support. Her attention
should be directed to this possibility gently, so as not to provoke expectation of
collapse. She can practice next to a wall, a walker, a wheelchair, a table and so on.
Possible poses are:
- Mountain pose
- First movement of tree pose, weight transfer, good for lifting the feet in order to improve walking.
- Breathing while standing and standing meditation.
- Stretching against a wall or table.
- Holding a table or a walker to go up and down on the toes.
- Twists near a wall or table.
- Warriors, for those who can.
I encourage students to persevere and practice poses that develop strength and
stamina every day, even in a limited way. I emphasize postures that strengthen the
connection to the center of the body such as:
- Standing poses as mentioned above.
- Exercises for strengthening abdominal muscles, lying down or sitting.
I use props to create situations where the student has to stabilize her body and find
the connection between her feet and her abdomen.
Sensitivity is required while working with MS patients. We must take care not to aggravate their instability and fear of falling.
Numbness in the limbs
Loss of feeling in a body part is very common and, typically, a sufferer may lose all
sensation on one side. Often, the student does not feel what her body is doing. A foot
may slip sideways while doing a pose and she will not feel it. The picture of Gillian on
the right shows her left hand working spontaneously. Yet she does not feel that her
left hand functions differently from her right one and cannot see the difference
between them because of vision problems.
I work a lot with props such as balls of different sizes, blocks and belts, because
physical contact can strengthen sensation. It is easier to activate a muscle against
something tangible than to operate it on its own. A prop provides immediate feedback
if the muscle stops working. For example, if we hold a ball between the legs and it
starts to fall, then we know that we’ve stopped pressing with the inside thigh muscle,
and we can try to find a way to activate the muscle again.
Body pain (sometimes strange and unexpected), pins and needles, burning sensations
The nervous system sends erroneous messages provoking symptoms of
hypersensitivity or severe pain, even when there is no “realistic reason” for it. When
this happens, I try to calm the student, reminding her to breathe and relax, to release
her from a state where she feels pain even if there is no “objective” reason for it. This
requires attentiveness and flexibility on the part of the teacher, not following a predefined plan, but being adaptable to the needs of the student.
We should also be careful with touch, even gentle touch, since the skin can be
hypersensitive to it. On the other hand, many patients live isolated lives and touch
and caring are important to them. The challenge for the teacher then becomes how
to use physical contact carefully and gently to convey the feeling of caring, closeness
and support, without causing unpleasant physical sensations.
Every teacher has to find a path to every student. There are no templates and no
formulas except listening to the student and being aware of her needs.
Muscle spasms and tremors
Muscles can contract or tremble strongly at unpredictable moments, and usually
people react with fear and panic, so it is essential to create a safe space where if the
student’s body abruptly stops functioning, she doesn’t fall and get hurt. If this
happens, the teacher has to project an energy field of peace and calm and not panic.
Then, she can work with the student on extended breathing, and making low sounds
to try to relax with intent and imagery of release. I encourage students to talk to their
body and soothe it, even out loud. I try to teach an alternative response to this
occurrence in everyday life too. Such spasms take place when great effort is made,
but not only at these times. So while they may diminish if the student can learn to
work from a place of intent, breathing from a place of relaxation and “without effort”, it is unrealistic to think that they will disappear altogether.
Imbalance between the left and right sides
It is very common to have one side of the body weaker than the other. I stress connecting to the abdomen and finding the start of an action there. I work on awareness of both sides of the body, visualizing the weak side getting stronger and
working equally as well as the strong side, because frequently feeling has been lost
on the weak side.
Banana exercises to stretch the shorter side of the body.
Loss of fine motor skills
- Working with the hands to keep the range of motion and the ability to make small movements.
- Working on Mudras, circles, closing and releasing, hand movements.
- Working with small balls held in the hands.
Problems in excreting urine and feces
Lack of control over pelvic floor and rectum can cause constipation, but also the
opposite with urinary and fecal incontinence. This is one of the most difficult
symptoms of MS, causing patients great distress. It is crucial to treat this matter
gently. We should be careful with exercises contracting the pelvic floor muscles and
the anus, since they might cause immediate loss of control. I do these exercises in a
gentle and indirect manner, through working with hands, feet and facial muscles,
using the Paula Method. I also work on activation and release. I do not use strong
work with the Bandhas or the internal Vayus.
Development of new neurological pathways
The idea is to try to develop new pathways, which will replace the damaged ones.
This is important from a physical point of view, but also gives great satisfaction to
patients, because they suddenly discover that many things they thought they couldn’t
do are in fact possible for them. The emphasis is on unusual movements like figure
eight exercises, and exercises coordinating between right and left, to teach
It is important to play with exercises activating the arms and legs lying on both sides, 4 point kneeling, lying on the stomach, sitting on a chair and standing.
Problems with concentration
Multiple sclerosis may affect the ability to concentrate, especially when there are
external disturbances. The tools of yoga, contemplation and concentration, can assist
the students to develop and improve concentration. The calmness of a yoga class
gives space and rest for those who find it difficult to deal with environmental noise.
Problems as a result of prolonged sitting
MS sufferers mostly spend a long time sitting and their range of motion in everyday
life is very limited. As a result, muscles atrophy and shorten, joints become stiff, the
back becomes weak and bent, feet and ankles swell and blood flow is impaired.
These symptoms are lifestyle related and not direct symptoms of the disease, but
yoga has to address them.
Exercises to release the back of the neck and shoulders sitting or lying down
- Turn the head from side to side; stretching the neck.
- Draw circles and figure eights with the head.
- Shoulder exercises
- Arms lifted up, extending the shoulder blades and releasing.
- Windmill movements with the arms.
- Circles with the arms.
- Eagle pose and gomukhasana.
Exercises lying on the back
The opportunity to perform the exercises lying down should be maintained. Mentally
it’s important to maintain a broad-minded attitude because when a student does not
perform a certain action she loses the potential and the ability to do it, with the result
that her life and her abilities are further and further reduced. The exercises can be
done while lying on a bed, if the student wants. However the teacher should keep in
mind that this is an intimate situation and not always appropriate.
Nevertheless, lying on the floor can be quite a challenge for MS sufferers. The floor
seems so far away from them, and they are afraid of not being able to get up again.
The movements required to get down to the floor and up again are very difficult. I’m
all in favor of encouraging and helping people to lie down on the floor, when
applicable, but we must remember to respect those who cannot, or will not, in
general or on a particular day. We need to find a middle way between abandoning
the attempt and insisting on the student doing something inappropriate for her.
Practice lying on the back
Lying on the back allows the body to let go into the ground and by doing so
straighten passively. I also like to use stronger passive releases, for example, lying
on a mat or a rolled towel under the back or lying on a bolster. Please note that this
work is very powerful for most people who suffer from multiple sclerosis and is not
suitable for everyone .Practice is done lying on a soft and stable surface. I put a
Yoga mat on top of a softer mattress.
Exercises lying on the back include:
- Small bridge, an excellent exercise for rooting, connecting and strengthening, and releasing the lower back.
- Clasping the knees to the stomach and rocking from side to side. Stretching the legs with a belt. The student will hold a ball or a block between her legs throughout to encourage her to keep them straight and up. Holding the ball activates the muscles of the inner thighs and as a result activates the pelvic floor and the internal abdominal muscles, causing elongation along the core of the body
Exercises lying on the stomach
I advise the student to lie down with a pillow under the abdomen to release her back.
This position does the movement of Samana Vayu for her.
Exercises lying on the stomach include:
- Lying and elongating.
- Preparation for Cobra.
- Working on lowering the shoulders.
- Locust and playing with lifting the arms and legs.
- Stretching the front of the thighs.
- Stretching one side of the body.
- Child’s pose.
Exercises sitting in a chair
They can be done sitting on the floor, for those who can, or sitting with the back
against a wall or with the feet rooting into a wall. I prefer to work with a straightbacked chair and not with a wheelchair, in which the posture is less upright .I use
props such as pillows to straighten the back as much as possible and to build a
sitting pose that is balanced on both sides. I check that the feet are rooted in the
ground and add a prop to lift them if necessary.
Exercises for shoulders and neck release:
- Seated twists.
- Working on rooting the feet, elevation and elongating.
- Working on rooting the sitting bones elevation and elongating.
- Releasing the feet.
- Forward bends.
- Lifting one leg and then the other and making walking movements while
- Providing another chair for the legs for poses such as paschisottanasana or
- baddha konasana.
MS patients spend most of their time sitting, so while it is convenient for them to do
exercises in a familiar and unthreatening position, it is also very important to
challenge them to try to strengthen other muscles and stretch the body in different
Sitting or lying down with legs up
Lifting the legs relative to the heart or at least as high as possible helps the blood
flow and treats swelling.
Exercises with the feet like rotating the ankles, activation through the heel and toes
Summary – yoga as a path of healing
Patients with MS may live with the constant feeling that they have less and less
options and a decreasing number of things they can do. Their lives are thus reduced
further and further, until they live most of the time in the same house, the same room,
the same chair. They sink into depression and feel victimized.
As yoga teachers, we cannot cure multiple sclerosis patients, but our work can help
greatly to relieve their symptoms. And beyond that, yoga brings with it an
empowerment of the student and healing at all levels, physical, mental, spiritual and
energetic .Our spiritual practice helps us, as teachers, to treat our students with love,
empathy, patience and listening. It gives us the tools to help the student develop this
approach towards herself and her body. Combining these qualities with the yoga
principles provides students with tools to use both at a yoga class and outside it, to
cope with all the challenges of living with the disease.
During class, students express weakness in various ways such as “I can’t”, “It’s
impossible”, “My body is not functioning” and other statements that give vent to
despair, frustration, anger and also tears The teacher’s presence and listening
creates a space of love and peace, that allows these things to come out and contains
them. It helps the student to look at them and develop detachment from them,
permitting her to begin a gradual process of transformation in her inner world, and in
her inner dialogue. For example: “I see that I feel frustrated, but I can also look at this
frustration from outside”. This approach weakens the power of frustration, and makes
room for new feelings of energy and optimism to emerge out of the experiences that
yoga provides in class, both in pranayama and asanas. From a state of anxiety and
stress and feeling down, a door opens on to experiences of development and
Yoga exercises, combined with the principles of Vijnana Yoga, can thus contribute
substantially to improving the quality of life for someone with multiple sclerosis. The
principles that one learns in a yoga class are also useful and practical in daily life.
When I was a student in England, I worked with hospitalized MS patients and ever
since then I have been interested in the disease and in ways of assisting patients to
improve their quality of life. When I started teaching yoga for multiple sclerosis
sufferers, I saw how effective yoga is in achieving this goal. Working with MS patients
is exciting and satisfying because I see the contribution yoga makes and the
possibilities that are inherent in its principles, to help sick and healthy people alike. I
believe that yoga is suitable for people of any age or physical condition and working
with MS patients gives me a chance to prove that this is true.
To view a video on this subject please click on the following link: (in the video Gillian
talks about what yoga gives her)
Recommended books for further reading:
Sam Dworkiss, Recovery Yoga – A Practical guide for the Chronically Ill, Three
Rivers Press, 1997
Loren M. Fishman MD and Eric Small, Yoga and Multiple Sclerosis, Demos Medical
Carol Mackie, Me and My Shadow – Learning to Live with Multiple Sclerosis,
Aurum Press 1999
Yoga with Eric Small
About the author
My first exposure to multiple sclerosis was as a student in England, when I
participated in a volunteer project in a hospital with patients hospitalized in the MS
ward. At the end of the project I continued to work as an assistant in the MS ward for
two more years. During this period I saw that although there are classical and
general symptoms, the disease develops differently in each person.
In Israel, as a certified Vijnana Yoga and Integrative Yoga teacher, with 20 years
experience, I have been teaching MS patients privately for 12 years. In addition I
teach a whole range of yoga classes in the areas of Jerusalem, Beit Shemesh and
Tzur Hadassah. I teach in a number of clubs for the elderly and retired. In all my
classes, I put an emphasis on adjusting the postures and exercises of yoga to the
needs of each practitioner.
I live in Moshav Bar Giora near Jerusalem with my husband Steve and our three
web site: http://kingsimons.wix.com/Yogawithstacey