Multiple Sclerosis: Considerations & Resources

• Additional considerations for people with multiple sclerosis.

Overview of Topics:

• Brief review of multiple sclerosis (MS).
• Discussion on examination and MS-specific tools.
• Introduction to cases, physical therapy interventions for persons with MS (PwMS).
• Applying knowledge to diverse cases.
• Additional considerations and available resources.

Lecture Objectives:

• Characterize the wellness framework that supports long-term health for individuals with MS.
• Recognize MS-specific assessment tools to capture unique disease features and monitor changes.
• Construct holistic examination and treatment plans for individuals with MS.
• Detail evidence-based practices for aerobic, strengthening, flexibility, and balance training.
• Apply critical thinking to develop effective and individualized plans of care from case studies.
• Recognize the need for external referrals and clinical resources for comprehensive MS care.

Knowledge Check:

• What is the pathophysiology of MS?
• What are the different types of MS?

Key Modules:

• Health & Equity, Physiology, Motivational Interviewing, Assessing Health Behavior, Autonomic nervous system (M1).
• Anatomy (cont.), Motor learning, Gait & Transfers, Human Movement, Life span consideration (M3).
• Moderators of Movement; task analysis; Movement system diagnosis; Core Outcome Measures; Complex neuro exam; Principles of Neuroplasticity and Active Ingredients of Motor Learning (M5).
• Anatomy (cont.), neuro exam subset, Gait assessment (M4).
• Additional Considerations: Multiple Sclerosis (M6).
• Anatomy (M2).

Pathophysiology Review:

• MS is a central nervous system disorder.
• It causes demyelination of axons in grey and white matter.

Key Facts about MS:

• Clinically Isolated Syndrome (CIS) involves initial neurologic symptoms caused by inflammation and demyelination.
  • High risk for MS.
• Relapsing-Remitting MS (RRMS) includes attacks with new or increasing neurologic symptoms, followed by recovery and remissions.
  • Some symptoms may disappear or become permanent during recovery.
• Secondary Progressive MS (SPMS) follows RRMS, with disability increasing over time without defined relapses.
• Primary Progressive MS (PPMS) means neurologic function worsens over time without relapses or remissions.

Knowledge Check:

• What are common symptoms/impairments that individuals with MS report?

Movement System Diagnosis:

• Includes identifying deficits in: force production, fractionated movement, sensory selection and weighting, movement pattern coordination, dysmetria/hypermetria, and sensory detection.

Prognostic Factors in MS:

• Positive factors include female gender, onset before age 40, sensory symptoms only, involvement of one CNS system, full recovery between attacks, and absence/late onset of cerebellar symptoms.
• Negative factors include male gender, onset after age 40, initial symptoms involving the cerebellum/mental function/urinary control, initial symptoms in multiple regions, frequent attacks after onset, incomplete remissions, and rapid progression.

Extended Disability Status Scale (EDSS):

• The EDSS measures disability in MS on a scale from 0 (normal neurological function) to 10 (death).
• 1-3.5 represents minimal to mild disability.
• 4-5.5 represents mild to moderate disability.
• 6.0-7.5 represents moderate to severe disability, where 6.0 requires intermittent or constant use of a UL device/brace, 6.5 needing constant BL device use, and 7.0 means being unable to walk 15' even with aid.
• 8.0-9.5 signifies severe disability with restriction to bed/WC.

Physical Therapy Interventions Across EDSS Levels:

• Preventative:
  • EDSS 0-3.5 focuses on falls prevention and energy conservation.
  • EDSS 4-5.5 focuses on falls prevention and energy conservation.
  • EDSS 6.0-7.5 involves a falls program and caregiver training.
  • EDSS 8-9.5 includes caregiver training, HEP, bed mobility along with patient safety, and prevention of secondary complications.
  • Treatment includes vigorous aerobic, strengthening and flexibility based on examination (EDSS 0-3.5).
  • Treatment includes aerobic, strengthening, and flexibility to minimize deconditioning (EDSS 4-7.5).
• Restorative/Remediation Approach:
  • EDSS 0-3.5 involves promoting active lifestyles with task-specific training.
  • EDSS 4-5.5 involves continuing active lifestyles with adaptations and task-specific training.
  • EDSS 6.0-7.5 involves promoting maintenance of mobility by modifying tasks and intermittent exercise.
  • EDSS 8-9.5 focus on rehab strategies for severe deficits/respiratory involvement.
• Compensatory Approach:
  • EDSS 4-5.5 involves cardiovascular and aerobic fitness with adapted equipment.
  • EDSS 6.0-7.5 involves the consideration of walking aids/braces for maximizing mobility along with cardiovascular and aerobic fitness with adaptive equipment.
  • EDSS 8-9.5 focuses on caregiver training as well as the use of positioning aids for comfort.
  • Treatment involves limiting the use of walking aids where unnecessary, while providing task-specific training (EDSS 4-7.5).

Concerns for Secondary Health Effects:

• Falls, aspiration pneumonia, pulmonary dysfunction, urosepsis, skin breakdown, untreated depression, and osteoporosis.

Health, Promotion, and Wellness:

• Only 1/3 of patients post-relapse received rehab services.
• Health, promotion and wellness means identifying/resolving participation barriers, scheduling follow-ups, and designing individualized attainable/measurable exercise programs.
• Interventions lack of recommendations, perceptions of necessity and information.

Physical Therapy Across Lifespan:

• The role physical therapy plays in supporting aging with a neurodegenerative disorder is an important consideration.
• PTs can identify and resolve participation barriers, schedule follow-ups, and design individualized exercise programs.

Common Impairments in MS:

• Weakness (primary/secondary), fatigue, heat intolerance, difficulty walking and decreased aerobic capacity.
• Also: imbalance, bowel/bladder dysfunction, pain, sensory loss/paresthesia, hypertonicity/spasticity, vision problems dizziness/vertigo, speech/swallowing impairments, cold intolerance, impaired cognition/memory, tremor, sleep disturbance, sexual/emotional/mood impairments.

Knowledge Check:

• What tests and measures would be useful when examining a person with MS?
• What standardized assessments do you know, or have you used when examining someone with MS?

Guiding History Questions:

• Changes in function/symptoms?
• Type of MS/neurologist?
• Meds (DMTs)?
• Walking ability/AD use?
• Frequency of Falls
• Issues with fatigue/pain/senses/stiffness/spasms?
• Caregiver support?
• Dizziness?Vision Problems? Breathing Issues? Memory/Cognition? Mood? GI/GU Function? Driving?
• Is variability of symptoms understood ?

Outcome Measures (Core Set):

• Berg Balance Scale, Functional Gait Assessment, 10MWT, 6-Minute Walk Test, 5 times sit to stand, Activities-Specific-Balance Confidence Scale.

ANPT Task Force for IP/OP recommended outcome measures:

• 12-Item MS Walking Scale, 6-Minute Walk Test, 9-Hole Peg Test, Berg Balance Scale, Dizziness Handicap Inventory, MS Functional Composite, MS Impact Scale (MSIS-29), MS Quality of Life (MS Qol-54), Timed 25 Foot Walk, Timed Up & Go (TUG) with Cognitive and Manual.

ANPT Task Force tools:

• MS Functional Composite assesses gait, UE function, and cognition.
  • Gait: Timed 25ft walk test (T25FW).
  • UE Finction: 9-hole peg test.
  • Cognition: Paced Auditory Serial Addition test (PASAT-3).
• A Timed 25 ft Walk Test may be recorded walking.

Falls

• Falls are common but also preventable
• Falls have several Risk Factors
• Must evaluate Capacity vs. Performance

Self Report Outcome Measures

• 12 item MS walking scale (MSWS-12)*
• Percentage of impact of walking abilities in past two weeks
• MS Impact Scale (MSIS-29)* Impact of MS on daily life over the past 2 weeks
• MS Quality of Life (MS Qol-54)* 12 subscales and 2 individual items
• Dizziness Handicap Inventory (DHI)* 25- item report of Dizziness throughout the day */100 with higher score = greater dizziness

Examples of cases Lauren

• EDSS 1.0 ###Autumn
• EDSS 4.0

Exercise is safe

• It is also supervised and individualized

Physical recommendations

• Aerobic Activity*
• Two times per week
• Try to hit 30 mins each work out
• Try moderate intensity
• Strenght Activity*
  • Two Times Per Week
  • Lift weights or do resistant workouts
  • Gradually build up to do 2 sets of of each excise

Managing exercise

• Make sure levels of Symptoms should return to baseline (pre-exercise levels) and have a 30 min resting period

Evidence of training

• The evidence from aerobic training for moderate is effective with MS

Autonomic function

• May have attenuated pressor response = blunted CV response with exercise, potential syncope
• Other dysfunctions include bowel, bladder and thermoregulator

Intervel Training

• May be a good option to improve performance

High intensive training

• There is Emerging evidence for HIT training for MS population

Good Alternativea

• When need to be Non Ambility the BEST aerobic training is cycling or using arm equipment

Heat intolence

• Keep the area cool and HYDRATED
• Use the correct Equipment

Sample goals Lauren

- Ran 1/2 marathon at 8 min/mile pace
 - Mild headaches, worse with heat
  - Goal to make National Air force Softball Team

Sample goals Autumn

• • Fatigues when walking greater than 3/4 mile

For Patients like Lauren

• Keep Long runs at 60-80% HRR
  • Interval training 70-85% HRR with rest breaks

For Patient Like Autum

• Walks with partner in park HR 50-70% HRR
  • Rest breaks before hitting limit
• Step tracking due to variability of workday to help with pacing

Resitivity training

• It may be benifical for patients with osteoporosis and fracture
• There is no effects on static balance following strengthening program Specificity

General Recommendations

• Moderate may be optimal

Use of aquatics

• It has been shown these is an improvement with using water
• The aquatic improved T25ftW, STS and Balance

Use of pilates

• Use pilates, Focus will be on stability, strength, flexibility, posture, and breathing

Rehab treatment

• Start by Enhancing maximal inspiratory and expiratory pressures and clear airways with Diaphragmatic breathing/ positioning

Balance

• Should be a Small but significant effect on improving stability and reducing falls

Customized treatment

• When giving a customized treatment its imporant to check results

For people with a vestibular disorder:

• May include vestibule therapy to return to sport and work

To Treat fatigue

• Start with Physical activity for patients is good
• Get Patients to be social

Impairments

• Look for Impairments

Management of Fatigue

• Use of low intensity and structured moderate exercise

Autum treatment

• It is important to manage to work and decrease pain. Its good to use scooter equipment while still trying to do simple activities

Tools to use

• Try looking for a Step tracker/smart phone, or Walking foot cane

Impairments

• Some patients experience Difficulty managing bladder
• Make sure to assist those patients

To Treat Cognition

• The major Goal its to ensure the patients know home safety and what equipment to use.

Additional considerations for future treatment.

Vision and Tremor

Multiple scrlosis care across lifespan

• Ensure to re-access the patient through out care

Final Thoughts

• There are mutiple patient resources you must understand and know to refer to when treating.

Remember

• Its important to give the patient The freedom of choice to make decisions so there is trust and an equal footing.