Rehabilitation in Multiple Sclerosis PDF

Reviews Rehabilitation in multiple sclerosis Anna M. Kubsik-Gidlewska1, A–E, Paulina Klimkiewicz1, B, Robert Klimkiewicz1, A, Katarzyna Janczewska1, C, Marta Woldańska-Okońska1, E, F Department of Rehabilitation and Physical Medicine, Division of Physiotherapy Military Medical Faculty, Medical Univ...

Reviews Rehabilitation in multiple sclerosis Anna M. Kubsik-Gidlewska1, A–E, Paulina Klimkiewicz1, B, Robert Klimkiewicz1, A, Katarzyna Janczewska1, C, Marta Woldańska-Okońska1, E, F Department of Rehabilitation and Physical Medicine, Division of Physiotherapy Military Medical Faculty, Medical University of Lodz, Poland A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation; D – writing the article; E – critical revision of the article; F – final approval of article Advances in Clinical and Experimental Medicine, ISSN 1899-5276 (print), ISSN 2451-2680 (online) Adv Clin Exp Med. 2017;26(4):709–715 Address for correspondence Anna Kubsik-Gidlewska Abstract E-mail: [email protected] The aim of the study is to present a strategy of rehabilitation in multiple sclerosis on the basis of the lat- est developments in the field of physiotherapy. The publications on the problem discuss a wide range of Funding sources This work was supported by the methods of physiotherapy that can be used in order to reduce the degree of disability and alleviate the Medical University of Lodz research task symptoms associated with the disease. The complexity of the disease, the difficulty in determining the ap- No. 502-03/5-139-04/502-54-098. propriate treatment and a wide range of symptoms require a comprehensive approach to the patient, which would include both pharmacology and neurorehabilitation. Rehabilitation, which includes psychotherapy Conflict of interest None declared and symptomatic therapy, is regarded nowadays as the best form of treatment for multiple sclerosis. An in- depth diagnostic assessment of functional status and prognosis should be carried out before the start of the rehabilitation process. The prognosis should take into account the mental state, the neurological status and Received on July 23, 2015 Revised on August 15, 2015 the awareness of the patient. The kinesiotherapy program in multiple sclerosis is based on a gradation of Accepted on March 22, 2016 physiotherapy which assumes a gradual transition from basic movements to more complex ones till global functions are obtained. The most appropriate form of treatment is functional rehabilitation combined with physical procedures. Recent reports indicate the need for aerobic training to be included in the rehabilitation program. The introduction of physical activities, regardless of the severity of the disease, will reduce the negative effects of akinesia, and thus increase the functional capabilities of all body systems. Key words: physiotherapy, multiple sclerosis, physical activity, neurorehabilitation DOI 10.17219/acem/ 62329 Copyright Copyright by Author(s) This is an article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc-nd/4.0/) 710 A. Kubsik-Gidlewska, et al. Rehabilitation in multiple sclerosis Multiple sclerosis is a chronic inflammatory demy- Rehabilitation in multiple sclerosis elinating disease of the central nervous system (CNS) the etiology of which is not fully understood and whose Multiple sclerosis affects most aspects of life of both course is difficult to predict. The pathology and symp- the patients and their families. The complexity of the toms of the disease were first described by Jean-Martin disease, the difficulty in determining the appropriate Charcot in 1868. It is believed that a key role in the for- treatment and a wide range of symptoms call for a com- mation of demyelinating lesions may be played by au- prehensive approach to the patient, which would involve toimmune processes as well as environmental and ge- both pharmacology and neurorehabilitation. Physiother- netic factors. The research into the pathophysiology of apy, which is an integral part of rehabilitation, consists multiple sclerosis indicate that demyelinating changes in kinesitherapy, physical therapy, massage and hydro- affect the cerebral cortex and gray matter, including therapy. Physiotherapy in multiple sclerosis is aimed at basal nuclei and cerebellar cortex.1 The process of in- improving mobility through compensation mechanisms flammation, which is associated with the presence of that involve the activation of capabilities of effectors and pro-inflammatory cytokines and T-lymphocytes and behavior, which results in the patient regaining function- macrophages, damages the blood - brain barrier, which ing, not movement. All applications included in physio- is associated with neuronal malfunctioning and swell- therapy should be recommended in such a way as to act ing, which in turn can can result in a relapse of the upon the largest possible number of motor deficits. The disease.2 Pathologists indicate that it may be oligoden- introduction of physical activity, regardless of the sever- drocytes, cells responsible for the construction of the ity of the disease, will reduce the negative effects of aki- myelin sheath around the axon, that cause the immune nesia, and thus increase the functional capabilities of all response. Damage to the myelin sheath and neurode- body systems.8 generative processes lead to a reduction in the number In the period of acute illness, it is necessary to avoid im- of synapses and axons, and eventually to the loss of mobilization of patients due to the consequences of aki- nerve cells. 3 Viral infections, deficiency of vitamin D nesia. Physiotherapy of these patients involves frequent and the action of sex hormones are listed among many changes of body position in order to prevent bed sores, causes of the disease. Viral infections in combination prevention of contractures using passive exercises, and with genetic factors may initiate an autoimmune pro- the implementing breathing exercises to prevent compli- cess. An increasing rate of MS cases may also be associ- cations of the respiratory system. What is essential in pa- ated with reduced exposure to the radiation of the sun. tient care is the prevention of infections of the urogenital Insufficient exposure to sun radiation results in vitamin system and assistance in activities of daily living. D deficiency, which reveals an immunoregulatory ac- The rehabilitation program should take into consider- tion preventing autoimmune inflammation of the brain ation the phase of the disease, degree of disability and and spinal cord. Sex hormones constitute an important neurological deficits. The therapy at the time of remis- factor influencing the development of MS, which is re- sion is therefore based on the degree of impairment and flected in the increase of MS cases among women. Stud- the objectives of treatment. The rehabilitation in this ies have shown that women suffering from MS who have phase of the disease is conducted in hospitals, outpa- higher levels of estradiol and low levels of progesterone tients and the home, depending on the functional sta- experience a greater severity of the disease.4,5 tus of the patient. Before the implementation of phys- Multiple sclerosis is a disease that affects young peo- iotherapy, an in-depth diagnostic assessment of the ple. The occurrence of the disease in the world varies functional status and prognosis should be carried out. depending on latitude: the incidence increases with the The prognosis should take into account the mental state, rising latitude and the number of MS cases decreases the neurological status and the state of cognitive func- nearer to the equator, which proves the correlation be- tions of the patient.9 The rehabilitation program is often tween MS and exposure to sun radiation. Currently, hampered by fatigue associated with the disease, which there are about 2.5 million people suffering from MS limits not only the possibility of movement of the patient around the world and the numbers are growing. In Eu- but also their mental functions. Improving motor skills rope or the U.S. the incidence is 40–150 patients per of MS patients aims at enhancing muscle strength, nor- 100,000 inhabitants, while in Poland this figure is 55–57 malizing muscle tension, improving coordination and per 100,000 inhabitants, which means that the country balance, preventing urinary incontinence, increasing or is at high risk of MS occurrence.6 The Caucasian race maintaining the range of motion in the joints, prevent- is the most vulnerable. The disease affects people of ing muscle atrophy and counteracting the consequences productive age leading to their disability. The greatest of immobilization. The continuity of the rehabilitation number of cases are observed between 20 and 40 years process should involve exercises that would eliminate of age. MS is also diagnosed in children as childhood the problems resulting from the disease. Therefore, daily form of MS. People over 50 may be diagnosed with the rehabilitation would consist of balance and coordination late form of MS.7 exercises as well as breathing, stretching and relaxation Adv Clin Exp Med. 2017;26(4):709–715 711 exercises. It would also include aerobic training, un- exercises are carried out according to the Frenkel meth- loaded exercises, exercises which strengthen particular od, in which footprints painted on the floor are used to groups of muscles, and improve proprioception. The rate learn proper gait. The exercises are performed in 3 phases of exercise and load should be such as not to cause fa- (right foot steps forward, shift weight, left foot joins the tigue and overheating of the body, which could result in right one). Learning to sit down and stand up is part of increased muscle tension. this method. The movement is divided into three phases (feet withdrawn, forward leaning of the trunk, straighten- ing of the legs and getting up). Balance and proprioceptive Impairment-based approach exercises in patients with stability in standing position are carried out with the use of stabilometric and posturo- Kinesis program is based on a pyramid of physiotherapy metric platforms based on the biofeedback method. The planning in multiple sclerosis, which assumes a gradual examinations conducted with these devices prove better transition from basic movements to more complex ones control of the posture in patients with multiple sclerosis.13 until global functions are reached. The most appropriate Coordination and balance exercises can be combined form of therapy, that is functional rehabilitation, aims at with a proprioception exercises that can be performed in the recovery of lost functions by performing movements sitting or standing positions. Proprioreception disorders in three dimensions.10 The methods designed to recre- are common symptoms of multiple sclerosis. They influ- ate natural human movement include Proprioceptive ence various stages of rehabilitation. The implementation Nuromuscular Facilitation (PNF) and Bobath Neurode- of neuromuscular control training in the early stages of velopmental Treatment (NDT). These neurophysiologi- rehabilitation reduces the risk of further injuries resulting cal methods allow the recovery of impaired functions of from loss of balance.14 Hippotherapy is an alternative form the body by using appropriate patterns of movement and of exercise which improves balance and stability in pa- techniques of coordination, stabilization and relaxation. tients with MS. Better balance and gait were observed in It has been observed that the movements performed in patients undergoing hippotherapy when compared to the everyday life are diagonal and multiplane. Therefore, pat- control group in which classical physiotherapy was used.15 terns of movement for the upper limb, lower limb, neck One of the many symptoms related to MS is spasticity, and head have been developed. One of the techniques which often makes rehabilitation and care difficult and that both the methods employ is a manual technique of most importantly deepens the patient disability. Spastic facilitation of movement (PNF). The purpose of this tech- paresis affects both lower and upper limbs with greater nique is to assist the patient to correctly perform a move- severity of pathological tension in the lower extremities. ment in a particular activity, thus preventing a pathologi- It occurs in 40–60% of patients with multiple sclerosis. cal position of the body and assisting in the initiation and It is a symptom of the impairment of upper motor neuron finishing of movement.11 The PNF method also includes which reveals excessive activity of alpha cells of the ante- gait re-education and exercises of facial muscles. It elimi- rior horn of the spinal cord. Mild spasticity is a beneficial nates dysfunction of chewing, swallowing and breath- phenomenon as it improves blood circulation in the limbs ing. Bobath neurodevelopmental concept assumes that and prevents muscular atrophy. High degree of spasticity the essence of motor deficits resulting from impairment (3 or 4 in Ashworth scale) causes contractures, joint defor- in the CNS is a dysfunction in posture reflexes that are mities and bedsores which lead to infections. Apart from needed to coordinate movements in space. The correct pharmacotherapy, physiotherapy plays an important role muscle tension and active movements can be acquired by in the cases of severe spasticity. The plan of the rehabilita- inhibiting the pathological patterns of posture. The ad- tion program should take into account the fact that the use vantage of these methods is the ability to work in various of physical applications before kinesiotherapy has positive positions, including lying position on the mattress, which effects while greater physical efforts can increase muscle allows for the adjustment of the method of rehabilitation tension.16 The physical application which is used before to the functional status of the patient. The use of these kinesiotherapy is cooling the defined areas of the body, methods and their efficiency of the therapy has been con- and even the spinal cord is treated with low temperatures. firmed in evidence based medicine (EBM).12 This is to produce the effect of local anesthesia in periph- Problems with balance and coordination are common eral sensory receptors. The use of cold reduces responses symptoms of the disease that cause difficulty in move- to active stretching. Passive stretching is a contraindica- ment, so the inclusion of balance and coordination ex- tion, as it reduces the excitability of the motor neurons ercises into the therapy is necessary. These exercises and maintains elasticity properties of muscles and joints. increase stability during gait, prevent falls and enhance Cryotherapy is applied in the form of an ice-slush bath, posture control. Coordination exercises consist of motor ice massage, coldpacks (bags with frozen silicone gel), acts of specified complexity, which improve coherence of cryogenic suits and compression cryocuffs. Cryotherapy movement and reduce energy consumption which is due is also applied systemically in patients with MS to obtain to deficiency of coordination. Coordination and balance an analgesic effect as well as reduce fatigue syndrome.17 712 A. Kubsik-Gidlewska, et al. Rehabilitation in multiple sclerosis Other physical methods used in the treatment of spas- shortened by 0.5 s till it reaches continuous emission. The ticity are electrotherapy and magnetic therapy. Electrical analgesic effect results from the secretion of endogenous stimulation of neuromuscular system (NMES), transcu- opiates from the group of β-endorphins, from the hyper- taneous electrical nerve stimulation (TENS), Hufschmidt polarization of nerve endings, and also from a mecha- method and functional electrical stimulation (FES) are nism for reducing the permeability of cell membranes.21 listed among the applications of electrotherapy. Electrical Although magnetostimulation has only recently started stimulation seems to be the best method because damage to be used in treatment, it is widely used in MS patients, to Upper Motor Neuron does not alter the excitability of as has been indicated in numerous publications. The in- the muscles to electrical stimuli, so that the impaired bio- duction value in magnetostimulation does not exceed 100 electrical function of muscles can be replaced. The treat- μT, the carrier frequency is about 3000 Hz, and the basic ment parameters are determined on the basis of EMG or frequency amounts to several Hz. The general effects of chosen according to the generally accepted standards. magnetostimulation include the stimulation of life pro- Electrical stimulation is applied with implant electrodes cesses and the maintainance of homeostasis. In multiple and methods of transcutaneous stimulation. Both meth- sclerosis therapy, it is used in the form of systemic mag- ods result in a reduction of muscle tension, which leads netostimulation applicator used as a mat. This results to a wider range of motion in the joints and improved in the reduction of muscular tension, relaxation, which gait efficiency. The use of implant electrodes runs the leads to the reduction of fatigue syndrome.22 The stud- risk of complications such as displacement of electrodes ies of magnetostimulation have confirmed the efficacy or the occurrence of adverse reaction of the body to the of this treatment for the secretion of hormones such as implant.18 Transcutaneous electrical nerve stimulation melatonin is related to an analgesic effect and serotonin (TENS) is a method that has been used in the treatment the increase of which improves well-being and mood.23 of pain in patients with MS. Electrodes are placed in areas Transcranial stimulation is used in order to stimulate the of pain or along the nerves. A segmental arrangement, on selected areas of the cerebral cortex. This process is used a specific dermatome, is also in use. The frequency ranges primarily in the treatment of retrobulbar optic neuritis from 1 to 100 Hz, and the value of intensity is determined in order to improve the conductivity of the optic tract. for the patients according their individual feelings. Huf- The application of reptitive transcranial magnetic stimu- schmidt method is also used to normalize muscle ten- lation (rTMS) in patients with MS resulted in a reduction sion through the stimulation of spastic muscles and their of spasticity in the lower limbs and improvement of the antagonists. Double square-wave impulses are used to neurogenic bladder dysfunction.24 achieve a functional balance between agonists and antag- MS patients also undergo therapy with the use of laser onists. This method allows for proprioceptive facilitation light. Due to the fact that laser treatment produced ben- and affects alpha motorneurons.19 Functional electrical eficial effects in other diseases, it has been included in the stimulation (FES) employs ministimulators that are ap- rehabilitation program for MS patients. Laser radiation plied to paretic muscles beyond the control of the central of low and medium power induces, first of all, changes nervous system. The most frequent uses of FES treat the at the cellular level and furthermore demonstrates anal- peroneal nerve in patients with hemiparesis in order to gesic, anti-inflammatory and anti-oedematous actions. improve the various phases of gait. The electrical stimu- Laser biostimulation causes the creation of biologically lation is carried out with rectangular pulse current with active compounds and, as a result, leads to changes in a frequency of 20–50 Hz and an impulse duration of 0.1– cell metabolism. The regenerative effect of laser radiation 0.2 ms. Magnetic fields of low and high frequencies are is important for patients with MS due to the fact that it also applied in patients with multiple sclerosis. Since the enhances the regeneration of demyelination in the CNS, introduction of alternating magnetic fields into physio- which reduces nerve conduction. Biostimulating laser therapy, the term magnetic therapy has referred to the ac- light affects the regeneration of nerves by stimulating tion of magnetic field with induction values ​​above 100 μT. the growth of Schwann cells enhancing nerve conduc- The application of fields with induction 100 μT is referred tion. Helium-neon lasers of 10 mW power and 632 nm to as magnetic stimulation. The advantage of the appli- wavelength are used in the therapy in the form of “contact cation of magnetic fields is the fact that they are pain- point” method. The area of the paraspinal nerve trunks less, athermal and permeable through the patient’s tissue. along the line in the C-Th and Th-L regions are irradi- In magnetotherapy, the frequency ranges from 2 Hz to 60 ated.25 Cold lasers, where cold is applied in combination Hz, and the induction can be up to 20 mT. The applied with laser radiation, are also used as they decrease mus- impulses can have a triangular, rectangular, sinusoidal cle tension and produce an analgesic effect.26 and trapezoidal shapes.20 This application in patients The rehabilitation program should also include the with MS is used to control pain and decrease muscle ten- pelvic diaphragm muscle exercises due to the neurogenic sion. In the case of spasticity, the intermittent mission of bladder dysfunction, which occurs in 78% of patients with magnetic fields is used starting with a 3 s break and then MS. Sphincter disorders occurring in the form of urinary in each subsequent application the break is gradually incontinence or retention cause discomfort for patients Adv Clin Exp Med. 2017;26(4):709–715 713 and limit their participation in activities of daily living drotherapy reduces the sensitivity of muscle fibers and and social activities. Kegel isometric exercises, which in- skin receptors by reducing the activity of gamma neu- volve tensing and relaxation of certain groups of muscles, rons, which is manifested by a decrease in spasticity. are performed to exercise the pelvic diaphhragm, which The temperature of water plays the key role for patients results in an increase in muscle mass and strengthening with multiple sclerosis due to the possibility of the oc- and the growth of the resting tension of these muscles. currence of Uhthoff’s symptom; therefore, hot baths The exercises allow for a prolonged contraction of the should be avoided. Thus, complete and partial baths at muscles, improving control of neuro-muscular and con- a temperature of 34–36°C are applied. The water at this nective tissue to stabilize the pelvis, which, in turn, im- temperature inhibits the flow of afferent impulses from proves the mechanism of urination. Pelvic diaphragm proprioceptors to the CNS, which has and analgesic and muscle training should be combined with enhancement relaxing action. Studies in patients with MS show that hy- of deep muscles such as transversus abdominis mainly drotherapy greatly improves independence and mobility due to the synergistic action of these structures. Co-acti- and reduces the symptoms of depression and fatigue.31 vation of these muscles is reduced or abolished in people with urinary incontinence.27 In addition, the training should also include gluteal muscles, the adductor muscle Task-oriented approach and the ischiocrural muscle group. The simultaneous use of Kegel exercises, EMG biofeedback and electrical stim- Physical activity, which the World Health Organiza- ulation (NMES) produces very good results.28 tion recommends, is an essential part of maintaining the The neurological diseases, including MS, also cause re- efficiency of the cardio-respiratory system and general spiratory disorders, which include difficulties in respira- health. The WHO recommends performing any physi- tion due to inspiratory muscle weakness. Patients with dys- cal activity of moderate intensity for 30 min a day, 5 days phagia are at risk of aspiration of fluids resulting from the a week or 20 min a day for 3 days a week with high intensi- weakening of the muscles of the upper respiratory tract. ty. Regular physical activity in the form of sport or recre- The introduction of breathing exercises in the early stages ation results in significant health benefits. The introduc- of multiple sclerosis may prevent further complications. tion of physical exercise into the plan of physiotherapy During the relapse, the patient usually remains in bed; for patients with multiple sclerosis have until recently therefore, breathing exercises often become the only form aroused controversy, as there was a belief that physical of activation. Breathing exercises are also used in patients effort may initiate a relapse of the disease. However, some with impaired speech in the form of speech therapy.29 studies published in recent years have refuted these ar- In patients with multiple sclerosis, impaired gait is guments. On the contrary, they confirmed the efficacy a consequence of neurological deficits such as balance of aerobic training in MS patients. The introduction of and coordination disorders, spasticity, visual disturbanc- fitness training for patients with MS is conditioned by es, paraparesis and hemiparesis. Deteriorated locomotion the requirement to maintain strict selection criteria for or movement in the form of pathological gait significantly physical effort, which guaranties an increase in efficiency reduces the quality of life of patients with MS and makes without exposing the patients to the possibility of pro- them dependent on family or friends. It is, therefore, nec- gression of the disease. The training should take several essary to include re-education of gait in the rehabilita- weeks or even months. Most frequently a treadmill or tion program. The re-education of gait should be pre- a cycloergometer are used in this type of exercise.9 ceded by a thorough analysis, which would aim to assess Physical activity in patients with multiple sclerosis the disorder in different phases of gait compared to the improves not only their physical capacity, but also their normal gait pattern. One of the methods of re-education mood and attitude towards the exercises. Better cardio- is learning to walk on a treadmill with body weight re- respiratory efficiency has been proven to enhance the lief. This allows for the improvement of gait parameters cerebrovascular function, which suggests that movement and increases strength and endurance of the muscles of can also significantly improve the brain function in pa- the lower limbs. LOKOMAT is a more advanced device tients with multiple sclerosis.32 Aerobic training increas- which consists of a treadmill relief system and a com- es muscle strength of the lower limbs, which manifests puter control system of the movement of the lower limb itself in reducing spasticity without the risk of relapse or orthoses connected to sensors.30 the symptoms of fatigue.33 Another stimulus in the field of physiotherapy, which Recent recommendations for patients with multiple comprehensively acts on the body of the patient, is hy- sclerosis suggest performing physical activities 2–3 times drotherapy. The physical properties of water such as hy- per week at an intensity of 50–70% of VO2max corre- drostatic pressure, hydrodynamic pressure, viscosity and sponding to 60–80% of maximum heart rate. The dura- buoyancy make the unloaded gymnastics of the motor tion of the exercise should not exceed the initial period of system feasible so that it is possible to obtain a greater 40 min. The intensity should increase gradually depend- range of joint movement without pain components. Hy- ing on the degree of disability. The training should also 714 A. Kubsik-Gidlewska, et al. Rehabilitation in multiple sclerosis include alternating resistance exercises at an 24–48 h in- References terval. Progressive resistance training induces a compen- 1. Vercellino M, Masera S, Lorenzatti M, et al. Demyelination, inflam- satory growth of muscle fibers. It is recommended that mation, and neurodegeneration in multiple sclerosis deep gray matter. 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