Multiple Sclerosis

ADVANCED NEUROLOGICAL PHYSIOTHERAPY (8027651) MPT

DR. HADEEL HALAWEH
What is MS?
MS
◦ Autoimmune disease characterized by inflammation, selective demyelination, and gliosis.
◦ Causes both acute and chronic symptoms, leading to significant disability and impaired quality of life.

Historical Background:
◦ First defined by Jean-Martin Charcot in 1868 based on its clinical and pathological characteristics.
◦ Cardinal symptoms include:
◦ Intention tremor, scanning speech, and nystagmus.

Gender and Ethnic Considerations:

◦ More common in women than men (ratio of 2:1 to 3:1).
◦ Incidence and prevalence of MS have increased over the past 5 decades, particularly in women.
Epidemiology of MS and Geographical
Distribution

Age of Onset:
◦ MS typically onset between ages 20 and 40.
◦ Rare in children or adults over 50 years.

Geographical Patterns:
◦ MS prevalence varies by geographic location:
◦ High-frequency areas:
◦ Temperate zones of northern United States, Scandinavia, northern Europe, southern Canada, New Zealand, and southern
Australia.
◦ Medium-frequency areas:
◦ Regions closer to the equator.
◦ Low-frequency areas:
◦ Tropical areas including Asia, Africa, and South America.
Etiology
Genetic and Environmental Risk Factors for MS
Increased risk with affected family members:
◦ 30% risk with an affected family member
◦ 50% risk with an affected sibling
◦ 250% risk with an identical twin

Genetic factors:
◦ HLA (Human Leukocyte Antigen) gene strongly correlated
◦ Genetic susceptibility to immune system dysfunction

Environmental triggers:
◦ Viral agents: Epstein-Barr virus, measles, human herpesvirus 6, and Mycoplasma pneumonia
◦ Other factors: Vitamin D deficiency and smoking
Pathophysiology
Immune System Dysfunction in MS
Activation of immune cells (e.g., T cells, helper T cells)
Immune cells cross the blood-brain barrier and trigger autoantigens
Autoimmune cytotoxic effects damage the central nervous system (CNS)
Demyelination disrupts neural transmission:
◦ Myelin acts as an insulator and speeds up nerve conduction
◦ Loss of myelin slows neural transmission and causes rapid fatigue
◦ Severe disruption leads to conduction block and functional impairment
Acute inflammation:
◦ Edema and immune cell infiltration (monocytes, macrophages, microglia)
◦ Chronic inflammation reduces remyelination capabilities
Disease Progression and
Neurodegeneration
Incomplete remyelination and eventual myelin repair failure
Demyelinated areas replaced by fibrous astrocytes (gliosis)
Axonal interruption leads to neurodegeneration and permanent disability
Lesion distribution:
◦ White matter (early stages)
◦ Gray matter (advanced disease)
◦ Affected areas: optic nerves, periventricular white matter, spinal cord, corticospinal tracts, posterior
white columns, cerebellar peduncles

Brain atrophy: loss of axons and myelin

Clinical Subtypes of MS

Relapsing-Remitting MS (RRMS):
◦ Most common (85% of cases)
◦ Discrete attacks followed by remission with partial or complete recovery

Secondary Progressive MS (SPMS):

◦ Begins as RRMS and progresses to steady, irreversible decline

Primary Progressive MS (PPMS):

◦ 10% of cases
◦ Continuous worsening from onset without distinct attacks

Progressive-Relapsing MS (PRMS):
◦ 5% of cases
◦ Steady deterioration with occasional acute attacks
 Multiple Sclerosis (MS) Relapses and
Exacerbations
Relapse/Exacerbation: New or recurrent MS symptoms lasting more than 24 hours, typically of longer duration, and unrelated to identified triggers.

Pseudo-Exacerbation: Temporary worsening of MS symptoms, usually resolving within 24 hours, often due to external or internal factors affecting body
temperature.

Common Triggers for MS Relapses:

Infections: Viral or bacterial (e.g., cold, flu, urinary tract infections, sinus infections).

Major Organ System Diseases: Conditions like hepatitis, pancreatitis, and asthma attacks.

Stress:
◦ Major Life Stressors: Divorce, death, job loss, trauma.
◦ Minor Stressors: Exhaustion, dehydration, malnutrition, sleep deprivation.

Factors Contributing to Pseudo-Exacerbations:

External Heat Stressors: Sun exposure, hot and humid environments, hot baths.

Internal Temperature Elevations: Fever, prolonged exercise.

Overview of MS Symptoms

MS symptoms vary based on lesion location

Early symptoms: Visual disturbances, paresthesias, numbness, weakness, fatigue
Advanced stages: Multiple, varying symptoms
Sensory Symptoms

Diminished or altered sensation (paresthesia, numbness)

Pain: Burning, pins-and-needles, limb pain, headaches
Trigeminal neuralgia, dysesthesias, Lhermitte’s sign
Pain in MS

80% experience pain; 55% with significant chronic pain

Types: Paroxysmal limb pain, trigeminal neuralgia, musculoskeletal pain
Pain worsened by temperature, stress, and fatigue
Visual Symptoms

Optic neuritis: Pain, blurred vision, graying, blind spots

Nystagmus, diplopia (double vision), reduced visual acuity
Light reflex disturbances and eye movement impairments
Motor Symptoms

Upper motor neuron syndrome: Spasticity, clonus, Babinski’s sign

Muscle weakness: Loss of strength, coordination, and endurance
Spasticity: Common in 75% of patients, leading to mobility issues
 Fatigue in MS
Affects 75-95% of patients
Worsens throughout the day, impacts daily activities
Exacerbated by heat, stress, and lack of sleep
Coordination and Balance Issues

Ataxia: Uncoordinated, oscillatory movements

Tremors: Postural and intention tremors
Vestibular dysfunction: Dizziness, vertigo, disequilibrium
Speech and Swallowing Difficulties

Dysarthria: Slurred, poorly articulated speech

Dysphonia: Changes in vocal quality
Dysphagia: Difficulty swallowing, risk of aspiration pneumonia
Cognitive and Emotional Impact

Cognitive: Memory loss, attention deficits, executive dysfunction

Emotional: Depression, anxiety, mood swings
Social isolation due to physical and emotional symptoms
Diagnosis of Multiple Sclerosis (MS)
Diagnosis made by a neurologist based on:
◦ Careful medical history
◦ Complete neurological examination
◦ Supportive laboratory tests

Evidence of damage must be present in at least two separate areas of the central nervous
system (CNS) (Dissemination in space)
Damage must have occurred at two separate points in time, at least one month apart
(Dissemination in time)
Other possible diagnoses must be ruled out
Laboratory Tests for MS Diagnosis

Magnetic Resonance Imaging (MRI)

◦ Highly sensitive for detecting MS plaques in the white matter of the brain and spinal cord
◦ New lesions with active inflammation seen as areas of increased signal intensity (“bright spots”) on
contrast-enhanced T1-weighted images
◦ Gadolinium-enhanced scans help identify recent inflammatory activity

Evoked Potentials (EP)

Lumbar Puncture (LP) with cerebrospinal fluid (CSF) analysis
Advanced Imaging and Laboratory Findings in
MS Diagnosis
Axonal Loss and Gliosis:
◦ Lesions seen as “black holes” on MRI; darker lesions indicate more extensive tissue damage
◦ 95% of patients with clinically defined MS show well-defined MRI changes
◦ Other diseases (e.g., disseminated encephalomyelitis) and healthy individuals can show similar lesions
Neurology guidelines recommend periodic MRIs to document disease progression and treatment
response
Evoked Potentials (EP):
◦ Up to 90% of MS patients show abnormal EP results
◦ Visual evoked potentials (VEPs) are the most helpful in the diagnostic process
Cerebrospinal Fluid (CSF) Analysis:
◦ Elevated total immunoglobulin G (IgG) and presence of oligoclonal IgG bands seen in 90% to 95% of patients
◦ Patients with Primary Progressive MS (PPMS) show higher IgG levels in spinal fluid than those with Relapsing-
Remitting MS (RRMS)
Medical management, acute stage
Medications for Treating and Managing MS
Corticosteroid Therapy:
◦ Used for acute disease relapses (exacerbations)
◦ Reduces episode duration with powerful anti-inflammatory and immunosuppressive effects
◦ Effects:
◦ Diminished swelling in the CNS
◦ Decreased T-cell activation
◦ Limited immune cell penetration of CNS
◦ Enhanced apoptosis of activated immune cells
◦ Administration:
◦ High doses (500–1000 mg/day) via IV for 3–5 days
◦ Followed by tapered oral dosage for 1–3 weeks
◦ Potential Side Effects:
◦ Mood changes, increased blood pressure, fluid retention
◦ Hyperglycemia, acne, insomnia
◦ Chronic use: Hypertension, diabetes, osteopenia, peptic ulcers

Plasmapheresis:
◦ Used for acute relapse recovery when steroids are ineffective
◦ Recommended for RRMS exacerbations, not for PPMS or SPMS
 Management of symptoms
Pharmacological agents provide symptomatic relief for a wide range of symptoms in Multiple Sclerosis (MS).
Clinicians must understand the medications patients take, expected benefits, and potential adverse reactions.
Spasticity management: Common medications:
◦ Oral Baclofen (Lioresal): Reduces muscle tone and spasm frequency.
◦ Tizanidine (Zanaflex), Dantrolene Sodium (Dantrium), Diazepam (Valium).

Spasticity reduction must balance with functional needs.

Pain management: Drug options based on pain type:
◦ Tricyclic antidepressants (Amitriptyline, Elavil) for burning, neuropathic pain.
◦ Carbamazepine (Tegretol) for paroxysmal pain.
◦ Gabapentin (Neurontin) for dysesthesias.
◦ Anti-inflammatory drugs for pain with spasticity.
◦ Mild painkillers (Acetaminophen, Ibuprofen) for general pain.
Rehabilitation Framework
MS is a chronic, unpredictable disease, often seen as challenging for rehabilitation.
Despite the disease's direct impairments being unalterable, strong evidence supports
rehabilitation in enhancing activity and participation levels.
Goals and Outcomes of Rehabilitation in MS

Rehabilitation should be initiated with any functional decline affecting mobility, safety,
independence, or quality of life.
Individuals with neurodegenerative diseases like MS benefit from interventions aimed at:
◦ Remediating impairments and improving activity and participation.
◦ Addressing indirect impairments from inactivity and disuse.
◦ Promoting self-management skills and coping strategies.
◦ Enhancing quality of life as a meaningful outcome.

Preventative interventions aim to minimize complications and disability severity.

Comprehensive Care and Maintenance
Therapy

Interdisciplinary team approach: Physician, nurse, PT, OT, speech therapist, nutritionist, social
worker, patient, and caregivers.
Comprehensive management addresses complex, multifaceted problems.
Maintenance therapy:
◦ Preserves current function and reduces risk of secondary impairments.
◦ Requires careful documentation and specialized knowledge.

Long-range planning and coordinated care ensure consistent support across disease stages.
 Physical Therapy Examination in MS
Multiple areas of the central nervous system may be affected
Careful examination determines the extent of neurological and functional involvement
Reexaminations distinguish changes in status and treatment effects
Differentiating symptom remission from treatment outcomes can be challenging
Observation over several days provides a representative baseline
Consider fatigue and exacerbating factors when scheduling exams
Fatigue and Temperature Sensitivity in MS
Patients

Fatigue Assessment:
◦ Frequency, duration, and severity should be examined.
◦ Precipitating factors, activity levels, and efficacy of rest should be documented.
◦ MS Fatigue Scale (MSF)

Temperature Sensitivity:
◦ Impact on fatigue and weakness should be assessed.
◦ Temperature changes can worsen neurological symptoms.
Motor Function and Neurological Symptoms in
MS Patients
Motor Function Examination:
◦ Look for signs of corticospinal dysfunction, paresis, spasticity, hyperactive reflexes, positive Babinski sign, and
spasms.
◦ Spasticity Scales:
◦ Modified Ashworth Scale for assessing tone intensity.
◦ Rated based on differences between limbs and factors influencing tone.

Cerebellar and Vestibular Function:

◦ Examine for signs like ataxia, tremor, nystagmus, and dysarthria.
◦ Assess the impact of position changes (e.g., sitting to standing).
◦ Postural control and tremors should be documented
Gait and Balance:
◦ Examine gait speed, stability, and endurance.
◦ Timed walk tests (e.g., 10-meter walk test, 6-minute walk test) are useful.
Functional Mobility and General Health
Measures

Functional Mobility and Activities of Daily Living:

◦ Examine patient’s mobility and safety during daily tasks (e.g., transfers, wheelchair use, energy
conservation).
◦ Assess safety and functionality of orthotics and assistive devices.

Vital Signs and Skin Integrity:

◦ Monitor heart rate, blood pressure, respiratory rate, and symptoms during activity.
◦ Examine skin for integrity, moisture buildup, bruising, and breakdowns.

General Health Measures

MS specific Measures
 Goals and Outcomes for Patients with MS
Purpose: Provides a basis for developing specific goals and outcomes tailored to individual patients.
MS (Multiple Sclerosis) Practice Pattern: Emphasizes functional mobility, balance, and strength.
Patient/Client Classification: Classification codes (e.g., ICD-10) used for accurate diagnosis and
prognosis.
Examination and Evaluation: Includes components of assessment and diagnosis for targeted
interventions.
Interventions: Suggestions for physical therapy treatments, focusing on specific patient needs.
Outcome: Helps physical therapists design appropriate care plans, document services, and assess
outcomes.
Physical Therapy Interventions
Impaired Sensory and Compensatory Strategies
Proprioceptive Loss:
◦ Impairs movement control and motor learning.
◦ Requires increased use of other sensory systems, especially vision.
◦ Strategies: Tapping, verbal cueing, biofeedback, proprioceptive loading (e.g., resistance bands, weights,
pool exercises).
◦ Goal: Improve movement awareness and residual proprioceptive function.
Pain and Exercise Strategies for MS
Rehabilitation

Pain Management:
◦ Categories of MS-related pain: Direct pain, secondary symptoms, pain from medication, and
independent pain.
◦ Interventions: Stretching, massage, postural retraining, adaptive seating devices, and aquatic therapy.
◦ Chronic Pain: Consider referral to comprehensive pain management programs and stress-reduction
techniques (e.g., biofeedback, meditation).

Exercise Strategies:
◦ Exercise Considerations: Tailor to the patient's ability; monitor fatigue, spasticity, balance, and
coordination.
◦ Types: Resistance training, circuit training, and aquatic therapy.
◦ Guidelines: Schedule exercise on alternate days, use appropriate intensity, and ensure adequate rest.
Cardiovascular and Respiratory Responses in
MS

Cardiovascular Responses:
◦ MS patients show expected physiological responses to submaximal aerobic exercise: heart rate (HR),
blood pressure (BP), and oxygen uptake (VO2) increase linearly with workloads.
◦ Dysautonomia: Cardiovascular responses may be blunted if cardiovascular dysautonomia is present.
◦ Exercise Challenges:
◦ Respiratory muscle weakness and dyssynergia can contribute to reduced exercise tolerance.
◦ Reduced VO2max and exercise capacity, increased fatigue, anxiety, and depression are common in MS.
Exercise Programming for MS and Precautions
Exercise Prescription:
◦ Frequency: 3-5 days per week (on alternate days).
◦ Intensity: 60%-85% of peak HR or 50%-70% of peak VO2.
◦ Duration: 30 minutes per session or multiple 10-minute sessions.
◦ Type of Exercise: Cycling, walking, swimming, or water aerobics. Circuit training may be optimal for training improvement.
◦ Non-weight-bearing activities for those with balance issues or sensory loss.
Precautions:
◦ Monitor fatigue and adjust the intensity accordingly.
◦ Avoid overexertion; ensure cooling during exercise to manage core temperature.
◦ Be mindful of medications (e.g., amantadine, baclofen) that can affect muscle strength and fatigue.
◦ Exercise in the morning when body temperature and fatigue are more manageable.
Outcomes & Education:
◦ Measure results using graded exercise tests (GXT) and monitor fatigue, lung function, and MS status.
◦ Patient education is critical for success: understanding training principles, self-monitoring, and exercise modifications based
on individual needs.
Stretching & ROM Exercises in MS

Importance of Stretching & ROM:

◦ Necessary to maintain adequate joint motion and counteract spasticity effects.
◦ Sedentary or inactive MS patients commonly experience tightness in hip flexors, adductors, hamstrings,
and plantar flexors.
◦ Limited overhead ROM is common due to tightness in the pectoralis minor, latissimus dorsi,
contributing to forward posture.
◦ Stretching and ROM exercises should be performed daily with a minimum of 30-60 seconds at end
ranges, repeated 2 times.

ROM Exercise Considerations:

◦ Trunk ROM may be necessary for trunk mobility and to improve function.
◦ Gait deviations and difficulty with transfers can arise from limited ROM and spasticity, so trunk ROM
should be included.
Fatigue in MS Patients

Fatigue in MS:
◦ Fatigue is one of the most debilitating symptoms in MS, often characterized by overwhelming tiredness
and weakness.
◦ Sudden onset of fatigue is common, which worsens with activity or emotional stress.
◦ Fatigue Management:
◦ Aerobic exercise and physical therapy are crucial in reducing fatigue.
◦ Differentiating between MS-related fatigue and expected exercise fatigue is essential. Rest, cooling, and pre-cooling treatments
during exercise help manage MS-related fatigue.
Energy Conservation Strategies

◦ Patients should track daily activities and rate fatigue levels to assess energy requirements.
◦ Activity Modification:
◦ Tasks should be adapted to conserve energy (e.g., using a motorized scooter or powered wheelchair for mobility).
◦ Complex activities can be broken down into smaller components with rest periods.
Pain Management Approaches
Musculoskeletal Pain:
◦ Caused by muscle weakness and joint malalignment
◦ Responsive to physical therapy interventions
◦ Techniques: stretching, exercise, massage, ultrasound
◦ Postural retraining and correction of movement patterns
◦ Use of orthotic and adaptive seating devices
Neuropathic Pain:
◦ Stabbing pain from Lhermitte’s sign: relieved with soft cervical collar
◦ Hydrotherapy or pool therapy can help with dysesthesias
◦ Pressure stockings or gloves convert pain sensation to pressure
◦ Neutral warmth from stockings or gloves can aid pain relief
Chronic Pain:
◦ Total pain management approach
◦ Stress management: relaxation training, biofeedback, meditation
◦ Transcutaneous electrical nerve stimulation (TENS): mixed results
Exercise Training in MS

Common Issues in MS:

oMuscle weakness and decreased endurance
oSedentary lifestyle limiting physical activity
Benefits of Exercise:
oProven physiological and psychological benefits
oImproves function, reduces disability, enhances quality of life
oStrong evidence for improving muscle power, exercise tolerance, and mobility
oModerate evidence for improving emotional mood
Exercise Considerations
oEarly exercise initiation leads to better outcomes
oTailored programs based on individual abilities and needs
oAddress factors like fatigue, spasticity, incoordination, balance issues, sensory loss, tremor, and heat
intolerance
oDepression may affect adherence; therapists should provide reinforcement and a positive
environment
oExercise Guidelines:
oAdjust focus and pace according to patient’s condition
oFor Relapsing-Remitting MS (RRMS): avoid exercise during exacerbations
oFor Primary Progressive MS (PPMS): exercise within capability limits to maintain function and slow
deterioration
Strength and Conditioning Considerations for
Individuals with MS

Reduced maximal muscle force during sustained isometric or isokinetic exercise due to:
◦ Decreased ability to activate muscles
◦ Reduced force unit and muscle mass
◦ Impaired muscle metabolic responses
◦ Muscle weakness from muscle fiber atrophy, spasticity, and disuse

Individualized exercise prescription is crucial:

◦ Tailored to each patient’s needs
◦ Balancing strength and endurance training
◦ Avoiding adverse effects on motivation and health
Precautions and Safety Measures
Monitor fatigue effects:
◦ Fatigue varies among individuals and is not correlated with physical impairment
Temperature regulation:
◦ Control environmental temperature to prevent overheating
◦ Use air conditioning and cooling devices (e.g., cooling suits, vests, misting sprays)
Address physical impairments:
◦ Ensure safe equipment use considering tactile/proprioceptive loss, incoordination, and tremors
◦ Visual feedback for monitoring performance
Manage cognitive and memory impairments:
◦ Provide written instructions and visual reminders
Stability in training postures:
◦ Use stable postures (e.g., modified plantigrade, quadruped, supported sitting)
Training Approaches and Outcome Measures
Functional training activities:
◦ Closed-chain exercises for strength and functional endurance
◦ Support balance and stability for individuals with ataxia
Group exercise classes:
◦ Enhance motivation and social support
◦ Therapist’s role as educator and leader
Outcome measures:
◦ Isokinetic dynamometry, functional tests (e.g., sit-to-stand), fatigue scales, and quality of life measures
Exercise guidelines:
◦ Schedule on non-endurance days and optimal times (e.g., mornings)
◦ Use resistance training (e.g., weight machines, bands, isokinetic machines)
◦ Circuit training to distribute load and reduce fatigue risk
◦ Ensure adequate rest periods and slower progression
◦ Avoid overwork and fatigue to prevent symptom worsening
Aerobic Conditioning
Expected physiological responses to submaximal aerobic exercise:
◦ Heart rate (HR), blood pressure (BP), and oxygen uptake (VO2) increase linearly with workload.
◦ Respiratory rate (RR) and minute ventilation also increase.
◦ Blunted HR and BP responses may occur with cardiovascular dysautonomia.
◦ Disease duration and extent correlate with increased likelihood of autonomic cardiovascular
dysfunction.
Respiratory muscle dysfunction and dyssynergia contribute to reduced exercise tolerance.
Reduced exercise tolerance and maximal aerobic power (VO2 max) due to:
◦ Physical inactivity and reduced cardiorespiratory fitness.
◦ Decreased physical work capacity and vital capacity.
◦ Increased resting RR and exaggerated exercise RR.
◦ Decreased muscular strength, increased fatigue, anxiety, and depression.
Exercise Testing and Protocols for Individuals
with MS

Performance measures:
◦ Ratings of Perceived Exertion (RPE), BP, and expired gas analysis (VO2).
◦ Peripheral muscle exertion often perceived as more stressful than cardiopulmonary exertion.

Protocols:
◦ Continuous or discontinuous protocols with 3–5 minute stages.
◦ Discontinuous protocol preferred for symptomatic disease and fatigue.
◦ Submaximal tests recommended (achieve 70%–85% of age-predicted HR max).

Termination criteria:
◦ Achievement of peak HR or VO2, volitional fatigue, significant BP changes, hypotensive response, or
decreased oxygen uptake with increasing workload.
Importance of Stretching and ROM Exercises
Stretching and Range of Motion (ROM) exercises are essential to maintain adequate joint motion and counteract the
effects of spasticity.
Sedentary or inactive individuals, especially those dependent on wheelchairs, often develop tightness in:
◦ Hip flexors
◦ Adductors
◦ Hamstrings
◦ Plantar flexors

Limited overhead ROM is commonly associated with tightness in:

◦ Pectoralis major and minor
◦ Latissimus dorsi

This often leads to a slumped forward posture.

Bed-bound patients typically present with tightness in:
◦ Hip and knee flexors
◦ Hip adductors and extensors
◦ Plantar flexors
Recommendations for ROM and
Stretching
Stretching and ROM exercises should be performed daily to maintain flexibility and prevent
contractures.
Effective stretching guidelines:
◦ Hold at end ranges for a minimum of 30 to 60 seconds
◦ Repeat for at least 2 repetitions

Consider the use of:

◦ Orthoses or dynamic splinting to prevent and, in some cases, reverse contractures

Trunk ROM is crucial for:

◦ Enhancing core muscle function (e.g., quadratus lumborum)
◦ Addressing gait deviations and bed mobility challenges
Management MS-Related Fatigue

Prevalence and Impact:

◦ ~75% of individuals with MS experience persistent or sporadic symptoms.
◦ Fatigue is one of the most debilitating symptoms.
◦ Characteristics include overwhelming sleepiness, excessive tiredness, and sudden, severe weakness.
◦ Aversion to activity and fear of triggering fatigue are common.
◦ Lowered activity levels contribute to diminished health status and deconditioning.
Balancing Exercise and Fatigue Management

Therapist’s Role:
◦ Balance prescribing exercise with avoiding overwork and development of fatigue.
◦ Aerobic exercise is central to intervention plans to reduce fatigue.
◦ Skilled therapists must differentiate between MS-related fatigue and typical exercise fatigue.
◦ Address thermal stress by ensuring adequate rest and using cooling and pre-cooling treatments.
Energy Conservation and Activity Management
Activity Tracking and Analysis:
◦ Patients maintain activity diaries to record sleep, daily activities, and fatigue levels.
◦ Rate activity importance, perceived performance, and satisfaction on a scale of 1-10.
Energy Conservation Strategies:
◦ Modify tasks or environments to reduce energy requirements.
◦ Use assistive devices like motorized scooters, wheelchairs, walkers, or orthotics.
◦ Break down difficult activities and intersperse rest periods throughout the day.
◦ Prioritize meaningful activities and limit non-essential tasks.
Collaborative Approach:
◦ Occupational and physical therapists collaborate with vocational counselors and physicians.
◦ Conduct environmental assessments and recommend home or workplace modifications.
◦ Ensure proper communication for consistent care and optimal pharmacological treatment.
Management of Spasticity in (MS)

Spasticity varies greatly from person to person.

Commonly affected muscles exhibit strong tone:
◦ Lower extremities (LE): quadriceps, hip adductors, plantar flexors.
◦ Upper extremities (UE): elbow, wrist, and finger flexors, shoulder adductors.

Spasticity is functionally limiting and contributes to secondary impairments:

◦ Contractures
◦ Postural deformity
◦ Decubitus ulcers
Physical Therapy Interventions for Spasticity
Management

Variety of techniques used:

◦ Cryotherapy (cold packs, wraps)
◦ Hydrotherapy (cool baths)
◦ Therapeutic exercise and stretching
◦ Positioning and prolonged stretching

Monitoring and balancing with pharmacological interventions:

◦ Antispasticity medications like Baclofen require timing of therapy to optimize results.
◦ Minimize factors aggravating spasticity: heat, humidity, stress, infections.
Stretching and Functional Training Strategies

Stretching techniques:
◦ Prolonged stretching (30 min to 3 hrs)
◦ PNF techniques: Hold-relax, Contract-relax
◦ Slow and controlled movements to avoid triggering spasticity

Functional training:
◦ Emphasize trunk and proximal segment control
◦ Activities like lower trunk rotation and quadruped to side-sitting transitions reduce extensor tone
◦ Proper positioning in bed and wheelchair to avoid fixed postures and improve mobility
Balance Impairments and Postural Instability
Common Deficits:
◦ Cerebellar deficits: Ataxia and postural instability
◦ Impaired somatosensory, visual, and vestibular systems
◦ Disordered proprioception
◦ Spasms and muscle weakness affecting balance
◦ Difficulty sustaining upright postures and performing functional activities
◦ Increased risk of falls
Strategies to Promote Postural Control

Static Control:
◦ Holding weight-bearing, antigravity postures (sitting, quadruped, kneeling, modified plantigrade,
standing)
◦ Gradual progression through postures by varying base of support and raising center of mass
◦ Increasing number of body segments and degrees of freedom

Stability Techniques:
◦ Joint approximation through proximal joints (shoulders, hips, spine)
◦ Rhythmic stabilization
Advanced Interventions and Dynamic Control
Dynamic Control:
◦ Activities like weight shifting and reaching
◦ Reciprocal patterns combining upper limb and trunk movements
◦ Swiss ball exercises to engage core balance
Functional Balance Training:
◦ Sit-to-stand transitions
◦ Narrowing base of support, moving from stable to unstable surfaces
◦ Varying sensory contexts (eyes open/closed, firm/foam surfaces)
Additional Techniques:
◦ Vestibular rehabilitation
◦ Aquatic therapy for graded resistance and balance practice
◦ Biofeedback training for balance function
◦ Proprioceptive loading and light resistance for tremor control
◦ Use of weighted devices for stability (weighted cuffs, belts, or utensils)
Walking Impairments and Gait Deviations
Walking ability is frequently impaired in Multiple Sclerosis (MS), but at least 65% of patients are
still walking after 20 years.
Early gait problems often include:
◦ Poor balance
◦ Heaviness in one or more limbs
◦ Difficulty lifting legs due to hip flexor weakness
◦ Weak dorsiflexors causing foot drop
◦ Foot clearance issues leading to circumducted gait patterns
Later gait problems evolve due to:
◦ Clonus, spasticity, sensory loss, and/or ataxia
◦ Weakness extending to quadriceps and hip abductors
◦ Quadriceps weakness resulting in:
◦ Knee hyperextension
◦ Forward trunk flexion with increased lumbar lordosis
◦ Hip abductor weakness causing Trendelenburg gait with strong lateral lean to the weak side
Exercise and Locomotor Training for Gait
Improvement in MS

Well-designed exercise programs focused on:

◦ Tone management
◦ Stretching and strengthening exercises

Walking and standing activities should stress:

◦ Safety and a stable base of support (BOS)
◦ Maximum weight bearing through lower limbs
◦ Adequate weight transfer and forward progression with proper trunk, limb, and pelvic kinematics
Functional activities for gait training:
◦ Walking forward and backward
◦ Side-stepping and cross-stepping
◦ Complex walking activities like stair climbing, negotiating curbs, and navigating obstacles
◦ Walking on varied surfaces for safety in community mobility

Locomotor training (LT) methods:

◦ Anti-gravity treadmill or treadmill training with body weight support (BWS)
◦ Demonstrated improvements in:
◦ Muscle strength, spasticity, endurance, balance, walking speed, and quality of life
◦ Reduced effort without increasing fatigue

LT with BWS is a feasible and safe intervention with potential for significant functional
improvements in MS patients
 Orthotic Devices for Patients (MS)
oAs ambulation skills decline, patients with MS often require orthotic devices for support and stability.
oAnkle-foot orthoses (AFOs) help improve ankle and foot stability, energy efficiency, and safety.
oAFOs are commonly prescribed for foot drop, poor knee control (e.g., hyperextension), mild to moderate
spasticity, and poor somatosensation.
oStandard polypropylene AFOs are lightweight and offer cosmetic benefits.
oArticulated AFOs with plantarflexion stops provide more rigid control.
oFunctional Electrical Stimulation (FES) devices are increasingly used for foot drop, enhancing walking
performance and satisfaction while reducing falls and fatigue.
oAdequate hip flexion strength is necessary for the effective use of AFOs or FES devices.
oContraindications include severe spasticity, foot edema, and significant muscle weakness (e.g., nonfunctional hip
flexors).
oKnee-ankle-foot orthoses (KAFOs) offer additional stabilization but are rarely used due to increased energy
expenditure.
 Mobility Aids and Assistive Technology
oForearm crutches and walkers help compensate for fatigue, strength, and sensory deficits.
oRolling walkers with large wheels, locking brakes, and seats offer rest opportunities and greater mobility.
oAdvanced upright walking devices with integrated technology aid ambulation.
oCosmesis plays a crucial role in patient acceptance; stylish canes and devices promote better adaptation.
oAs MS progresses, many patients benefit from wheeled mobility devices like powered scooters or wheelchairs.
oScooters provide mobility while conserving energy but require good trunk stability and cognitive skills.
oWheelchairs offer increased postural support, with power chairs recommended for patients with fatigue and limited
manual propulsion ability.
oProper wheelchair seating ensures pelvic, trunk, and limb alignment while enhancing function.
oAdditional supports like custom backs, lateral trunk supports, and seat cushions prevent malalignments and skin
breakdown.
oTherapists must document medical necessity to secure insurance coverage for assistive devices, especially as MS
symptoms fluctuate.
Functional Training
oDevelopment of Appropriate Decision-Making Skills and Training in Functional Mobility
oSkills should be adapted and practiced to ensure safe performance in both home and community
environments.
oTraining in functional mobility skills (e.g., bed mobility, transfers, and locomotion) is typically directed
by the physical therapist.
oTraining in daily living skills (e.g., dressing, personal hygiene, bathing, toileting, grooming, and
feeding) and household tasks (e.g., cooking, laundry, and bed making) is directed by the occupational
therapist.
oTraining in communication skills is provided by the speech-language pathologist.
oClose communication and coordination among team members are necessary to ensure consistent
training methods and successful outcomes.
oFull participation of the patient in all phases of planning and training increases personal involvement
while decreasing dependency and passivity.
Functional training
oDevelopment of Appropriate Decision-Making Skills and Training in Functional Mobility
oSkills should be adapted and practiced to ensure safe performance in both home and community
environments.
oTraining in functional mobility skills (e.g., bed mobility, transfers, and locomotion) is typically directed
by the physical therapist.
oTraining in daily living skills (e.g., dressing, personal hygiene, bathing, toileting, grooming, and
feeding) and household tasks (e.g., cooking, laundry, and bed making) is directed by the occupational
therapist.
oTraining in communication skills is provided by the speech-language pathologist.
oClose communication and coordination among team members are necessary to ensure consistent
training methods and successful outcomes.
oFull participation of the patient in all phases of planning and training increases personal involvement
while decreasing dependency and passivity.
Patient/family and caregiver education
Caring Professional, Expert Teacher, and Competent Practitioner:
The clinician’s role is categorized into three key areas:
◦ Caring Professional: Provides compassion, empathy, and understanding.
◦ Expert Teacher: Educates patients and family caregivers on the disease process and management.
◦ Competent Practitioner: Delivers effective clinical interventions and monitors patient outcomes.

Importance of a Positive and Affirming Attitude:

◦ Helps shape patients’ outlook and fosters a positive approach to rehabilitation.
◦ Encourages collaboration and mutual respect between clinicians, patients, and family caregivers.

Collaborative Relationships:
◦ Building strong partnerships based on respect, compassion, and effective communication.
◦ Ensuring the involvement of family caregivers for successful rehabilitation outcomes.
Education and Support for Patients and
Caregivers
Educational Areas:
◦ Disease process, clinical manifestations, and management strategies.
◦ Prevention of secondary complications and activity limitations.
◦ Rehabilitation process and specific interventions .
◦ Independent interventions and safe use of assistive devices.
◦ Monitoring medication effects and potential adverse reactions.
◦ Stress management and community resource referrals.
Community Resources and Support:
◦ Referral to support groups and organizations like the National Multiple Sclerosis Society
◦ Access to education, emotional support, and various services.
Caregiver Challenges and Support:
◦ Recognizing caregiver stress and providing counseling and education.
◦ Addressing physical, psychological, social, and spiritual challenges.
◦ Supporting children of patients to mitigate psychological impacts.
Summary
Early Intervention Matters: Timely referral to neurorehabilitation services is essential for managing
activity limitations, disability, and quality of life issues in patients with Multiple Sclerosis (MS). Too
often, services begin only after severe disability has developed.
Comprehensive Patient-Centered Approach: A well-structured plan of care (POC) should address the
whole patient’s needs and emphasize meaningful functional activities, patient education, and self-
management.
Focus on Safety and Self-Efficacy: Attainable and safe activities help ensure patient success and build
self-efficacy. Many MS patients report lacking the knowledge and skills needed to exercise safely.
Supervised Programs for Mastery: Promoting self-efficacy, self-management, and mastery can be
achieved through supervised programs focusing on regular exercise, activity pacing, energy
conservation, and healthy behaviors.
Coordinated Interdisciplinary Efforts: Comprehensive care requires coordinated efforts from an
interdisciplinary team, ensuring continued support across inpatient, outpatient, and community-
based care episodes.