Daniel, & Jordon Chandler, Chris, Multiple Sclerosis (MS) · Paltamaa J, Sjögren T, Peurala SH, Heinonen A. Effects of physiotherapy interventions on balance in multiple sclerosis:

Multiple Sclerosis (MS)Chandler, Chris, Daniel, & Jordon

Definition of MSMultiple sclerosis (MS) involves an immune-mediated process in which an abnormal response of the body’s immune system is directed against the central nervous system (CNS), which is made up of the brain, spinal cord and optic nerves. The exact antigen — or target that the immune cells are sensitized to attack — remains unknown, which is why MS is considered by many experts to be "immune-mediated" rather than "autoimmune.” 11

“The pathophysiology of multiple sclerosis (MS) is characterised by fatigue, motor weakness, spasticity, poor balance, heat sensitivity and mental depression. Also, MS symptoms may lead to physical inactivity associated with the development of secondary diseases.” 4

Disease profile- Affects about 400,00 Americans and 2

million worldwide

2

- Onset typically between the ages of 20-50;

average onset of 34

2

- 4 types:

- Relapse-remit: About 85% of patients initially

diagnosed with this type

2

- Primary-progressive: About 10% of patients

initially diagnosed with this type

2

- Secondary-progressive: 60% - 70% of people

who experience relapse-remit MS develop

secondary-progressive MS

1

- Progressive-Relapsing: rarest form - < 5%

initially diagnosed with this type

2

- “Attacks” last days to weeks

1

Signs and Symptoms1

- Pain and/or tingling

- Numbness or weakness in >1 extremities or the trunk, with one side more affected

than the other

- Vision impairment, with one side usually more affected than the other

- Electric shock sensation

- Dizziness or fatigue

- Poor coordination and unstable gait

- Bowel and bladder functional abnormalities

- Heat intolerance

Risk Factors- Idiopathic

- “Genetics are the gun and environment is the trigger”

- Women > men

- Northern latitudes > southern latitudes

- Thought to have a genetic component

2

- Comorbidities

- The most frequently reported comorbidities are hypercholesterolemia (37%), hypertension (30%),

and arthritis (16%)

12

- Mental Illness

- Vascular disease

- No evidence that vaccines or viruses cause MS

2

- Higher risk for initial attack within 6 months of giving birth

2

Case Study: Moderate Multiple Sclerosis-Related Disability3

The Patient: L.S.

- 60 y.o. female with 20 yr. history of relapse & remitting MS

- P1: Increased difficulty with walking, especially outdoors and in the community

- Admits to limited ability to complete household shopping independently

- Medical Hx

- Depression

- Urinary Incontinence

- Hypertension

- Pt. Goals: Feel secure walking out in the community

Test and MeasuresStrength: MMT

ROM/Flexibility: Limited Ankle DF

- L > R

- Left plantarflexor contracture

Outcome Tools

- Fatigue

- VAS

- 6/10 (10 being worst fatigue)

- Dynamic Gait Index (Balance + Fall Risk)

- 14/24

- Well below norms for her age group

- Elevated fall risk

- 12 item MS Walking Scale (MSWS-12)

- 46/100

- Elevated fall risk

Left RightHip Extension Hip Flexion Hip Abduction Knee Extension Knee Flexion Ankle DF Ankle eversion Ankle inversion

PT Evaluation: ICF ModelHealth Condition: Relapse & Remitting MS

Body Structure Impairments/Activity Limitations/Participation

Strength Bilateral LE Limited walking and balance function Limited in walking outdoors

ROM and Flexibility Fatigue Shopping for household

Impaired ability to navigate stairs/curbs

Environmental

Internal External

Depression Lives alone

Single story home, 4 stairs to enter

Why exercise patients like L.S.? “Despite the often unpredictable clinical course of MS, exercise programmes designed to increase cardiorespiratory fitness, muscle strength and mobility

provide benefits that enhance lifestyle activity and quality of life while reducing risk of secondary disorders”4

- Exercise is neuroprotective- High dosage is beneficial

- Management of fatigue and heat sensitivity- Improvements on gait speed5

- Alternative options- Aqua therapy

Prognosis and Plan of Care for L.S. - Prognosis

- Those with MS have normal or near-normal life span

2

- For L.S. : Likely patient will make improvement but unlikely to have complete recovery

from disease.

3

- Plan of Care

- Frequency and Time: PT 2x/week for 8-12 weeks with daily HEP

- Intensity: High repetition is needed with monitoring of fatigue and thermal regulation

- Type: Flexibility, Strength, Endurance, Balance, and Functional exercises

- Intervention

- Designed to address patient’s impairments and functional limitations

- Patient education and compliance

- Fall prevention (managing fatigue and thermal regulation)

- Community programs and HEP to combat deconditioning

Exercise Precautions:● Patient should check with doctor before starting new exercise program

● Cater to patients capabilities/limitations

● Carefully consider/address patient goals w/ exercise program

● Avoid strenuous exercise on days where patient has increased symptomatic

fatigue

● These patients need to be monitored closely during exercise program

● Uhthoff’s sign: blurry vision during overheating.

4

Treatment (Week 1)Address Impairments!

● Gastroc tight leading to gait/ balance issues:

○ General Stretching Guidelines 10 -15 mins daily, 20-60 sec per stretch.

4

■ Stretch: gastrocnemius (short periods throughout day

4

) and mobilize ankle to increase ROM.

● Decreased strength in multiple muscle groups:

○ Functional strengthening: Squats, bridges, step ups, multi‐directional stepping, walking practice,

and treadmill training

3

.

■ Strengthening exercise can improve functional mobility in people with MS

6

.

■ Dose = 2x/week for progressive resistive strengthening to specific major muscle groups

6

.

■ Do fewer reps per set with increased rest periods. This may create opportunity for more

strength training overall because patient is not exhausted after each set

7

.

● Helps avoid excessive build up of fatigue and heat stress which can worsen MS

symptoms

4

.

Week 1 Continued:Limited walking and balance function (increased fall risk per DGI score of 14/24).

● Static/Dynamic balance training by:

○ Decreasing BOS

○ Altering visual

○ Altering somatosensory inputs

■ Improve sensory integration for maintaining upright postural control

8

● Task‐specific training:

○ Dual‐task gait training (e.g. walking with head turning, stepping over and around obstacles, turning

around, carrying items, on varied surfaces, or with a cognitive task)

■ Can help to train dynamic standing balance.

9

Squats

Bridges

Step Ups

Multidirectional Stepping

Walking Practice/ Treadmill Training

BalanceSingle leg

Stepping over obstacles

Week 2 - 3Continue Strengthening and Balance Training and increase difficulty/intensity as

patients strength/balance improve (according to FITT principle).

Aerobic/Cardiovascular:

● Endurance training may reduce fatigue and improve balance.

7

● Favorable outcomes in as little as 4 weeks

4

.

● Program can include:

○ Stationary cycling with legs/arms, swimming/aquatic exercise, treadmill/elliptical training (higher

level MS patients)

4

.

○ In absence of symptoms aim for 11-14/20 (moderate intensity) on Borg scale of perceived exertion.

Note: Patient may not have the muscle strength to reach desired intensity. In that case

slowly progress both strength/endurance exercises until desired intensity is achieved.

Aquatic TherapyAquatic exercise is beneficial in temps of 80-84 degrees F

4

Primary benefit is better heat dissipation

4

Balance exercises are easier in chest high water

Greater ROM

Improves fatigue, and physical and mental HRQOL

10

Home Exercise ProgramWeek 1:

● Stretching:

■ Stretches: Calf Stretch, theraband/ wall

● 2 sets of 3o seconds, 3 times a day

● Strengthening:

○ Step ups on stairs with a rail (if they are easily accessible in the home) - 2 sets of 3-5 with a 2

minute break in between sets

○ Bridge Setting: lay supine and contract core (belly button through the table) and contract bottom -

5 sets of 10 second holds with a 1 minute break in between each.

■ Work up to bridges later this week if possible.

Home Exercise ProgramWeek 2-3

● Stretching:

○ Add a few more stretches (goal is to get up to whole body stretching).

○ Consider joining a yoga class?

● Strengthening:

○ Bridges

○ Step ups (increase the number or speed they do them at depending on patient progression -2 sets of

8-10 with a 2 minute break in between sets)

○ Walking (10 mins/day)

● Balance:

○ Stand on one leg while holding onto a rail or stable chair - 3-5 sets of 1 minute per day

Take-Home MessagesExercise programs with individuals with MS should target mobility, strength, and

cardiovascular fitness while decreasing chance for 2ndary disorders

Pick exercises that are fun, modifiable, and functional throughout their lives

Use less reps and sets with more rest periods

Avoid strenuous exercise on days where patient has increased symptomatic fatigue

Monitor MS pts. closely

References 1. Multiple Sclerosis. Mayo Clinic Website. Published October 1, 2015. Retreived from http://www.mayoclinic.org/diseases-conditions/multiple-

sclerosis/symptoms-causes/dxc-20131884. Accessed July 13, 2016.2. Multiple Sclerosis. University of Maryland Medical Center Website. Published September 25, 2012. Retrieved from http://umm.

edu/health/medical/reports/articles/multiple-sclerosis. Accessed July 13, 2015. 3. Schmidt D, Cohen ET. Clinical Example: Moderate Multiple Sclerosis-Related Disability. American Physical Therapy Association 2016. 4. White LJ, Dressendorfer RH. Exercise and multiple sclerosis. Sports Med. 2004;34(15):1077‐1100.

5. Sandroff BM, Klaren RE, Motl RW. Relationships Among Physical Inactivity, Deconditioning, and Walking Impairment with Persons with Multiple Sclerosis. JNPT. 2015; 39 (2): 103-110. doi: 10.1097/NPT.0000000000000087

6. Latimer‐Cheung AE, Pilutti LA, Hicks AL, et al. Effects of exercise training on fitness, mobility, fatigue, and health‐related quality of life among adults with multiple sclerosis: a systematic review to inform guideline development. Arch Phys Med Rehabil. 2013;94(9):1800‐1828.

7. Karpatkin H. Intermittent strengthening results in improved leg raise function in persons with MS. Paper presented at: 27th Annual Meeting of the CMSC and the 5th Cooperative Meeting of the CMSCACTRIMS; May 29‐June 1, 2013; Orlando, FL.

8. Paltamaa J, Sjögren T, Peurala SH, Heinonen A. Effects of physiotherapy interventions on balance in multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials. Journal of rehabilitation medicine. 2012 Oct 5;44(10):811-23.

9. Sullivan KJ, Brown DA, Klassen T, Mulroy S, Ge T, Azen SP, Winstein CJ. Effects of task-specific locomotor and strength training in adults who were ambulatory after stroke: results of the STEPS randomized clinical trial. Physical therapy. 2007 Dec 1;87(12):1580-602.

10. Kargarfard M, Etemadifar M, Baker P, Mehrabi M, Hayatbakhsh R. Effect of aquatic exercise training on fatigue and health-related quality of life in patients with multiple sclerosis. Archives of physical medicine and rehabilitation. 2012 Oct 31;93(10):1701-8.

11. Definition of MS. National Multiple Sclerosis Society. http://www.nationalmssociety.org/what-is-ms/definition-of-ms. Accessed July 17, 2016

12. Marrie RA, Horwitz R, Cutter G, Tyry T, Campagnolo D, Vollmer T. Comorbidity, socioeconomic status and multiple sclerosis. Multiple Sclerosis Journal. 2008; 14(8): 1091-1098.

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