Physical Therapy Management for Multiple Sclerosis (MS)

Physical Therapy Management

By: Dr.D.K.Kushwaha - July 01, 2024

Physical therapy - plays an essential role in keeping a patient with MS active and functional within the community

Aims of Physiotherapy

1. To re-educate and maintain all available voluntary control
2. Re-educate & maintain postural mechanisms
3. Incorporate treatment techniques into ways of life by relating to ADLs

Inhibit abnormal tone

1. Prevent abnormal movement
2. To stimulate all sensory and perceptual experience

The PT  assessment - focuses on posture, movement, and function, realise the patient's performance may be limited by fatigue, pain or other factors. An individualized program can then be set up. This program must easily be performed at home, and provide written instructions. Education is important to assist patients in managing their programs as independently as possible. Multidisciplinary treatment for MS patients leads to positive effects.

Expanded disability scale to evaluate degree of disability.

Multiple Sclerosis Functional Composite to assess 3 functional domains; ambulatory, hand and cognitive function.

Physiotherapy treatment

1. Exercise is essential. A narrative review highlights that exercises are safe and effective in symptom management and disease modification. The authors encourage neurologists, as they are critical in the treatment process along with the multidisciplinary healthcare team to prescribe and promote exercises at the diagnosis and across all stages of the disease trajectory using prescriptive clinical exercise guidelines as part of comprehensive MS care. Clinical education to dispel historical myths related to exercise in MS and behaviour change theory help overcome patients' barriers to exercise[17]. Exercise is beneficial at multiple levels and has an important role in delaying negative symptoms of the disease. Choose exercises appropriate to the client's strengths and weaknesses [18]. State the best ’dose’ (intensity, frequency and duration) of treatment in terms of activities and participation. Exercise is considered as a safe effective means of rehabilitation[19]. Exercise also has benefits on mood and quality of life. The use of therapeutic corticosteroids and inactivity due to fatigue and weakness may lead to osteoporosis and pathological fractures. Weight-bearing exercises are hence beneficial.
2. Strength and aerobic training:
   • The resistance training program is recommended for maintaining bone and muscle mass.
   • Other techniques e.g. Bobath, Vojtas, Proprioceptive Neuromuscular Techniques; carried out regularly and with sufficient intensity, have evidence of improvement in patients with MS Exercise improves impairments of aerobic capacity, lower extremity muscle strength, fatigue, and depression; reduced activity limitations such as walking performance and balance; and confirms that it positively impacts quality of life.
   • According to Döring et al., aerobic training seems to have a positive effect on fatigue. The physical activity guidelines for MS people state that those with mild to moderate disability need at least 30 minutes of moderate-intensity aerobic activity (2 times per week) and strength training' exercises for major muscle groups (2 times per week). There is sufficient evidence that these exercises may reduce fatigue, improve mobility, and enhance health-related quality of life, and people with MS and health professionals are encouraged to adopt these rigorously developed guidelines. Aerobic exercise training with low to moderate intensity can result in the improvement of aerobic fitness and reduction of fatigue in MS patients, affected with mild or moderate disability
   • According to the rapid review and synthesis by Yumi Kim et.al, the recommended exercise guidelines for MS: aerobic training 2–3 days/week  (10–30 minutes at moderate intensity) and resistance training 2–3 days/week of  (1–3 sets of 8–15 repetition maximum (RM)). However, further research is needed to examine the benefits and training adaptation with combined or isolated aerobic and strength training.
3. Aquatic exercise programs have a positive effect on persons with progressive multiple sclerosis. It promotes general health, improves energy levels and mental health, and aids social interaction in the presence of physical disability. Because of the reduced impact of gravity, aquatic training allows patients with even severe paresis of the lower extremities to perform standing and moving exercises. A systematic review and Meta-Analysis recommends combining aquatic therapy with conventional physical therapy for MS patients.
4. Specific balance exercises can improve balance. Poor postural control increases the risk of falls. MS patients have increased sway in quiet stance, delayed postural perturbations and reduced ability to move towards limits of stability. These impairments are likely causes of falls. Reduced gait speed, decreased stride length, cadence, and joint movement are observed in most studies of gait in MS.
5. Hippotherapy has a positive effect on the balance of persons with multiple sclerosis and improves the quality of life. A systematic review and meta-analysis of the therapeutic effect of Horseback riding intervention show positive physical and emotional effects of horse riding in individuals with neuromotor development and physical disabilities. Horseback riding improved balance and gait of ambulatory patients with MS and helps the rider, by providing effective sensory stimulation and rhythmic anterior and posterior swinging motion. It also improves posture and balance.
6. Motor Imagery is increasingly used in neuro-rehabilitation to facilitate motor performance. Motor imagery and rhythmic auditory stimulation can be used for walking rehabilitation in MS patients. Randomized controlled trial studying the effects of motor imagery showed significant improvement in walking speed, walking distance, perception and quality of living.
7. Cognitive Behavioral Therapy (CBT) ] has a moderately positive effect on fatigue in MS. However, this effect declines after cessation of treatment. To have good results, the patient should be referred to a CBT specialist. CBT can also be an effective intervention for reducing moderate depression, over a short term, in MS patients, which may also improve patient quality of life.
8. Gait rehabilitation forms a large part of neuro-rehabilitation for people living with MS. A systematic review published in Diagnostics describing the gait pattern in people with multiple sclerosis (MS) shows a decrease in speed stride and step length, increase in the step width, decrease in hip extension during the stance period, a reduction in knee flexion in the swing period, a decrease in ankle dorsiflexion in the initial contact and a decrease in ankle plantarflexion during the pre-swing phase; thus concluding that rehabilitation should focus on combating asymmetrical gait characteristics.

Aims in the progression of MS

1. During the early stages of MS (patients may present with minimal impairments) - focus on educating the patient and family members or caregivers on disease progression and compensatory strategies to conserve energy. Emphasize movement outdoors, especially in sunlight (direct benefits of sunlight in MS). Research suggests lifetime sun exposure appears to reduce the risk of Multiple Sclerosis regardless of race/ethnicity and indicates the protective effect of sun exposure in MS is most likely mediated through immunomodulatory mechanisms
2. In the moderate stage might notice impairments at varying degrees and activities of daily living (ADL) may require assistance. Therapy should focus more on improving or maintaining motor functions through strength, endurance, flexibility, balance, respiratory training and assistive device training as well as suggesting environment modifications to the home or assessing mobility aids required to move about in the community to sustain the quality of life. Education about correct postures is important to prevent further complications. A close collaboration between professional community carers and non-professional caregivers at home is a key factor for successful home rehabilitation.
3. Advanced stages of MS often present with multiple impairments at increasing severity compared to earlier stages. The primary goals of the PT in late stages are to maximize independence through postural and ADL training, respiratory function, safety and prevention strategies for contracture development or pressure wounds, equipment suggestions, and proper transfer techniques

Throughout all stages of MS, PT can offer psychological support to the patient and family/caregiver

General preventive measures

Here are certain problems seen in most patients with disability which are possible to anticipate and prevent

• Plantar flexed feet
• Predominant pattern of extension and adduction in lower extremities
• Knee flexion contracture
• Hip flexion Contracture
• Flexed thoracic spine
• Flexion and internal rotation at the shoulders
• Flexed head positions

PT Interventions for Common Symptoms of Patients with MS

In the 3-minute video below a PT advises on the PPMS treatment approach,

• Pain. Patients with MS often experience pain directly from the disease, secondary to medication or other symptoms, or from something completely separate. PT helps relieve pain through exercise, stretching, massage, ultrasound, postural training, or hydrotherapy.
• Sensory Deficits. Tapping and verbal cues during exercise and resistance training can help improve proprioception losses. Vision issues, such as blurred or double vision, often occur in patients with MS. PT can offer education on how to be safe at home and offer strategies to improve balance and coordination in dimly lit settings. PT treatment interventions for decreased sensation to light touch include education on awareness, protection, and personal care for desensitized body parts. Pressure-relieving devices are a primary prevention strategy along with proper transfer techniques and daily skin inspections for maintaining skin integrity.
• Fatigue. One of the most debilitating symptoms of MS is experienced by an overwhelming majority of patients: fatigue. PT strategies to help patients combat feelings of excessive tiredness include aerobic exercise, energy conservation, and activity pacing. Aerobic exercise activities are closely monitored by a PT to ensure a patient does not overheat but can work on increasing their endurance capacity which will help them be more functional throughout the day. PTs can also teach energy conservation strategies and activity pacing to help someone sustain their daily activities by minimizing fatigue.
• Spasticity. The physical and functional limitations spasticity leads to include a variety of impairments which can present as contractures, postural deformities, decubitus ulcers, and more. PT interventions range from cryotherapy and hydrotherapy to therapeutic exercise, stretching, range of motion activities, postural training, and electrical stimulation. A combination of therapeutic interventions is often the route taken.
• Balance, Coordination, & Postural Deficits. Ataxia, postural instability, muscle spasms, and generalized muscle weakness all contribute to balance and coordination deficits. PT techniques to address these issues include postural exercise, core strengthening, rhythmic stabilization, static/dynamic balance training, aquatic therapy, proprioceptive loading, and resistance training.
• Mobility Issues.  Weakness, particularly in the lower extremity, balance deficits, fatigue, posture, contractures, sensation deficits, heat intolerance, among other deficits, can impede an individual's ability to be mobile. In combination with the treatment previously described, PTs work to help patients overcome their mobility limitations through locomotor and functional training. Locomotor training focuses on increasing thigh and hip strength along with posture and balance training through walking activities. Orthotics and assistive devices are added as necessary. Functional training involves bed mobility, transfers, and developing strategies with the patient on how to be able to safely navigate around the home and out in the community.

Team Work

A study carrying out an online cross-sectional survey of physical therapists specialized in multiple sclerosis across Europe concluded that the content and delivery of physical therapy in Multiple Sclerosis differs across Europe and the guidance concerning access to treatment and adjustment according to disability do not appear to be widely implemented in clinical practice. Also. a recent online cross-sectional survey taken by Physical therapists specialized in Multiple Sclerosis, to study the real-world use of goal setting and outcome measures in Europe showed discrepancies in goal setting and assessment across European regions[.

Multiple sclerosis is a complex disease. In addition to sensory changes, weakness, and visual changes, coordination problems or spasticity can be seen. Other complaints related to general health include bladder and bowel dysfunction, cognitive impairment, depression, fatigue, sexual dysfunction, sleep problems, and vertigo. Because of the shortened life expectancy and multisystem involvement, the disorder is best managed by an interprofessional team that includes a neurologist, physical therapist, pain specialist, nurse specialist, ophthalmologist, mental health nurse, gastroenterologist and a urologist. Because there is no cure, it is vital to ensure that the patient's quality of life is not eroded. Social workers must be involved early in the care and the patient provided with all the possible supportive assistance.

Dietary Modification

Some preliminary research investigating inflammation-reducing diet which could help control chronic inflammation. Many researchers are exploring dietary intervention approaches in MS to improve lifestyle.

1. Probiotics may improve the health of people with MS by reducing disability and improving inflammatory and metabolic parameters according to an Iranian study.
2. Vitamin D supplementation may assist in the prevention and treatment of MS however existing evidence is of very low quality. Various research studies are studying the effectiveness of vitamin D therapy in MS. 
3. Fish oil supplementation given together with vitamins and dietary advice can improve clinical outcome in patients with newly diagnosed MS. More research is required to assess the effectiveness of dietary interventions of omega 3 in MS and its interaction with medications used for treating MS. Dysfunction of mitochondria is thought to play an important role in the mechanism of progression of demyelinating disorders. Observations in animal and histopathological studies suggest that dysfunctional mitochondria are important contributors to damage and loss of both axons and neurons. The relationship between mitochondrial dysfunction and neurodegeneration in MS is explored.
4. Ketogenic diet has the potential to treat the neurodegenerative component of progressive MS, though more research is required in this field.

Medical Management

Acute Relapse Management

Management works as immunosuppressants and anti-inflammatory drugs to reduce CNS swelling. There are numerous medications available to assist acute attacks, and disease progression, and to help manage symptoms.

• Prednisone:   Typically, a high dose of a corticosteroid, such as - methylprednisolone is the first line of treatment against an attack of MS. Corticosteroids help to reduce inflammation by suppressing the immune system, and when given intravenously can work quickly. Oral doses are often given as follow-up treatments during acute exacerbations. Side effects include sleep disturbance, headache, excessive sweating, or increased hair growth. Prolonged corticosteroid use can also lead to skin problems, oedema of the face or lower extremities, arthralgias, irregular menstruation, muscle cramps, and pain. Brand Name: Deltasone

• Plasmapheresis: As a supplemental or secondary treatment, plasmapheresis (plasma exchange) can be used in relapsing forms of MS to help control MS attacks [. During the plasmapheresis procedure, potentially harmful components of plasma are separated and removed from the blood, then replacement plasma and blood cells are returned to the body This method is thought to be useful as a secondary treatment option for severe relapsing forms of MS but is not recommended for PPMS or SPMS.

Disease-Modifying Agents

work to slow progress or reduce the number of MS attacks: They are most commonly used for decreasing relapses in patients with RRMS . Before initiating disease-modifying treatment, a complete diagnostic workup is crucial to help begin treatment at the appropriate time. Early intervention using disease-modifying drugs is most effective however the risks involved in prematurely starting treatment for MS if this is not the true diagnosis can cause an individual to become susceptible to the serious side effects of taking some of these drugs. The following disease-modifying drugs work to slow progress or reduce the number of MS attacks.

• Beta Interferons

• Glatiramer acetate - Injectable disease-modifying drugs that may help alter immune cells from attacking myelin.
• Mitoxantrone - an injectable drug given four times per year that suppresses immune functions thought to attack myelin. This drug is approved for treating SPMS, PRMS, and RRMS. Brand Name: Novantrone

• Natalizumab

• Fingolimod

Symptom Management

It is an integral component of helping patients with MS function in their daily lives. Numerous pharmacological agents can be used to relieve common symptoms of MS. e.g. Spasticity, Pain, Fatigue, Tremor, Cognitive & Emotional Impairments, and Bowel & Bladder Impairments.