Change Your World Week Fall 2021 (Archived)

Multiple Sclerosis (MS) is a main reason for disability in young adults affected with the disease. The name "multiple sclerosis" describes the disease very well. As MS attacks the body, sclerotic plaques build up throughout the central nervous system. Additionally, one of the protective layers of our nerves (myelin) is broken down which causes nerve conduction to be slower. MS is a chronic and progressive illness and is more prevalent in women compared to men, the onset age is usually in the person's 20's. There are lesions presenting on the person's spinal cord, these lesions occlude neural transmission, causing loss of senses, weakness, visual disturbances, and other symptoms. 

There are four different types of MS, being categorized into "Progressive + Relapsing", "Secondary + Progressive", "Primary + Progressive", and "Relapsing + Remitting". 

1. Relapsing and Remitting MS is described by relapses or "attacks", which are periods of dysfunction lasting anywhere from days to months and and followed up by a full or partial recovery. This is the most common pattern occurring in 85% of of newly diagnosed people. 

2. Primary and Progressive  MS is a steady decline in neurologic function. The most common manifestation of Primary Progressive is myelopathy, a gradual progression of weakening or wasting of muscles. This type of MS is usually seen in patients with an onset age above 40 years old. 

3. Secondary Progressive MS is when the beginning of the MS symptoms occur like the relapse and remitting but gradually turns into the progressive pattern in over 50% of individuals. The conversion commonly happens between 5-10 years after initial onset. 

4. Progressive and Relapsing MS is a progressive disease from onset of symptoms with clear exacerbation. This type of MS is the most rare. 

Signs and symptoms will vary depending on the progression and how much relapsing or remitting there is and can come and go.  Each person's Central Nervous System (CNS) has individualized thresholds (how well the CNS will adapt to the lesions) that determine how severe the signs and symptoms are. Some will have permanent disability while others may be asymptomatic.

The first sign most will have is optic neuritis, which affects the optic nerve and can cause pain, decreased visual field, double vision, loss of color vision, reduced clarity, or complete loss of vision. In addition, sensory changes are often one of the first signs which can result in numbness, tingling, edema and decreases sensitivity in the arms or legs. Most of these symptoms are often not reported until they have issues with moving or getting through the day.

 There are many disabling symptoms that can be seen with MS. Almost 90% of individuals with MS have fatigue that is most present in the midafternoon. Spasticity, which is stiffness in a joint, affects a significant amount of individuals and can be associated with spasms particularly at night which affects sleep. Weakness and balance can be present as well. Weakness can be influenced by the temperature so if it's hot, the individual may feel more weak than when it's cold. Signs in the face include facial spasms or weakness causing speech impairments, poor muscle control, coughing, weakened voice, or dysphagia (swallowing difficulties). In addition, motor control can be diminished in the eyes causing gaze palsies (difficulty looking around) or even gaze paralysis. Vertigo is also a common symptom and result in gait unsteadiness and vomiting. Coordination and balance can be affected as well and can be presented with tremors and can affect one side of the body or both in which posture and movement can be affected. Pain is present in 50% of MS individuals and is described as burning without relief and is worst at night.

Because the lesions develop in the brain, there is chemical and physical changes that cause depression or cognitive impairments. In some cases, there may be a loss of bladder or bowel control which is caused by the bladder's ability to store urine. Because MS affects each person differently due to the progression and uniqueness, there may be other signs and symptoms present. 

The treatment of MS can be split into two different categories, disease modifying therapies and symptomatic therapies. Disease Modifying therapies tend to be more specified to MS and the symptomatic therapies are used to treat the symptoms that MS produces. 

The number of disease modifying therapies has increased, interest in early treatment of MS in order to prevent long-term  disability has grown. In history, MS treatments include immunosuppressants such as fingolimod or ocrelizumab, and immunomodulatory such as interferon beta and glatiramer acetate. This treatment is necessary for suppression of inflammation and disease activity. The closest cure there is a to a cure for MS is immune reconstitution therapies such as cladribine, this can only be given in short courses with the goal of producing enduring immunological actions. 

Symptomatic treatments refer to the pharmaceuticals and physicals therapies that target active symptoms as a result of central nervous system (CNS) damage. These are the treatments that are not MS specific. These treatments include medication for neuropathy and other neurological derived conditions. These medications include antidepressants and nerve pain medications such as gabapentin. Treating the cognitive impairments for people with MS is extremely complex and focuses on avoidance of stressors. Other symptomatic therapies have been licensed specifically for MS such as Sativex for spasticity and fampridine for gait difficulty.  People diagnosed with MS have difficulty sleeping and increased difficulty as the disease progresses. Anxiety, depression, and fatigue are more common in those reporting poor sleep patterns.

Comorbidities such as vascular disease and smoking have a worsened outcome along with rapid progression of the disease. Recurring infections like UTI's may not only cause worsened MS symptoms but may also speed up the progression of MS.  

Evidence supporting lifestyle and wellness modifications in MS is weak, but general health is important. Exercise is medicine! Patients who exercise do better than those who do not. Patients should be encouraged to participate in 4-5 aerobic exercise sessions a week. But, individuals with MS should avoid strenuous exercise during relapse, as it may result in excessive demands on an already compromised individual. As for diet is concerned no diet is better than another but person's with MS should avoid processed foods.

 On average people with MS have one attack per year, varying in severity. Frequent attacks tend to occur with people who are in the early years of MS, attacks tend to slow down in later years. MRIs, or scans of the brain, are the best indicators for clinical outcomes. Because disability is common in individuals with MS, lifestyle changes are often necessary. Movement impairment is commonly associated with MS, and difficulty walking is a major disability. If MS is untreated, 15 years after diagnosis 50% of individuals with MS will need to use an assistive device to walk, such as a cane, walker, crutches etc. After 20 years approximately  50% of people will be wheelchair-bound.  About 1/4 of persons with MS will require human assistance with ADLs eventually. There is evidence that exercise can improve fitness and function for those with mild MS and exercise  helps maintain function for those with moderate to severe MS. Different forms of exercise have been investigated and for most people with MS, aerobic exercise that incorporates balance training and socialization is more effective. Time constraints, access, impairment level, personal preferences, motivation, and funding sources influence the prescription for exercise and other components of rehab. Life expectancy is reduced by a significant amount with MS. The risk of dying because of MS is strongly associated with disability. The death rate of people who are unable to stand or walk is 4x higher than able bodied individuals. As for  mildly disabled individuals, the death rate is approximately 1.5 times higher than that of age matched peers. Suicide is more than 7x more common than people without MS. Depression must be treated aggressively.

Because MS is a progressive disease, the main goal of physical therapy is to alleviate the symptoms and slow the progression. It can be beneficial in all stages of the disease from the first onset of symptoms to highly advanced stages. Physical therapy can also prevent spasticity and paresis which are commonly a consequence of the progression. An individual with MS can expect to perform resistance exercises, gait training (walking mechanics), aerobic endurance training or aquatic therapy during physical therapy. 

Individuals with MS have heat intolerance, so vigorous activity is limited or eliminated to not asperate that symptom and problems associated with high temperature.

Treatment for Symptoms: 

Fatigue, which affects 75-90% of individuals with MS is a major focus with physical therapy because it can limit physical activity and social life and thus quality of life decreases.  It is recommended to do therapy in the morning when most energized as fatigue increases throughout the day and should not be overexerting to the individual. Group therapy, energy conservation, and aerobic exercises can reduce fatigue. 

Spasticity affects 90% of individuals with MS which can cause decreased range of motion (ROM), joint pain, and general movement patterns. Physical therapy will focus on active and passive ROM, physiotherapeutic techniques, and proprioceptive neuromuscular facilitation (PNF). 

60-70% of individuals with MS will have mood disruptions and 45-70% will have cognitive deficits. Aerobic exercise and regular exercise has been shown to improve the symptoms related to mood and cognition. However, there is not much research available for specific physical therapy techniques that are shown to improve these effects. 

Paresis / paralysis are not as common symptoms, but can be detrimental to walking and fine motor function. Physical therapy will use a variety of techniques to prevent numbness, tingling, or loss of movement in the body, especially the hands and feet.  Aquatic therapy is very beneficial due to the reduced impact of gravity on the body. Also passive ROM exercises is beneficial for immobilized individuals. 

Aerobic and Resistance:

Aerobic endurance training includes treadmill walking or cycle ergometer for legs and/or arms and has been shown to improve fatigue as mentioned above as well as walking, coordination, aerobic capacity and quality of life - especially mood, vitality, and energy. 

 Progressive resistance training is beneficial for increase muscle strength. They Those with MS are shown to specifically gain strength in their arm and leg endurance which can improve gait and speed, stair climbing,, fatigue, mentality (decreased depression and fear of falling).In addition, balance training is a part of resistance and the therapist will have the patient on weight bearing, weight shifting, and body positioning which not only increases balance, but also posture and walking. 

Dobson, R., and G. Giovannoni. “Multiple Sclerosis – A Review.” Wiley Online Library, John Wiley & Sons, Ltd, 18 Nov. 2018, https://onlinelibrary.wiley.com/doi/full/10.1111/ene.13819.

Doring, A., Pfueller, C., Friedemann, P., and Dorr, J. " Exercise in Multiple Sclerosis - An Integral Component of Disease Management. EPMA Journal. 2012. https://link.springer.com/content/pdf/10.1007/s13167-011-0136-4.pdf

Marshall, Charlene. “Chapter 20, Section 4.” Pathology for the Physical Therapist Assistant, Saunders, Philadelphia, PA, 2017, pp. 650–657.