Rehab Management of Multiple Sclerosis: What You Need to Know · Chapter 1 Pathophysiology and...

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Rehab Management of Multiple Sclerosis: What You Need to Know

Herb Karpatkin, PT, DSc, NCS, MSCS


• Financial– None

• Nonfinancial– None

Disclosures


• Recognize how the distinct pathology of multiple sclerosis results in its unique clinical presentation

• Describe the impact of specific medical management on therapy practice in persons with multiple sclerosis

• Analyze the findings of a physical therapy examination for a person with multiple sclerosis, to attain an accurate picture of the patient’s specific mobility deficits

• Design a treatment plan for a patient with multiple sclerosis that addresses the unique set of impairments found on the evaluation

Learning Objectives


True or False: Progression of disability in MS is due entirely to disease activity:

A. TrueB. False

Poll Question


Which test would be the best to measure objective fatigability in MS?

A. 25-foot walk test B. 6-Minute walk test C. Manual muscle test

Poll Question


The primary problem affecting the mobility of all persons with MS is:

A. WeaknessB. Sensory lossC. Spasticity D. Fatigue

Poll Question


Chapter 1Pathophysiology and Medical Management


• Chronic• CNS

• Variability/heterogeneity• Demyelinating• Autoimmune

• Inflammatory

Multiple Sclerosis Defined


• Lasts a lifetime• Progresses over a lifetime

• PT needs change over a lifetime

Multiple Sclerosis: Chronic Disease


• Any CNS structure can be affected• Any CNS symptom is therefore possible

Multiple Sclerosis: Disease of the CNS


• Any area on the CNS, any intensity, any time frame• No stereotypical presentation

• “If you’ve met one person with MS, you’ve met one person with MS”

Disease of Heterogeneity


• Variable intensity• Variable location

• Variable presentation• Variable prognosis

Heterogeneity and Variability


• Loss of covering over CNS axons• Slowing and stopping of saltatory conduction through

an axon• Remyelination occurs following demyelination, but with

less efficiency, resulting in slowing and diminishing of saltatory conduction

Demyelination


Demyelination

• With disease progression, there is increasing loss of myelin

• Eventually, the underlying axon is destroyed, and myelin is replaced by fibrous scarring called gliosis, which inhibits transmission of impulses


• Myelin-producing cells in the CNS• Also destroyed in MS, resulting in inability to remyelinate

Oligodendrocytes


• Their survival is one of the factors behind remyelination and recovery in early attacks

• In later stages of the disease, no oligodendrocytes are preserved, and remyelination occurs only at the borders of the plaques, if at all

Oligodendrocytes (cont.)


• Semipermeable layer of cells within the capillaries of the central nervous system

• Allows oxygen and essential nutrients to enter the central nervous system

• When functioning normally, prevents foreign invaders (immune cells) from passing out of the bloodstream and into the central nervous system

Blood–Brain Barrier (BBB)


• In MS, immune cells pass through the BBB leading to compromise or damage

• Immune cells (T-lymphocytes) attack the myelin in the brain and spinal cord, incorrectly recognizing it as an invading virus, causing the lesions which lead to MS symptoms

• Triggers inflammatory processes, stimulating other immune cells (cytokines, antibodies, macrophages)

• Much of the damage in MS occurs due to inflammation, and therefore can be limited by controlling it

Blood–Brain Barrier in MS


Blood–Brain Barrier Pathology in MS


MRI: Diffuse Cortical Lesion


MRI Spinal Lesions


• Female more than male 2:1• Uncommonly diagnosed before adolescence

• Most commonly diagnosed at 30–35 years old, and uncommon after 60, but the disease can be very mild until 60, then require medical intervention

Prevalence/Incidence/Epidemiology


• High-risk areas– Northern US, Northern Europe, Southern Canada, New

Zealand, Southern Australia

• Medium-risk areas– Southern US and Europe, Northern Australia

• Low-risk areas– Africa, Asia

Geographical Pattern of Prevalence


• Interaction between environmental and infectious inciting factors and a genetically susceptible host

• Risk of developing MS is greater if you have a sibling with MS, greater risk for female sibling vs. male sibling

Etiology


• Previously required a very accurate history that might reveal vague complaints that had gone on for years without being diagnosed

• Recent use of MRI, CSF analysis, and strict criteria has led to earlier diagnosis, earlier treatment, and less disability

Diagnosis


• Clinical evidence of two spatially and temporally distinct attacks

and• Laboratory evidence of two or more distinct lesions on

MRI, CSF, or EPand

• Exclusion of other, better explanations for the clinical features

• Probable MS: less clinical or laboratory evidence

Diagnosis: McDonald Criteria; Definite MS VS Probable MS


• Spatial distinction: symptoms must be in two different regions of the body (e.g., LE spasticity and ON)

• Temporal distinction: symptoms must be at least six months apart

Spatial and Temporal Distinction


• Multiple foci in brain and/or cord• Gadolinium-enhanced T1-weighted scans show

inflammation, indicative of new lesions• T2-weighted scans show older, inactive lesions and

number and size of lesions• 5% false negatives on MRI

MRI


MRI: Diffuse Cortical Lesion


• Elevated IgG antibodies• Oligoclonal bands

• Rule out other non-MS causes• Differentiate between RR and other types?

Cerebrospinal Fluid Analysis (CSF)


• Measures electrical activity of the brain in response to stimulation of specific sensory nerve pathways

• Can detect slowing of electrical conduction caused by demyelination if change is too subtle to be noted by the patient or on neurologic examination

• MS diagnosis requires evidence of demyelination in two distinct areas of the CNS; EP testing can help confirm

• Visual EP most commonly used due to prevalence of optic neuritis as an early symptom

Evoked Potentials


• First neurologic episode that lasts at least 24 hours and is caused by inflammation/demyelination in one or more sites in the central nervous system (CNS)

• The episode can be monofocal or multifocal• To treat or not to treat?

Clinically Isolated Syndrome (CIS)


• Definitions: attack (exacerbation, relapse) • An episode of neurological disturbance of the kind seen

in MS• Should last for at least 24 hours• Event should not be a pseudoattack, such as might be

caused by a change in core body temperature or infection

McDonald Criteria


• Exacerbation: acute demyelinating event• Pseudoexacerbation: acute but transient worsening of

symptoms brought on by fatigue, temperature rise, stress, etc.

• Not demyelinating• Pseudoexacerbations can be caused by excessive

exercise, but exercise does not cause exacerbations

Exacerbations vs. Pseudoexacerbations


• Disease-modifying therapy (DMT)• Exacerbation management

• Symptom management• PT implications of medical management

Medical Management


• Earlier diagnosis• Earlier treatment

• Decreased lesion load• More effective rehab

Medical Management in MS: Implications for Rehab


• Disease-modifying therapy: CRAB drugs (Copaxone, Rebif, Avonex, Betaseron), Tysabri

• Newer/second-order drugs: Rituxan, Ocrevus, mitoxantrone, methotrexate, IVIG

• Exacerbation treatment: steroids• Symptomatic treatment

Medical Management


• Beta interferons: Avonex, Betaseron, Rebif• Heals the BBB by preventing immune cells from

entering CNS• Efficacy: reduced relapse frequency and intensity in

RRMS by 1/3 • Side effects: flu-like symptoms one to two days after

injection• Limitation: not effective in progressive disease; by

lowering immune response, increases likelihood of infections

Disease-Modifying Therapy


• Copaxone (glatiramer acetate)• Limits inflammatory properties of immune cells that

cross the BBB• Efficacy: equally as effective as beta-interferons• Side effects: no flu-like symptoms, but daily vs. weekly

injections• Limitations: not effective in progressive disease

Disease-Modifying Therapy (cont.)


• Tysabri (natalizumab)• Blocks passage of inflammatory cells across the blood–

brain barrier• Efficacy: twice as effective as CRAB drugs in RRMS• Administration: monthly infusion

• Limitations: progressive multifocal leukoencephalopathy (PML)

Disease-Modifying Therapy (cont.)


• Rare but fatal inflammation of white matter in the brain• JC virus, normally suppressed, becomes activated

during immunosuppression• JC virus can be tested for via LP or brain biopsy

Progressive Multifocal Leukoencephalopathy (PML)


• Mitoxantrone (Novantrone): suppresses immune function, injection every three months, some effectiveness in SPMS, cardiac side effects

• IT methotrexate: may be effective in PPMS and SPMS• IVIG: mixed success in progressive MS

Disease-Modifying Therapy: Second-Order Drugs


• Suppresses the immune system• Targets and depletes B-cells from the blood

• Given by infusion every 6–12 months• Well tolerated and effective

Rituximab (Rituxan)


• Treatment of RR and progressive disease• Given by infusion

• Multiple side effects and infusion reactions

Ocrelizumab (Ocrevus)


• Dimethyl fumarate (Tecfidera)• Fingolimod (Gilenya)

• Teriflunomide (Aubagio)• No complications associated with injections/infusions• Possible contraindications for patients with dysphagia

Oral DMTs


• Methylprednisolone (Solu-Medrol)• Limits the inflammatory process of an acute attack

• Stabilizes the BBB• Limits immune response• Occasionally used as a monthly pulse for progressive

disease• Energizing effect

Steroids


• LT use leads to osteoporosis, wound healing difficulties• Steroid psychosis

• Less effective in progressive disease• Decreased effectiveness over time• Immediate effect which does not persist

Steroids: Limitations


• Baclofen (Lioresal) oral and intrathecal• Tizanidine (Zanaflex)

• Dantrolene sodium (Dantrium)• Sedation/specificity

Symptomatic Treatment: Spasticity


• Intrathecal baclofen for spasticity refractory to oral medication

• Requires neurosurgical procedure• Excessive spasticity control can limit movement;

requires dialogue with MD

Spasticity


• Dalfampridine (Ampyra)– Potassium channel blocker– Improves CNS transmission, motor fatigue– Seizure risk

• Modafinil (Provigil)– Antinarcoleptic– Global/mental fatigue

Symptomatic Treatment: Fatigue


• MS is a disease of tremendous variability• Any CNS structure can be affected, so almost any type

of sign or symptom can be seen• Medical management can address both the direct

neuropathology and the symptoms

Chapter 1 Summary


Chapter 2Evaluation and Assessment


• MS phenotypes• Global measurement: the EDSS

• Primary vs. secondary findings• The impact of fatigue• Evaluation of specific mobility-related deficits

Chapter 2 Objectives


• Relapsing-remitting• Relapsing-progressive

• Chronic progressive (primary progressive)• Secondary progressive• Benign

• Fulminant

Types of MS Describe Behavior but Not Severity


Relapsing-Remitting MS

• Episodes of rapid, abrupt deterioration with variable degrees of recovery over time

• Also known as exacerbating-remitting

https://www.mstrust.org.uk/about-ms/what-ms/types-ms#relapsing-remitting-ms


Relapsing-Remitting MS (cont.)

Three months laterRelapse


Relapsing-Progressive MS

• Progressive worsening with occasional relapses

• Also known as exacerbating-progressive

• Least common form

https://mswa.org.au/living-well/learning-about-conditions/multiple-sclerosis/types-of-ms


Primary Progressive/Chronic Progressive

• Steady progressive deterioration

• Pace of deterioration can vary

• Occasional plateaus

https://www.mstrust.org.uk/about-ms/what-ms/types-ms#primary-progressive-ms


Secondary Progressive

Begins as relapsing-remitting, then becomes progressive

https://www.mstrust.org.uk/about-ms/what-ms/types-ms#secondary-progressive-ms


Occasional symptoms without significant functional impairment

Benign


• Rapidly progressive• Leads to early, severe disability and death

Fulminant (Marburg Syndrome)


• Most medications only address RR• Progressive has a faster time to disability

MS Phenotypes


• Best known and most widely used scale for quantifying MS disability

• Ordinal rating scale from 0 (normal neurologic exam) through 10 (death from MS) in half-point increments

• Quantifies disability in eight functional systems (FS) and assigns a functional system score (FSS) in each of these

• Functional systems: pyramidal, cerebellar, brainstem, sensory, bowel and bladder, visual function, cerebral function, and other

Measurement of Disease Severity: The Expanded Disability Status Scale (EDSS)


• Steps 1.0–4.5 refer to people with MS who are fully ambulatory; scored based on disability to the functional system

• Steps 5.0–9.5 are defined by the impairment to ambulation

EDSS


• 0–3.5 mild disability: ambulatory without AD• 4–6.5 moderate disability: ambulatory with AD

• 7–9.5 severe disability: minimal ambulation, wheelchair or bedbound

• PT interventions at all levels

• Criticized for excessive emphasis on ambulation, insensitivity to nonambulatory clinical change

EDSS (cont.)


Depends on many factors, including– Type of disease (RR vs. progressive) – Structures affected by disease (cord, cortex, brainstem

etc.) – Years since diagnosis– Age at diagnosis– Use of DMTs– Presence/absence of comorbidities– Physical activity– Positive and negative lifestyle factors

How Does MS Present?


• Much of the disability that is seen in MS may not be due to the disease itself but due to compensations or adaptations to the disease

• Much of the disability is due to disuse, deconditioning, lack of practice

• Much of the disability may be “learned”

• It is therefore much easier to remediate• Secondary findings remediate quickly with intervention

Primary vs. Secondary Findings


• Primary loss: cannot walk due to CNS findings• Secondary loss: cannot walk due to progressively

decreasing lack of practice of walking

Primary vs. Secondary Findings (cont.)


• No stereotypical presentation• Few “rules of treatment”

• Primary and secondary findings will both be present

Variability of Findings


• Most common MS symptom• Tremendous impact on function

• Can worsen impact of impairments• Objective and subjective components• Primary and secondary components

Fatigue


• Objective: fatigability, worsening of motor performance over time– Related to decrease in action potential traveling through

a demyelinated nerve

• Subjective: fatigue, feeling tired, lethargy, lassitude, depression, overwhelmed, sleepiness– Not correlated

Objective vs. Subjective


• Primary: due to a specific pathology of the disease• Secondary: due to an adaptation, compensation, or

lifestyle choice that occurs as a result of the disease• Deconditioning

Primary vs. Secondary Fatigue


Interaction of Primary and Secondary Fatigue/Fatigability

• Less movement is performed, deconditioning results, and tasks become “unlearned”

• Where can clinicians intervene in this cycle?


6-Minute Walk Test: Fatigability


• Shorter evaluations (25FWT, TUG) will not show deficits• Longer tests are needed to uncover the impact of

fatigue• Suggests that patients with MS give different evaluative

findings when assessed unfatigued vs. fatigued

Effect of Fatigue on Gait Evaluation in MS


What percentage of people with MS experience limitations in their walking ability?

A Patient Survey of Mobility and Exercise Issues Among MS Patients [Harris Poll]. Poll commissioned by: Acorda Therapeutics, Inc., and the MS Association of America. February 21, 2008.

Almost Nine Out of Ten People With MS Experience Some Limitation in Walking


• Falls are a common source of morbidity and mortality in MS

• Balance evaluations should identify falls risk• Is there an impact of fatigue on balance in MS?

Effect of Fatigue on Balance Testing in MS


BBS Scores: Fatigued vs. Nonfatigued

• Persons with MS performed Berg Balance Scale two times under two conditions

• Condition 1: interspersed with 6-minute rest

• Condition 2: interspersed with 6-minute walk

• Result: increased falls risk when fatigued

• To determine falls risk, test fatigued and unfatigued


• Loss of balance can also be secondary• Lack of practice of situations that challenge balance

• Avoidance of situations that challenge balance• Balance progressively worsens as a result of primary

MS damage and secondary lack of practice

Balance Evaluation in MS


Strength Testing in MS

• MMT may misrepresent strength

• Patient may appear to have normal strength initially but fatigue with repeated repetitions


• Sensory loss is common in MS• Worsens with fatigue—test before and after 6MWT to

assess impact of fatigue• Sensory loss may be due to disuse

Sensory Testing in MS (cont.)


• Lesions in the cerebellum or pons• Higher incidence of BPPV

• Vestibular findings worsen with fatigue

Vestibular Findings in MS


Central vs. Peripheral Vestibulopathy

Central– Direction-changing

nystagmus– Rotatory or linear

components– Can be separate from

vertigo– Unable to suppress

with fixation

Peripheral– Unidirectional

nystagmus– Rotary and linear

components– Matches with vertigo– Suppresses with

fixation


Changes in respiration can occur due to– Demyelination of central respiratory tracts– Deconditioning due to sedentary lifestyle– Contractures of respiratory muscles due to prolonged

positioning – Decreased space for gas exchange in thoracic category

Respiration


• Weak ineffective cough• Diminished oxygenation to muscles

• Contributes to fatigue• Vicious cycle of deconditioning and respiratory

insufficiency

• Mortality in MS frequently due to respiratory compromise

Respiration (cont.)


Range of Motion

ROM loss in MS is multifactorial

– Common finding due to spasticity, lack of antagonist strength, prolonged positioning

– Common areas: plantar flexors, hip flexors, hamstrings, trunk flexors (prolonged sitting postures)

– Vicious circle of inactivity and decreased range


Range of Motion Deficits in MS

Foot drop– Due to tightness of

plantar flexors, weakness of dorsiflexors

– Common reason for falls in MS

– Impact may only be evident when fatigued


Foot Drop in MS

Quick assessment– Patient supine– Max dorsiflexion AROM– Should be fairly equal– Lower side more at risk

for developing foot drop


• ROM loss in MS is primary and secondary• Primary: spasticity, weakness of antagonists

• Secondary: prolonged positioning, inactivity

Assessing for Flexibility Deficits in MS


• How do the range-of-motion limitations impact function?• Are they primary or secondary (due to disuse)?

• Test when fatigued and unfatigued

ROM Assessment in MS


• Deficits seen in MS are multifactorial and multidimensional

• Evaluate when fatigued and unfatigued• Assume that part of the deficit is secondary and

therefore more remediable• How does this lead into treatment planning?

Evaluation of MS Mobility Deficits


• Multiple ways of classifying MS: each provides specific useful information

• MS is not stereotypic, but fatigue is a pervasive symptom, and its impact on the disease needs to be understood for effective treatment to occur

• Much of the disability that is seen in MS is secondary and therefore very amenable to remediation

Chapter 2 Summary


Chapter 3Intervention Strategies and Case Examples


• Overarching principles • Specific remediation

• Case examples

Chapter 3 Objectives


• Neurologic disease of tremendous variability• No stereotypic presentation

• Intervention strategies that might be appropriate for other neurologic diagnoses might not be appropriate for MS

Intervention Strategies in MS


• Thermosensitivity: worsening of physical performance when the temperature of the person increases

• Temperature rise can be extrinsic (warm room, hot weather)

• Temperature rise can be intrinsic • Exercise causes increased core temperature

Fundamental Problem of Rehab Therapy and MS: Thermosensitivity


• Exercise is needed to address mobility impairments in MS

• Exercise causes rise in core temperature• Rise in core temperature slows conduction through

demyelinated nerves

Fundamental Problem of Rehab Therapy and MS: Thermosensitivity (cont.)


• For improvements to occur as a result of exercise, a certain volume or dosage has to occur

• Due to thermosensitivity, that dosage cannot be attained

• What can clinicians do?

Fundamental Problem of Rehab Therapy and MS: Thermosensitivity (cont.)


• Use of cooling garments• Worn before activity to “precool” the core

• Takes longer time for core to reach temperature that limits activity

• Greater volume of exercise

Cooling Therapy


• Persons with MS walked for 6 minutes in two conditions– Condition 1: wearing cooling vest for 30 minutes before

walk– Condition 2: without cooling vest for 30 minutes prior to

walk

• Distance in cooled condition: 835′ • Distance in uncooled condition: 784′• p = .001

Effect of Cooling on 6-Minute Walk Test Performance in Persons With MS


• Cooling increases the time for the core to increase temperature

• Decreasing core temperature increases time spent exercising, increases time to onset of fatigue

• What else can be done to lower core temp and increase time to fatigue

How Else to Solve the “Dosage” Problem?


• AKA interval training, fractionated training• Intersperse periods of exercise with periods of rest

• Allows core temperature to lower during rest breaks• Allows for greater dosage of exercise

Intermittent Training


• Consider two persons with identical MS• One is asked to walk as far as he can without stopping

• The other is asked to walk for 2 minutes, rest for 2 minutes for as long as he can

• The one who rests will walk a longer distance

Consider


• Subjects asked to walk under two conditions• Condition 1: walking 6 minutes continuously

• Condition 1: walking 6 minutes, interspersing 2 minutes of walking with 2 minutes of rest

Intermittent Walking


Greater Distance: Continuous vs. Intermittent 6-Minute Walk

• Distance decreases when walks are continuous

• Distance increases, then stabilizes, when walks are intermittent

• Continuous distance: 998′

• Intermittent distance: 1126′

Karpatkin et al, 2014


• Allows for more distance walked• Breaks allow core temperature to dissipate

• During breaks, patients can work on nonfatiguingexercises (e.g., ROM)

Intermittent Walking


• Use standardized tests• Berg Balance Scale (BBS) for static balance

• Dynamic Gait Index (DGI) for walking balance• Mini-BESTest (MBT) for both • MBT better for lower levels of disability; BBS better for

higher• Test fatigued and unfatigued

Balance Interventions in MS


• The limitation on the test informs you of what you need to practice– Example: LOB with eyes closed? Practice balance with

eyes closed.

• Limitations are due to primary impairments and secondary complications

• CNS damage plus lack of practice: LOB and falls

Standardized Tests for Balance in MS


• Practicing too hard leads to insufficient dosage of exercise due to fatigue

• Greater volume of practice if breaks are taken• Greater volume of practice if patient is cooled prior to

the practice or during the breaks

How Hard to Practice?


• Connection between impairments (e.g., ROM, strength) and balance loss– Example: Is patient losing balance because of “tripping

over their foot”?

• Examine the ankle– Tight plantar flexors? Stretch!– Weak dorsiflexors? Strengthen!

Impact of Impairments


• Strength loss can be primary or secondary in MS• Primary: due to CNS damage

• Secondary: due to disuse• The problem: how to train at sufficient dosage to make

a meaningful improvement?

Strength Training in MS


• Taking breaks limits effects of fatigue• Consider: 10 sets of 3 versus 3 sets of 10

• Greater volume of strength training can occur if breaks are taken

Intermittent Strengthening


Intermittent vs. Continuous Motor Performance

• Straight-leg raises (SLRs) performed to fatigue continuously vs. intermittently

• Continuous: 1 SLR every 3 seconds

• Intermittent: 2 consecutive SLRs with 5-second recovery

• Continuous performance: 31• Intermittent performance: 114


Strength Training: How Hard?

• Lower loads customarily used, presumably to limit fatigue

• Higher loads thought to lead to greater CNS activation

• Can persons with MS tolerate and benefit from higher loads?

• Hunter study: maximal strength training in MS

• 85%–90% of 1RM for unilateral leg press

• Intervention: 4 sets, 4 reps, 2 times per week, with 60- to 120-second recovery between sets, for 8 weeks

• Outcome measures: LE strength, BBS, 6MWT


Maximal Strength Training in MS

Berg Balance Scale– Pretest (M = 44.29,

SD = 8.34)– Posttest (M = 49.57,

SD =5.83) – p = .008

6-Minute Walk Test– Pretest (M = 1040.04,

SD = 429.3) – Posttest (M = 1190.7,

SD = 579.9)– p = .045

No dropouts, no injuries, no increased complaints of fatigue


• Loss of flexibility in MS: primary and secondary• Primary: spasticity, weakness of antagonist

• Secondary: prolonged positioning

Flexibility Training in MS


• Consider: patient with foot drop• PROM dorsiflexion 0–10

• Minimal ambulation• In sitting or supine, foot is always mildly plantar flexed• If patient stretched for 30 seconds, 2–3 times a day

– Time in plantar flexion: 23 hours, 58 minutes, 30 seconds– Time in dorsiflexion: 1 minute, 30 seconds

• Who’s winning?

Stretch: How Much?


Flexibility Training in MS: The Volume Problem

• Night splint• Prolonged passive

positioning• Can be worn for hours at

a time


• Stretching is not enough• Combine with strengthening the antagonist

• Combine with functional use • Pragmatic training: stretch plantar flexors, strengthen

dorsiflexors, practice gait with heel strike

Flexibility Training in MS


• Prolonged phonation• Postural stretching to increase space in thoracic cavity

for air exchange• Respiratory muscle training: the Breather

– https://www.pnmedical.com/product/the-breather/

Respiratory Training


• AFO: limits range, limits activation of weakened muscle• Worsens the problem it is intended to correct

• If decreased PROM of joint is due to secondary disuse, consider exercise prior to bracing

A Word About Splinting


• EDSS 0–3.5• Often not referred to PT for MS

• First encounter may be for orthopedic reason

Case: Mild MS


• Physical findings and mobility issues may not turn up on standard eval

• Test fatigued and unfatigued• Monitor for change in activity profile since diagnosis

Case: Mild MS (cont.)


• 30-year-old man diagnosed with MS two years ago• Reports no symptoms

• Daily runner, tried to increase his mileage• Fell at end of longest run, injured shoulder• Referred to PT for shoulder pain




Unfatigued– Exam: PROM, AROM,

MMT, sensation all normal. No neuro signs.

– BBS: 56/56– 25-Foot Walk Test: 4.1

seconds, no gait deviations

– Scuff marks on toes of right shoe

– Had patient run on treadmill for 2 miles then repeated tests

Fatigued– Increased tightness in

right plantar flexors– Right dorsiflexors 4/5– Diminished sensation

right foot– Right Achilles reflex 3+,

three beats of clonus– BBS: 53/56; difficulty with

tandem stance, single-limb stance


Interventions– Intermittent running to improve running endurance– Stretching Achilles during breaks– Using precooling in warmer weather– Education

• Keep activity high! Avoid sedentarism! Prevention!



• EDSS 4.0–6.5• Often first point of contact with rehab

• Deficits have been present for some time

Case: Moderate MS


• 40-year-old man diagnosed with RRMS ten years ago• Works FT at a sedentary position, has wife and young

children• Ambulates three to four blocks with straight cane• Exercise: walks partway to and from work each day,

quite exhausted when he gets there• CO occasional falls late in the day

Case: Moderate MS (cont.)


Evaluation findings– Right-sided foot drop in gait; compensates with

contralateral vaulting, circumduction– BBS: 48/56; difficulty with single-limb stance, tandem

stance, step-ups, narrow base of support, eyes closed– 6-Minute Walk Test: 750 feet (450 feet in the first three

minutes, 300 in last three)– Last three minutes multiple near falls due to toe catching,

right Trendelenburg



• PROM: right ankle 0–10, SLR 25 degrees• Posture: forward head, thoracic kyphosis, PPT

• Sensation: severely diminished distal RLE • MMT: right ankle dorsiflexion 2/5, knee flexion 3−/5, hip

flexion 3−/5, abduction 3−/5

• Positive right Babinski, RLE reflexes 3+



Case: Moderate MS—Interventions

• Foot drop: night splint to tolerance, AROM dorsiflexion, practice gait with heel strike

• Strength: RLE; 3–4 reps hip abduction, hip flexion, knee flexion, with long recoveries, slowed eccentric phase

• Balance: practice of tasks identified on the BBS

• Gait: intermittent walking, one block followed by a 1-to 2-minute recovery, repeat to tolerance 3–4 times a day

• Posture: practice standing and sitting with scapular retraction, decreased thoracic kyphosis

• Out of chair very hour to stretch


• A change in priorities• Prevent complications, morbidity, and mortality

• Training of caregivers• Equipment

Case: Severe MS


• 60-year-old man with EDSS 8.0, diagnosed 30 years ago

• In wheelchair or bed 24 hours• HHA 12 hours a day• Dependent for all transfers and bed mobility

• Recent HO pneumonia, skin breakdown

Case: Severe MS (cont.)


Interventions– Respiratory training: DBE, ACB, incentive spirometry,

respiratory muscle training– Is mobility dependence primary or secondary? How can

he contribute?– Caregiver training: daily PROM– Equipment: wheelchair cushion? Motorized or manual

wheelchair?– Aerobic training: UBE?

Case: Severe MS (cont.)


• Rehab needed at levels of severity in MS• Fatigue is the most common finding and can impact all

aspects of mobility. Test for it, and use interventions to address it.

• Many of the deficits are secondary and therefore more amenable to remediation

• Educate patients on consequences of immobility

Summary

Rehab Management of Multiple Sclerosis: What You Need to Know

1

Course Bibliography

Rehab Management of Multiple Sclerosis: What You Need to Know Herb Karpatkin, PT, DSc, NCS, MSCS

Bibliography (5 minimum):

1. Karpatkin, H, Cohen E et al. (2015): Effects of intermittent versus continuous walking on distance Walked and fatigue in persons with Multiple Sclerosis: A randomized crossover trial. Journal of Neurologic Physical Therapy 39.3 172-178.

2. Garg, H., Bush, S., & Gappmaier, E. (2016). Associations between fatigue and disability,

functional mobility, depression, and quality of life in people with multiple sclerosis. International journal of MS care, 18(2), 71-77.

3. Callesen, J., Cattaneo, D., Brincks, J., Kjeldgaard Jørgensen, M. L., & Dalgas, U. (2019).

How do resistance training and balance and motor control training affect gait performance and fatigue impact in people with multiple sclerosis? A randomized controlled multi-center study. Multiple Sclerosis Journal, 1352458519865740.

4. Mañago, M. M., Hebert, J. R., Kittelson, J., & Schenkman, M. (2018). Contributions of

ankle, knee, hip, and trunk muscle function to gait performance in people with multiple sclerosis: a cross-sectional analysis. Physical therapy, 98(7), 595-604.

5. McLoughlin, J. V., Barr, C. J., Patritti, B., Crotty, M., Lord, S. R., & Sturnieks, D. L.

(2016). Fatigue induced changes to kinematic and kinetic gait parameters following six minutes of walking in people with multiple sclerosis. Disability and rehabilitation, 38(6), 535-543.

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