Physical Therapy for MS (Multiple Sclerosis)

Physical therapy is a part and parcel of MS (Multiple Sclerosis) treatments. Since MS is a progressive disease and restricts the person’s mobility, physical therapy can prevent contractures and help in mobilizing the patient.

Multiple sclerosis is a chronic, usually progressive, disease that primarily affects young adults. Approximately 2.5 million people worldwide have been diagnosed with MS.

Its effects vary widely. Although there is no known cure for the disease, it can be successfully controlled with medical management and rehabilitation.

Physiotherapy is important and emerging new techniques are really helpful in controlling the symptoms and helping patients to keep physically and mentally better [Ref].

Signs and Symptoms of MS

• Fatigue that does not improve with rest.
• Difficulty walking and problems with balance.
• Stiffness and spasms or a feeling of heaviness in your limbs.
• Bladder and bowel problems, such as urgency or incontinence.
• Sexual dysfunction, such as less sensation, dryness, decreased libido, and trouble reaching orgasm.
• Memory and thinking problems.
• Pain and other unpleasant sensations.
• Emotional or mood problems, including depression and apathy.
• Vision problems, such as control of eye movements, seeing a double, and blurry vision.
• Dizziness or vertigo.
• Speech and swallowing problems.

Many of these symptoms can be managed by medical therapies but they are not completely controlled and physiotherapy hence tends to play an important role.

Fluctuating symptoms:

Symptoms vary from one person to another and even in the same person the level of morbidity may wax and wane. Few days can be better than others.

Environmental factors like exertion, stress, overheating, and extreme weather can have bad effects.

Some symptoms can lead one to the hospital for acute management and some are managed at home.

Among these symptoms is depression which is often debilitating and psychological as well as physical therapy tends to play an important role and hence its efficacy cannot be negated.

A team comprising physical therapists as well as psychologists can lead the person’s life toward better productivity of life.

How can Physiotherapists Help MS Patients?

Physical therapists will periodically visit the patient and determine their impairment.

Impairments might include:

• Mobility reduction
• Unable to dress
• Contractures
• Weakness in limbs
• Loss of sensation
• Getting into the vehicle
• Household tasks
• Social activities

After this, a physiotherapist will give an exercise program for the patient that ll help him or her to restore normality in life as much as possible.

Where to have Physical therapy for MS patients:

Physical therapy can be done at the following stations:

1. Home
2. Outpatient facility
3. Inpatient facility
4. MS treatment center

Inpatient physical therapy for MS patients:

The patient will receive Inpatient care while he or she is staying at a healthcare facility. Physical therapy conducted in an inpatient facility is often done in a hospital, MS treatment center, or long-term care facility.

Most of the people who will seek an inpatient facility would have a debilitating onset of symptoms or new relapse or a complication due to MS hence needing the admission. That complication will also be concomitantly managed in the hospital.

Outpatient Physical therapy for MS patients:

Outpatient means that a patient will come to a doctor’s or the office physical therapist where he will receive his indicated physical therapy and then he can leave and can go home.

It is good for those who are recovering from relapse and can be managed in a domiciliary environment.

It also decreases the incidence of complications associated with inpatient care and also reduces the financial burden on patients as well as on the government.

Physical therapy at home:

It is a good option for those who are recently diagnosed and need adjustment to their impairment and to manage their day-to-day activities.

Or those who have an end-stage disease and are non-ambulatory patients.

Physical therapy for MS patients:

The doctor or physiotherapist will assess the patient’s impairment and needs. And will provide a program or plan for what a patient will be needing. The location will be discussed as per requirement.

Aims of physiotherapy:

1. To educate and maintain all possible voluntary control of oneself.
2. Educate and maintain postural mechanisms
3. By incorporating treatment techniques to maintain ADLs (activities of daily life)
4. Inhibit abnormal tone
5. To maintain all sensory and perceptual experiences.

Physical therapy for MS: Treatment Options

• Exercise is essential:

A multidisciplinary approach must be adopted. It is the duty of the team to dispel the historical myths regarding the disease and to inculcate the meaning of life.

Positive reinforcement always plays a big role and is rewarding. Patients should be re-educated as well as their families and they should also be taught side by side.

Always choose appropriate exercise keeping in view the strengths and weaknesses of the patient.

Exercise has a positive effect on mood and maintains a balance of life. Use of long-term steroids in MS may lead to proximal myopathy and osteoporosis and hence weight-bearing exercise from the early stage of the disease can be helpful.

• Aerobic training:

Aerobic exercises and training maintain muscle and bone mass it is necessary to do resistance exercises.

Other techniques e.g Bobath, Vojtas, and 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 the quality of life.

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.

• Aquatic exercise program:

They 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 a 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.

• Specific balance exercises:

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 and trauma.

Reduced gait speed, decreased stride length, cadence, and joint movement are observed in most studies of gait in MS.

• Hippotherapy:

This technique is considered to be effective in improving proprioception.

Horseback riding improves patient rhythmic control and vibration sense.

It also inculcates feelings of power and one’s perception of being in control.

It helps the rider by providing rhythmic sensory anterior and posterior motion.

Horse riding has a positive emotional effect on the rider.

• Motor imagery:

It is increasingly used in neuro-rehabilitation in order to facilitate motor performance. Motor imagery and rhythmic auditory stimulation can be used for walking rehabilitation in MS patients

Randomized controlled trials studying the effects of motor imagery showed significant improvement in walking speed, walking distance, perception, and quality of living.

• Cognitive behavioral therapy:

It has a moderate effect on fatigue in MS

It is also helpful in mild to moderate depression.

It improves the quality of life.

• Gait rehabilitation:

It forms a large chunk of rehabilitation in MS patients

A systematic review published in Diagnostics describing the gait pattern in people with multiple sclerosis (MS) shows:

• a decrease in speed and stride and step length,
• an increase in the step width,
• a 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.

Certain problems seen in most patients with a disability are possible to anticipate and prevent:

1. Plantar flexed feet
2. The predominant pattern of extension and adduction in the lower extremities
3. Knee flexion contracture
4. Hip flexion Contracture
5. Flexed thoracic spine
6. Flexion and internal rotation at the shoulders
7. Flexed head positions.

Physical therapy interventions for common symptoms of MS

• Pain:

Patients with MS often experience pain directly from the disease, secondary to medication or other symptoms, or from something completely separate.

Physical therapy 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

Physical therapy can offer education on how to be safe at home and offer strategies to improve balance and coordination in dimly lit settings.

Physical therapy treatment interventions for decreased sensation to light touch include education on awareness, protection, and personal care to desensitize 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 experienced by an overwhelming majority of patients is 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 is able to work on increasing their endurance capacity which will help them be more functional throughout the day.

Physical therapy 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:

Physical therapy 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:

MS is a debilitating disease with contracture formation, weakness of lower limbs, and pain which can affect the locomotor system.

PT can overcome this through team efforts by using various techniques as well as the use of assistive devices and orthotics.

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.