Management of Sensory Deficits and Skin Care
In patients with MS, inflammation causes a disruption in neuronal signaling, causing a variety of sensory symptoms.103 Strategies should be instituted to increase awareness of sensory deficits, compensate for sensory loss, and promote safety.104 It is important to remember that sensory deficits may remit, so ongoing examination is necessary. The success of compensatory training strategies depends on the availability of other intact sensory systems. For example, visual compensation techniques can be instituted when deficits in proprioception produce imbalance and place the patient at risk for falls.
If multiple sensory systems are involved (e.g., vision is also impaired), sensory compensatory strategies are not likely to be successful.
Patients with proprioceptive losses demonstrate impairments in movement control and motor learning. They require increased use of other sensory systems, especially vision. Tapping, verbal cueing, and/or biofeedback can all be effective forms of augmented feedback. Proprioceptive loading through exercise, light tracking resistance, resistance bands or weights, and the use of a pool may heighten residual proprioceptive function and improve movement awareness.
Visual loss will interfere with movement and postural control. Blurred vision, especially at night or in low light situations, can occur after episodes of optic neuritis. When individuals with MS have to stand in an upright position in the dark, the likelihood of falls increases.105 It is therefore important to instruct the patient to maintain adequate lighting at all times (e.g., use of a bright light at night) and reducing clutter to improve safety. Adding color contrast between items in the environment (e.g., stair markings) can also improve safety. Double vision is frequently the result of impaired coordination and weak eye muscles. It can be controlled by placing a patch over one eye and is an important strategy for improving reading, driving, or watching television. However, eye patching should not be used all the time, because it will prevent possible adaptation of the CNS. Eye patching also interferes with depth perception. The symptoms of visual blurring and double vision also fluctuate and can be heightened with fatigue, an increase in temperature, stress, and infection. Management of these symptoms is important to improve vision.104 If low vision persists, the patient should be referred to a low-vision specialist or one of the national service organizations that provide help to individuals with vision impairments (National Association for Visually Handicapped, National Federation of the Blind, American Foundation for the Blind).
One of the most common early sensory symptoms of MS is decreased sensitivity to touch.103 Patients with MS face an increased risk of developing pressure ulcers owing to the symptoms of MS, including loss of sensation, immobility, loss of bowel and bladder control, and a catabolic nutritional state.104 Changes in skin turgor, static posturing, and prolonged pressure over bony prominences increase the likelihood of skin breakdown. Approximately 20% of patients with MS will develop a pressure ulcer during the course of the disease.8 Patients may not feel the discomfort of a prolonged position or may be unable to shift position because of weakness or spasticity. In addition, spasticity and/or spasms may cause friction effects between the skin and supporting surfaces. Awareness, protection, and care of desensitized parts should be taught early in the rehabilitation process and consistently reinforced by all members of the team. It has been demonstrated that patient education programs result in 50% reductions in pressure sore incidence.106 The patient/family/caregiver should be educated in the following principles of skin care:
The skin should be kept clean and dry. Soiled skin should be cleansed and dried promptly.
The skin should be inspected regularly (at least once a day) and carefully, with particular attention to persistent areas of redness and over bony prominences.
Clothing should be breathable and comfortable (soft, not too loose or wrinkled, or too tight). Seams, buttons, and pockets should not press on the skin, particularly in weight-bearing areas.
Regular pressure relief is essential. Patients should be instructed to change their position or be changed frequently, typically every 2 hours in bed and every 15 to 30 minutes when sitting in a wheelchair.107
Pressure-relieving devices (PRDs) may be necessary to protect insensitive areas and should be implemented as appropriate. These can include mattresses (water, gel, air, or alternating pressure) to distribute body weight and reduce shear and friction in bed. Sheepskins, air or foam cushions, cuffs, and/or boots may be necessary to protect body areas prone to breakdown (shoulder blades, elbows, ischial tuberosities, sacrum, trochanters, knees, malleoli, or heels). Cushions (foam; fluid or air pressure– relieving cushions) are necessary for patients who spend prolonged periods of time sitting in their wheelchair. When evaluating a PRD it is imperative that a pressure mapping system be used to determine its effectiveness and to ensure that the areas of high pressure are adequately protected.107,108,109
Prevention is the best strategy. Important measures for maintaining skin integrity and function include maintaining good nutrition and drinking plenty of fluids. Studies suggest that for patients with MS with pressure sores, there are increased requirements for specific nutrients; particularly zinc and iron supplementation should be considered.110 The patient must be cautioned against activities that might traumatize the skin. Dragging, bumping, or scraping body parts during a transfer or bed mobility activities can injure the skin. Thermal injury can result from contact with hot water or hot objects. If nonblanchable skin redness develops (lasting longer than 30 minutes), patients should be instructed to stay off the area until the redness disappears. If the redness does not disappear within 24 hours, the individual should seek medical attention. Blisters, blue areas, or open sores indicate more serious injury and require immediate attention. This may include systemic antibiotic therapy for infection and wound management techniques (cleansing and débridement, topical antibiotic agents, and protective dressings).8
Pain can be classified into four categories: pain directly from MS, pain secondary to other symptoms of MS, pain as a result of drug treatment for MS, and pain independent of MS. The management of pain depends on an accurate determination of its causes. Musculoskeletal strain or joint malalignment from chronically weakened muscles are important considerations and are responsive to physical therapy intervention. Patients may experience relief of pain with regular stretching or exercise, massage, and ultrasound. Postural retraining and correction of faulty movement patterns along with orthotic and/or adaptive seating devices can reduce malalignment and pain. Stabbing pain from Lhermitte's sign may be relieved with a soft cervical collar to limit neck flexion. Hydrotherapy or pool therapy using lukewarm water may have a beneficial effect on painful dysesthesias. Pressure stockings or gloves can also be used to relieve pain, converting the sensation of pain to one of pressure. Neutral warmth may be an additional factor in the pain relief experienced with stockings or gloves. Patients with chronic pain may benefit from referral to a total management approach for chronic pain, for example, the multidisciplinary pain clinic (see Chapter 25, Chronic Pain). Stress management techniques, relaxation training, biofeedback, and meditation are often helpful in reducing both anxiety and pain. The use of transcutaneous electrical nerve stimulation (TENS) to modulate pain in patients with MS has had conflicting results, with some patients experiencing improvement and some a worsening of symptoms.9,10
Muscle weakness and decreased endurance are common findings in patients with MS. In addition, patients with MS often adopt a sedentary lifestyle and limit their physical activity. The benefits of exercise have been firmly established in terms of producing meaningful physiological and psychological changes, improving function while lessening disability, and enhancing quality of life.111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128 In a Cochrane Database Systematic Review of Exercise Therapy for MS, researchers identified nine high-quality RCTs (260 participants).128 Six trials compared exercise versus no exercise while three trials compared two types of exercise therapy. The researchers found strong evidence in favor of exercise therapy for improving muscle power, exercise tolerance, and mobility-related activities. Moderate evidence was found for improving emotional mood. There were no adverse effects on fatigue and perception of handicap. The researchers found no evidence that a specific exercise therapy program was more successful in improving level of activity and participation than another. Individuals with minimal to moderate impairments (i.e., EDSS scores between 1 and 6) demonstrate the best exercise tolerance. This speaks to the need to institute exercises early in the course of the disease. Exercise responses of the patient with MS are influenced by a host of factors that require careful attention during exercise, including fatigue, spasticity, incoordination, impaired balance, sensory loss (numbness), tremor, and heat intolerance. Depression may affect adherence to an exercise program. Therapists therefore need to provide constant reinforcement and a positive environment.
Individuals with MS will vary greatly in their responses to exercise. The focus and pace of therapy must be readjusted according to the patient's specific abilities and needs at that time. Patients with RRMS who are experiencing an exacerbation should not exercise until remission is evident. Exercise therapy can be reinstituted when the deterioration has stabilized and no new symptoms are appearing. Patients with PPMS can exercise within the limits of their capabilities as exercise may slow further deterioration and optimize remaining function.129,130 Box 16.5 Evidence Summary presents a summary of selected research on exercise and MS.
Box 16.5 Evidence Summary Exercise and Multiple Sclerosis
|Reference ||Subjects ||Design/Intervention ||Duration ||Results ||Comments |
|Andreasen et al122 (2011) ||Identified 21 studies ||Systematic review of studies evaluating the effect of exercise on MS fatigue; studies included endurance training, resistance training, combined training, or other training modalities || ||Heterogeneous results; only a few studies evaluated MS fatigue as the primary outcome; many studies applied nonfatigued study populations; those studies that included fatigued patients with MS show positive results ||Exercise has the potential to have a positive effect on MS fatigue; remains unclear whether any exercise modalities are superior to others; high-quality studies are needed regarding the different exercise interventions, using fatigue as a primary endpoint |
|Cakit et al124 (2010) ||45 subjects, in 2 exercise groups, 1 control group; relapsing-remitting or secondary progressive MS, mild-mod MS, no exacerbation, able to stand indep || |
Exer group 1: PRT on bicycle ergometer and balance exer Exer group 2: home-based LE strengthening and balance exer Control group: home-based LE strengthening and balance exer Outcome measures: duration of exercise; TMW; TUG; DGI, FR, FES; 10-mWT, FSS, Beck Depression Inventory, SF-36
|8 weeks, 2X/wk 15 repetitions of high resistance (40% TMW) 2 min followed by low resistance or rest 2 min ||Exer group 1: significant improvement in all outcome measures Exer group 2: significant improvement in FES, TMW, and duration of exer Control group: no improvements ||PRT results in improved balance, decreased fear of falling, and decreased depression; there were no injuries or increases in MS symptoms |
|Dalgas et al123 (2010) ||45 subjects with RRMS, EDSS, 3.0-5.5, able to walk > 100 m, age > 18 ||RCT, crossover design; 5 min warm-up followed by PRT (loads and volume increased every 2 weeks); control group participated in same intervention after 12 weeks Outcome measures: FSS, MDI, SF-36, muscle strength (MVC), functional capacity ||12 weeks, 2X/wk; post-study follow-up period of 12 weeks ||Significant improvements in strength, fatigue, and functional capacity score; significant changes in mental but not physical components of SF-36 ||Resistance training well tolerated; improved scores for strength, fatigue, mood, QOL, and ambulatory function; at follow-up no significant deterioration in scores |
|Rampello et al125 (2007) ||19 subjects with mild to mod MS, score of 6 or less on EDSS, no recent relapse ||RTC, crossover design AT group: leg cycle ergometer (5 min warm-up; 30 min at 60% max work rate; 5 min cool-down) Control group: neurological rehab program (NR) Outcome measures: MFIS, MSQOL-54; 6-MWT; walking speed ||3 training sessions per week for 8 weeks ||With AT but not NR, walking distances and speeds, max work rate, peak O2 uptake and max work rate significantly improved; no differences on fatigue ||AT improves maximum exercise capacity and walking capacity; subjects who were most disabled tended to benefit from AT; there was a high rate of subject loss (4/19 in AT group) |
|Rietberg et al128 (2004) ||Identified 9 studies (RCTs); 262 subjects with MS ||Meta-analysis of 9 high-quality RCTs Inclusion criteria: exercise therapy for adults with MS (not currently experiencing an exacerbation) Outcome measures: activity limitation and QOL, or both ||6 trials: exercise therapy versus no exercise therapy; 3 trials: compared 2 interventions of exercise therapy ||Best evidence: Strong evidence in favor of exercise compared to no exercise, improvements in muscle power function, exercise tolerance functions, mobility-related activities noted; moderate evidence: for improving mood; no evidence: effect on fatigue and perception of handicap; no evidence: any specific exercise therapy better than others ||No deleterious effects of exercise therapy described. Exercise therapy is beneficial for patients with MS not experiencing an exacerbation. Consensus is needed for core set of outcome measures. Better controls needed for type, intensity of training and for type of MS. |
|Surakka et al112 (2004) ||95 subjects with MS, mild-mod disability; EDSS scores between 1 and 5.5; exercise group = 46; non-exercise group = 48 ||RCT, 5 PRT and 5 AT sessions; aerobic exercises in pool (temp 82.4°F[28°C]), 65%-70% age-predicted HRmax; resistance training (RT) = circuit training UE and LE Ms, 50%-60% 1-RM; home exercise program (HEP): RT used elastic bands; aerobic training, walking; subjects kept daily diary Outcome measures: Ms torque (dynamometer); Fatigue (FI, FSS, AFI) || ||Significant decrease in motor fatigue in women (n = 30) but not men (n = 17) after 6 months of aerobic and strength exercise; exercise activity of women was 25% more than men ||Long training period (6 months) may have masked disease progression, especially in men. Men more likely to have PPMS then RRMS. |
|Mostert and Kesselring113 (2002) ||26 subjects with MS, mild-mod disability, inpatient rehabilitation; EDSS scores between 2.5-6.5; MS-exercise group =13; MS-no intervention group = 13; healthy control group = 26 ||Randomized control trial Aerobic exercise training: leg cycle ergometry Outcome measures: max GXT; tests of lung function (FVC); spasticity LEs (mAS); EDSS Baecke Activity Questionnaire; SF-36 Health Survey; FSS ||4 weeks, 5x/wk, 30 min sessions ||MS training group increased aerobic threshold, improved health perception (vitality increased 46%, social interaction increased 36%); increased activity level (17%); tendency for less fatigue; lung function did not change ||Aerobic training is safe and improves aerobic capacity; symptom exacerbation lower than expected (6%); compliance of MS training group was low (65%); stresses need for motivational setting; MS patients less fit than healthy controls; more disabled MS patients improved more than less impaired patients; small sample size. |
|Sutherland et al121 (2001) ||22 subjects, with MS, mild-mod disability; EDSS of 5.0 or less; no-special-activity group = 11; exercise group = 11 ||RCT, exercise intervention: land-based weight training; water aerobics, water jogging Outcome measures: submax GXT; HRQOL ||10 weeks, 3x/wk, 45 min sessions ||Exercise group increased in physical fitness (not significant); reported increased energy and vigor, mood, better social and sexual functioning; less bodily pain and fatigue ||Exercise improved psychological health and quality of life; use of water-based aerobics can be effective in patients with MS who have spasticity and coordination deficits; small sample size. |
|Snook and Motl127 (2009) ||Meta-analysis of 22 studies of 600 patients with MS ||Search included published exercise training studies from 1960 to 2007; studies measured walking mobility, using instruments identified as acceptable walking mobility constructs and outcome measures for individuals with neurological disorders, before and after an intervention that included exercise training. ||22 studies over 47 years ||Computed effect sizes expressed as Cohen's d. Sixty-six effect sizes were retrieved and yielded a weighted mean effect size of g = 0.19 (95% confidence interval, 0.09-0.28). There were larger effects associated with supervised exercise training (g = 0.32), exercise programs that were less than 3 months in duration (g = 0.28), and mixed samples of RRMS and progressive MS (g = 0.52). ||The cumulative evidence supports that exercise training is associated with a small improvement in walking mobility among individuals with MS. |
|Dodd et al126 (2006) ||Seven women and two men (mean age 45.6 years, SD 10.7) with MS ||Cohort study Gymnasium-based progressive resistance strengthening program: 3 exercises for the legs (leg press, knee extension, seated heel raise) and 3 exercises for the arms (lat pull down, seated chest press, and seated row) ||10 weeks, 2X/wk ||Positive physical, psychological, and social benefits and decreases in fatigue. Key extrinsic factors for program completion were the leaders' encouragement and knowledge of exercise and the group aspect of the program ||Progressive resistance strength training is a feasible fitness option for some people with MS. Choosing encouraging leaders with knowledge of exercise and exercising in a group may contribute to program success. |
Strength and Conditioning
Maximal muscle force during sustained isometric or isokinetic exercise is lower for persons with MS secondary to reduced ability to activate muscles (reduced force/unit muscle mass), reduced muscle metabolic responses, and muscle weakness secondary to muscle fiber atrophy, spasticity, and disuse.129 Determining an appropriate exercise prescription to improve strength and endurance is challenging and needs to be carefully individualized for each patient. Prescription is based on four interrelated elements: frequency of exercise, intensity of exercise, type of exercise, and time or duration (the FITT equation). The following guidelines can be used:130
Exercise sessions should be scheduled on alternate (non-endurance) days and during optimal times, such as in the morning, when body core temperatures tend to be lowest and before fatigue sets in. Patients with greater neurological involvement may require more frequent exercise (e.g., daily exercise time).
Resistance training modes can include weight machines, free or pulley weights, latex resistance bands, or isokinetic machines.
Circuit training, in which improved work capacity is developed through the use of various different stations that alternate work between UEs and LEs, distributes the load among muscles and may prove beneficial for reducing the likelihood of fatigue.
Sessions should involve discontinuous work, carefully balancing exercise with adequate rest periods.
Progression is generally slower than with healthy individuals.
Precautions should be taken to prevent the deleterious effects of overwork. Exercising to the point of fatigue is contraindicated and can result in worsening of symptoms, most notably increased weakness. This may have additional adverse effects on the continuing motivation of the patient.
Precautions should be taken to monitor the effects of fatigue. Time to fatigue varies greatly among individuals with MS and is not correlated with the level of physical impairment or disability.
Precautions should be taken to manage core body temperature and prevent overheating.131,132 Environmental temperatures should be carefully controlled. Air conditioning is a medical necessity in many climates. Additional cooling can be achieved through the use of fans, wet neck wraps, spray bottles for misting the skin with cool water, and immersion in cool water with aquatic exercises. Surface cooling devices have emerged as effective tools in managing body temperatures, controlling fatigue, and improving function. These include cooling suits or vests.133,134,135
Precautions should be taken with certain impairments. Tactile and proprioceptive losses or incoordination and tremors may make the use of some equipment (e.g., free weights) unsafe. Visual feedback, when intact, should be used to monitor exercise performance. An alternative suggestion would be to use synchronized arm/leg ergometers to control limb movements.
Precautions should be taken with cognitive and memory impairments. Individuals may require written or posted exercise instructions/diagrams including reminders of the number of repetitions, proper form, and correct use of equipment.
Functional training activities (e.g., closed chain exercises) can be used to promote strength and functional endurance. Individuals with ataxia and balance problems may require the use of more stable postures (e.g., modified plantigrade, quadruped, or supported sitting).
Group exercise classes can provide valuable motivation and social support. The therapist's primary role is one of educator and group leader. Successful management of group classes requires careful, individualized examination of group members to determine specific goals and exercises.
Outcome measures can include isokinetic dynamometry, MMT (may be unreliable if spasticity is present), functional tests (e.g., sit-to-stand), fatigue (MFIS), and quality-of-life measures (HRQL).
Individuals with MS demonstrate expected physiological responses to submaximal aerobic exercise; that is, heart rate (HR), blood pressure (BP), and oxygen uptake (VO2) all increase in a linear fashion in response to increasing workloads. Respiratory responses (respiratory rate [RR] and minute ventilation) also increase.129 However, HR and BP responses may be blunted if cardiovascular dysautonomia is present. A direct relationship exists between the duration and extent of disease and the likelihood of autonomic cardiovascular dysfunction. Patients with MS can also demonstrate respiratory muscle dysfunction (weakness, dyssynergia), contributing to reduced exercise tolerance.
Exercise tolerance and maximal aerobic power (VO2max) are reduced in individuals with reduced cardiorespiratory fitness secondary to physical inactivity. Decreased physical work capacity, decreased vital capacity, increased HR at rest and in response to exercise, decreased muscular strength, increased fatigue, increased anxiety, and depression are common findings.
Determining an appropriate exercise prescription to improve cardiovascular conditioning needs to be carefully individualized for each patient. While predicting exercise capacity and cardiorespiratory fitness is challenging for individuals with MS, recent studies have shown that peak VO2 and exercise capacity can be predicted through submaximal testing. 136,137 The following guidelines for clinical exercise testing can be used.130
The preferred mode is either an upright or recumbent leg cycle ergometer. A recumbent device is indicated if sitting balance is impaired. Combination leg and arm ergometry or UE ergometry alone may be necessary in the presence of significant LE involvement. Toe clips and heel straps are recommended to control foot placement especially in patients with spasticity, tremor, or weakness.
Performance measures include HR, ratings of perceived exertion (RPE), BP, and expired gas analysis (VO2). Using the RPE scale, peripheral (muscles, joints) exertion is consistently rated as more stressful (higher) than central (cardiopulmonary) exertion.
A continuous or discontinuous protocol (3- to 5-minute stages) can be used; the discontinuous protocol is indicated with symptomatic disease, especially fatigue.
A submaximal test should be used. Most individuals with MS can achieve 70% to 85% of their age-predicted maximal heart rate (HRmax).
Recommendations for increasing workloads for each stage are 12 to 25 watts for LE work and 8 to 12 watts for combined UE and LE work.
Termination criteria include achievement of peak HR, peak VO2, volitional fatigue, significant BP changes (systolic blood pressure [SBP] greater than 250 mm Hg or diastolic blood pressure [DPB] greater than 115 mm Hg or a hypotensive response), or a decrease in oxygen uptake with increasing work rate.
Precautions should be taken to monitor for attenuated HR or BP responses during exercise. A category-ratio RPE scale can be used to estimate central and peripheral exertion.84
Precautions should be taken to manage core body temperature and prevent overheating (e.g., use of a fan for cooling).
Precautions should be taken to monitor the effects of fatigue.
Precautions should be taken to prevent the deleterious effects of overwork.
Precautions should be taken with certain medications that can affect results: amantadine hydrochloride (HCl) may temporarily reduce fatigue; baclofen and amitriptyline HCl may cause muscle weakness; prednisone can also cause muscle weakness along with reduced sweating and hypertension.
Morning is the optimal time for testing.
Prescription is again based on the four interrelated elements of the FITT equation. Recommendations for exercise programming to improve aerobic conditioning include the following:130
Recommended training frequency is 3 to 5 days/week, on alternate days. Daily exercise at lower levels of intensity is recommended for individuals with more limited exercise capacities (e.g., 3 to 5 metabolic equivalent [METs]).
Training intensity should be limited to 60% to 85% HRpeak or 50% to 70% peak VO2.
Recommended duration is 30 minutes per session or, for more involved individuals, three 10-minute sessions per day.
Type of exercise can include cycling, walking, swimming, or water aerobics.
Circuit training may prove best for optimizing training.
Individuals with balance problems or sensory loss will require non–weight-bearing activities.
Exercise precautions: discussed in previous section.
Outcome measures include graded exercise test results (GXT), HR (which may be difficult to monitor with dysautonomia; sensory loss in the fingers may make self-monitoring difficult), tests of lung function (forced vital capacity [FVC]), body composition, RPE, fatigue (FI, MFIS), functional status, and quality-of-life measures (HRQL).
Patient education is particularly important because the overall success of a fitness program is influenced by the individual's level of understanding of the basic principles of training, independence in self-monitoring, and skill in decision making relative to level of impairment and exercise modifications required, as well as lifestyle and general health and safety considerations.
Stretching and ROM exercises are necessary to ensure adequate joint motion and to counteract the effects of spasticity (Fig.16.3). Sedentary or inactive persons who are dependent on wheelchairs often develop tightness in hip flexors, adductors, hamstrings, and plantarflexors. Limited overhead ROM is seen with tightness in the pectoralis major/minor, and latissimus dorsi and is associated with a slumped, forward posture. Patients confined to bed typically present with tightness in hip/knee extensors, adductors, and plantarflexors. Stretching and ROM exercises should be performed daily. For adequate stretching, holding at end range should be a minimum of 30 to 60 seconds repeated for a minimum of 2 repetitions. The use of orthoses or dynamic splinting is an appropriate option for prevention and in some cases reversal of contractures.138,139 Considering the gait deviations and difficulty with transfers/bed mobility that arise from limited ROM and spasticity, it is important to also include aggressive trunk ROM to allow for full function of the core musculature, most notably the quadratus lumborum (Fig. 16.4). More active patients may benefit from Tai Chi, which provides additional important benefits of relaxation and balance training. ROM measurement using goniometry is an appropriate outcome measure.
Side-lying hip flexor/rectus femoris stretch. This position allows the therapists to control the hip and ensure that excessive lumber lordosis is prevented while also modulating the amount of stretch between the iliopsoas and the rectus femoris.
Seated trunk stretch. The pictured position allows the therapist to control the pelvis to ensure trunk stretching while maintaining control of the individual's trunk to apply the correct emphasis to the desired muscle groups.
With approximately 75% of individuals with MS describing persistent or sporadic symptoms, fatigue is among the most debilitating. Fatigue is characterized by overwhelming sleepiness, excessive tiredness, and sense of weakness that comes on suddenly and severely. Aversion to activity for fear of bringing on fatigue is also common. The resultant lowered activity levels have important implications for diminished health status and deconditioning. Therapists are faced with a balancing act, on one hand prescribing exercise, while on the other hand avoiding overwork and the development of fatigue. Aerobic exercise training (previously discussed) and energy effectiveness strategies (EES) are central to any intervention plan to lessen fatigue.13 During exercise prescription and physical therapy sessions, it is imperative that a skilled therapist recognize the difference between MS-related fatigue and the expected exercise-related fatigue. MS-related fatigue during exercise is often associated with thermal stress, which can be offset with adequate rest and the use of cooling and precooling treatments during exercise.132,133,134
Patients are instructed to keep an activity diary in which they record how they slept the night before, daily activities by hour, and how costly those activities were. For each activity, they can be asked to rate their level of fatigue (F), the value or importance of the activity (V), and satisfaction perceived with performance of the activity (S) by assigning a number between 1 and 10 with 1 being very low and 10 being very high. For example, the activity might be fixing lunch. Scores reported for this activity might be F = 7, V = 3, and S = 2. Aggravating factors associated with increasing fatigue (e.g., heat stress) and MS symptoms that appear or worsen during the day are also recorded. An MS Daily Activity Diary is presented in Appendix 16.C.140
Based on this information, therapists can initiate training sessions, teaching energy effectiveness strategies. Energy conservation refers to the adoption of strategies that reduce overall energy requirements of the task and overall level of fatigue. These can include modifying the task or modifying the environment to ensure successful completion of daily activities. For example, a motorized scooter or powered wheelchair can be considered for community or home mobility to help conserve energy and maintain independence. Other mobility equipment such as walkers, crutches, or orthotics can also be considered. Activities that are difficult or have high energy needs can be broken down into component parts, requiring accurate activity analysis. Activity pacing refers to the balancing of activity with rest periods interspersed throughout the day. For the patient with chronic fatigue, rest–activity ratios are developed, with periodic rest periods planned in advance. Time-outs with complete rest should be instituted if an activity becomes exhaustive. Overall levels of energy can be improved if patients learn to set priorities and limit their activities, saving their energy for those activities that are truly important to them (e.g., activities that are enjoyable and meaningful in terms of the individual's lifestyle). The occupational therapist addresses EES and can provide valuable suggestions in terms of planning, work simplification, and developing energy-efficient activities for self-care and home management. The vocational rehabilitation counselor can provide useful strategies for behavioral modification and vocational rehabilitation. Team efforts with the physical therapist and others are important for consistency and reinforcement. Weekly review of activities and recommended modifications is used to evaluate progress. The MFIS should be administered on a regular basis to monitor ongoing fatigue status (see Appendix 16.A). Finally, stress management techniques are important components of symptom management.
The occupational and physical therapist should complete a direct environmental examination of the home and/or job site (see Chapter 9, Examination of the Environment). A number of adaptations may be considered to improve efficiency and safety, including air-conditioning, home, or work modifications, or ergonomic equipment. The patient/family/caregivers should be educated as to the importance of these recommendations for improved function. Periodic review of equipment and environmental modifications is also recommended.
Proper communication between the occupational and physical therapist and the patient's physician can ensure that the correct doses of the pharmacological treatments are in place, as the therapist has the unique opportunity of observing the patient in various circumstances and activity levels.
Although spasticity varies greatly from person to person, muscles that typically demonstrate strong tone include the antigravity muscles. For example, in the LEs, the quadriceps, hip adductors, and plantarflexors are often spastic while in the UEs the elbow, wrist, and finger flexors together with shoulder adductors are spastic. Individuals with MS typically demonstrate stronger spasticity in the LEs than the UEs. Spasticity is functionally limiting and contributes to the development of a number of secondary impairments such as contractures, postural deformity, and decubitus ulcers.
A variety of physical therapy interventions can be used, including cryotherapy, hydrotherapy, therapeutic exercise, stretching, positioning, or any combination thereof. The responses to these interventions must be monitored closely and carefully balanced with pharmacological interventions. The therapist must closely monitor the effects of the antispasticity medications prescribed and optimize physical therapy interventions with the dosing cycle. For example, patients on baclofen will respond better to stretching techniques if they are applied in the middle of the dosing cycle rather than at the end or beginning. Physical therapists must also recognize contributing factors that affect tone and respond appropriately. For example, infection or fever that increases tone may require a referral to the physician. It is important to reduce or eliminate all factors that can aggravate spasticity (e.g., heat, humidity, stress).
Topical cold (ice packs or wraps) or hydrotherapy (cool bath) can temporarily reduce spasticity by decreasing tendon reflex excitability and clonus and by slowing conduction of impulses in nerves and muscles. The effects of cryotherapy are relatively short-lived, although some patients may experience enhanced ability to move that lasts for minutes or hours. It is important to remember that some patients, particularly those with intact sensation, may react to the unpleasant sensation of cold with fight or flight (autonomic nervous system) responses, such as increased HR, increased RR, or nausea. Cryotherapy is contraindicated in these patients.
Stretching and ROM exercises begun early in the course of the disease and continued daily can help patients maintain joint integrity and mobility in the presence of spasticity. Combining stretching with movements using rhythmic rotation (gentle rotation of the limb) or proprioceptive neuromuscular facilitation (PNF) stretching techniques (hold–relax active contraction [HRAC], contract–relax active contraction [CRAC]) is effective in gaining ROM.141 See Chapter 10, Strategies to Improve Motor Function, for a discussion of these techniques. Maintained stretch, held for 30 minutes to 3 hours, also can be used to decrease stretch reflex activity. Maintained stretch can be achieved with prolonged positioning (e.g., tilt table standing with toe wedges), low-load weights applied using skin traction, or serial casts. Air splints also provide an effective mechanism to maintain limbs in lengthened, out of spasticity positions. Patients/family members/clients should be taught stretching exercises as part of a home exercise program (HEP). Fast, ballistic stretching movements are contraindicated, because spasticity is velocity sensitive. Stretching movements need to proceed slowly to gradually achieve the desired range.
Active exercises at slow or self-selected speeds should focus on expanding the available ROM. Emphasis on contracting the antagonist muscles can assist through mechanisms of reciprocal inhibition. Electrical stimulation of muscles antagonist to the spastic muscles can also be used to decrease spasticity. Movements that encourage abnormal postures should be discouraged. Patients with abnormal co-contraction may benefit from exercises focused on improving motor control (timing exercises) or biofeedback. Tai Chi, yoga, and aquatic exercises combined with cool water temperatures (less than 85°F [29.44°C]) can also be helpful in producing desired relaxation.12
Functional activities aimed at reducing tone should concentrate on trunk and proximal segments, because many patterns of hypertonus seem to be fixed from the action of the stronger proximal muscles. Extensor tone seems to predominate, so activities that stress LE flexion with trunk rotation are generally the most effective. For example, lower trunk rotation (LTR) in hook-lying can be effective in reducing proximal extensor tone. One very effective strategy is to position the patient in hook-lying with a therapy ball under the flexed legs and gently rock the ball back and forth. Moving from quadruped position to side-sitting can also be effective in reducing extensor tone in some patients as the activity combines LTR with prolonged inhibitory pressure on the quadriceps.142
For the patient with limited functional mobility (EDSS levels of 7.0 or above) positioning out of abnormal spastic postures is an important component of the management program. In general, prolonged or static positioning in any fixed posture can be deleterious to the patient with strong spasticity and should be avoided. For example, the patient who remains in bed all day with the LEs positioned in extension, adduction, and plantarflexion may be unable to flex enough at the hips and knees to sit in a wheelchair. Similarly, the feet will remain fixed in plantarflexion and cannot be positioned on the footpedals. A positioning schedule using varied positions (in bed, chair, or wheelchair) will help keep the patient from getting stuck in any one posture. Mechanical positioning devices (e.g., resting splints, toe spreader, finger spreader, ankle splint) are helpful in maintaining position and preserving joint structures.
Management of Coordination and Balance Deficits
Cerebellar deficits (ataxia, postural instability) are common in MS. Impairments in somatosensory, visual, and vestibular systems are also common and result in disordered proprioception. Spasms and muscle weakness can affect balance by changing the force and sequence of muscle contraction.143 These combined effects result in difficulty in sustaining upright postures, walking, and other functional activities, leading to an increased risk of falls.
Interventions directed at promoting postural control should first focus on static control (holding) in weight-bearing, antigravity postures (e.g., sitting, quadruped, kneeling, modified plantigrade, and standing). Progression through a series of postures is used to gradually increase postural demands by varying the base of support (BOS), raising the center of mass (COM), and increasing the number of body segments (degrees of freedom) that must be controlled. Specific exercise techniques that can be used to promote stability include joint approximation applied through proximal joints (shoulders or hips) or spine, and rhythmic stabilization (PNF). Patients with significant ataxia will not be able to hold steady and may benefit from the application of the technique of PNF dynamic reversals (slow reversals), progressing through decrements of range.141 Dynamic postural control can be challenged by incorporating activities such as weight shifting and UE reaching (Fig. 16.5) or LE stepping. In sitting, a resisted PNF chop pattern that combines UE movements with trunk movements (flexion with rotation and extension with rotation) is an excellent activity. This can be progressed to more advanced dynamic activities with the patient sitting on a therapy (Swiss) ball as opposed to sitting on a hard flat surface (Fig. 16.6). Core musculature is engaged while the demands on ankle and knee musculature are minimized. This allows for a more focused core balance program that can be progressed to standing.144,145
Dynamic postural control is promoted through weight shifting and upper trunk rotation to the right.
Sitting on the ball, the patient practices dynamic postural control activities: (a) unilateral resisted overhead reach, (b) reciprocal stepping and overhead arm swing, and (c) resisted bilateral symmetrical PNF D2 flexion patterns with extension.
An important goal of therapy is to promote safe and functional balance. Effective training should involve a variety of everyday functional tasks that challenge balance. Figure 16.7 demonstrates a dynamic postural control activity of combined stepping and reaching. Figure 16.8 demonstrates sit-to-stand movement transitions. As training progresses, tasks are modified (e.g., wide base to narrow base to tandem stance, stable surface to moveable surface) to promote adaptation of skills. Sensory contexts are also varied to promote adaptive control in various different perceptual contexts (e.g., eyes open to eyes closed, firm surface to thick foam surface).142 Patients with MS and central vestibular dysfunction may benefit from vestibular rehabilitation to improve impaired balance and disability due to dizziness or disequilibrium (Fig. 16.9). See Chapter 21, Vestibular Disorders, for additional discussion.146
Dynamic postural control activities. This position demonstrates an advanced stepping and reaching activity with the added challenge of a resistance tube.
Sit-to-stand movement transition. The sit-to-stand transition is an important component of pre-gait/gait training, transfer training, and balance training.
Head turns for vestibular training.
The pool is an important therapeutic medium to practice static and dynamic postural control in both sitting and standing, as well as walking. Water provides graded resistance that slows down the patient's ataxic movements, while the buoyancy aids in upright balance. Water aerobics have been shown to be effective in improving strength, decreasing muscular fatigability, increasing endurance, and improving quality of life in patients with MS.120,147 When recommending aquatic exercise programs it is imperative to assess the individual's tolerance to heat. It is commonly recommended that persons with MS exercise in a pool that is 80° to 85°F (26.66° to 29.44°C).
Biofeedback training using augmented feedback can be used to improve balance function. Augmented visual feedback148 and augmented proprioceptive feedback (e.g., whole body vibration platform training)149 have been used to improve function in patients with MS. Training on a moveable force platform (e.g., SMART Balance Master® [NeuroCom International, Inc., Clackamas, OR 97015]) can also improve balance. The added biofeedback from visual and/or auditory feedback displays on force platform training machines is especially useful for patients with somatosensory deficits. The patient with ataxia needs to learn how to reduce excess postural sway (frequency and amplitude) and to control center of alignment position. Prolonged latencies (onset of responses) should be expected. Additionally, with advancements in technology, whole body vibration150 and household video game platforms (i.e., Nintendo Wii) have become useful tools for balance training for individuals with neurological conditions.151,152
Control of ataxic limb movements (tremor and dysmetria) can be achieved through proprioceptive loading and light resistance. For example, the therapist can use PNF extremity patterns using the technique of dynamic reversals with light tracking resistance to modulate force output and reciprocal actions of muscles. Ataxic movements have sometimes been helped by the application of latex resistance bands or light weights to stabilize movements. Velcro® weight cuffs (wrist or ankle), weighted boots, or a weighted jacket or belt can reduce tremors of the limbs or trunk. The extra weight will also increase energy expenditure, and must therefore be carefully balanced against the increased fatigue they might cause. Weighted canes or walkers can be used to reduce ataxic UE movements that interfere with the use of an assistive device during ambulation. Weighted spoons or forks can be used to enhance eating. For patients with significant tremor, these devices may mean the difference between dependent and independent function. External devices (braces or splints) can be used to stabilize ataxic limbs but also have the undesirable effect of adding weight to limb movements. Air splints can also stabilize limb movements and should be considered, because they are lighter and less energy costly. A soft cervical collar can be used to stabilize head and neck tremors. All these strategies, however, should be viewed as temporary and compensatory. Once the devices are removed, ataxic movements will return or in some cases may actually temporarily worsen.
Unwanted movements are worse under conditions of stress, anxiety, and excitement. The increased arousal, the result of adrenalin pumping through the system, increases existing tremors while decreasing function. Stress management techniques are therefore an important component of the POC. In general, patients do better in a low-stimulus environment that allows full concentration on control of movements. They benefit from augmented feedback (verbal cueing of knowledge of results and knowledge of performance; biofeedback) and repetition to improve motor learning. The patient with MS is often restricted in practice by neuromuscular fatigue and neurological deficits that impair sensory feedback, attention, memory, and concentration. The successful therapist will need to carefully identify the patient's resources and abilities and capitalize on them to maximize motor learning.
Walking ability is frequently impaired. However, at least 65% of patients with MS are still walking after 20 years.9 Early gait problems often include poor balance and heaviness of one or more limbs. Patients frequently report difficulty lifting their legs (hip flexor weakness). Weak dorsiflexors are also common, resulting in foot drop. Problems with foot clearance may result in a circumducted gait pattern, among other gait deviations. Later problems evolve owing to clonus, spasticity, sensory loss, and/or ataxia. Weakness generally extends to include the quadriceps and hip abductors. Quadriceps weakness typically results in hyperextension of the knee and forward flexion of the trunk with increased lumbar lordosis. Hip abductor weakness results in a Trendelenburg gait pattern with a strong lateral lean to the weak side.
A well-designed exercise program of tone management, stretching, and strengthening exercises can improve walking. Standing and walking activities should stress safety and maintaining a stable BOS; maximum weight-bearing through the LEs; and adequate weight transfer and forward progression with trunk, limb, and pelvic kinematics consistent with safe walking. Verbal and manual cueing can assist the patient in the correct mechanics of gait. A variety of functional activities should be practiced. These include walking forward and backward, side-stepping, and cross-stepping (Fig. 16.10). Braiding (a PNF activity that combines side-stepping and cross-stepping) is a complex, higher-level walking activity. Stair climbing, negotiating curbs and ramps, navigation around obstacles, and walking on varied surfaces should also be practiced for safety in community mobility. See Chapter 11, Locomotor Training, for further discussion. As previously mentioned, the pool is an important medium that can be used to assist training of the more involved patient with ataxia while reducing tone and fatigue.
Patient practices cross-stepping. Dynamic standing activities are an integral component of an exercise program geared toward improving gait/locomotion.
Locomotor training (LT) using an antigravity treadmill or a treadmill training (TT) with body weight support (BWS) has been the focus of increasing attention in the literature and used extensively to improve gait in patients with spinal cord injury and stroke (see discussion in Chapter 10 and Evidence Summary Boxes in Chapter 15, Stroke, and Chapter 20, Traumatic Spinal Cord Injury). In studies involving persons with MS using LT and BWS, improvements in muscle strength, spasticity, endurance, balance, walking speed, and quality of life have been reported. Level of effort was reduced while detrimental effects on fatigue are not evident.153,154,155 Robot-assisted treadmill training (RATT) with BWS has also been used and when compared to conventional BWS TT, patients in both groups experienced similar improvements in outcome measures.156,157 When RATT was compared to conventional gait training, no difference in outcomes was found between the groups.158 In summary, LT with BWS is an activity-dependent intervention that is feasible and safe and has the potential to result in significant improvements in function for patients with MS.
Orthotics and Assistive Devices
Patients with MS typically require orthotic devices as ambulation skills decline. Ankle-foot stability can be achieved by the addition of an ankle-foot orthosis (AFO). Improvements in energy efficiency and safety are also important outcomes. AFOs are prescribed for foot drop, poor knee control (especially hyperextension), minimal to moderate spasticity, and poor somatosensation. The most common type used is the standard polypropylene AFO, which is lightweight and has the added benefit of cosmesis (Fig. 16.11). An AFO with an articulated joint can be prescribed to provide more rigid control for the ankle with the addition of a plantarflexion stop. Functional electrical stimulation (FES) devices have become prevalent in treatment and compensation for foot drop with improvements in walking performance and satisfaction reported. Patients also experienced fewer falls and reduced fatigue.159,160,161 In order to effectively use any orthotic or FES device for foot drop, an individual must have adequate hip flexion strength. Relative contraindications to the prescription of these devices include severe spasticity, foot edema, and weakness (nonfunctional grades of LE muscles, especially hip flexors). Although knee-ankle-foot orthoses (KAFOs) can provide additional stabilization control of the knee, they are rarely used because of the increased energy expenditure required.
Patient is wearing an ankle-foot orthosis (AFO) to stabilize the ankle and prevent foot drop.
Canes, forearm crutches, or a walker may be necessary to compensate for deficits in fatigue, strength, sensory loss (numbness), or balance (Fig. 16.12). For many patients acceptance of an assistive device involves full recognition of their disability. They need to be convinced that use of these devices is far safer than "wall walking" or "furniture walking." Devices also provide recognition to the community at large that patients are not staggering or losing their balance because they are "drunk," a frequent occurrence with many patients. The devices may be the difference between community participation or remaining homebound because of fear of falling. Patients should be encouraged to try out different devices to determine which works best for them. For example, the patient with significant fatigue levels may benefit from a large-wheeled walker with locking hand brakes and a seat that allows for frequent rests. Recent technological advancements have brought a new breed of mechanical upright walking devices that have integrated computer chips, sensors, and motors to aid an individual in ambulation. Cosmesis is an important factor in promoting acceptance. There are many innovations in assistive technology that make the choices easier. For example, designer canes now come in many different colors and styles, including clear Lucite. ABLEDATA (www.able-data.com) is a federally funded project that offers product information, resources, and links to manufacturers.162
Locomotor training with a front-wheeled rolling walker.
As the disease progresses, many patients benefit from a wheeled mobility device (powered scooter or wheelchair). The course and progression of the disease and presenting symptoms should be taken into consideration when deciding on a device. For patients with adequate trunk stability, UE function, and appropriate visual, perceptual, and cognitive skills, a scooter provides needed mobility while conserving energy. Scooters also do not carry the same negative stigma as that of a wheelchair. Both three- and four-wheel scooters are available. Four-wheel scooters have superior outdoor and uneven terrain performance, but are not as easily transported. Features that should be recommended include a seat that rotates for easy mounting and dismounting, easy dismantling for loading into the car, and steering mechanisms that minimize the work of the UEs. One disadvantage of scooters is that seating cannot always be customized. They are often not designed for prolonged sitting or for patients with moderate to severe postural instability. Some new three-wheeled scooters are designed to turn in very small areas while others have a wide turning radius and may not be suitable for in-home use. The individual with MS must be adequately educated on the safety precautions of a scooter, because the trunk strength and stability requirements are significantly higher than those of a power wheelchair.
A wheelchair should be considered when postural demands necessitate increased support. A standard wheelchair requires additional energy expenditure and coordination for propulsion. When prescribing a manual wheelchair to an individual with MS it is important to include education on proper wheelchair propulsion for both preservation of shoulder strength and energy conservation. A power wheelchair should be considered when impairments prevent or limit manual propulsion or when fatigue is a major limiting factor in mobility (Fig. 16.13). However, they are more costly and require specialized transportation by a wheelchair-accessible van or bus. Most patients will navigate using a joystick. For patients with impaired hand strength and sensation, the joystick can be adjusted to increase sensitivity. Wheelchair seating should ensure proper alignment of the pelvis, trunk and head, and limbs while enhancing function. Common malalignments include posterior tilting of the pelvis (sacral sitting) with kyphosis, typically the result of spasticity in the hamstring muscles. This can be improved with the addition of a seat cushion. Postural alignment can also be assisted by the addition of contoured seating (custom built). A solid back support and adjustable lateral trunk supports may be needed to enhance postural alignment and upright sitting. Footrests should be positioned to ensure that the thighs are parallel to the floor. If extensor spasms are strong, they can actually propel the patient out of the chair. A strong lap belt that secures firmly around the pelvis is necessary for safety. For patients with strong adductor spasticity, a medial knee block (pommel) may be necessary. Heel loops and straps may be required to maintain foot position on the footrests. Patients who no longer demonstrate adequate trunk and head stability require an alternate seating design. A tilt-in-space wheelchair with head/neck support is a better option than a reclining wheelchair with high back and elevating leg rests. The former maintains the normal hip sitting angle; the latter produces extension of the hips and may feed into strong extensor spasticity. Elevating leg rests tend to stretch hamstring muscles and may cause posterior pelvic tilting when spasticity is present. The reclining wheelchair with elevating leg rests also creates greater environmental access problems. Motorized control of the seat back available in tilt-in-space wheelchairs will allow the patient to make easy adjustments in position, thus preventing skin breakdown. See Chapter 32, The Prescriptive Wheelchair, for additional discussion.
An individual with MS using a power wheelchair with joystick control for mobility. The correct power wheelchair prescription can encourage proper alignment of the pelvis, trunk, head, and limbs.
Patients should be instructed in transfer and wheelchair mobility/management skills. A transfer board or hydraulic lift may be necessary as UE function deteriorates. Attention to good sitting posture and pressure-relief techniques is essential to maintain alignment and prevent skin breakdown. Patients should be encouraged to balance time in the wheelchair with other activities, such as walking or exercising, and should be extra diligent in stretching muscles that tend to contract as a result of prolonged sitting (e.g., hip and knee flexors).
One of the constraints the therapist will have to deal with is financial reimbursement for the changing mobility needs of the patient with chronic MS. Private or public insurance organizations require a statement of medical necessity for payment. Because symptoms are not static in MS but rather typically exacerbate or remit, the therapist needs to provide clear and convincing documentation of need, stressing improved function and safety. Many third-party payers will not reimburse for new wheelchairs prescribed within specified time intervals or may be hesitant to finance expensive specialty wheelchairs such as the tilt-in-space chair or a second lightweight chair for traveling. The therapist will need to provide careful documentation of potential adverse outcomes to justify the cost of the new chair. For example, a likely deleterious outcome for a patient who is denied reimbursement for a tilt-in-space chair may be skin breakdown. The costs of nursing and surgical care for decubitus ulcers can then be compared to the cost of the new wheelchair, which can be justified as a preventive measure. It is equally important to anticipate future needs as they relate to rate of disease progression when ordering equipment.
Functional training should focus on problem solving and the development of appropriate decision making skills required to meet the challenges of being disabled. Skills should be adapted and practiced to ensure safe performance in both the home and community environments. Training in functional mobility skills (e.g., bed mobility, transfers, locomotion) is typically directed by the physical therapist whereas ADL (e.g., dressing, personal hygiene, bathing, toileting, grooming, and feeding) and IADL (e.g., cooking, laundry, and bed making) training is directed by the occupational therapist and training in communication skills by the speech-language pathologist. Close communication and coordination among team members is necessary to ensure that training methods are consistently applied and successful. Full participation of the patient in all phases of planning and training will increase personal involvement while decreasing dependency and passivity.
The majority of patients with MS will use multiple adaptive devices. This requires careful attention to appropriate prescription of devices and environmental modifications to assist the patient in conserving energy and maintaining function. Adaptive equipment can include bed or bathroom grab bars, overhead trapeze, raised seats, transfer board, or hydraulic lift. Appropriate positional and functional splints to facilitate writing or typing and plates and cups with lips to minimize spills are often helpful in assisting with hand function. Long-handled shoehorns, reachers, button hooks, sock aids, or Velcro® closures can assist in dressing. Effective communication may require built-up writing utensils or a universal cuff for written communication or more sophisticated computerized devices. Patients with severe speech problems may require voice amplification devices, electronic aids, or computer-assisted alternative communication systems. The team must recognize when a device is indicated, and assist the patient in acceptance and in learning how to use the device before significant deterioration of function occurs.
Management of Speech and Swallowing
Impairments in communication and swallowing have been identified in individuals with MS.163 The scientific literature reports that 44% of MS patients experience impairments of speech and voice in the early onset of their disease, and as many as 35% to 43% of MS patients can acquire voice, chewing, and swallowing disorders.164 Respiratory deconditioning, characterized by reduced diaphragmatic support and shortening of the intercostal muscles, contributes to speech disorders and increases the likelihood of respiratory infections. Thus, collaborating with a speech-language pathologist to develop a resistive breathing training (RBT) program paired with activities to improve trunk stability, head control, and sitting balance is an important component of the POC for patients with MS. Improved respiration can be facilitated through the implementation of prolonged phonation exercises, resistive breathing exercises, and incentive spirometry. The therapist should focus on diaphragmatic and segmental chest expansion, expiratory training, and volitional and effortful coughing.165
When dysphagia or difficulty in swallowing occurs, physical therapists should work closely with speech-language pathologists to preserve safety of swallowing. Often a detailed examination is needed to investigate the deceptively complex swallowing mechanism. Diagnostic methods include Videofluoroscopic Swallowing Studies (VFSS) and Flexible Endoscopic Evaluation of Swallowing (FEES).166 The role of the physical therapist is important in assisting with improving sitting position, body posture, and head control. An upright body posture with a slightly forward and downward-pointing chin position can be helpful in achieving a safe swallow and preventing aspiration.167 Application of transcutaneous neuromuscular electric stimulation (NMES) to the submental muscles (suprahyoid triangle) to facilitate muscle reeducation was cleared by the FDA in late 2002, after the submission of data from over 800 patients (adults and children). NMES of the submental muscles paired with selected oral–motor exercises and swallowing maneuvers (e.g., Mendelsohn maneuver, effortful swallow, super-supraglottic swallow) can improve the strength, ROM, and coordination of the swallowing musculature.165
Thermal-tactile stimulation (TTS) is a sensory technique whereby stimulation is provided to the anterior faucial pillars to improve swallowing reflexes and the pharyngeal phase of swallowing. Anecdotally, the use of cold and icy beverages such as a shakes, fruit slushes, and ice chips provide heightened sensory input, which can improve the initiation of swallowing for many patients. Some patients also benefit from alternating small (teaspoon sized) sips of liquids with their food during mealtime. Most patients should be discouraged to engage in consecutive swallowing because it increases demand on the respiratory system and decreases airway protection. Resistive sucking through a straw can also be helpful. Thick liquids such as honey-thick and nectar-thick liquids can provide some resistance to facilitate muscle strengthening.168 Moist foods (with sauces, broth, water, or milk) are easier to manage than dry ones. Semisolid and pureed foods are easier than regular solids. Foods that irritate the throat (e.g., vinegar) and crumbly or stringy foods (e.g., cake, cookies, potato chips, celery, cheeses) should be avoided. Patients also benefit when instructed to focus their effort on eating and never attempting to talk during active eating (mastication). Maintaining a quiet and peaceful environment during meals is helpful in improving attention and focus. Fatigue can also affect food intake. Many patients with MS benefit from reducing the size of their meals and eating smaller, more nutrient-dense meals throughout the day. Percutaneous endoscopic gastrostomy (PEG) feeding tubes and/or nasogastric tubes may become medically necessary for individuals with severe dysphagia.169 For overall safety, it is important that family members, caregivers, and health care providers alike are educated in the use of the Heimlich maneuver in the event of an emergency.170
Cognitive impairments can present major difficulties for the patient and for the rehabilitation team in general. Referral to a neuropsychologist may be indicated to determine the patient's strengths and weaknesses and to assist in the adaptive process. Compensatory strategies for memory deficits can be helpful. These include the use of memory aids, timing devices, and environmental strategies. Memory can be assisted by using a memory notebook to log daily events and reminders. With the increasing availability of mobile technologies, mobile devices have proven helpful for individuals with cognitive impairment related to MS. Trials have shown that use of a personal digital assistant (PDA) device significantly improves functional performance of everyday tasks. Patients who have incorporated mobile devices into their daily routines note improvement in organization and self-efficacy that positively affected their daily lives.171 A pill dispenser can assist the patient in maintaining a correct medication schedule. Cueing devices such as an alarm clock, bell timer, or watch alarm can help patients remember when to do certain tasks (e.g., taking medications, performing pressure relief). Structuring and labeling the environment is also an effective strategy to assist memory (e.g., labeled drawers, cabinets). Directions for functional tasks (e.g., transfers, self-stretching techniques) should be carefully written down for both patients and caregivers. Complex tasks can be broken down with clear written directions provided for each step. Directions can be posted in different areas of the home (e.g., steps to follow for toilet or tub transfer posted in the bathroom). Additional cognitive strategies that may be helpful include mental rehearsal, requesting assistance, maximizing alertness, avoidance of difficult situations, and mental exercises. Poor follow-through should be expected among patients with severe cognitive deficits, because often there is very little insight. In this situation, the efforts of family and caregivers must be fully maximized.17
Cognitive-behavioral therapy (CBT) for patients with MS can yield significant improvement in the ability to deal with distress, debilitating symptoms, impairment and disease exacerbation, and progression.172 As with healthy individuals, regular physical activity can have a positive effect on cognitive function, self-efficacy, and quality of life.173,174 A computer-based home training program used in conjunction with other treatments has been shown to improve function in patients with MS.175