10/28 MS Rehab Lecture

Question 1

What are some of the comments you might hear from a patient with MS?

Answer 1

1) “feeling I can’t do things correctly”
2) “concern about safety”
3) “feeling what I do doesn’t help”
4) “lack of information about what to do”
5) “lack of help from health care professionals”

Question 2

If a patient with MS is at a moderate disability level:
What might you expect to see?
What type of training would be beneficial?

Answer 2

Moderate: Expect to see:

• restricted walking
• weakness & spasms
• moderate problems with balance

Training: - Adapt program to limitations
- Assistance with exercise program

Question 3

Besides the risk factors, what needs to be considered with patients with MS?

Answer 3

• Heart rate & blood pressure response to exercise (dysautonomia)
• Heat intolerance – Thermosensitivity
• Respiratory weakness (weakness of trunk)
• Impaired bowel/bladder control
• Medication effects and side-effects
• Equipment needs (adaptive)

Question 4

Where is the ideal exercise intensity level for patients with MS on the Borg scale?

Answer 4

It is best to keep the patient exertion level between 12-14 (somewhat hard).

Question 5

What are the key factors for intervention when you have a patient with MS?

Answer 5

1) Energy conservation
2) Strength training
3) Resistive exercise training
4) Aerobic exercise/Endurance
5) Stretching (hypertonicity)
6) Complimentary alternative medicine (CAM) - Yoga, T’ai Chi
7) Aquatic therapy
8) Balance

Question 6

Many patients with MS take meds for spasticity, what is an important side effect of these meds?

Answer 6

An important side effect of spasticity meds is fatigue.

So, its important for a PT to know dosage and when meds were taken

Question 7

Name 2 anti-spasticity meds. Name one paralytic med.

Answer 7

Spasticity meds: Baclofen, Zanaflex

Paralytic: Botulinum Toxin injection

Question 8

Yoga (author: Oken) found what results with his yoga intervention?

Answer 8

Yoga and exercise (stationary bike) groups both experienced decreased fatigue and improved health status/quality of life (SF-36)

Question 9

Husted completed a study on T’ai Chi - how did it benefit patients with MS?

Answer 9

• improved walking speed
• increased hamstring flexibility
• improved health status/quality of life (SF-36)

Question 10

An article by Hebert “The Ass’n between MS-related fatigue and balance as a function of central sensory integration” looked at what conditions?

Answer 10

Computerized dynamic posturography: sensory organization test (SOT)

1) Eyes Open - no sway reference
2) Eyes Closed - no sway reference
3) Eyes Open - visual/surround sway reference
4) Eyes Open - support surface sway reference
5) Eyes Closed - support surface sway reference
6) Eyes Open - visual/surround and support surface sway reference

Found there was a high correlation with fatigue.

Question 11

What systems are used for balance?

Answer 11

1) vision
2) somatosensory
3) inner ear (internal vestibular system)

Question 12

Where are the key lesion locations for MS?

Answer 12

• Supratentorial brain structures
  1) perventricular
  2) corpus collosum
  3) optic nerves
• Spinal cord
• Infratentorial brain structures
  1) cerebellum (cerebellar peduncles)
  2) brainstem

Question 13

Where are lesions most prevalent?

Answer 13

1) Brainstem

2) Cerebellum (cerebellar peduncles)

Question 14

Describe VOR

Answer 14

VOR - visual fixation during head movement; vestibulo-ocular reflex; stabilizes images during head movement by producing an eye movement in direction opposite to head movement - preserving the image on the center of the visual field.

• Tracking (smooth pursuit & VOR cancelation (overshooting the target))
• Saccadic eye movements
• Convergence/Divergence

Question 15

What cranial nerve and nucleus are associated with vertigo?

Answer 15

CN VIII - vestibulocochlear nerve

Medial vestibular nucleus (MVN)

Question 16

What is the BEEMS program?

Answer 16

BEEMS: Balance & Eye Movement Exercises for persons with MS

Eye movements: eye movements, visual fixation

Balance: varied feet alignment, varied compliance of standing surface, varied visual input, head movements, multi-tasking, “on command” walking tasks

Question 17

What is an example of multi-directional compliant surface? Of multi-directional responsive surface?

Answer 17

Multi-directional compliant surface - foam

Multi-directional responsive surface - trampoline (uses up a lot of energy, surface won’t allow large motions)

Question 18

What are 2 types of CNS repair and reorganization?

Answer 18

1) Neural repair (axonal and dendritic collateral sprouting, axonal regeneration, &/or neurogenesis)
2) Circumduct pathological neural pathways (neural adaptation & recruitment of parallel neural pathways that are able to control the same motor units)

Question 19

What are the “X-factors” for MS?

Answer 19

1) Impaired balance
2) Dizziness
3) Fatigue

Question 20

Where should falls be classified? Activity; Body, structure, & function; or Participation?

Answer 20

Participation restriction - determine if they are due to impaired balance and which system is affected

Question 21

T/F - Transient associated with relapse; non-fatiguing positional vertigo is tested with Dix-Hallpike

Answer 21

False!

Transient associated with relapse/non-fatiguing positional vertigo is consistent with lesion involvement of CN VIII &/or vestibular nucleus. Test for BPPV is not required.

Chronic recurring episodes/fatiguing positional vertigo is consistent with BPPV and is tested with Dix-Hallpike

Question 22

What test is used to assess the disability level of a patient with MS?

Answer 22

The Expanded Disability Status Scale (EDSS)

Question 23

What levels of the EDSS will benefit most from MS physical therapy?

Answer 23

0-6.5 benefit most (per my notes listening)

The box is around 0-6.0, but it doesn’t say what that means.

Question 24

Describe the EDSS disability levels.

When is an AD needed?

Answer 24

0-2.5 = None to minimal

3. 0-4.5 = fully ambulatory without aid
4. 0-5.5 = limited ambulation without aid
5. 0 = Intermittent or unilateral aid for 100m
6. 5 = Constant BIL aid for 20m
7. 0-10.0 = Extreme limits or absent ambulation

Question 25

What tests are done for VOR?

Answer 25

1) Gaze stabilization test (GST) (establishes speed of mead motion with fixation)
2) Dynamic visual acuity test (DVAT) (establishes acuity/fixation at constant speed of head motion); uses snelling chart; abnormal if visual acuity is above 3 lines of static acuity line

Question 26

What 4 conditions of the mCTSIB are used for patients with MS?

Answer 26

1) eyes open, firm surface
2) eyes closed, firm surface
3) eyes open, foam surface
4) eyes closed, foam surface

3 trials each, up to 30 seconds; validated in other populations such as older adults

Question 27

Top clinical tests to perform for a patient with MS.

Answer 27

1) DGI (cutoff 19; sens 87%, spec 51%)
or (cutoff 12; sens 45%, spec 80%)

2) Berg balance scale (cutoff 44; sens 40%, spec 90%)
3) Self-report: Activities-specific Balance Confidence (ABC) (cutoff 40; sens 65%, spec 77%)
4) Self-report: Dizziness Handicap Inventory (DHI) (cutoff 59; sens 50%, spec 74%)
5) Self-report: Modified Fatigue Impact Scale (MFIS) (cutoff 38); The MFIS correlates with walking capacity and disability - minimal detectable change (16.2 or 20.2)

Question 28

Which of the 2 tests when combined are best at discriminating falls?

Answer 28

1) ABC

2) DHI

Question 29

For a patient with MS, what are MS-specific important factors to consider?

Answer 29

1) Pyramidal function (strength/motor force production; tone/spasticity)
2) Cognition (attn to task; memory)
3) Psycho-social
4) Depression
5) Monocular or binocular loss of vision