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PHTY3140 > L23: Management of Multiple Sclerosis > Flashcards

L23: Management of Multiple Sclerosis Flashcards

1
Q

What are the 2 Motor Control Systems Theory for physiotherapy assessment of multiple sclerosis?

A
  1. Motor relearning andfunctional recovery require thecapacity to reacquire or modify movement
  2. Cognition, action, perception -often ≥2 are affected
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2
Q

What are 4 features of cognition in MS?

A
  1. Higher level processing
  2. Impaired executive function
    • Give clear concise instructions
    • Check list for exercise
    • Extra person as motivator
  3. Short term memory
  4. Apraxia
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3
Q

What are 4 features of cognition in MS?

A
  1. Higher level processing
  2. Impaired executive functio
    1. Give clear concise instructions
    2. Check list for exercise
    3. Extra person as motivator
  3. Short term memory
  4. Apraxia
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4
Q

What are 4 features of action in MS?

A
  1. Muscle weakness
    • 1 contraction 10 reps - if deteriorating performance, then it is neuromuscular fatigue
  2. Motor ataxia
  3. Spasticity - risk of falls
  4. Fatigue: MS people use more brain energy to achieve simple tasks because they are adapting to lesions (neuroplasticity)
    • Break down the fatigue, and treat each part - sleep, bladder intervention, exercise for brain health and to prevent deconditioning.
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5
Q

What are 2 features of perception in MS?

A
  1. Slowed or lost conduction of visual, somatosensory, vestibular resulting in sensory or vestibular ataxia (balance and mobility)
  2. Pain
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6
Q

What are 2 features of the lack of information when identifying missing information?

A
  1. Due to lack of client/carer/health professional awareness about MS
  2. Due to MS-related cognitive impairments: Short term memory, lack of insight
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7
Q

What are 16 systems are affected by CNS demyelination and axonal damage in multiple sclerosis (MS)?

A
  1. Motor
  2. Sensory
  3. Visual
  4. Vestibular
  5. Respiratory
  6. Bladder
  7. Bowel
  8. Circulatory
  9. Cognitive
  10. Emotional
  11. Behavioural
  12. Swallowing
  13. Speech
  14. Auditory
  15. Olfactory
  16. Taste

Always expect complexity with MS

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8
Q

What are 5 system impairments which may impact on other impairments in MS?

A
  1. Variability: No easily identifiable pattern, differ from day to day
  2. Contradictory: Masking of the true nature of the problem
  3. Subjectivity: No easily collected objective data
    • Limited MS-specific vocabulary - educate them on how to describe symptoms
  4. Range of possible presentations - no typical presentation
  5. Range of causative/aggravating factors and their interactions
    • Ask targeted, specific questions to find the underlying causes ○ Treat the underlying cause, not the superficial symptom
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9
Q

What are 5 general questions for multiple sclerosis (MS)?

A
  1. Have you noticed any changes with…?
    1. e.g. Eating, bladder, bowels, memory
    2. Especially reasons for referral, things that will affect treatment
  2. Do you have problems with…?
  3. What is your regular routine with or how do you manage…?
    • e.g. Toileting, sleeping
    • Ask about things you cannot see in session
  4. Provide examples/descriptions of possible symptoms
    • Bladder function
    • Bowel function
    • Speech/swallowing
    • Respiration
    • Fatigue factors
    • Regular activity level
    • Mobility
    • Sensory changes
    • Balance
    • ADL
  5. Patient’s goals (reason for referral)
    • NDIS is about ICF participation goals
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10
Q

What are 5 examples/descriptions of possible symptoms for general questions for multiple sclerosis (MS)?

A
  1. Bladder function
  2. Bowel function
  3. Speech/swallowing
  4. Respiration
  5. Fatigue factors
  6. Regular activity level
  7. Mobility
  8. Sensory changes
  9. Balance
  10. ADL
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11
Q

What are 6 features on the type of MS, which will give clues about potential for recovery?

A
  1. Relapsing remitting with complete recovery or with residual deficits
  2. Secondary progressive
  3. Chronic progressive with slow or fast deterioration
  4. Primary progressive
  5. History of recovery post-exacerbation will indicate their potential for recovery
  6. Any change from their usual pattern may indicate a change in MS activity - need review and new management strategies and planning
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12
Q

What are 2 medical management of multiple sclerosis (MS)?

A
  1. Disease-modifying drugs slow the progression of MS activity and disability
  2. Exercise improves QoL as much as disease-modifying drugs
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13
Q

What are 3 features of “disease-modifying drugs” as medical management of multiple sclerosis (MS)?

A

Disease-modifying drugs slow the progression of MS activity and disability

  1. Decrease relapses rate by ~35%
  2. Minimise severity of relapses by ~50%
  3. Not a cure
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14
Q

What are 2 features of “exercise” as medical management of multiple sclerosis (MS)?

A

Exercise improves QoL as much as disease-modifying drugs

  1. Exercise + disease-modifying drugs = improved long term outcomes
  2. Aerobic exercise increases neurotrophins, which protect brain and minimise MS progression
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15
Q

What are “injections” as medical management of multiple sclerosis (MS)?

A

Injections are safe and effective, but patients tend to be reluctant with injections

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16
Q

What are 2 injections as medical management of multiple sclerosis (MS)?

A
  1. Interferon-beta (IFN)
    • Betaferon: Every second day subcutaneous injection
    • Rebif: Three times a week subcutaneous injection
    • Avonex: Once weekly intramuscular injection
  2. Glatiramer acetate (GA)
    • Copaxone: Daily subcutaneous injection
  3. 10 oral drugs
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17
Q

What are 5 features of infusions as medical management of multiple sclerosis (MS)?

A

Tysabri (Natalizumab): Monoclonal antibody that stops T-cells crossing BBB into CNS.

  1. Improves physical & cognitive functions
  2. Given as 4 weekly infusions (300 mg IV)
  3. 2x more effective for reducing relapses then Interferons (68%)
  4. Needs monitoring
  5. Main risk is PML 1-1000.
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18
Q

What are2 oral drugs as medical management of multiple sclerosis (MS)?

A
  1. Cladribine
    • Given orally 1-2x per year, depending on the treatment regimen.
    • Currently used as an injection to treat leukaemia. It has been withdrawn but there are still QLDers on this medication.
  2. Fingolimod
    • Given orally daily.
    • Reduce nerve damage and enhance nerve repair.
    • Neuroprotective properties.
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19
Q

What are 4 features of “intravenous methylprednisolone for 3-5 days” as medical managements of multiple sclerosis (MS) exacerbation?

A
  1. Only for acute exacerbations, functional deterioration
  2. Reduces inflammation, size of lesion, impairment and disability caused by oedema
  3. Accelerate spontaneous recovery within 1-2 weeks.
  4. Mild acute exacerbations will spontaneously resolve without steroid treatment
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20
Q

What are 5 features of “post methylprednisolone” as medical managements of multiple sclerosis (MS) exacerbation?

A
  1. Drug effect lasts ≤6 weeks
    • Initially great functional increase is the false impact of steroids
    • May cause “euphoria”, boost in energy levels and willingness to be active
  2. ~2 weeks later, may experience a severe “physical and psychological crash”
  3. Long-term repeated use of steroid reduces its effectiveness, so it is only given for significant exacerbation
  4. Need a well-controlled, safe, intensive exercise program including stretching and ADLs to maintain current level
  5. Allow for individuality of responses
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21
Q

What are 4 physiotherapy specialties for Multiple Sclerosis (MS) for physiotherapy management?

A
  1. MSK: Management of pain related to poor movement patterns; poor core strength in the early stage MS
    • Fatigue easily because not enough neural signals to MSK
  2. Women’s health: Continence issues - increased urinary frequency
  3. Vestibular: Specific vestibular related balance/mobility issues
    • Vertigo
    • Balance issue is prevalent (show impairments in CTSIB)
    • Balance costs much brain energy - fatigue
  4. Cardiorespiratory: Acute management/preventative strategies in end stage MS
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22
Q

_______ physiotherapy practiced in interdisciplinary team framework is recommended for MS.

A

Neurological

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23
Q

What are 3 neurological physiotherapy for Multiple Sclerosis (MS) for physiotherapy management?

A
  1. Identify and managing MS impairments, including promoting self management
  2. Screening for symptoms - identifying referral needs
  3. Managing the episodic periods of exacerbations
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24
Q

What are 4 MS continuum of care?

A
  1. 1st stage Diagnostic
  2. 2nd stage Minimal impairment
  3. 3rd stage Moderate Disability
  4. 4th stage Severe disability
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25
Q

What are the 2 focuses of rehabilitation management in the MS continuum of care?

A
  • Diagnosis
  • Rehabilitation
    1. Disease modifying treatments
    2. General rehabilitation goals:
    3. Participation in family, occupation and financial
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26
Q

What are the 3 focuses of maintenance management in the MS continuum of care?

A
  1. Therapeutic interventions
  2. Preventative interventions
  3. General rehabilitation goals
27
Q

What are the 3 focuses of prevention management in the MS continuum of care?

A
  1. Therapeutic interventions may change
  2. Preventative interventions increases
  3. Maximise activity and participation by adapting social environments
28
Q

What are the 4 focuses of palliative care management in the MS continuum of care?

A
  1. Provide supports with ADL, respite, care plan
  2. Modified environment aiming to maintain social participation
  3. Preventative interventions
  4. Carer education and training
29
Q

What are the 4 strategies of management for 1st stage (diagnostic) in the MS continuum of care?

A
  1. Neuroplasticity principles
  2. Challenging physical activities
  3. Early physiotherapy strategies
  4. Wellness workshops
30
Q

What are the 3 neuroplasticity principles of strategies of management for 1st stage (diagnostic) in the MS continuum of care?

A
  1. Developing healthy habits: e.g. Regular exercise
  2. Do new skills to drive neuroplasticity
  3. High intensity interval training for brain health
31
Q

What are the 4 challenging of principle strategies of management for 1st stage (diagnostic) in the MS continuum of care?

A
  1. Fitness
  2. Strength
  3. Flexibility
  4. Functional goals
32
Q

What are the 3 early physiotherapy strategies of management for 1st stage (diagnostic) in the MS continuum of care?

A
  1. Neurological screening
  2. Physical activity audits
  3. Coaching correct movement patterns (e.g. Pilates)
33
Q

What is a wellness workshop as strategies of management for 1st stage (diagnostic) in the MS continuum of care?

A

Yoga, Tai Chi, Pilates, Heartmoves in MS

34
Q

What are the 3 neuroplasticity principles of strategies of management for 2nd stage (minimal impairment) in the MS continuum of care?

A
  1. Developing healthy habits: e.g. Regular exercise
  2. Challenging physical activities
  3. Functional goals
35
Q

What are the preventative strategies of management for 2nd stage (minimal impairment) in the MS continuum of care?

A

Preventative strategies based on symptom-specific management to support functioning

  • A&E strategies
36
Q

What are 4 specialist clinic strategies of management for 2nd stage (minimal impairment) in the MS continuum of care?

A

MS mobility/balance clinics with MDT

  1. Botox in gait facilitation, spasticity
  2. FES gait aides (Bioness)
  3. Very high level balance activities - dual/multi-tasking
  4. Group training
37
Q

What are 5 “maintain and build strength” strategies of management for 3rd stage (moderate impairment) in the MS continuum of care?

A
  1. Maintenance exercise related to independence in the absence of a problematic activity.
  2. Fitness
  3. Strength
  4. Flexibility
  5. Functional tasks training
38
Q

What are adaptive strategies of management for 3rd stage (moderate impairment) in the MS continuum of care?

A

Adaptive strategies to support functioning

  • Usually cannot go to work
39
Q

What are preventative strategies of management for 3rd stage (moderate impairment) in the MS continuum of care?

A

Preventative strategies for symptom management to prevent negative consequences

40
Q

What are 6 maintence and preventative strategies of management for 4th stage (severe impairment) in the MS continuum of care?

A
  1. Positioning
  2. Skin integrity
  3. Minimise contracture - flexibility
  4. Preserve ease of care: e.g. Hygiene and dressing
  5. Respiratory management Not related to maintaining independence
41
Q

What are 2 features of the Methylprednisolone + MDT approach for physiotherapy management of MS exacerbation?

A

Methylprednisolone + MDT approach was better.

  1. Significant improvements ≤3 months for disability, motor function, QoL
  2. In reality, you do not really see the benefits because methylpred is a day procedure - patient goes home after injection
42
Q

What are 4 features of program for physiotherapy management of MS exacerbation?

A
  1. Immediate stretching and positioning for effected areas
  2. Prescribe active movements (assisted?) and activities to maintain unaffected areas
  3. Avoid compensatory strategies while waiting for spontaneous recovery
  4. This will enhance the spontaneous recovery process by ensuring that the patient has the best physical state to attend rehabilitation post-exacerbation
43
Q

What are 4 fast track referrals to physiotherapy (first day of treatment) if exacerbations for physiotherapy management of MS exacerbation?

A
  1. Ward policies specifying minimum standards of care including referral to PT for screening and advice
    • MS is not the highest priority patients in hospital - coming after strokes etc.
  2. Staff education
  3. Patient resources: A&E on self-management strategies during their brief ward stay
    • Teach family to assist exercises
  4. Individualised physiotherapy programs for complex presentations
44
Q

What are 4 physiotherapy management for post MS exacerbation?

A
  1. The brain can repair itself across the lifespan of an MS patient.
  2. Thus, we needs to consider the potential of functional recovery at a cellular and structural level when planning rehabilitati on.
  3. For the medium-long terms, we need to prevent immobility and disuse to prevent adaptive changes and learned non-use.
  4. But at some point, we need to transition from rehabilitation strategies to compensatory strategies to facilitate functional r ecovery and QoL.
    • No clear timeline on when to change strategies
45
Q

What are 3 factors that the duration of access to physiotherapy depends on for management for post MS exacerbation?

A
  1. Organizational policy
  2. Availability of resources
  3. Patient’s financial ability for extended physiotherapy.
46
Q

What are 3 features of motorised cycling as an intensive aerobic exercise for management for post MS exacerbation?

A
  1. For people who cannot generate force
  2. Unsure if increase neuroplasticity?
47
Q

What are 3 clicnial presentations of MS in neuroplasticity (MRI)?

A

Clinical presentation of MS is the combined results of tissue damage, tissue repair and cortical reorganisation.

  1. The progressive failure of tissue repair and cortical reorganization either initiates further cortical reorganization to prev enting clinical S&S, or contributes to the eventual clinical manifestation of the disease.
  2. fMRI studies showed that in all types of MS, there is significant cortical reorganization in CNS centres of visual, cognitive and motor functions, and in the spinal cord and optic nerves.
  3. fMRI studies have confirmed the potential of neurorehabilitation to affect motor recovery via cortical reorganization post br ain damage.
48
Q

Clinical presentation of MS is the combined results of ______, _______ and ________.

A

tissue damage; tissue repair; cortical reorganisation

49
Q

What are 2 features of “targeted physiotherapy have efficacy for all types of MS” for physiotherapy implications on neuroplasticity?

A
  1. Although physiotherapy does not bring on cortical reorganization, it does benefit motor function recovery.
  2. Variety of service delivery models: Home based, community based, hospital based.
    • No consensus on which delivery model is the best.
50
Q

What are 5 features of “fMRl studies identified movement-associated cortical reorganization that reflect different stages of MS” for physiotherapy implications on neuroplasticity

A
  1. Unmasking of latent pathways
  2. Cortical reorganization initially involved recruiting more cortical areas related to a specific motor function
  3. Increasing recruitment of functionally related areas
  4. Bilateral activation of functionally related areas
  5. As disability progresses, the motor tasks recruited more thalamus and more cortical areas related with new or complex tasks.
51
Q

What are 5 features to promote neuroplasticity for physiotherapy implications on neuroplasticity?

A
  1. Be guided by the neuroplasticity research
  2. Early assessment & rehab to promote good neuroplasticity and prevent bad neuroplasticity
  3. Use new technologies (e.g. fMRl scans) to determine the potential for neuroplasticity
  4. Implement preventative programs to prevent disuse, inactivity and secondary complications
  5. Be aware of Motor Learning Theory
52
Q

What are 8 features of “motor learning principles in stroke rehab that promote neuroplasticity” for physiotherapy implications on neuroplasticity?

A
  1. Amount and timing of rehabilitation - high reps!
  2. Functional tasks
  3. Bilateral tasks
  4. Mental practice
  5. Error free learning
  6. Feedback (type, timing)
  7. Mirror box therapy
  8. Constraint induced therapy
53
Q

What are 2 features of cognitive impairments and motor learning for MS?

A
  1. Cerebellum is actively involved in motor recovery in MS. •
  2. The reacquisition of skilled movements require the capacity to learn
54
Q

What are 6 cognitive impairments for MS?

A
  1. Subcortical demyelination causes difficulty in
    • Concentrating
    • Understanding complex issues
    • Disjointed thinking
    • Lack of insight into cognitive changes.
  2. Frontal lobe changes cause difficulty in:
    • ​Executive function
    • Adynamia
    • Cannot change ideas and thought patterns
    • Distractibility
    • Impaired conscious organization for planned action
    • Cannot learn from errors.​
  3. Slower thinking
  4. Poor short term memory
  5. Difficulty regulating behaviour
  6. Lack of motivation/cooperation
55
Q

What are 4 things that subcortical demyelination causes difficulty in as cognitive impairments for MS?

A
  1. Concentrating
  2. Understanding complex issues
  3. Disjointed thinking
  4. Lack of insight into cognitive changes.
56
Q

What are 6 things that frontal lobe changes cause difficulty in as cognitive impairments for MS?

A
  1. Executive function
  2. Adynamia
  3. Cannot change ideas and thought patterns
  4. Distractibility
  5. Impaired conscious organization for planned action
  6. Cannot learn from errors
57
Q

What are 6 severe cognitive impairments for MS?

A

Severe cognitive impairments may significantly restrict potential for motor learning

  1. Language function and social skills are generally okay, so the cognitive deficits may stay hidden
    1. MS patients with minimal physical impairment and intact superficial cognitive ability may have significant cognitive deficits
  2. Declarative or explicit learning is impaired
  3. Trial and error learning is not recommended for MS, because the incorrect way needs to be unlearned before the correct way ca n be learned.
  4. Significant cognitive impairment is the cause of apraxic gait disorders in people without sensory or motor impairment.
  5. The severity of cognitive impairment is linked to the amount of damage on MRI, but is not linked to the degree of motor impairment.
  6. Ideally, we need to read comprehensive neuropsychological reports to aid the planning of motor learning.
58
Q

What are 6 major strategies for cognitive impairments?

A
  1. Simple Instructions
  2. Complex Skill Learning
  3. Environmental Factors
  4. Self‐Generated Learning
  5. Repetition of Movement
  6. Feedback
59
Q

What are 6 simple instructions as strategies for cognitive impairments?

A
  1. Too much explanation may be too difficult to process.
  2. Keep instructions and feedback consistent and simple
  3. Allow time for instructions and feedback to be processed
  4. Set realistic expectations.
  5. Only teach the correct way
  6. Need time for supervised practice
60
Q

What are 3 feedbacks as strategies for cognitive impairments?

A
  1. Precise and directive feedback is necessary, and needed to be given >1x for every 5 trials.
  2. Auditory cues were effective for gait re-education in MS with cerebellar ataxia.
  3. Self-generated learning
61
Q

What are 4 complex skill learning as strategies for cognitive impairments?

A
  1. Breaking tasks down into small steps
    • Prompts may assist them to remember some steps initially
    • Memory of all steps may occur over time
  2. Procedural memory is usually intact in MS, so remembering a learnt activity is easy.
    • But not remembering to practice an activity is common.
  3. Learning “new task” is possible but may take longer
    • New learning is more effective with context and imagery, especially for moderate to severe learning impairments.
    • Practice within the functional environment is good
  4. Strategies to aid memory
    • Written programs and instructions
    • Create simple meaningful associations to the activity
62
Q

What are 2 environmental factors as strategies for cognitive impairments?

A
  1. Need to minimise distractions, because auditory and visual stimuli may distract patients with poor selective concentration.
  2. Cooler room temperature can minimise heat-related cognitive impairment and temporary flare-ups (e.g. Neuromuscular fatigue, weakness).
63
Q

What are 3 self-generated learning as strategies for cognitive impairments?

A
  1. Self-generated information is easier to remember and learn.
  2. More effective then didactic learning
  3. Self‐generation may enhance new learning for MS patients with cognitive impairments.
    1. Allowing them to design verbal and internal cues, feedback and instructions
    2. Allowing them to choose which tasks and activities are practiced
64
Q

What are 4 repetition of movement as strategies for cognitive impairments?

A
  1. MS patients need more repetitions to reach the target performance
  2. Procedural learning requires repetition and varied practice conditions
    • The shift from procedural memory to explicit memory is a long process, if it occurs at all.
  3. In reality, practice frequency may be inconsistent due to neuromuscular fatigue and general fatigueability.
    • Practice may be limited to mornings when energy levels are higher.
    • If they have short term memory problems, then practice is limited to the availability of supervision.
  4. Variation of practice conditions is hard for MS patients with delayed or absent processing of sensory feedback and external environmental cues
  5. Need external cueing, feedback and supervision

PHTY3140 (28 decks)

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