MS Intervention Flashcards
What is important to prioritize when writing PT diagnosis for people with MS?
their problems (balance, weakness, fatigue, falls, gait, speed, outcome measure scores)
What are some common MS outcome measures?
- 12 item MS walking scale
- 6 min walk test
- 9 hole peg test
- berg balance
- dizziness handicap inventory
- MS functional composite
- MS impact scale
- MS quality of life
- TUG
Modifiable risk factors for MS
smoking, exercise
What does increased fatigue cause in MS patients?
- RPE and HR max is lower than most patients
- as PTs we are worried about heat and how it makes the symptoms worse
Anyone with an autoimmune disease should receive _______?
vaccinations
** make sure they communicate with their Drs to ensure the vaccinations they are getting is safe for them to receive
PTs help with deficits but also educate on ______
symptom management
Triggers to avoid with MS
- lack of sleep
- stress
- over activity
- heat
- childbirth
- staying healthy
- low vitamin D
Relapse education
- UTIs are common and may even cause relapses
- replapses reduce cognitive function
- if relapse is significant, advise patient to seek medical treatment
- tell patient you are going to reduce activity for 2 weeks (you don’t have to complete cut out activity, but decrease the amount/intensity and watch for S/S)
Medical interventions for patients with MS
disease modifying therapies (DMT) which reduce the progression of the disease and reduce exacerbations
1. infusions
2. medications
3. oral injections
One DMT is interferon β therapy, what does it do?
helps reduce the inflammation in diseases/cancer which, if started early, will reduce the progression and reduce exacerbations of MS
- some interferon β are lab made by labs
- some interferon β are made by white blood cells
Direct role of a PT for MS:
intervention, education, adherence
- muscular exercise
- cardiovascular activity
- fatigue education
- function & balance training
- prevention
Education on prevention for MS
all autoimmune diseases have a risk of cancer because of the increased inflammation so education on staying as healthy as possible, especially during remission is important
Why do balance and function training with MS patients?
they have decreased somatosensory so you want to decrease fall risk
Why is cardiovascular activity important for patients with MS?
it is important to help patients increase their HR and cardiovascular function because it helps reduce inflammation and increases the amount of myelin in the body
** aerobic activity increases myelin
The framework for movement:
the interaction between the task/goal, the environment, and the individual
MS related fatigue is caused by?
due to immune activation
- glial cells and mitochondrial damage account for the severe levels of intractable fatigue in MS
Types of fatigue in MS?
chronic persistent fatigue = > 6 weeks for 50% of the time
acute fatigue = recent onset
** always asses BP, HR, fatigue level, and symptoms
What are some secondary causes of fatigue in MS?
medications, stress, weather, depression
Strategies for fatigue
- LE weakness = strengthen
- respiratory system fatigue = aerobic activity
- environmental stress = modifications
Education strategies for fatigue
- stop smoking!
- encourage midday nap/rest (10-30 mins, breathing to allow for perfusion to brain)
- adjust activity levels
- well balance low fat diet (MAYBE?? fatty diets increased myelin in rats)
- drink cool liquids (reduces myelin loss)
Considerations in exercise for MS
exercise does NOT increase the disease process
- increases in core temp can lead to a transitory increase in clinical S/S of MS (weakness, fatigue, visual Sx.)
- it was previously thought that exercise would cause MS exacerbation or worsen the disease activity
- cooling vests help a lot
Why is exercise important for patients with MS?
physically fit patients had fewer lesions and if they did they were smaller compared to those who weren’t fit
- spares the cognitive status of the patient
- have better brain functioning
Remyelinatin: motor learning
motor learning enhances the ability of oligodendrocytes to generate additional myelin and maintain preexisting sheaths
–> work at the cellular level makes changes from within to increase myelin
Remyelination: aerobic fitness
aerobic fitness is associated with less damaged brain tissue in BOTH gray and white matter
–> targeting younger patients can help with the overall outcomes because they are more hopeful
Why is motor learning more efficacious?
you get more feedback with motor learning
- rewards! –> feel good chemicals
- many different feedback systems which help the brain make connections
- outcomes (basal ganglia, adrenaline)
- external (auditory, visual, vestibular, somatosensory)
- internal (cerebellum, muscle spindles/reflexes)
Exercise recommendations for MS
150+ mins/wk total 4-6 days/wk
aerobic = 2-3 days (10-30 mins at mod intensity)
resistance = 2-3 days (1-3 x 8-18)
- changes made based on abilities, goals, preferences
Why do aerobic activity with MS patients?
- increases blood flow to oxygen rich areas (hippocampus and basal ganglia)
- increases hippocampus volume
- increases in memory
- increases in hippocampus resting state function
Considerations in exercise for MS
- start soon after diagnosis
- work on static balance which works the somatosensory system
- higher exercise levels relate to slower accumulation of functional limitations
** PREVENT SECONDARY DISUSE PATTERNS
How is MS spasticity different than stroke spasticity?
spinal cord conditions (MS) tend to be worse bc there is no inhibition of the muscles (the muscles are having a “party”) which increases fatigue seen in MS and spinal cord injuries
- rest allows for prolonged muscle stretch which is needed to relax the spasms
- spasticity is velocity dependent so a quick stretch will NOT be effective
- emotions/energy affects spasticity (especially in kids)
Spasticity management: flexor spasticity
allow 5-10 mins to relax (20 is optimal)
- prone, feet hang over edge of bed, arms at 90-90 close to head
Spasticity management: extensor spasticity
allow 5-10 mins to relax (20 is optimal)
- sidelyining with hips and knees bent, pillow between legs and chest
Spasticity management: movement
ROM stretching program done daily, move through full ROM, hold at end range for at least 1 min
** needs to be prolonged stretch vs. quick stretch (quick = velocity = more spasticity)
Spasticity management: general
meds, exercises/stretching, fatigue management
Why do exercise with MS patients?
improves muscle power and function, exercise tolerance, and mobility
* muscles are like dogs! they will listen and train and improve
MS symptoms and exercise
- reduce activity and exercise after exacerbation
- there are NO deleterious effects but it may cause a temporary worsening of symptoms
Dual tasking in MS
white matter lesions and gray matter atrophy from MS affect areas of the CNS implicated in dual tasking and motor learning (cerebellum, prefrontal cortex, parietal lobe)
- these are NEGATIVELY associated with postural control and motor learning performance
- postural control becomes subconscious with most control going to the lateral aspects of the feet
** postural control is ALWAYS dual tasking (standing and washing dishes, standing and folding clothes)
What is dual task training?
- real world multi tasking
- strategies for balance with every day tasks
- reduces falls
IDEAS: walking and counting, walking and naming, standing and folding clothes
Why is folding clothes such a good dual task?
- organization and planning of folding clothes and sorting them
- weight shift to reach
- fine motor with hands/fingers
- postural control
-vestibular with head turns - vision and proprioception
- eccentric component with squats to pick up clothes
Functional strengthening
** speed is important
- sit to stand
–> alternating hand position, adjust height
- squats
–> B or single hand support, height
- calf raises
–> B to unilateral, change support
!! patients who need strength, make them do it faster!! they need to learn how to adjust
What are the main causes of balance dysfunction in MS?
can be affected by many factors but decreases sensory input is the most common which reduces confidence and increases fear in unpredictable environments
- slowed conduction of proprioception
- impaired central integration
** weakness and decreased force production leads to balance problems that are unpredictable
Quiet stance deficits in MS
75% of patients had sway disturbances in quiet stance
- possibly due to increases sensory issues in MS
- means they need vision to balance because of decreases proprioceptive and vestibular deficits
Sensory based exercises for MS
–> proprioceptive and vestibular exercises
- walk and rotate head
- object manipulation with trunk movement
- standing with feet in different directions
–> sensory augmentation
- sub threshold vibrations
- changes in floor/environment
Whole body vibration
there is not enough evidence for MS but it is helpful in parkinsons
- equilibrium and gait improvements
- improves balance
Sensory weight vest trial for balance improvements (video)
- small weights are placed strategically on vest
- provides info for balance
- improvements in dynamic and static balance
- improves postural control during gait (changes COM, provides subconscious feedback)
- allows for better axial loading
- we don’t really know the mechanism, it just worked :)
Why is axial loading important for MS patients using the weighted vest?
increases in axial loading increases proprioceptive awareness of GTO and muscle spindles to send signals (the added weight essentially activates the signals)
Gait training
- don’t just do strengthening
- virtual reality did not do any better than conventional therapy
- speed interval training is good
- allow rest
- task based for specificity and salience
- training 40+ mins
- do type I strengthening to glute med/gastroc/soleus
Why didn’t virtual reality help that much in MS patients?
there are vestibular and optic nerve deficits found in MS which may have prevented improvement when using VR
Why is speed interval training good for MS?
- good for endurance
- the “rest” time reduces heat limiting fatigue
20s intense walking
1-6 min slow or rest period
Why do you want MS patients to take short steps?
- keeps COM within a safe parameter
- allows for increases double stance time for better balance
- limits fatigue
- compensates for loss of proprioception
Assistive devices in MS
** provide at first sign of postural deficiencies!!!
- any abnormal LOB or if speed of responses are slow
- reduces energy expenditure
Assistive devices in MS: types
start with straight single point cane –> trekking poles –> rollator –> scooter
Why do you want to avoid a quad cane in MS patients?
reduces walking efficiency, you have to make sure they really plant that cane onto the floor before moving
What to look at when deciding to use an assistive device?
- ankle strategy
- how many steps they take when they lose their balance
- watch trunk posture/proprioception
Cardiorespiratory training for MS recommendations
- mod intensity (40-60% HRmax)
- RPE 11-13
- 10-30 mins
- 2-3x/wk
- gradual increase to target HR/RPE
Beneficial POC for MS:
INDIVIDUALIZED
- increase functional skills
- increase strength
- improve balance
- reduce severity of disease w/ aerobic exercise
- reduce effects of fatigue
- reduce falls with appropriate devices
- exercises/activities that are enjoyable
Where is spasticity found more for stroke patients?
UE>LE for stroke patients
Hypertonia (spasticity) components:
- connective tissue/biomechanical
- hyperactive stretch reflex
- muscle weakness
Pathophysiology of spasticity:
UMN lesion –> weakness/overactivity –> immobilization/spams/clonus/flexor withdrawal –> reduced ROM/abnormal posture/contracture –> impaired function
Medications for spasticity types
- generalized spasticity = oral meds
- focal spasticity = botox injections
- regional spasticity = intrathecal baclofen
How do you know when to treat spasticity?
- Does it affect function (gait, transfers, dressing)?
- Does it cause pain or discomfort (especially with brace/footwear)
- Is there a risk of complications (contractures/skin breakdown)
** if YES, then ya need to do it
Factors that increase spasticity in MS (according to Monica)
- pressure ulcers
- bowel and bladder dysfunction
- infections
- pain
Galileo
- provides sensory information
- resets spinal reflex (muscle spindle)
Whole body vibration
the muscle spindle responds to length and velocity that whole body vibration provides
- decreases spasticity temporarily
- a peripheral mechanism is used but a central stimulus/reaction is created
TENS and spasticity
100 Hz, 0.3 ms pulse, 20 mins/day x4 wks
- high intensity TENS gets hella deep
- primes muscle “warms up” before performing AROM
Gating mechanism
basically reciprocal inhibition
- also called inhibitory influence
- stops the ongoing stimulus
ex: activate quads which will inhibit hamstrings (prime muscle to quiet the overactive muscle spindles)
Other methods of combating spasticity
use a sensory modality to stop signals that go to AHC
- compressive blanket
- touch/pressure
Prolonged stretching
- SLOW (quick will activate stretch reflex or spindle will initiate clonus)
- allows lengthening reaction to occur, muscle spindle habituates and reduces signaling
- type II fibers respond more to the overall length of the fiber rather than the rate of change in fiber lengths
Brain derived neurotrophic factor (BDNF)
- supports neurogenesis
- improves synaptic connections to reduce spasticity
- promotes brain vascularization
BDNF and exercise
aerobic exercise increases BDNF for new cells and better memory
- 3x/wk for 8 wks
