Multiple Sclerosis Flashcards
What is MS?
- Autoimmune disease
- Affects 30 in 100,000 in Australasia
- Mechanism of disease is an immunologically mediated inflammatory response in the CNS
What is the aetiology of MS?
- Affects young adults
- Genetic involvement
- Environmental influences
What is the pathophysiology of MS?
Demyelination of neurons in the CNS results in disruption of neural transmission & the consequent neurological signs & symptoms
What are the stages of inflammation in MS?
- Accumulation of inflammatory cells, lymphocytes & monocytes at the lesion site
- Active destruction of the oligodendrocyte & its myelin sheath
- Depletion of oligodendricytes
- Healing of lesion by scar formation (plaques)
What are the most common sites of plaques in MS?
- Periventricular regions
- Cerebellar white matter
- Optic nerves
- Cervical portion of spinal cord
- Grey-white boundary in cerebrum
What are the 4 types of MS?
- Benign
- Relapsing-remitting (most common)
- Secondary progressive (65% of RR patients)
- Primary progressive (10%)
What does the diagnosis of MS involve?
- Based on MRI, lumbar puncture & clinical assessment
- Diagnosis made after either 2 episodes or evidence of 2 separate lesions
What does the drug therapy management of MS involve?
- Disease modifying therapies e.g. interferon
- Anti-inflammatories e.g. steroids
- Alleviation of symptoms e.g. baclofen for spasticity
What are the 2 main ways stem cell treatment for MS could be developed?
- Immunomodulation: Preventing immune damage to the nervous system
- Remyelination: Repairing the myelin sheath that has already been damaged
What are the impairments in MS?
- Complex, variable & unpredictable (patient to patient, episode to episode)
- Sensorimotor
- Autonomic
- Cognitive
- Behavioural
- Language
- Special senses
- Fatigue
- May affect one limb, one side of the body or all 4 limbs
What are the primary motor impairments in MS?
- Loss of strength
- Loss of dexterity
- Loss of sensation
- Spasticity
What should the subjective assessment of an MS patient include?
- Current activities (mobility, ADLs)
- SHx (family support, carer/care packages, work, leisure)
- Medication
- PHx (previous exacerbations, falls, other relevant)
What should the objective assessment of an MS patient include?
- Strength
- Dexterity
- Sensation
- Spasticity & contracture
- Activity limitations
What are the important components of activity assessment?
- Relevant to the patient’s current level
- Specific to the patient’s environment
- Meaningful to the patient
What are some of the measures used in MS?
- Expanded disability status scale
- MS functional composite
- MS impact scale
- Fatigue severity scale (differentiates fatigue from depression)
- MS self efficacy scale
What are the physio aims in MS?
- Optimise performance in ADLs
- Prevent unnecessary disability
- Improve QOL
What does physio for MS involve?
- Preserve/improve muscle strength & aerobic capacity
- Preserve musculoskeletal integrity
- Activity training
- Management of fatigue
- Providing necessary aids
- Ensuring interventions are relevant & collaboration in setting goals
What did Cruickshank et al 2015 find regarding PRE training in MS?
- Systematic review of 7 RCTs
- Patients with MS with mild-mod disability
- Interventions were PRE training 3 weeks-6 months, 2-5 times weekly
- Significant increase in strength & improvement in fatigue & QOL
What did Paltamaa et al 2012 find regarding balance training in MS?
- Systematic review of RCTs looking at balance training
- Examined specific balance training in ambulatory patients with mild-mod MS
- Significant increase in balance
What did Van den Berg 2006 find regarding treadmill training in MS?
- MS patients in a crossover trial to examine the efficacy of TT
- Patients trained for 30 mins, 3 times/week for 4 weeks
- Significant increase in walking speed & endurance
What is spasticity often associated with in MS?
Painful crams & spasms
What does the medical management of spasticity include?
- Medication
- Surgical management
What are the interventions for contracture?
- Active movement through range
- Activity training
- Active assisted movement through range
- ES
- Positioning during the day
- Resting splints
- Prolonged positioning
- Serial casting
What are the important components of activity training in MS?
- Must be guided by the assessment & goals of the patient
- Must take into account the nature of MS
- May include wheelchair skills (transfer & propulsion)
What are the principles of activity training?
- High reps
- Task specificity
- Accurate instructions
- Specific & timely feedback
- Ensure appropriate strength & flexibility coincides with activity training
What are the characteristics of fatigue in MS?
- Considered the most disabling feature
- Occurs in up to 80% of MS patients
- Not related to degree of disability or mood state
- Assessment should identify the nature, extent & precipitation factors in fatigue
What does the management of fatigue involve?
- Incorporate rest breaks
- Simplify tasks
- Time management
- Low impact aerobic exercise gradually increasing in intensity, duration & frequency
- Address other factors (diet, sleep, depression)
- Pharmacological agents have demonstrated limited positive effects
What should be considered prior to commencing an aerobic fitness program with an MS patient?
- Patient is medically stable
- Medical clearance
- Patient has the ability to activate large muscle groups (walking or cycling)
- Goals, duration, frequency, intensity, monitoring, mode, barriers, special considerations
What are the aerobic testing protocols that can be used in MS?
- Graded cycle ergometer
- Balke treadmill test
- 6MWT
- Shuttle test
What is the testing protocol for a graded cycle ergometer?
- Use HR monitor
- 3 mins at 25W at 50 RPM
- Increase work rate by 10W every 2 mins
- Discontinue when the patient is unable to continue or is at 80% predicted HR max
What is the testing protocol for the Balke treadmill test?
- Constant speed, incremental graded walking test
- Treadmill at 5.3km/hr
- Increase grade by 1% per min
- Record time when person is unable to continue
What is the dose-response principle?
- Dose: Combination of intensity, duration & frequency
- Response: Outcome in response to the training
- Optimal dose & response will depend on the neurological disability & current fitness level
What duration and frequency should be set for aerobic exercise for MS patients?
- Start with sets of 2-3 mins
- Increase each session to 30-45 mins
- If patient can walk 15-20 mins, train 3 time/week
- If patient is unable to walk 15 mins (even with rests) train 5 days/week, twice/day
- Increase time then intensity
What intensity should be set for aerobic exercise for MS patients?
- Aim for 60-80% HR max
- Aim for 15-30 beats above resting HR
- Utilise a rating of somewhat hard on BORG scale
How is max HR calculated for people on beta blockers?
(220-age) x 0.85 (as beta blockers slow HR)
What should monitoring during aerobic exercise include?
- HR
- RPE
- BP
- Signs & symptoms
What mode of aerobic exercise should be used for MS patients?
- Mildly impaired patients can use gym equipment or walk OG
- Mod-severe patients can be trialled used treadmill with up to 15% BWS, stepper with harness or cycle ergometer
What are some of the barriers to aerobic exercise in MS?
- Cost
- Lack of energy
- Transportation
- Lack of knowledge regarding available exercise programs
- Behavioural impairments, especially apathy
- Beliefs about exercise
- Lack of prior exercise experience
What are the special considerations for exercise in MS?
- CAD
- Medication e.g. beta blockers
- Age
- Habitual exercise
- Lower limb weakness
- Sensory impairments
What did Mostert & Kesselring 2002 find regarding exercise in MS?
- Patients with MS randomly assigned to exercise training or non-training group
- 5 x 30min bike riding session a week for 4 weeks
- Significant increase in work rate & sub-max VO2, improved health perception & increase in activity level
- But compliance only about 65%
What are the advantages of walking aids?
- Greater stability
- Reduced falls risk
- Increased walking distance
- Increased walking speed
- Improved efficiency
- Reduced fatigue
What are the disadvantages of walking aids?
- Reduced use & strength of lower limbs
- Reduced trunk & head movement
- Reduced balance stimulus (use of arms for postural adjustments)
- Abnormal posture
- Compromised upper limb function
What are some of the management strategies for immobilisation during disease progression/relapse?
- Respiratory physio
- Positioning/splinting to prevent contracture
- Positioning to prevent pressure areas
- Strength training/FES
- Sitting
- Education of carers
What are some of the services available to MS patients?
- MS society
- Independent living centre
- Accessible leisure centres
- Respite care
- Sporting groups
- Carer support groups
- Vocational rehab
When should a wheelchair or scooter be considered?
To allow
- Ongoing participation in work or social activities
- Community mobility
- Fatigue minimisation
- Patient to prioritise effort
What should physios educate carers about?
- Disease process & its impact on physical activity
- Safe & efficient manual handling
- Appropriate motor training strategies to maintain or improve activity performance
- Appropriate assistive devices
What is one of the common first signs of MS?
Visual disturbances (plaques forming on optic nerve)
