Neuromuscular 2 Unit 10: Dx specific interventions: MS, GBS

Question 1

MS-EDGE OM

With the 12-Item MS Walking Scale OM, where does this fall in the ICF category?

Answer 1

Activity

Question 2

MS-EDGE OM

With the Timed 25 ft Walk OM, where does this fall in the ICF category?

Answer 2

Activity

Question 3

MS-EDGE OM

With the MS QOL-54 Instrument OM, where does this fall in the ICF category?

Answer 3

Participation

Question 4

MS-EDGE OM

With the Fatigue Severity Scale OM, where does this fall in the ICF category?

Answer 4

Body Structure/Function

Question 5

MS EDGE OM

What is the 12-Item MS Walking Scale (MSWS-12)?

Answer 5

• A 12 item scale that captures perspective on how much the MS has affected different aspects of walking
• 1 (not at all) to 5 (extremely) scale
• Max score of 60 (Higher score indicate MS has a greater impact on walking)

Question 6

MS-EDGE OM

What is the Timed 25 Foot Walk OM?

Answer 6

This helps capture quantitative info about mobility and function

• This is an average of 2 trials, the pt is directed to walk 25 ft as quickly and safely as possible. The second trial is immediately administered, having the pt walk the same distance. Pt can have an AD if needed

Normative Values:
- The median score for pt with MS is 4.4 seconds
- The median score for healthy individuals is 3.7 seconds

Question 7

MS-EDGE OM

What is the MS QOL-54 OM?

Answer 7

A structured self report questionnaire the pt can generally complete on their own or with assistance about their changes over time
- There are 54 items, divided into 12 subscales
- Advantages: Its easy to administer and covers a wide range of topics and domains related to QOL; Also includes the Short-Form 36 (SF-36)

⬆️ These are the sub-scales

Question 8

MS-EDGE OM

What is the Expanded Disability Status Scale (EDSS) OM?

Also known as Kurtzke Disability Scale or Functional System Scale

Answer 8

This is the GOLD STANDARD in classification of disability and people with MS
- This OM measures the disability and monitoring change over time
- Scale ranges from 0 (no disability) to 10 (death due to MS) in intervals of 0.5. There are 20 total levels
- This is administered by the neurologist

(B & B: bowl and bladder)

Question 9

With theExpanded Disability Status Scale (EDSS) OM, what does a score of 1.0 - 4.5 represent?

Answer 9

A score of 1.0-4.5 refer to people with MS who are able to walk without any assistance

Question 10

With theExpanded Disability Status Scale (EDSS) OM, what does a score of 5.0 - 9.5 represent?

Answer 10

There is an impairment of walking, needs assistance

Question 11

MS-EDGE OM

What is the Fatigue Severity Scale (FSS)?

Answer 11

This is a 9-item self-report questionnaire and it targets how fatigue interferes with activity
- Lowest score = 9 ; Highest score = 63 (The higher the score, the more severe the fatigue)
- The cutoff score > 36 means significant fatigue, this may warrent a referral for further medical evaluation
- The MDS for MS is a change in the FSS of 1.9 points

Question 12

MS

What are Exacerbations?

What are factors that are linked to exacerbations or relapse?

Answer 12

These are new and recurrent MS symptoms lasting more than 24 hours

• Multiple bouts of exacerbations over a 1 year period is needed for diagnosis

Factors that are linked to increased risk of exacerbations or relapse:
- Viral or bacterial infection (common cold, FLU, UTI, sinus infection, etc)
- Disease of major organs systoms (Hepatitis, pancreatitis, asthma attacks,etc)
- Stress

Question 13

MS

What are Pseudoexacerbations?

Answer 13

These is a temporary worsening of symptoms; resovled within 24 hours

• The most common one is called Uthoff’’s syndrome: Heat sensitivity - Patients will have temporary worsening of Sx (Overexertion, exposure to heat)

Considerations for those in south FL
Precautions in warm gyms and aquatic therapy

A large number of individuals suffer from this

Conider a fan when in the gym or a cooling vest. Or havig the pt workout first thing in the moring when their body temp is the lowest

Question 14

Clinical Subtype of MS

What is Relapsing-Remitting MS (RRMS)?

Answer 14

This is the most common (85% of pts have this type)

• This is characterized by acute attacks or relapses, followed by partial or full revovery or remissions.
• Of all the subtypes this has the best prognosis
• However at some point, the oligodendrocytes get wiped out and they are unable to fully remelinate the nerves, and the patients ability to fully recover goes down.
• At this point when the pt relapses and remites they cant go to baseline anymore, this is called permanent deficit
• These patient then progress to Secondary Progresive MS

Remission can last weeks, months , or years. Symptoms may be a little worse then the 1st relapse.
Ex. if a patient goes through their first relapse and they have blurred vision and then they remit back to baseline. After the pt remits after a period of time they may relapse again but this time their sx are worse they may have foot drop and paresthesia in addition to the blurred vision. But after some time they remit once again back to baseline. However, once the patient losses all the oligodendrocytes they cannot full recover or get back to baseline (right side of pic). So when they have a relapse and remission they do not get back to baseline anymore. So now if the patient may have permanent foot drop

Question 15

How does Secondary Progressive Relapse (SPMS) begin?
How is it characterized?

Answer 15

• It begins with a Relapsing Remitting Course, followed by a progression to Secondary Progressive MS
• This is characterized by a steady and irreversible decline with or without acute attacks (relapse)
• Whether the person has those acute attacks or not, they are never recover/remit and they continue to lose function over time

On the (L) is RRMS, on the (R) is SPMS

Question 16

What is Primary Progressive MS?

Answer 16

This type is not as common ~10% have this subtype

• This is characterized by a steady functional decline from onset
• In this subtype there are no attacks or exacerbations and there are no periods of remission
• Overtime the Sx get worse and worse at a steady decline
• There are periods of platues, where the patient does not get worse but after the platues are over they continue to get further away from the baseline

Question 17

NM 1 review

How is Relapse-Remitting MS (RRMS) clincally Diagnosed?

Answer 17

When the patient has experienced at leat 2 attacks (exacerbations) or relapses that last more than one day and are separated by more than 1 month

For example, if a pt complains of blurred vision that lasted 2 days and then a month and a half later complained of foot drop that lasted for a few days will be RRMS.

Question 18

What is Progressive Relapsing MS (PRMS)?

Answer 18

Least common: 5%, however most severe

• Its characterized by a steady deterioration from onset
• Is this subtype the patient are in a steady decline from onset and they have occasional acute attacks and the Sx get way worse (or heightened) and after the relapse they continue on their steady decline without remission (recovery)

Question 19

NM 1 review

How is Primary Progressive MS Clinically Diagnosed?

Answer 19

The pts impairments need to be present for greater than 6 months

Question 20

With MS, what is the Framework for Rehabilitation?

Answer 20

• Consider stage of disease
• Restorative intervention
• Preventative intervention
• Compensatory intervention
• Maintenance therapy

Question 21

MS: Rehab Framework

What is the Goal for Restorative Interventions?

Answer 21

To mediate or improve impairments, activity limitations or participation restrictions
- Focusing on getting the patient that’s that level or close to the functional level that he/she was before the relaps

Question 22

MS: Rehab Framework

What is the Goal for Preventative Interventions?

Answer 22

To minimize potential complications, impairments, activity limitations as the disease progresses. Trying to prevent disability; focus on promoting health habits, wellness, fitness to preseve optimal function

Question 23

MS: Rehab Framework

What are Compensatory Interventions?

Answer 23

We are modifying the task or activity or the environment so the patient can still function to the best of their ability despite the existing impairments and limitations.
- This is where we introduce ADs or different strategies to complete task

Question 24

MS: Rehab Framework

What is Maintence Therapy?

Answer 24

This is the occasional, clinical, educational or administrative service that is designed to help patients maintain their current level of function

Question 25

# Inteventions throughout the Disease Course for MS What is done At the Time of Diagnosis?

Answer 25

- Pt education - Baseline evaluation

Question 26

# Inteventions throughout the Disease Course for MS What is done Following an Acute Exacerbation?

Answer 26

The goal is to return to baseline

Question 27

# Inteventions throughout the Disease Course for MS What is the goal with Progressive MS Disease?

Answer 27

Support, avoid deconditioning, maintain safety, maximize health and independent function - We assess current and future mobility aids

Question 28

# Inteventions throughout the Disease Course for MS What is the goal with Advanced MS?

Answer 28

PT likely focused on seated positioning, transfers, strength, respiratory function, equipment needs - Use of standing devices, wheelchairs

Question 29

What are Clinical Considerations for interventions for MS?

Answer 29

Exacerbating Factors: new and recurrent MS symptoms lasting > 24 hrs - Stress - Affective disorders - Disease of major organ systems - Viral or bacterial infection - **Pseudoexacerbation**: temporary worsening of symptoms ≤ 24hrs {Uthoff's Sx: adverse reaction to heat (internal or external); effects are usually immediate; increased fatigue and reduced function}

Question 30

What are some common PT interventions for MS?

Answer 30

- Skin management - Exercise training -strength, conditioning, aerobic, flexibility exercise - Management of fatigue - Management of spasticity - Management of coordination and balance deficits - Locomotor training - Functional training - Cognitive - Psychosocial

Question 31

What are the Clinical Considerations for MS and Exercise? What are Contraindications?

Answer 31

- Avoid Overheating: Consider schedule; provide rest intervals (excellent opportunities for education); AC, fans, wet neck wrap, spray bottles, cooling suits or vest - Exercise and activity should be challenging, but NEVER a struggle - Progression is generally slower **Contraindications** **- Exercising to fatigue** **- Pt with RRMS during an exacerbation**

Question 32

Once discharged from PT, what are some activies the patient can do to prevent deconditioning?

Answer 32

- Aquatic exercise - cool pool (< 85°) - Gentle yoga - Tai Chi - Hippotherapy - Resistance and aerobic activites

Question 33

What are the Clinical Considerations for MS and Fatigue?

Answer 33

- Fatigue: sudden and severe sleepiness, excessive tiredness, sense of weakness - Energy Effectiveness Strategies (EES) -Activity Diary: record sleep, activites, aggrating factors and symptoms -Energy conservation techniques: reduce energy requirements and fatigue -Activity pacing: balancing activity with interspersed rest periods - Team effort for consistency and reinforcement

Question 34

What is Guillan-Barre Syndrome (GBS)?

Answer 34

- Acute inflammatory demyelinating immune-mediated polyneuropathy - Nerve roots and peripheral nerves affected - Leading to rapid symmetrical bilateral onset of flaccid paralysis, sensory impairment and autonomic nervous system impairment ## Footnote More males are affected than females

Question 35

What are varient forms of GBS?

Answer 35

- Acute motor axonal neuropathy - Miller Fischer Syndrome: CN, Ataxia, and Areflexia - Chronic Inflammation Demyelinating Polyneuropathy: Progressive relapsing or remitting numbness and weakness

Question 36

What is the Clinical Presentation of those with GBS? (Acute vs Subacute/Chronic stages)

Answer 36

- Acute Stages: Ventilator dependent, complete flaccid paralysis, ANS symptoms. (Typically last 10 days) - Subacute/Chronic: **Weakness, fatigue**, functional mobility deficits

Question 37

What is the Prognosis of GBS?

Answer 37

- Typically a plateau occurs 2-4 weeks - Overall good - Low mortality rate: 3-7% - Varying degree of functional outcomes: -~80% will return to ambulation by 6 months, 84% at 1 year -20% will require external aid to walk, 3% may remain unable to ambulate long term

Question 38

# GBS OM What is the Guillain-Barre Syndrome Disability Scale?

Answer 38

- This tracks the course of GBS - Scale 0-6 - Emphasis of Activiy limitations - Low sensitivity to change

Question 39

What are common OM utilized in assessing function post GBS?

Answer 39

- Fatigue Severity Scale (FSS) - Bathel Index and FIM - Canadian Occupational Performance Measure - Modified Rakin Scale - Timed 25 foot walk test - Core Outcome Measure CPG

Question 40

With GBS, what are some General Goals for interventions?

Answer 40

- Repsiratory care and resolution - Address communication deficits and dysphagia - Pain management/reduction and desensitization to dysethesias - Maintain ROM, improve positioning and prevention of contractures - Improve strength and endurance - Functional task improvement/independence - Appropriate prescription of DME is needed - Psychosocial health in returning to life roles at optimal level

Question 41

With GBS, what are 2 Intervention considerations we should keep in mind during our intervention planning?

Answer 41

- Stage of Condition - Fatigue ## Footnote With the bottom half of the box, Reinnervation typically has occurred when muscle strength grade (MMT) exceeds a 3/5 - Then start conservative -- **Must Prevent Overwork Weakness and Fatigue** *In Denervation (early stages or worsening of condition) and early stages of reinnervation. If we prescribe strenuous exercise OR if we induce fatigue, it is likely that the patient will experience loss of function, this will evoke further damage to the neural muscular connection*

Question 42

# GBS With the Positioning and ROM consideration, what should be done in the Acute Stage?

Answer 42

- Repositioning in bed every 2 hours/Skin checks - PROM ➡️ AAROM - Splinting, specialty mattresses/cushions ## Footnote To prevent skin breakdown and contractures

Question 43

# GBS With the Positioning and ROM consideration, what should be done in the Subacute Stage?

Answer 43

- PROM ➡️ AROM - Educate for self-positioning/stretching

Question 44

# GBS With the Positioning and ROM consideration, what should be done in the Chronic Stage?

Answer 44

- Teach self stretching of key muscles, i.e. gastroc, hamstrings

Question 45

# GBS With the Pain Management consideration, what should be done in the Acute Stage?

Answer 45

- Repositioning - Corrrdinate medication timing with therapy - Bed tent for sheets or ace wrap for extremeties

Question 46

# GBS With the Pain Management consideration, what should be done in the Subacute Stage?

Answer 46

- Thermal Modalities (beware of contraindications) - Repositioning

Question 47

# GBS With the Pain Management consideration, what should be done in the Chronic Stage?

Answer 47

- TENS

Question 48

# GBS With the Ventilation consideration, what should be done in the Acute Stage?

Answer 48

- Postural Drainage - Assisted cough - Diaphragmatic breathing

Question 49

# GBS With the Ventilation consideration, what should be done in the Subacute Stage?

Answer 49

- Continued interventions from acute stage if needed - Functional mobility

Question 50

# GBS With the Ventilation consideration, what should be done in the Chronic Stage?

Answer 50

- Not Applicable ## Footnote We want the patient dependent at this stage

Question 51

# GBS With the Adaptive Equipment Management consideration, what should be done in the Acute Stage?

Answer 51

- Splinting - Abdominal blinders/compression stockings - Tilt table/standing frame

Question 52

# GBS With the Adaptive Equipment Management consideration, what should be done in the Subacute Stage?

Answer 52

- Harness systems- body weight support - Assistive devices - i.e. walkers, canes

Question 53

# GBS With the Adaptive Equipment Management consideration, what should be done in the Chronic Stage?

Answer 53

- Ankle- foot orthosis

Question 54

# GBS With the Strengthening consideration, what should be done in the Acute Stage?

Answer 54

- AAROM- submaximal (avoid fatigue) - < 3 days/wk, low reps, frequent breaks - Monitor for post-exercise weakness, DOMS and increased paresthesia for 1-5 days post-exercise (If felt, exercise does need to be reduced) ## Footnote **NO ECCENTRIC STRENGTHING, NOT RECOMMENDED**

Question 55

# GBS With the Strengthening consideration, what should be done in the Subcute Stage?

Answer 55

*Once MMT 3/5 or greater*: - **Gradual progression** to > 1 set of 10 - 15 reps at 60-70% 1 RM - Frequency: 2-3 days/wk - Mode: Functional task practice, low resistance bands ## Footnote **NO ECCENTRIC STRENGTHING, NOT RECOMMENDED**

Question 56

# GBS With the Strengthening consideration, what should be done in the Chronic Stage?

Answer 56

- **Follow ASCM guidelines** once greater than 3/5 strength and no signs of overwork weakness ## Footnote **NO ECCENTRIC STRENGTHING, NOT RECOMMENDED**

Question 57

# GBS With the Aerobic consideration, what should be done in the Acute Stage?

Answer 57

- Not Appropriate - Monitor vitals for stability with all mobility/activities ## Footnote **Vital sign Assessment for stability throughout Interventions**

Question 58

# GBS With the Aerobic consideration, what should be done in the Subacute Stage?

Answer 58

- Low to moderate intensity (40-60% HRMax), RPE 12-13 - Frequency/Duration: 20 min, 3-5 x/wk - Mode: Walking, stationary bike, UE ergometer ## Footnote **Vital sign Assessment for stability throughout Interventions**

Question 59

# GBS With the Aerobic consideration, what should be done in the Chronic Stage?

Answer 59

- Moderate to high (60-80% HRMax), RPE 14-17 - Frequency/Duration: 30 min or greater, 4-5 x/wk - Mode: Variable options ## Footnote **Vital sign Assessment for stability throughout Interventions**

Question 60

# GBS With the Functional Retraining consideration, what should be done in the Acute Stage?

Answer 60

- Bed mobility, transfers - Sitting/standing tolerance - Wheelchair mobility ## Footnote **Consider vitals, strength and fatigue**

Question 61

# GBS With the Functional Retraining consideration, what should be done in the Subacute Stage?

Answer 61

- All mentioned in acute phase - Gait on level and unlevel surface - Stair training (if aerobically appropriate) ## Footnote **Consider vitals, strength and fatigue**

Question 62

# GBS With the Functional Retraining consideration, what should be done in the Chronic Stage?

Answer 62

- Gait adaptability - Community mobility - Recreational activities ## Footnote **Consider vitals, strength and fatigue**

Question 63

# GBS With the Balance Training consideration, what should be done in the Acute Stage?

Answer 63

- Unchallenged static and dynamic sitting balance - Unchallenged standing if appropriate

Question 64

# GBS With the Balance Training consideration, what should be done in the Subacute Stage?

Answer 64

- Challenged static and dynamic sitting balance - Challenged static and dynamic standing balance

Question 65

# GBS With the Balance Training consideration, what should be done in the Chronic Stage?

Answer 65

- Higher level balance challenges

Question 66

What are Psychosocial Considerations?

Answer 66

- Post-traumatic Stress Disorder (PTSD) - Anxiety - Depression - Panic Disorder - Changes in life roles, financial stress Intervention considerations: - Be vigilant in patient's awareness - Communication prior to each specific intervention throughout - Referral to additional healthcare providers if necessary