Neuromuscular 2 Unit 10: Dx specific interventions: MS, GBS Flashcards
MS-EDGE OM
With the 12-Item MS Walking Scale OM, where does this fall in the ICF category?
Activity
MS-EDGE OM
With the Timed 25 ft Walk OM, where does this fall in the ICF category?
Activity
MS-EDGE OM
With the MS QOL-54 Instrument OM, where does this fall in the ICF category?
Participation
MS-EDGE OM
With the Fatigue Severity Scale OM, where does this fall in the ICF category?
Body Structure/Function
MS EDGE OM
What is the 12-Item MS Walking Scale (MSWS-12)?
- 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)
MS-EDGE OM
What is the Timed 25 Foot Walk OM?
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
MS-EDGE OM
What is the MS QOL-54 OM?
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)
MS-EDGE OM
What is the Expanded Disability Status Scale (EDSS) OM?
Also known as Kurtzke Disability Scale or Functional System Scale
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
With theExpanded Disability Status Scale (EDSS) OM, what does a score of 1.0 - 4.5 represent?
A score of 1.0-4.5 refer to people with MS who are able to walk without any assistance
With theExpanded Disability Status Scale (EDSS) OM, what does a score of 5.0 - 9.5 represent?
There is an impairment of walking, needs assistance
MS-EDGE OM
What is the Fatigue Severity Scale (FSS)?
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
MS
What are Exacerbations?
What are factors that are linked to exacerbations or relapse?
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
MS
What are Pseudoexacerbations?
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
Clinical Subtype of MS
What is Relapsing-Remitting MS (RRMS)?
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
How does Secondary Progressive Relapse (SPMS) begin?
How is it characterized?
- 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
What is Primary Progressive MS?
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
NM 1 review
How is Relapse-Remitting MS (RRMS) clincally Diagnosed?
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.
What is Progressive Relapsing MS (PRMS)?
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)
NM 1 review
How is Primary Progressive MS Clinically Diagnosed?
The pts impairments need to be present for greater than 6 months
With MS, what is the Framework for Rehabilitation?
- Consider stage of disease
- Restorative intervention
- Preventative intervention
- Compensatory intervention
- Maintenance therapy
MS: Rehab Framework
What is the Goal for Restorative Interventions?
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
MS: Rehab Framework
What is the Goal for Preventative Interventions?
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
MS: Rehab Framework
What are Compensatory Interventions?
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
MS: Rehab Framework
What is Maintence Therapy?
This is the occasional, clinical, educational or administrative service that is designed to help patients maintain their current level of function
Inteventions throughout the Disease Course for MS
What is done At the Time of Diagnosis?
- Pt education
- Baseline evaluation
Inteventions throughout the Disease Course for MS
What is done Following an Acute Exacerbation?
The goal is to return to baseline
Inteventions throughout the Disease Course for MS
What is the goal with Progressive MS Disease?
Support, avoid deconditioning, maintain safety, maximize health and independent function
- We assess current and future mobility aids
Inteventions throughout the Disease Course for MS
What is the goal with Advanced MS?
PT likely focused on seated positioning, transfers, strength, respiratory function, equipment needs
- Use of standing devices, wheelchairs
What are Clinical Considerations for interventions for MS?
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}
What are some common PT interventions for MS?
- 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
What are the Clinical Considerations for MS and Exercise? What are Contraindications?
- 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
Once discharged from PT, what are some activies the patient can do to prevent deconditioning?
- Aquatic exercise - cool pool (< 85°)
- Gentle yoga
- Tai Chi
- Hippotherapy
- Resistance and aerobic activites
What are the Clinical Considerations for MS and Fatigue?
- 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
What is Guillan-Barre Syndrome (GBS)?
- 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
More males are affected than females
What are varient forms of GBS?
- Acute motor axonal neuropathy
- Miller Fischer Syndrome: CN, Ataxia, and Areflexia
- Chronic Inflammation Demyelinating Polyneuropathy: Progressive relapsing or remitting numbness and weakness
What is the Clinical Presentation of those with GBS?
(Acute vs Subacute/Chronic stages)
- Acute Stages: Ventilator dependent, complete flaccid paralysis, ANS symptoms. (Typically last 10 days)
- Subacute/Chronic: Weakness, fatigue, functional mobility deficits
What is the Prognosis of GBS?
- 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
GBS OM
What is the Guillain-Barre Syndrome Disability Scale?
- This tracks the course of GBS
- Scale 0-6
- Emphasis of Activiy limitations
- Low sensitivity to change
What are common OM utilized in assessing function post GBS?
- Fatigue Severity Scale (FSS)
- Bathel Index and FIM
- Canadian Occupational Performance Measure
- Modified Rakin Scale
- Timed 25 foot walk test
- Core Outcome Measure CPG
With GBS, what are some General Goals for interventions?
- 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
With GBS, what are 2 Intervention considerations we should keep in mind during our intervention planning?
- Stage of Condition
- Fatigue
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
GBS
With the Positioning and ROM consideration, what should be done in the Acute Stage?
- Repositioning in bed every 2 hours/Skin checks
- PROM ➡️ AAROM
- Splinting, specialty mattresses/cushions
To prevent skin breakdown and contractures
GBS
With the Positioning and ROM consideration, what should be done in the Subacute Stage?
- PROM ➡️ AROM
- Educate for self-positioning/stretching
GBS
With the Positioning and ROM consideration, what should be done in the Chronic Stage?
- Teach self stretching of key muscles, i.e. gastroc, hamstrings
GBS
With the Pain Management consideration, what should be done in the Acute Stage?
- Repositioning
- Corrrdinate medication timing with therapy
- Bed tent for sheets or ace wrap for extremeties
GBS
With the Pain Management consideration, what should be done in the Subacute Stage?
- Thermal Modalities (beware of contraindications)
- Repositioning
GBS
With the Pain Management consideration, what should be done in the Chronic Stage?
- TENS
GBS
With the Ventilation consideration, what should be done in the Acute Stage?
- Postural Drainage
- Assisted cough
- Diaphragmatic breathing
GBS
With the Ventilation consideration, what should be done in the Subacute Stage?
- Continued interventions from acute stage if needed
- Functional mobility
GBS
With the Ventilation consideration, what should be done in the Chronic Stage?
- Not Applicable
We want the patient dependent at this stage
GBS
With the Adaptive Equipment Management consideration, what should be done in the Acute Stage?
- Splinting
- Abdominal blinders/compression stockings
- Tilt table/standing frame
GBS
With the Adaptive Equipment Management consideration, what should be done in the Subacute Stage?
- Harness systems- body weight support
- Assistive devices - i.e. walkers, canes
GBS
With the Adaptive Equipment Management consideration, what should be done in the Chronic Stage?
- Ankle- foot orthosis
GBS
With the Strengthening consideration, what should be done in the Acute Stage?
- 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)
NO ECCENTRIC STRENGTHING, NOT RECOMMENDED
GBS
With the Strengthening consideration, what should be done in the Subcute Stage?
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
NO ECCENTRIC STRENGTHING, NOT RECOMMENDED
GBS
With the Strengthening consideration, what should be done in the Chronic Stage?
- Follow ASCM guidelines once greater than 3/5 strength and no signs of overwork weakness
NO ECCENTRIC STRENGTHING, NOT RECOMMENDED
GBS
With the Aerobic consideration, what should be done in the Acute Stage?
- Not Appropriate
- Monitor vitals for stability with all mobility/activities
Vital sign Assessment for stability throughout Interventions
GBS
With the Aerobic consideration, what should be done in the Subacute Stage?
- Low to moderate intensity (40-60% HRMax), RPE 12-13
- Frequency/Duration: 20 min, 3-5 x/wk
- Mode: Walking, stationary bike, UE ergometer
Vital sign Assessment for stability throughout Interventions
GBS
With the Aerobic consideration, what should be done in the Chronic Stage?
- Moderate to high (60-80% HRMax), RPE 14-17
- Frequency/Duration: 30 min or greater, 4-5 x/wk
- Mode: Variable options
Vital sign Assessment for stability throughout Interventions
GBS
With the Functional Retraining consideration, what should be done in the Acute Stage?
- Bed mobility, transfers
- Sitting/standing tolerance
- Wheelchair mobility
Consider vitals, strength and fatigue
GBS
With the Functional Retraining consideration, what should be done in the Subacute Stage?
- All mentioned in acute phase
- Gait on level and unlevel surface
- Stair training (if aerobically appropriate)
Consider vitals, strength and fatigue
GBS
With the Functional Retraining consideration, what should be done in the Chronic Stage?
- Gait adaptability
- Community mobility
- Recreational activities
Consider vitals, strength and fatigue
GBS
With the Balance Training consideration, what should be done in the Acute Stage?
- Unchallenged static and dynamic sitting balance
- Unchallenged standing if appropriate
GBS
With the Balance Training consideration, what should be done in the Subacute Stage?
- Challenged static and dynamic sitting balance
- Challenged static and dynamic standing balance
GBS
With the Balance Training consideration, what should be done in the Chronic Stage?
- Higher level balance challenges
What are Psychosocial Considerations?
- 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
