The document discusses the various aspects of physical therapy for patients with multiple sclerosis (MS), including its historical perspective, epidemiology, and pathophysiology. It outlines different clinical forms of MS, typical symptoms, and the impact of rehabilitation methods such as exercise and physiotherapy assessment on managing symptoms and improving quality of life. Key strategies for management include energy conservation techniques, balance training, and tailored exercise programs to enhance mobility, reduce fatigue, and address specific challenges faced by individuals with MS.

1. PHYSICAL THERAPY IN
MULTIPLE SCLEROSIS
SHEETAL MALHAN
ASSOCIATE PROFESSOR

3. HISTORICAL PERSPECTIVE
Jean-Martin Charcot (1825–1893)
described features of MS
MS-related central nervous system
pathology—Jean Cruveilhier, 1841

4. MS EPIDEMIOLOGY

6. WHAT CAUSES MS?
Genetic
Predisposition
Environmental
Trigger
Autoimmunity
Loss of myelin
& nerve fiber

7. THE GENETIC FACTOR
 The risk of getting MS is approximately:
 1/750 for the general population (0.1%)
 1/40 for person with a close relative with MS (3%)
 1/4 for an identical twin (25%)
 20% of people with MS have a blood relative with MS
The risk is higher in any family in which there are several family
members with the disease (multiplex families)

9. PATHOPHYSIOLOGY
...cross the blood-brain barrier…
…launch attack on myelin & nerve fibers...
“Activated”T cells...
…to obstruct nerve signals.
myelinated nerve
fiber
myelinated nerve fiber

12. Source: National Multiple Sclerosis Society & NIH estimates
Clinical Forms of MS
Four internationally recognized general categories
Relapsing-
remitting
(RRMS): 55%
Secondary
Progressive
(SPMS): 35%
Primary
Progressive
(PPMS) 9%
Progressive
Relapsing
(PRMS): 1%
• Clearly defined flare-ups &
remissions; inflammatory
lesions developing constantly
• Early 20s & 30s; women 2:1
• Initial disease activity in brain
(cognitive)
• Better prognosis: supporting
equipment
avg. 20 yrs
• Majority of RRMS pts will
develop SPMS
(90% in 25-30 years)
• Relapse frequency
decreases but disability
increases
• Less remyelination &
more plaques, resulting in
steadily progressive
disability with less
recovery
• Could represent
different, advanced
stage of RRMS
• At onset, steady worsening
without relapses or remissions
• Variations in rates of
progression; occasional
plateaus or temporary minor
improvements
• Late 30s/early 40s; men as
likely as women
• Initial disease activity in spinal
cord (physical disability)
• Worse prognosis: supporting
equipment avg. 6-7 yrs
• From onset steadily
worsening disease with
clear acute relapses with or
without recovery
• Unlike RRMS, remission
periods contain clinically
observable continuing
disease progression

13. Disease Overview
Disease course:
MS is an ongoing process of demyelination,
remyelination, and eventual neuron loss
Relapses & Remissions: Most MS
sufferers experience periods of acute
exacerbations (flares, relapses) varying in
number and severity, followed by periods of
remission, where all symptoms
spontaneously cease: inflammation
damage to CNS is continuous, occurring
during flares AND remissions
Results: Repeated attacks on the axon, the
surrounding myelin sheath eventually causes
scarring or plaques that interrupt or even
block nerve impulses, causing progressive
cognitive/physical disability
Heterogeneity:
Symptoms, severity,
and course vary per
person and disease
seems to follow a
distinct progression in
each individual pt

14. MS Symptoms
Develop during acute exacerbations or as the cumulative result of multiple
lesions in the CNS
Cerebrum &
Cerebellum
Lesion Location
• Not all symptoms affect all MS patients
• No two persons have identical complaints
• No one person develops all of the symptoms
Signs/Symptoms
Balance problems, depression, speech problems,
coordination, tremors, neuritis
Spinal Cord/Motor
nerve tracts
Muscle weakness, spasticity paralysis, vision problems,
bladder and/or bowel problems
Spinal Cord/
Sensory nerve tract
Altered sensation, numbness, prickling,
burning sensation
Symptoms can include: Fatigue (most common), sensory complaints,
tremors, balance/coordination, depression, spasticity, bladder, bowel,
vision loss, cognitive and emotional dysfunction, and sexual difficulties
CNS Lesion Location and Possible Associated Symptoms of MS:

21. PROGRESSIVE CHANGES

22. DIFFERENTIAL DIAGNOSIS
 Spinal Cord Neoplasm
 Spinal Cord AVM
 Cryptogenic Stroke
 Subacute Combined Degeneration
 Amyotrophic Lateral Sclerosis

23. UPON DIAGNOSIS OF MS:
 Pt. Should be counselled of the nature of the disease
 Understand the patient’s concerns
 Stress the importance of overall wellness
• STOP SMOKING
• Weight Control
• Healthy diet

24. MEDICAL MANAGEMENT

25. PHYSIOTHERAPY ASSESSMENT
 Strength
 Tone
 Range of motion
 Balance
 Coordination
 Cardiovascular and respiratory
status
 Bed mobility and transfer
 Bowel and bladder impairment
 Swallowing
 Speech and communication
impairment
 Visual status
 Sensory impairment
 Activities of daily living
 Cognition
 Physical environment
 Medical stability

26. The main areas of difficulty for someone with MS can include:
 Poor exercise tolerance on a background of high levels of fatigue.
 Altered gait pattern, often with the dragging of one foot and poor
floor clearance.
 Decreased balance and risk of falls, as a result of a combination of
factors including muscle weakness/stiffness, spasms, altered
sensation.
 Difficulty with bed mobility secondary to spasms and pain

32. FATIGUE: MANAGEMENT
 Energy conservative techniques: adoption of strategies that
reduce overall energy requirements of task & overall level of
fatigue.
 Activity pacing: balancing of activity with rest periods
 General exercises
 Breathing exercises
 Stretching
 Adaptive equipments

33. BALANCE AND COORDINATION

34. BALANCE & COORDINATION
 Promote static postural control: holding in weight bearing,
antigravity positions like quadruped, plantigrade, standing,
sitting.
 Varying wide base to narrow base
 Raising COG low to high.
 Rhythmic stabilization, slow reversals.
 Weight shifts/ reaching
 Frenkel’s exercises

37. SPASTICITY : REHABILITATION
 Cryotherapy
 Hydrotherapy
 Positioning
 ROM exs.
 Stretching
 PNF

40. SENSORY DEFICIT: REHABILITATION
 Increase awareness of deficits
 Compensating for the loss: use of vision to compensate for
proprioceptive loss; verbal cuing or biofeedback;
proprioceptive loading through exercise, resistance bands
 Visual deficit: use of eye patch for double vision; maintenance
of adequate lighting; adding contrast between items in
environment
 Routine safety instructions
 Wheelchair cushioning, pressure relieving devices
 Pressure relief techniques.

43. PAIN : REHABILITATION
 Regular strecthing or exercise
 Massage
 UST/ TENS
 Postural retraining
 Correction of faulty movement patterns
 Soft collar to relieve Lhermitte’s sign pain
 Pressure stockings or gloves

46. AMBULATION AND MOBILITY
 Supported body weight treadmill training
 Orthosis: AFOs, KAFOs, canes, crutches, walkers
 Wheelchair mobility training.
 Electric wheelchair.

47. SPEECH

48. SWALLOWING

49. SPEECH & SWALLOWING: REHABILITATION
 Respiratory muscle training
 Incentive spirometry
 Upright posture with slightly forward head position & chin
parallel to table or slightly tucked for swallowing
 Oral motor exs
 Stimulate swallowing reflexes by use of icy beverages
 Resistive sucking
 Power swallow: inhale then hold the breath, thereby closing the
airway, then swallow, exhale and swallow again

50. EXERCISES IN MS

51. BENEFITS OF EXERCISE
 Improved strength and mobility
 Improved balance and endurance
 Improved lung function
 Improved bowel and bladder function
 Decreased fatigue and spasticity
 Improved function and quality of life, and sense of well-being
 Decreased depression
 Decreased risk of heart disease

52. EXERCISE GUIDELINES
 Sessions scheduled on alternate days & during optimal times
 Submaximal exercise intensities
 Resistance training modes
 Circuit training
 Balance ex with adequate rest periods
 Monitor the effects of fatigue
 Manage core body temp & prevent overheating

53. STRETCHING PROGRAM:
 Should be performed daily, and helps manage spasticity and
reduce risk of contractures
 AROM & PROM
 T’ai Chi, yoga, and pilates have also been shown to improve range
of motion

55. STRENGTHENING:
 Should be performed 3-5 times per week, 1-3 sets of
repetitions for each muscle group exercise
 Focus on specific muscle groups that are the weakest and
contribute to decreased function

56. CARDIOVASCULAR CONDITIONING
•Pts may show autonomic
cardiovascular dysfunction in
advanced stages of the
disease.
•Respiratory muscle
dysfunction may also result in
reduced ex tolerance
•Training frequency is 3
sessions/week, on alternate
days
•Training intensity limited to
60-75% peak HR or 50-65%
peak VO2
•Circuit training
•Non weight bearing activities
in balance problems or
sensory loss
•Duration 30 min/ session or
three 10 min sessions/day

57. AQUATIC EXERCISE
- Cool water exercise

58. COMBATING HEAT SENSITIVITY
WHILE EXERCISING

60. COMBATING HEAT SENSITIVITY
WHILE EXERCISING
 Keeping hydrated with cool water/iced drinks
 Using cooling garments such as cooling vests or neck wraps
 Using a fan or misting fan during exercise
 Using ice packs
 Exercising in an air conditioned environment
 Avoid outdoor exercise during warm parts of the day
 Wear proper lightweight clothing and shoes
 Taking a cold shower or running hands under cold water post
exercise