MS

• Progressive Disorders/Degenerative Diseases: Clinical Management of the Patient with Multiple Sclerosis

  
• PT 545, Spring 2024, Dr. Priore PT, DPT, MS, PCS
• Ch. 16 O'Sullivan
• Learning Objectives


  • Review the epidemiology, cause/etiology and pathophysiology, diagnostic process and prognostic indicators, clinical course, clinical presentation, and medical management and other potential medical options for patients with Multiple Sclerosis
  • Identify the physical therapy examination components appropriate for patients with Multiple Sclerosis through the course of the disease progression, inclusive of disease specific standardized outcome measures
  • Analyze and interpret patient data to complete a physical therapy evaluation, diagnosis, and prognosis for patients with Multiple Sclerosis
  • Develop appropriate physical therapy intervention plans for patients with Multiple Sclerosis through the course of the disease progression
• Clinical Manifestations of MS


  • Fatigue
  • Sensory Disturbances
  • Motor Impairments
  • Ataxia, Intention tremors, Spasticity
  • Bowel and Bladder
  • Sexual Dysfunction
  • Cognitive Impairments
  • Depression
  • Heat Intolerance (Uthoff's symptom)
  • Visual Disturbances
  • Communication Limitations
  • Various Secondary Limitations

  
• Clinical Presentations
• Functional Observation


  • Bed mobility
  • Transitions
  • Transfers
  • Ambulation/Stairs/Ramps/Curbs
  • Wheeled Mobility
  • ADL's/IADL's
• History Taking for the Patient with MS


  • Questions surrounding diagnosis
  • Course of the disease: exacerbations, recovery of function
  • Current level of function
  • History of falls (or near falls)
  • Medications/PMH/PSH
  • Current driving status
  • Environmental set up
  • Social Support
  • Followed by Neurologist? MS specialist? Other involved MDs
  • Fatigue
  • Current level of work and exercise
• History Taking for the Patient with MS


  • Symptoms related to heat intolerance?
  • Problems with Vision?
  • Problems with dizziness or vertigo?
  • Pain or Sensory changes?
  • Deficits in Memory or Cognition?
  • Symptoms of Emotional or Mood problems?
  • GI/GU difficulties?
  • Problems with Speech or Swallowing?
  • Difficulty with stiffness and spasms?
  • Problems with breathing or coughing?
• Examination: Tests and Measures - Musculoskeletal


  • AROM/PROM
  • Strength and Muscular Endurance
  • MMT, Functional Strength Assessment
  • Repeated Movement Testing
  • Concept of 'fatigability'
  • Posture
  • Functional positions for that specific patient (ex: sit, stand)
• Examination: Tests and Measures - Neuromuscular


  • Tone
  • Modified Ashworth Scale
  • DTR's and Reflexes, Cranial nerves (motor)
  • Cerebellar Signs
  • Metria, Diadokokinesia, Rebound
  • Postural Control/Balance
  • Static, Anticipatory, Reactive in functional positions
  • Activities-Specific Balance Confidence Scale
  • BERG*, Mini-BEST, DGI, Functional Reach Test, Rivermead Mobility Index
  • Vestibular
  • Dual Task/Motor Planning
• Examination: Tests and Measures - Sensorimotor


  • Superficial
  • Deep
  • Cortical
  • Pain (provoking stimuli, headache, hyperpathia, dysesthesias, Trigeminal Neuralgia, Lhermitte's Sign)
  • Visual Analog Scale, McGill Pain Questionnaire, Dallas Pain Questionnaire
  • Vision
  • Acuity, Tracking, Fields, Accommodations
  • Cranial Nerves (sensory)
• Examination: Tests and Measures - Cardiopulmonary


  • Vitals: HR, BP, RR
  • Response to Exercise
  • Links to core body temperature
  • Perceived Exertion
  • Rating of Perceived Exertion, Dyspnea Scale
  • Respiratory Strength
  • Maximal inspiratory and expiratory pressures
• Examination: Tests and Measures - Cognition/Affect


  • Memory & Attention (DUAL TASK)
  • Reasoning & Problem Solving
  • Stress/Anxiety/Coping Strategies
  • Sleep Disorders
  • Safety Awareness
  • Mini Mental Status Exam, Minimal Examination of Cognitive Function in MS, Beck Depression Inventory
• Examination: Tests and Measures - Fatigue & Fatigability


  • Frequency
  • Duration & Severity
  • Precipitating & Relieving Factors
  • Examine in fresh and fatigued states
  • Activity Levels & Efficacy of Rest Attempts
  • Modified Fatigue Impact Scale, Visual Analog Scale for Fatigue, Fatigue Scale for Motor and Cognitive Functions
• Fatigue Scale for Motor and Cognitive Function
• MFIS - Self-report: measures physical, cognitive, psychosocial function. Some studies use 38 as a cut off score to distinguish between fatigued and non-fatigued patients.
• Examination: Tests and Measures - Skin Integrity and Orthoses/AD


  • Areas of insensitivities
  • Bruising or breakdown
  • Continence
  • Positioning (bed, w/c)
  • Pressure relieving strategies
  • Safety awareness
  • Alignment & Fit
  • Practicality & Ease of Use
  • Energy Conversation vs. Expenditure
  • Safety
  • Functional Performance
• Examination: Tests and Measures - Gait


  • 12-item MS Walking Scale*
  • Timed 25' Walk Test (T25FW)*
  • FGA (dynamic walking balance)
  • Timed Up-And-Go (cognitive and manual tasks)
  • 6MWT*, 2 MWT*
  • SWOC
  • Stair/Curb Negotiation
• Rivermead Mobility Index (RMI) - 15 item measure (14 self report, 1 performance) that examines gait, balance, transfers. Scored as yes (1) or no (0), 0-15 (higher score = higher function).
• Examination: Tests and Measures - Environmental


  • Barriers & Facilitators
  • Safety
  • Access
• Examination: Tests and Measures - Fine Motor Skills


  • Grip strength
  • Manual Dexterity
  • Impact on ADLs
  • Dressing, tying shoes, etc.
  • 9-Hole Peg Test
• Expanded Disability Status Scale (EDSS)


  Objective approach to quantify level of function in MS. Total score ranging 0-10 over eight functional system scores (FSS) scored 0 (low level of problems) to 5 (high level of problems).
• EDSS Scoring


  • 0-3.5 "Little/Mild Disability"
  • 4-6.5 "Mod. Disability"
  • 7-9.5 "Severe Disability"
• Risk of falling is highest between EDSS scores of 4-6
• Additional Disease Specific Measures for Multiple Sclerosis


  • Multiple Sclerosis Quality of Life-54 (MSQOL-54)
  • MS Quality of Life Inventory (MSQLI)
  • Multiple Sclerosis Impact Scale (MSIS-29)

  
• Physical Therapy Evaluation


  Clinical judgments and decisions based on analysis of exam. ICF: Contextual Factors.
• Physical Therapy Diagnosis


  McDonald Criteria (medical), Clinically Isolated Syndrome (CIS). Motor dx use labels that identify "the impact of a condition on function at the level of the system (especially the movement system) and at the level of the whole person."
• Physical Therapy Prognosis


  Great Variability (intra and inter patient), rate of progression affected by multiple intrinsic and extrinsic factors, Primary vs. Secondary Disability, disease activity vs learned disuse
• Unfavorable Prognosis Factors


  • Male after 40 yrs. of age
  • Initial symptoms involving cerebellum, mental function, urinary control affecting multiple regions
  • Frequent or short time between exacerbations with incomplete remissions
  • Obesity
  • Smoking
• Favorable Prognosis Factors


  • Female before 40 yrs. Of age
  • Initial symptoms sensory only
  • Involvement of only one CNS region
  • Full recovery
  • Absence/Late onset cerebellar symptoms
  • BMI WNL ; no smoking
• Median life expectancy is 74.7 years for MS and 81.8 years for general population. 77.2 years for women with MS and 72.2 for men with MS. RRMS 77.8 years, PPMS 71.4 years. Median survival rate from disease onset is 41 years. COD: pneumonia, infections, falls/fear of falling, suicide, heart disease due to inactivity.
• PT Interventions for the Patient with MS


  • Coordination, Communication, and Documentation
  • Patient/Client Related Instruction
  • Procedural Interventions* (At Diagnosis (preventative, restorative), Periods of Stability (preventative, maintenance), Surrounding Relapse (restorative), Disease Progression (maintenance, compensatory))
• PT's role is fluid, differs in episodes of care, and adapts to presentations.
• Evidence now suggests that physical activity and exercise is now considered to be disease modifying (considered neuroprotective) - Reduced relapse rate, Decreased mobility disability and progression, Decreased lesion volume
• RRMS


  Relapsing-Remitting Multiple Sclerosis
• PPMS


  Primary Progressive Multiple Sclerosis

  
• Median survival rate from disease onset is 41 years
• Causes of death (COD) for people with MS


  • Pneumonia
  • Infections
  • Falls/fear of falling
  • Suicide
  • Heart disease due to inactivity
• All of the COD for people with MS have something in common