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    Move Forward Guide

    Physical Therapist's Guide to Multiple Sclerosis

    Multiple Sclerosis (MS) is a chronic, usually progressive, disease that primarily affects young adults. More than 350,000 people in the United States and 2.5 million worldwide have been diagnosed with MS. Its effects vary widely. Although there is no known cure for the disease, it can be successfully controlled with medical management and rehabilitation.


     

    What is Multiple Sclerosis?

    Multiple Sclerosis is a disease that involves the loss of myelin, a material that covers and protects the nerves in the body's central nervous system. Without myelin, nerves cannot properly communicate with each other. Multiple Sclerosis symptoms vary from person to person, depending on what part of the nervous system is affected, including structures that control movement, sensation, and mental processes. However, more than 91% of all persons with MS report difficulty walking, and difficulty with body movements.

    Although MS is rarely fatal, its complications can be severe, including difficulty with breathing, injury due to falls, and a general lack of mobility. With appropriate medical support and physical therapy, the disease process can be controlled, and movement can be improved and maintained.

     

    How Does it Feel?

    MS leads to multiple signs and symptoms, which may include:

    • Fatigue that does not go away with rest
    • Difficulty walking, and problems with balance
    • Stiffness and spasms or a feeling of heaviness in your legs or arms
    • Bladder and/or bowel problems such as urgency or leaking
    • Memory and thinking problems
    • Pain and other unpleasant sensations
    • Emotional or mood problems, including depression
    • Vision problems, although vision itself may be good
    • Dizziness or vertigo
    • Speech problems

    Medical management of the disease can improve many, but not all of the signs and symptoms. Because MS affects each person differently, individuals may experience different signs and symptoms than another person with the same type of MS.

    Fluctuating symptoms

    Symptoms of MS can come and go, and the disease can go into remission. When a relapse is experienced, the symptoms can vary in duration and strength. A severe relapse can require hospitalization, but milder symptoms may be managed with medication at home. After a relapse occurs, the symptoms will again settle down, but may cause a slight loss of function. Some individuals will recover well from a relapse, but others may experience a higher level of disability.

    When MS goes into remission, you feel stable and may be able to gain some improvement in your ability to perform daily activities. Your physical therapist can help you gain strength and endurance during a remission.

    Depression

    Depression affects 25% of individuals with MS. It can complicate the initial adjustment period following diagnosis. Facing the ongoing challenges of MS can be overwhelming at times, and depression can significantly affect a person's quality of life. For these reasons, depression should be medically managed along with control of the disease itself. Your health care team, including your physician and your physical therapist, will work with you to reach and maintain your goals for living an active, productive life.

     

    How Is It Diagnosed?

    A diagnosis of MS is made if all of the following criteria have been met:

    1. Evidence of 2 symptoms occurring at least 6 months apart and occurring in 2 different parts of the body (ie, arms and legs, sensation and motor skills, vision and speech).
    2. MRI evidence of recent attacks in the brain or spinal cord.
    3. Abnormal findings in the cerebral spinal fluid obtained via a lumbar puncture.
    4. Ruling out of conditions that may have similar symptoms such as stroke, tumor, or other progressive neurologic disease.
     

    How Can a Physical Therapist Help?

    Physical therapy for people with MS focuses on helping them return to the roles performed at home, work, and in the community. Your first visit to physical therapy will consist of a complete examination to determine your areas of strength and weakness. Following the examination, your physical therapist will develop a specific exercise program for you based on your condition and goals, including a home-exercise program.

    Research studies have found that people in the early stages of MS may experience changes in their walking ability, balance, and breathing. If ignored, these early signs can lead to further disability. When someone receives a diagnosis of MS, the best option is to begin physical therapy right away to help improve any mild challenges, and possibly slow down the progression of the symptoms of the disease.

    Exercise programs

    Types of exercises beneficial for someone with early MS are aerobic training using a treadmill, rowing machine, or any type of stationary bike, strengthening, balance training, and stretching. In general, the program should be based on the individual’s ability and progressed at that person’s tolerance level. The goal of physical therapy in the early stages of MS is to help you perform all your normal activities.

    As MS progresses, further disability can occur. Research in physical therapy has identified benefits for people with MS in many areas after completing different types of exercise programs. Aerobic exercise, using equipment, such as an elliptical machine, a treadmill, or a stationary bike can improve your leg strength, walking and exercise endurance, balance, and mood.

    General strengthening

    Other types of exercise therapy include general strengthening for arms and legs, balance training, stretching activities, and relaxation techniques. These types of exercise have been found to improve walking ability, leg strength, and general balance during normal activities.

    Aquatic therapy

    People with MS may find aquatic exercise a beneficial way to increase their activity. Pool temperature can help maintain a normal core body temperature during exercise to support your general strength. The buoyancy of the water can offer support for people who cannot walk on solid ground, and provide gentle resistance to exercise movements. The Multiple Sclerosis Association of America strongly supports the use of aquatic therapies for people with MS. A list of MS aquatic programs can be found at mymsaa.org.

    Tai Chi and yoga

    Programs that include Tai Chi and yoga may also be beneficial for people with MS. Tai Chi is a low-intensity, movement-based form of exercise that can be performed in standing or sitting positions. Deep breathing is included in the technique. Yoga includes breath work, exercises for strengthening and flexibility, and meditation or relaxation techniques. A physical therapist trained in these programs will modify these exercises specifically for each individual's needs and goals.

    All adults should complete at least 150 minutes of moderate exercise a week (30 minute sessions, 5 days a week), per the Physical Activity Guidelines for Americans developed by the Office of Disease Prevention and Health Promotion in partnership with the President's Council on Fitness, Sports, and Nutrition.

     

    Can this Injury or Condition be Prevented?

    Scientists have yet to determine a specific cause of MS. The best measure of prevention is the maintenance of a healthy lifestyle. Performing at least 150 minutes of moderate physical activity per week (30 minutes per day, 5 days a week), eating a healthy diet, getting an appropriate amount of sleep, and managing daily stress are all aspects of a healthy lifestyle. Early diagnosis and appropriate treatment for MS can lead to a more successful and active life.

     

    Real Life Experiences

    Annie is a 34-year-old woman who began to notice her legs felt weak and unsteady when she climbed stairs, and that her left foot began to drag after she took a long walk. She also noted that she felt extremely tired after taking a hot bath and that her feet felt "numb and tingling" for 30 minutes after the bath. Given the fact that she had always been athletic and had kept in shape, these findings concerned her; she contacted her family physician, who referred her to a neurologist.

    The neurologist ordered an MRI and a lumbar puncture. The results of both tests, along with Annie's medical history, confirmed a diagnosis of early-stage multiple sclerosis. Annie was quite overwhelmed with the diagnosis. Her physician reassured her, noting that she was diagnosed when the disease was still quite mild, and that with medical management and physical therapy, the odds were that her MS would be managed successfully over her lifetime. He prescribed some medications, and referred her to a physical therapist who specialized in MS.

    Annie's physical therapist performed a full evaluation, examining her strength, flexibility, sensation, coordination, gait, and balance. Based on the specific findings of the evaluation, he developed a detailed program for her to follow. The program was carried out in the physical therapy clinic, under his supervision. He also designed a home-exercise program for Annie to follow. He arranged to see her 1 to 2 times a week for the next 4 weeks.

    On successive visits, Annie's physical therapist re-examined her and found that many of the difficulties she originally noticed had decreased. She was able to walk longer distances with less fatigue, and her foot dragged less. She was having far less difficulty on stairs and her balance improved. She still noticed that her feet became a little numb after a hot bath, and that if she was very tired or very hot, her symptoms became worse. Most importantly, though, she realized that, despite some of the limitations caused by MS, she was still able to live her life much like she did before her symptoms appeared. Annie and her physical therapist formed an effective team—determined to work together to ensure her active and productive lifestyle for years to come.

     

    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and experience to treat Mutiple Sclerosis. However, MS is a unique condition and you may want to consider:

    • A physical therapist who is experienced in treating people with neurological conditions, specifically Multiple Sclerosis.
    • A physical therapist who is a board-certified clinical specialist or who has completed a residency or fellowship in neurologic physical therapy and uses the designation NCS. This therapist has advanced knowledge, experience, and skills that may apply to this condition.
    • Physical therapists who have earned a Multiple Sclerosis Certified Specialist (MSCS) certification from the Consortium of Multiple Sclerosis Centers (CMSC), and have spent a minimum of at least 1 year working with MS patients and have passed a required exam.

    You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you're looking for a physical therapist (or any other health care provider):

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have multiple sclerosis.
    • During your first visit with the physical therapist, be prepared to describe the physical issues and symptoms that are causing the most difficulty.
    • Plan to talk about what goals are most important to help increase the patient's independence performing daily activities, and ensure a healthy future.
     

    Further Reading

    Feinstein A, Rector N, Motl R. Exercising away the blues: can it help multiple sclerosis-related depression? Mult Scler. 2013;19:1815-1819. Free Article.

    Schlaeger R, D’Souza M, Schindler C. Prediction of long-term disability in multiple sclerosis. Mult Scler. 2012;18:31-38. Free Article.

    Rietberg MB, Brooks D, Uitdehaag BM, Kwakkel G. Exercise therapy for multiple Sclerosis: a review. 2011. The Cochrane Collaboration. Chichester, United Kingdom: John Wiley & Sons Ltd. 2011;(1). Free Article.

    Rampello A, Franceschini M, Piepoli M, et al. Effect of aerobic training on walking capacity and maximal exercise tolerance in patients with multiple sclerosis: a randomized crossover controlled study. Phys Ther. . 2007;87:545-555. Free Article.

    Martin CL, Phillips BA, Kilpatrick TJ, et al. Gait and balance impairment in early multiple sclerosis in the absence of clinical disability. Mult Scler. 2006;12:620-628. Article Summary on PubMed.

    Hemmett L, Holmes J, Barnes M, Russell N. What drives quality of life in multiple sclerosis? QJM. 2004;97:671–676. Free Article.

    Rosati G. The prevalence of multiple sclerosis in the world: an update. Neurol Sci. 2001;22:117-139. Article Summary on PubMed.

    McDonald WI, Compston A, Edan G, et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis. Annals of Neurology. 2001;50:121–127. Article Summary on PubMed.

    *PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

    Reviewed by the MoveForwardPT.com editorial board.