Physiotherapy Strategies for

Multiple Sclerosis
Goals and Expected Outcomes
1. To prevent risk of secondary impairment
2. To improve cognition
3. To improve joint mobility
4. To reduce pain
5. To improve muscle performance
6. To improve postural control
7. To manage fatigue
8. To enhance aerobic capacity
9. To enhance ability to perform physical actions, tasks, or activities
10. To improve Health status and quality of life are improved.
11. To improve sensory integrity
12. To improve skin awareness of skin integrity
 Interventions
Management of Sensory Deficits and Skin Care
• Use augmented feedback
• Proprioceptive loading : Exercise , resistance bands etc
• Instruct patient to maintain adequate lightening all the
time
• Decrease sensitivity to touch so awareness should be
made
• Awareness, protection, and care of desensitized
parts
Management of Sensory Deficits and
Skin Care
 Management of
• Pain
Stabbing pain from Lhermitte’s sign may be relieved with a
soft cervical collar to limit neck flexion.

• Hydrotherapy or pool therapy using lukewarm water

may have a beneficial effect on painful dysesthesias.

• Pressure stockings or gloves can also be used to relieve pain,

converting the sensation of pain to one of pressure.

• Neutral warmth may be an additional factor in the pain relief

experienced with stockings or gloves.
• TENS ( questionable)
 Exercise Training
• Exercise responses of the patient with MS
are influenced by a host of factors that require
attention
careful during exercise, including fatigue
spasticit incoordination, impaired ,
y, loss (numbness), tremor, and balance
sensory
intolerance.
heat ,
• Depression may affect adherence to an
exercise program.
• Therapists therefore need to provide
constant reinforcement and a positive
environment.
 Exercise Training
• The focus and pace of therapy must be readjusted
according to the patient’s specific abilities and needs at
that time.
• Patients with RRMS who are experiencing an
exacerbation should not exercise until remission is
evident.
• Exercise therapy can be reinstituted when the
deterioration has stabilized and no new symptoms are
appearing.
• Patients with PPMS can exercise within the limits of their
capabilities as exercise may slow further deterioration
and optimize remaining function
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5602953/
 https://pubmed.ncbi.nlm.nih.gov/25248447/

Conclusions: An intensive task-oriented rehabilitation protocol is

effective in improving motor function and has a positive impact on
quality of life in MS patients with moderate disability.
 https://bmcneurol.biomedcentral.com/articles/10.1186/147
1-2377-14-124
Conclusions
This two weeks high-intensity task-oriented circuit class
training followed by a three months home-based exercise
program seems feasible and safe in MS people with
moderate mobility impairments; moreover it might improve
walking abilities.
 Aerobic
•
Conditioning
Recommended training frequency 3 to
days/week,
is on alternate days. 5
• Daily exercise at lower levels of intensity is
recommended for individuals with more limited
exercise capacities
• Recommended duration is 30 minutes per session
or, for more involved individuals, three 10-minute
sessions per day.
•Type of exercise can include cycling, walking,
swimming, or water aerobic
 Flexibility
Exercises
• Stretching and ROM exercises should be
performed daily.
• For adequate stretching, holding at end range
should be a minimum of 30 to 60 seconds
repeated for a minimum of 2 repetitions.
• The use of orthoses or dynamic splinting is an
appropriate option for prevention and in some
cases reversal of contractures.
 Management of
•
Fatigue
Aerobic exercise training and energy effectiveness
strategies (EES) are central to any intervention plan
to lessen fatigue
• MS Daily Activity Diary (patient maintains)
• Based on this information, therapists can initiate
training sessions, teaching energy effectiveness
strategies.
• Energy conservation refers to the adoption of
strategies that reduce overall energy requirements
of the task and overall level of fatigue
 Energy
Conservation
• For example, a motorized scooter or powered
wheelchair can be considered for community or
home mobility to help conserve energy and
maintain independence.
• Other mobility equipment such as walkers,
crutches, or orthotics can also be considered
 Management of
Spasticity
• Cryotherapy
• Hydrotherapy
• therapeutic exercise
• Stretching
• positioning
• or any combination there
of.
 Management of Spasticity
• patients on baclofen will respond better to
stretching techniques if they are applied in the
middle of the dosing cycle rather than at the end or
beginning.
• Combining stretching with movements using
rhythmic rotation (gentle rotation of the limb) or
proprioceptive neuromuscular facilitation (PNF)
stretching techniques (hold–relax active contraction
[HRAC], contract–relax active contraction
[CRAC]) is effective in gaining ROM.
 Management of Balance and
Coordination
• Interventions directed at promoting postural
control should first focus on static control (holding)
in weightbearing, antigravity postures (e.g., sitting,
quadruped, kneeling, modified plantigrade, and
standing).
• Progression through a series of postures is used to
gradually increase postural demands by varying the
base of support (BOS), raising the center of mass
(COM), and increasing the number of body
segments (degrees of freedom) that must be
controlled.
 Locomotor Training
• walking forward and backward,
• side-stepping, and cross-stepping
• Braiding (a PNF activity that combines side-
stepping and crossstepping) is a complex, higher-
level walking activity.
• climbing, negotiating curbs and ramps, navigation
around obstacles, and walking on varied surfaces
• BWS
• Robot Assisted
Orthotics and Assistive Devices
 Functional Training
• Adaptive equipment can include bed or bathroom
grab bars, overhead trapeze, raised seats, transfer
board, or hydraulic lift. Appropriate positional and
functional splints to facilitate writing or typing and
plates and cups with lips to minimize spills are
often helpful inassisting with hand function.
• Long-handled shoehorns, reachers, button hooks,
sock aids, or Velcro® closures can assist in
dressing.
 Speech and
Swallowing
• Collaborating with a speech-language
pathologist to develop a resistive
training (RBT) program paired with activities to
breathing
improve trunk stability, head control, and sitting
balance is an important component of the
POC for patients with MS
 Cognitive Training
• Patients who have incorporated mobile devices
into their daily routines note improvement in
organization and self efficacy that positively
affected their daily lives
• Cognitive-behavioral therapy (CBT) for
patients with MS can yield significant
improvement in the ability to deal with distress,
debilitating symptoms, impairment and disease
exacerbation, and progression
 PATIENT AND FAMILY/
CAREGIVER EDUCATION
• The disease process, clinical manifestations,
and their significance in terms of
management
• Prevention of secondary complications, indirect
impairments, and activity limitations
• The rehabilitation process, the POC, and
its specific interventions
 PATIENT AND FAMILY/
CAREGIVER EDUCATION
• The HEP, including interventions that can be
carried out independently
• Monitoring the effects and possible adverse
reactions of medications
• Use of assistive devices and adaptive
equipment
• General health and stress management
techniques
• Community resources
 Summary
• Timely referral to neurorehabilitation services is
the key to successful management of activity
limitations, disability, and quality-of-life issues in
patients with MS.
• Too often services are not begun until the
individual becomes severely disabled.
• A comprehensive POC that addresses the needs of
the whole patient and emphasizes meaningful
functional activities, patient education, and self-
management is ideal for such a
complexneurodegenerative disorder.
 Summary
• Activities that prove attainable and safe ensure
patient success and build self efficacy.
• Many patients with MS report that they lack the
knowledge and skills needed to exercise safely.
• Promoting self-efficacy, self-management, and
mastery can be achieved through supervised
programs that focus on regular exercise, activity
pacing, energy conservation, and overall healthy
behaviors.
• Comprehensive efforts of the interdisciplinary
team are needed to provide the coordinated
and continuing care required with anticipated
inpatient, outpatient, and home/community
episodes of care.