Signs and symptoms of MS?
Variable presentation!
Depends on lesion location, severity of symptoms and person’s age
Sensory and motor symptoms can occur anywhere in body with varying fatigue and intensity
Fatigue is the MOST common MS symptom, often most disabling. Multifactorial etiology and can affect all aspects of mobility. So address fatigue!
Define:
Fatigue vs …
Fatiguability
- Which is the subjective vs objective measure?
- What is different in pathologic fatigue or fatiguability?
Define:
Fatigue: SUBJECTIVE state of being TIRED. A feeling of not being able to perform a task/activity effectively, if at all. It is noted in the individual whether the person is engaged in activity or not. Fatigue is general, tends to have a global effect.
Fatiguability: OBJECTIVE measure of how fast someone gets tired. Can be observed (and felt) on any prolonged and/or intensive task for any individual - refers to a SPECIFIC motion, task, body part, or physiologic process that objectively worsens in performance over time.
- Patients can have one without the other, or both!
- Pathological fatigue or fatiguability: happens faster or more severely than expected in a non-disabled person
Differentiate between primary vs secondary fatigue/fatiguability.
PRIMARY Fatigue / Fatiguability:
- A distinct and particular physiologic change resulting in fatigue or fatiguability that is SPECIFICALLY DUE TO the DISEASE PROCESS ITSELF and is a typical and expected result of the disease
- Primary fatigue/fatiguability is refersible ONLY by treating the 1* physiologic process
- E.g. Diminished conduction through a demyelinated nerve in MS
SECONDARY Fatigue / Fatiguability:
- Fatigue that occurs as a result of an ADAPTATION or compensation to the disease pathophysiology
- Occurs as a RESPONSE to the dz, not due to the dz itself
- Reversible if the compensations or adaptations are prevented or limited
- E.g. deconditioning d/t sedentary lifestyle
Examples of signs of fatiguability (which is [subjective / objective ]) in MS?
(consider gait, effect of a repetitive task, physiologic measures, etc)
Example of an outcome measure to assess this?
Examples of signs of fatiguability (which is OBJECTIVE) in MS:
- Progressive slowing of gait
- Progressive weakness of repeated contractions (e.g. with high rep antigravity hip flexion)
- Worsening of sensation / speech / vision during a repetitive task
- Decreased performance on a functional measure following exertion
- Physiologic measures: e.g. temperature, EMG, cardiovascular
- Pt/caregiver complaint / identification of fatiguability
Would assess via an objective measure e.g. 6MWT!
Symptoms of fatigue (which is [subjective / objective ] ) in MS?
Symptoms of fatigue (which is SUBJECTIVE) in MS?
- Pt c/o fatigue
- Pt avoids exercise program or other activities
- Caregiver report
- Decreased scores on self-report fatigue measures
- Can also present as depression, anxiety, sleepiness, lassitude, and lethargy
How is disease severity categorized in MS? Name the scale and give the ranges for each level of disability.
Expanded Disability Status Scale (EDSS)
0-10 scale, 0 = normal, 10 = death
0-3.5: Normal to mild disability 4-5.5: Mild to mod disability 6.0-7.5: Mod to severe disability 8-9.5: severe disability, restricted to bed or w/c 10: Death
Mild disability in early-stage MS can often be subtle and hard to identify on PT exam (e.g. might have strong MMT and be functionally independent but have early changes in gait & fatiguability!)
Recommended outcome measures for…
- Endurance?
- Balance?
- Cognition?
Mild disability in early-stage MS can often be subtle and hard to identify on PT exam (e.g. might have strong MMT and be functionally independent but have early changes in gait & fatiguability!)
Recommended outcome measures for…
- Endurance? 6MWT! Evaluates distance covered per minute to assess slowing/ fatiguability
- Balance?
- -> MiniBESTest: less of a ceiling effect than the Berg; combines anticipatory, reactive, and sensory aspects of gait and balance
- –> DGI: evaluates specific walking tasks, including stairs
- Cognition?
- –> TUG with dual and cognitive task: looks at effect of cognition on motor performance
*Recommend initial assessment, then do 6MWT to fatigue them, and then REASSESS balance, gait, MMT and /or repeat leg raises to look at impact of fatiguability
Diagnostic signs of MS found on work-up?
Imaging? LP?
Imaging: MRI with +gadolinium enhancing lesions
LP: positive for oligoclonal bands
Interventions in Mild/early MS?
Muscle length? Strength recs?
- Address muscle length problems early on! E.g. if PF tightness worsens w/fatigue, it will likely progress as dz progresses (as well as as a secondary effect from decreased standing/activity as dz progresses) -> increased falls. Recommend 30-60 second stretches every 1-2 hrs during the day
STRENGTHENING
- Intermittent strengthening exercises - go for MANY sets of FEW reps with rests between (e.g. 10 sets of 3 reps).
- LOW rep, high intensity (85-90% of 1RM; aka “maximal strength training”) exercise - may result in greater activation of neural drive!
- Functional strengthening of mm through functional practice (e.g. of eccentric ankle DF as required during early stance) - may be best to do right after stretching PFs so that the increased ROM can be used in the strengthening exercise! May be helpful to do DF exercises in a closed chain (e.g. standing) as it approximates walking where calf tightness and DF weakness occur.
*It’s tricky because often fatigue prevents exercising at a high enough volume to result in improvements in weakness that is specifically induced with fatigue
SO intermittent exercise lets you get greater volume by increasing the amount of rest so fatigue never accumulates!!
BALANCE:
- Go for task-specific practice with the areas of balance that pt has most difficulty (e.g. balance w/reduced BOS, gait with horizontal head turns)
- Alter the amount of fatigue (induced through other physical activities) to scale the level of difficulty for appropriate dosing of the exercise. - because pt loses balance when fatigued, it’s importance to practice balance when pt is fatigued! E.g. could walk x6 mins, then immediately practice balance exercises. Appropriate level of fatigue is so pt is successful w/balance task, but with some difficulty. If too easy, the level of fatigue is insufficient; if unable to do task, level of fatigue is excessive.
GAIT training:
- Go for intermittent, task-specific practice of walking / running, with focus on quality. I.e. repeat short distance activity, separated by rest periods. Also need to address deficits in other relevant impairments (e.g. flexibility, strength). To improve endurance, need to achieve a certain amount of volume, which is hard w/MS-related fatigue - intermittent training (rest breaks during a walk or run) can help to increase volume without increasing fatigue!
What does a person with “moderate MS” look like?
- EDSS score range?
- Impact on life/work?
- Getting PT yet?
Recommended outcome measures for…
- Fatigue?
- Balance?
- Endurance?
What does a person with “moderate MS” look like?
- EDSS score range? 3.5-6.5ish
- Disability is readily apparent, but may not have profound effect on life/work
- This is often the 1st point of referral to PT, as they are accumulating and progressing disability
OUTCOME MEASURES:
Fatigue:
- Fatigue impact scale: overall impact
- VAS: immediate impact
Balance:
- Berg & DGI for fall risk assessment and to identify task limitations
Endurance: 6MWT - looking at total distance and minute-by-minute
Twelve-Item MS Walking Scale - self report measure, rates the impact of MS on the pt’s ability to walk (>75/100 indicates fall risk; but recall, pt might overestimate their abilities)
Rehab interventions in moderate MS?
Depends on presentation! Address deficits.
FLEXIBILITY:
- Likely to need calf stretches, ?ankle mobilization.
- May do best with short periods of stretching THROUGHOUT day, rather than 1x stretching daily.
STRENGTH: Do it!
- Functional activities are great. Consider squats, bridges, step ups, multidirectional stepping.
- Progressive resistance strengthening to specific major muscle groups 2x/week
- Fewer reps per set, increased rest periods may allow for greater total volume of training
BALANCE
- Static balance trainign decreasing BOS and altering visual and somatosensory inputs can improve sensory integration for maintaining upright postural control - which is needed for SLS activities (e.g. to step up stairs or over obstacles)
- Task-specific training (e.g. gait training) is good - include dual task training (head turns, over/around obstacles, turning, carrying items, varied surfaces, cog task etc) to help train dynamic standing balance
- Intermittent walking (w/rests) may reduce fatigue and improve endurance
Other thoughts:
- Focus is on adaptive when able; limit use of walking aides, which can lead to decreased mobility, and try to remediate first!! Need to practice the task, not the compensation.
Fall prevention: Lots of pt education!
- Home safety checklist
- Information booklet
- Community balance program or exercise class
- Aerobic, strength, and flexibility exercise program to reduce deconditioning
- HEP
What does a person with “severe MS” look like?
- EDSS range?
- Ambulation status?
- At risk for…?
- What drives the severity?
What does a person with “severe MS” look like?
- EDSS 8-9.5 (recall, 10 = death)
- Non-ambulatory or minimally ambulatory (maybe short distances w/assist); regardless, pts need assist for fxn’l mobility
- At risk for. morbidity and mortality d/t complications
- –> Significant restrictions in flexibility, at risk for developing further restrictions
- –> Poor posture/postural control and associated problems (e.g. impact on communication, feeding, swallowing, bathing, dressing, toileting - but some aspects of function may not be limited!)
- –> Unlikely to have substantial fxn’l recovery
- Severity can be d/t multifocal involvement or profound local involvement
Focus of PT interventions in severe MS includes…
Focus of PT interventions in severe MS includes…
Rehabilitate deficits which aren’t yet severe in order to maintain maximum fxn’l
Try to prevent further deterioration d/t disuse and prevent complications - improvements may be possible, especially if disability is d/t deconditioning rather than dz!
Prescribe activities and equipment to maximize independence
- W/c seating and positioning
- Adaptive equipment to assist w/standing
Maintain enough flexibility (even if pt has limited strength)
- …to maximize fxn, pain control/prevention, skin integrity
- Consider use of positioning aides in bed / chair
- Maximize/maintain respiratory fxn/hygiene
Caregiver training
- Bed mobility, transfers
- Home exercise/ stretching program
- QoL
Prognosis for developing severe disability related to MS?
Negative indicators (–> a less than favorable prognosis)?
Positive indicators (–> a favorable prognosis)?
- *Consider:
- Sex?
- Age of symptom onset?
- Type of initial symptoms and where (body regions) affected?
- Symptoms during remissions / between attacks?
Prognosis for developing severe disability related to MS?
NEGATIVE indicators (–> a less than favorable prognosis)?
- Male sex
- Onset of symptoms >40yo
- Initial symptoms involving the cerebellum, mental function, or urinary control
- Initial symptoms that affect multiple regions of the body
- In the first years after onset, attacks that are frequent, OR a short time between the first 2 attacks
- Incomplete remissions
POSITIVE indicators (–> a favorable prognosis)?
- Female sex
- Onset of symptoms <40yo
- Initial symptoms that are SENSORY only
- Involvement of only one CNS system at time of onset
- FULL recovery between attacks
- Absence or late onset of Cerebellar symptoms
*Recall, not all cases of MS are progressive! 20 yrs post diagnosis, ~2/3 people w/MS are ambulatory w/out a w/c!
Tests and measures and interventions for use with individuals w/severe MS:
- Respiratory fxn?
- UE function?
- Mobility?
- Other impairment level things to look at?
Severe MS tests/measures:
- Respiratory: maximal inspiration and expiration pressure
- –> Diminished respiration results in decreased ability to clear secretions and increased risk of respiratory compromise (big cause of morbidity and mortality in MS, d/t combined effect of inactivity + weakness of respiratory mm)
- –> Intervention: prolonged phonation exercises, use of breathing training devices, positioning to stretch restricted thoracic muscles.
- UE measures: Block and Box; Nine-hole Pegboard Test
- Bed mobility, transfers, CAREGIVER TRAINING / ASSESSMENT is huge in this phase. May need to consider mechanical lifts as dz progresses.
- –> Pts may use motorized scooters initially, but if/when hand function diminishes, next step is to obtain a manual w/c that the caregiver can propel to facilitate community access. Could also trial a motorized wheelchair to assess pt’s ability to use hand controls (pt may not have dexterity for hand controls, but pt may not want to be dependent on caregiver)
- Strength, ROM, skin integrity
- –> PROM and progressive resistance exercises (to minimize risk for further deconditioning)
- –> Night splints to maintain ankle ROM
- –> Bed positioning to prevent further activity
Pediatric multiple sclerosis:
- Defined as MS
Pediatric multiple sclerosis:
- Defined as MS <18 yo
- Makes up 2.7-10.5% of all cases of MS
- Females»_space; Males (2.1-3 F to every 1 M)
- Higher proportion of AFRICAN AMERICANS
- +Family history in 6-20%
Initial symptoms in pedi MS?
- Optic neuritis 52%
- Sensory disturbance 16%
- Initial presentation RAPID, resulting in admission to hospital within hours to a few days in 71%
Progression: conversion from relapsing remitting MS to secondary progressive MS takes LONGER in children (23 yrs) than adults (10 yrs)
Overall morbidity is GREATER in children w/MS when they reach adulthood.
How does aging differ between Late Onset MS (LOMS) and Early Onset MS (EOMS)
50% of individuals w/MS live >30 years after diagnosis!
45% of people with MS are >55yo
LOMS (typically…)
- Primary progressive course (rather than relapsing remitting)
- Motor > sensory symptoms
- Spinal symptoms more prevalent than cortical
- Cb symptoms are less frequent
- LESS responsive to steroids
- Associated w/FASTER progression
Comorbidities associated with Aging in MS:
- Cardiovascular?
- Neurologic?
- Respiratory?
- Integumentary?
- MSK?
- Vision?
- Vestibular?
Comorbidities associated with Aging in MS:
- Cardiovascular: decreased exercise tolerance
- Neurologic: decreased neuroplasticity, diminished NCV
- Respiratory: reduced volume and efficiency –> decreased oxygenation to working mm
- Integumentary: reduced thermoregulation
- MSK: decreased soft tissue extensibility, decreased force production
- Vision: diminished acuity
- Vestibular: diminished postural control
Are the following more common in CIDP or AIDP (GBS)…
Autonomic dysfunction Respiratory insufficiency Sensory signs Preceding illness Need for ventilation Maintaining independent ambulation
Are the following more common in CIDP or AIDP (GBS)…
Autonomic dysfunction: GBS > CIDP
Respiratory insufficiency: GBS > CIDP
Sensory signs: CIDP > GBS
Preceding illness: GBS > CIDP
Need for ventilation: GBS > (infrequent in) CIDP
Maintaining independent ambulation: CIDP > GBS
Summary... In GBS, we see more common: - Autonomic dysfxn - Respiratory insufficiency - Preceding illness - Need for ventilation - Loss of independent ambulation for a time (sensory signs can occur but are RARE in GBS!)
In CIDP:
- Ambulation is often maintained
- Sensory signs are COMMON
- …but autonomic dysfxn, respiratory insufficiency, preceding illness, and need for ventilation are less common.
