16
- Drive home neuroplasticity
- Safe intensity while being mindful of MS-fatigue
- Brain derived neurotrophic factor and nerve growth factor
Neurology specific concepts during treatment
What is primary MS fatigue called?
MS lassitude
Fatigued, depressed, cognitive dysfunction, sleepy, combination of above
"Tired"
- Feelings of stiffness and a wide range of involuntary muscle spasms
- May be mild or severe with painful uncontrolled spasms of the legs
- More common in the legs (rare in the arms)
- Worsened by sudden movements or position changes, temp changes, humidity, light clothing
- If left untreated, spasticity can lead to serious complications: contracture, pressure sores
- Some degree of spasticity can provide benefit, especially for people who have significant leg weakness, as it can give their legs some rigidity, making it easier for them to stand, transfer or walk
Spasticity
Impaired conduction of nerve impulses, lesions in BG and hypothalamus may play an important role
- Generally occurs on a daily basis
- May occur early in the morning, even after a full nights sleep
- Worsens as the day progresses
- Aggravated by heat and humidity
- Comes on easily and suddenly
- More severe than normal fatigue
Primary (lassitude) fatigue ***
Avoidance of fluids later in day, consistent sleep habits, effective management of MS symptoms that impact sleep (spasticity). Talk about fully charged or next day/cell phone example. Exercise earlier in the day. Sleep in cool room. No TV or electronics before bed
Sleep habits for fatigue management in MS
- Allow adequate warm up/cool down
- Assess the days presentation and adapt if tolerance has changed
- Sweating with MS does not mean they are working too hard, sweating helps cool the body down. THEREFORE, abnormal sweat response with MS patients means negative thermoregulatory response due to impaired autonomic nervous system, may need to find alternate ways to keep body cool during exercises (water, cooling garments)
- Evidence of intolerance = unable to cool down, concerned if not sweating and working very hard
MS specific concepts during treatment
1. BBB function (loss of integrity of BBB, more inflammation)
2. Brain connectivity (networking, better connections)
3. Neurotrophic factors: brain derived neurotrophic growth factor (BDNF) and nerve growth factor (NGF)
4. Brain imaging
Exercise impacting CNS (both aerobic and strength training)
- Stretching program
- Strengthening program
- Medication
- Botox
- Surgical
How to manage spasticity effectively
Outcome measure specific to MS that is physical, cognitive, psychosocial
Modified fatigue impact scale (MFIS)
How many minutes of moderate exercise will significantly induce BDNF production?
30 minutes **
Sleep disturbances, spasticity, med SE, deconditioning, other medical conditions, obesity, depression, noxious stim, extra exertion required for daily activities, temperature sensitivity
Secondary fatigue
- Functional
- PNF/NDT
- Spasticity management
- Neuromuscular electrical stimulation (NMES)
- Functional mobility and gait training
- Patient/caregiver education
- Bracing - aids, restricts, or stabilizes movement
- WC management/AD training
PT interventions for MS
- Production of neurotrophins (BDNF and NGF) - heightened with AEROBIC exercise
- Neurotrophins may play a critical role in neuronal repair and plasticity, may be neuroprotective
- Increased motor learning
Aerobic exercise
Light to moderate exercise (RPE scale) - pool below 85 degrees, stop when compensation happens to assess appropriate fatigue during exercise and remember each day is different, need to keep cool when exercising, avoid very warm environments, spasticity management, proper posture/trunk alignment, energy conservation techniques (rest breaks, pacing, prioritizing, recognizing warning signs, task simplification, delegate), use of ADLs, healthy lifestyle changes, cooling/heat management
Energy management strategies for fatigue management
The Canadian physical activity guidelines for adults with MS is ___ minutes of moderate intensity aerobic activity, ___x per week AND strength training exercises for major muscle groups, __x/week
30 mins , 2x/week
2x/week
- Flexor: hamstrings, hip flexors
- Extensor: quads, adductors, ankle PF
Types of spasticity common to MS
T/F: 43-67% of persons with MS are unemployed within 12-15 years of dx
True
The current concepts in rehab recommend at least ____ minutes of exercise per week of exercises and/or lifestyle physical activity (gardening, dancing)
150 mins
- Worsening fatigue
- Regression in therapy
- Relapse
- Disease progression
Red flags in MS
Have feasible goals been met?
Will d/c from therapy result in a regression?
Need measurable data
- Determine if safe trial of home program/community integration is appropriate
- Completion of fall recovery as life skill/falls program/falls prevention education
- Tune ups: every 6 months-1year
- Empower with right info
When to d/c from skilled PT
What are the (3) main areas that contribute to MS QOL from MNSS:
1. MS knowledge
2. Health
3. Independence **
- Variable course
- Chronic disease; acute on chronic management
- Lengthy list of symptoms/potential symptoms
- Invisible symptoms
- Anxiety/psychosocial issues
- Insurance/ongoing rehab needs
- Rehab isn't the only care needed - prioritization of care/services
- Adherence (rehab, meds, MD visit)
Rehab challenges in MS
When do we need to reassess MS patients?
Every 6 months for highly active MS ; at least once yearly