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Multiple Sclerosis : Occupational Therapy

[MS : Multiple Sclerosis]

Help Educate your Client on Multiple Sclerosis

 

Multiple sclerosis (MS) is one of the most common causes of nontraumatic neurologic disability in young adults in the United States [1]. 

 

“Rehabilitation is still the only way to improve function in Multiple Sclerosis” [1]

 

A disease characterized by two overlapping processes of nervous system injury: inflammatory destruction of myelin and neurodegeneration of grey and white matter [2]

Central nervous system disorder

There are 4 types of MS and the individual can move throughout these stages along the lifespan of the illness

Affects the myelin coating around nerve fibers and causes plaques to form in the brain and spinal cord

Numerous drugs are available to slow the progression of MS, prevent or reduce the severity of relapses, and decrease the severity of its symptoms. However, currently no drug exists that can cure MS 

Many clients with MS are sensitive to overheating and require a cooling vest or other ways to stay cool in the heat, as heat can cause an exacerbation or relapse (Fig. 32-2). Some clients with MS simply avoid going outside in the heat, which may limit participation in valued occupations, or some chose to move to cooler climates.

Stress, heat, and emotional or physical trauma can exacerbate the disease and cause relapses.

            Never overwork your clients! Especially important for those of you working in SNF or IRF settings where you are required to get a certain amount of minutes! Overworking your client (especially when they say they are tired or didn’t sleep well) is a contraindication and you cannot do this! Advocate for your client and don’t put your client or your license at risk!

Types of Multiple Sclerosis

 

Relapsing-Remitting MS  [3]

  • Most Common
  • Characterized by clearly defined relapses/exacerbations of worsening neurological function that are followed by partial or complete recovery periods (Remissions), during which symptoms improve partially or completely

 

Secondary-progressive MS [3]

  • Follow after relapsing-remitting course
  • Most people are initially diagnosed with relapsing-remitting MS will eventually transition to secondary progressive, which means that the disease will begin to progress more steadily

 

Primary-progressive MS (PPMS)  [3]

  • Steadily worsening neurological function from the beginning
  • Rate of progression varies over time with occasional plateaus and temporary, minor improvements
  • No distinct relapses or remissions
  • Approximately 10% of MS cases are PPMS

 

Progressive-relapsing MS [3]

  • Least common of the 4 types of disease courses
  • Steadily progressing disease from the beginning and occasional exacerbations along the way
  • May or may not experience some recovery after these attacks
  • Disease continues progressing without remissions

Symptoms and Clinical Presentation of Multiple Sclerosis

 

MS is not considered a fatal disease, and most people with MS have a normal or near-normal life expectancy.

**With advances in MS management, persons with multiple sclerosis (pwMS) are living longer (median survival time from the time of diagnosis, 40y 6 ); therefore, issues related to progressive disability (physical and cognitive), psychosocial adjustment, and social reintegration need to be addressed over time [6]

 Most Common Symptoms of Multiple Sclerosis:

  • Fatigue
  • Weakness
  • Numbness and/or tingling
  • Dizziness and vertigo
  • Sexual Problems
  • Emotional Changes
  • Visual changes
  • Pain
  • Walking difficulties
  • Bladder and Bowel dysfunction
  • Spasticity
  • Cognitive changes
  • Depression

Evaluations and Progress Notes for Multiple Sclerosis

 

(S) Subjective

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(O) Objective

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(A) Assessment

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(P) Plan

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General Treatment Ideas for Multiple Sclerosis

 

Person

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Environment

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Occupation
  • ADLs : Ambulation/turning and Transitional Movements (bed mobility and sit to stand), Dressing, reaching activities requiring coordination, Dual tasking components
  • Discuss with client what symptoms are impacting their physical ability to perform desired occupations remembering that their are 9 domains of occupation — don’t limit your client to self-care tasks or IADLs!
  • Employment: Psychosocial interview (Kawa River, Self-Efficacy Scale). Determine what symptoms of MS are causing barrier and seek to correct both physical and psycho-social based barriers. You can use assessments as checkpoints toward a bigger goal.

 

 

Research Approach Ideas for Multiple Sclerosis

 

**All text is directly from article. Italics are BOT interpretation**

Efficacy of Cognitive Rehabilitation in Multiple Sclerosis [4]

  • Computerized Cognitive Rehabilitation 3x weekly for 6 weeks
  • At least 45 minutes consecutively
  • Cognitive impairment is present in 40–65% of individuals with MS [specifically information processing speed, concentration, & working memory]
  • There exists mounting evidence for neuroplasticity as a mechanism to compensate for accumulating pathology in MS and some tentative evidence that cognitive rehabilitation may be effective in preserving or improving cognitive function in patients with MS

Treatment sessions for Cognitive rehabilitation in MS

  • Working memory – remembering a series of cards presented on screen. Complexity of task increased by requiring patient to only remember particular values or suits or the number of items to remember increases, then remember those cards in reverse order) 
  • Divided attention – (driving a car with distractions requiring modulation of speed)
  • Topological Memory (visual spatial memory) – Have a grid and remember items (objects/shapes/obscurities of increasing complexity) and where they are located in space.

Outcomes of Efficacy of Cognitive Rehab in MS

  • Significant brain alternations in fMRI activations were seen at follow-up. Information processing speed was not maintained after cessation of cognitive rehabilitation, but functional MRI changes remained 3+ months post cessation demonstrating lasting impact.
  • QOL measures did not significantly improve between test and control group because multiple factors exist: employment status, social networks, perceptions of self-work, and self-efficacy 
  • It has been shown that the prefrontal cortex is critical in the executive control of working memory and has a role in response inhibition. Effective organization of working memory may attenuate task difficulty resulting in improved working memory performance 
  • Previous work in MS has indicated that attention may be one of the domains most amenable to rehabilitation 
  • This solidification of neural networks may extend to areas/networks outside those directly trained and may explain why working memory centres such as the prefrontal cortex were seen to be persistently active after cessation of formal training 

Upper limb task-oriented rehabilitation in progressive multiple sclerosis [5]

  • Upper limb dysfunction (ULD) is a core deficit of multiple sclerosis (MS), affecting about 60%–75% of patients with MS
  • 36 treatments for 1-hour (2x/weekly) = 13 weeks
  • Most participants had Relapse-Remitting Multiple Sclerosis (RRMS)
  • Neural Plasticity seems to be present despite diffuse damage
  • It has been previously reported that task-oriented upper limb motor rehabilitation has an impact on both motor behavioral performance and WM integrity
  • Although this article reported the benefits of task-oriented rehabilitation interventions for improvement of bimanual fine motor tasks and tasks requiring accurate coordination of both limbs; also, it prevented clinical deterioration and induced significant improvement in complex tasks of finger opposition movements – no specific treatment protocol was mentioned. The vagueness of this article renders it less useful. However, it is helpful to know that it takes consistency, repetition, and an extended time period to produce these results.

 

Rehabilitation in MS – A Systematic Review of Systematic Reviews[6]

 This is a complete article of interventions that were proven effective for treating multiple sclerosis. I would recommend reading this article in its entirety.

Associated with complex disabilities including disorders of strength, sensation, coordination, and balance, as well as visual, cognitive, and affective deficits.

These disabilities usually lead to progressive limitation of functioning in daily life, requiring longer-term multidisciplinary management.

**With advances in MS management, persons with multiple sclerosis (pwMS) are living longer (median survival time from the time of diagnosis, 40y 6 ); therefore, issues related to progressive disability (physical and cognitive), psychosocial adjustment, and social reintegration need to be addressed over time [6]

Persons with MS can present with various combinations of deficits such as physical (motor weakness, spasticity, sensory dysfunction, visual loss, ataxia), fatigue, pain (neurogenic, musculoskeletal, and mixed patterns), incontinence (urinary urgency, frequency), cognitive (memory, attention), psychosocial, behavioral, and environmental problems, which limit a person’s activity (function) and participation

High-quality evidence for physical therapeutic modalities (exercise/physical activities) for improved functional outcomes (mobility, muscle strength, aerobic capacity), reduced fatigue, and improved quality of life. Comprehensive fatigue management programs for patient-reported fatigue

Exercise performed 2 times a week at a moderate intensity increased aerobic capacity and        muscular strength in pwMS with mild to moderate disability

Significant improvement in walking speed, endurance, and distance with a walking program

Significant improvement in fatigue with a larger effect associated with endurance training, mixed training, and yoga

Strong evidence for exercise-based and educational rehabilitation for reducing severity of patient-reported fatigue

 

Moderate evidence for MDR for longer-term gains at the level of activity (disability) and participation, cognitive-behavioral therapy for the treatment of depression, and information provision in increasing patient’s knowledge

 

Strong evidence for improvement in disability, participation, and QoL outlasting treatment period Moderate evidence for inpatient or outpatient rehabilitation programs for improving disability, bladder-related activity, and participation outcomes up to 12 months Limited evidence for short-term improvements in symptoms and disability for outpatient and home-based rehabilitation programs (Multi-disciplinary approach)

 Energy conservation management education

 Moderate-level evidence for CBT for treatment of depression in MS

 Moderate-level evidence for improved participant knowledge, mixed results on decision making and QoL           

Low and Very Low Evidence: Whole body vibration, electrical stimulation, hippotherapy, occupational therapy interventions of goal-directed occupation-based activities and health management

References

References
  • Sutliff, M.H., et al., Rehabilitation in multiple sclerosis: Commentary on the recent AAN systematic review. Neurology. Clinical practice, 2016. 6(6): p. 475-479.
  • Ploughman, M., A new era of multiple sclerosis rehabilitation: lessons from stroke. Lancet neurology, 2017. 16(10): p. 768-769.
  • Mahle, A.J. and A.L. Ward, Adult Physical Conditions 2019, Philadelphia: F.A. Davis Company.
  • Campbell, J., et al., A Randomised Controlled Trial of Efficacy of Cognitive Rehabilitation in Multiple Sclerosis: A Cognitive, Behavioural, and MRI Study. Neural plasticity, 2016. 2016: p. 4292585-9.
  • Boffa, G., et al., Preserved brain functional plasticity after upper limb task‐oriented rehabilitation in progressive multiple sclerosis. European journal of neurology, 2020. 27(1): p. 77-84.
  • Khan, F.M.M.D.F. and B.M.D.M.P.H. Amatya, Rehabilitation in Multiple Sclerosis: A Systematic Review of Systematic Reviews. Archives of physical medicine and rehabilitation, 2016. 98(2): p. 353-367.