CONTRIBUTION OF OCCUPATIONAL THERAPY IN REHABILITATION TREATMENT OF MULTIPLE SCLEROSIS

Occupational therapy in patients with multiple sclerosis (SM) using both the evaluation process and therapeutic intervention, daily activities (Activities of Daily Living – ADL), in order to: to achieve maximum functional independence possible, to prevent possible disability, to improve quality of life.
Occupational therapy will always adapt functional stages of the disease and disability occurred.
Occupational therapy is a health care profession that contributes to the quality of life of vulnerable groups / disabled by occupation.
By definition, OCCUPATION is a set of daily activities (Activities of Daily Living – ADL),  relevant and meaningful for all of us, they execute in order: 1. We take care of our own person (self-care ADL) scale from stage 3 Kürtzke; 2. To contribute to social and economic welfare of our community (and labor productivity ADL); 3.To enjoy the pleasures of life (ADL leisure)
Occupational therapy in patients with multiple sclerosis has as main objectives: development and testing performanenţelor sensorimotor sensory, cognitive or psychosocial, educating the patient and his family in order to make possible interventions to assist the patient-help.

Definition:

Multiple sclerosis (MS) is a nervous system disorder of unknown aetiology characterized by demyelination processes affecting the white matter of the brain and the spinal cord.

Causes:

The causes are unknown. Aetiological hypotheses are numerous, but not confirmed.

Manifestations:

A. Beginning phase is characterized by:

• Insidious onset
• Eye disorders
• Vestibular Disorders
• Sensitivity Disorders
• Motor disorders.

B. Second Phase (encephalomyelitis syndrome) is characterized by:

• Charcot’s triad
• Pyramidal Signs
• Cerebellar signs
  • Hesitant gait
  • Balance and orthostatism disorders
  • Impaired coordination:  asynergy, dysmetria, adiadochokinesis, intentional tremor, the patient cannot wash and comb, cannot put on clothes and shoes, cannot feed, cannot write by him/herself
• Speech problems
• Vestibular signs
• Reduction or loss of vision and eyelid drooping
• Disorders of sensitivity
• Sphincter disorders
• Sexual disorders
• Mental degradation.

Occupational therapy (OT) is defined as “a form of therapy that uses specific methods and activities to develop, improve or restore the patient’s ability to perform all the appropriate activities necessary for the individual life. It aims to compensate for dysfunction and to reduce physical disabilities”. OT is a health care profession that helps disabled individuals to earn their full potential for independence and productivity across their lifespan, using “activities” to improve and restore physical and mental state of such individuals at the functional level required by challenges of ordinary daily life.  Rehabilitation by means of occupational therapy can be successfully used in medical pathology mainly.

OT in patients with MS uses both the assessment process and that of therapeutic intervention, daily activities (Activities of Daily Living – ADL), in order to:

• achieve maximum possible functional independence
• prevent disability as much as possible
• improve quality of life.

OT will be adapted continuously to functional stages of the disease and to the disabilities that occur.

OT is a health care profession concerned with promoting the quality of life of vulnerable/disabled groups through engagement in occupation. By definition, occupation is a set of daily activities (Activities of Daily Living – ADL), relevant and meaningful for all of us, which we perform in order to:

1. take care of our own person (self-care ADL) starting  from stage 3 on Kürtzke’s scale:

Personal care

• feeding and hydration
• dressing-undressing
• personal hygiene
• using the toilet
• body washing (shower / bath)
• infant care – for mothers.

Functional Mobility 

• moving outside the home (figure no. 1)

Figure no. 1 – Moving away from home

• movement in the house
• transfers
• mobility in bed

1.a. ensure independence in the community through technological means or devices (Instrumental ADL):

Community management 

• Going shopping
• Using the cooker
• Using kitchen appliances
• Using the washing machine
• Using the vacuum cleaner
• Using urban means of transport
• Taking medicine drugs
• Using the phone and the computer.

2. contribute to social and economic welfare of our community (ADL productivity and work) 

Paid / unpaid work 

• search-find-keep a job
• volunteering

Household management 

• house a management  – cooking, washing, cleaning, ironing, gardening
• taking care of children / family / grandchildren / sick people

3. enjoy the pleasures of life (ADL leisure) 

Passive Recreation

• hobbies
• reading, painting
• television, computer
• dexterity for a given activity (Figure no. 2), etc.

Figure no. 2 – Dexterity for a particular activity

Active recreation

• outings, walks
• sports
• journey.

Socialization 

• visit
• parties
• telephone conversations
• writing letters, correspondence

The main targets of OT in patients with MS are:

• Development or testing sensitive-sensory, cognitive or psychosocial skills
• Educating the patient/family in order to increase participation in and performance of daily activities and to achieve the possible interventions of assisting the patient.

Rehabilitation through OT can take several forms: learning therapy, ludo-therapy and ergotherapy. Ergotherapy or performing work-based activities is a means of expression, allowing the patient to create in reality what he saw, lived or imagined. Ergotherapy activities involve thinking, planning assumptions and choice so that in the end the person should be proud to have created something useful. This gives a refreshing feeling, a sense of achievement and self -confidence, helping to structure the status and role of the person recognized socially. Ludo-therapy is one of the methods of treatment through games.

Training for transfers 

In stage 7 of Kürtzke’s the  scale, an important element is the ability of the patient to perform transfers by him/herself (moving from chair to bed and vice versa, and generally moving around the house). Transfer depends on physical factors such as impaired coordination, fatigue, etc. Based on these elements, the patient will perform active training for half an hour every morning (the most favourable time of day); this training will take place in the patient’s room, to reproduce as closely as possible the situations his/her  normal environment.

The proposed training programme has roughly the same sequence:

1. transition from sitting to standing position in bed
2. execution of the transfer bed – wheelchair
3. transfer performance from wheelchair to toilet
4. transfer performance from wheelchair to bed
5. dressing and undressing
6. walking with crutches around the room.

Training will be individualized according to patient’s abilities , motivation, etc.. Once the degree of dysfunction has reached Kürtzke’s level 7, the ergotherapist must go to the patient’s home to try to apply the techniques of transfers in the context of the reality that the patient must face. On this occasion, the therapist will give his/her opinion whether it is necessary for the patient to make home adaptations or not. It might be possible that a home visit should be appointed only to establish the necessary adaptations. Ergotherapists have different elements, such as physical skills of the patient, resources on the market, norms for home adaptations. These items will be weighed against other factors such as financial possibilities of the family, family cooperation, architectural possibilities.

Home adaptations are especially necessary for patients in wheelchairs.

Three rules should be observed:

• Doors must have a free pass of at least 80 cm
• Level differences must be remedied
• The interior adaptation should provide full release to allow access to kitchen, bathroom, etc..

Access to the house can be a simple threshold, but also a series of steps. The solution for adaptation may be a ramp, but sometimes one has to build a monolift.

Inside the home, often more rooms have to be adapted (priority will be given to adaptation of WC, bathroom, bedroom and kitchen).

WC adaptation will be possible if the door opening is large enough and if the door opens to the outside of the room. A space around the toilet seat  will be needed to allow the patient to perform transfer manoeuvres. In general, placement of bars in precise places will be made, depending on patient needs.

Adaptations for the bathroom – It is essential that different bathroom appliances should be wheelchair accessible. If possible, prefer a shower to the traditional bathtub, which pose serious challenges to the transfer. If you want to keep the tub, the solution may be a bath seat. The space under the sink must remain free to facilitate access of the wheelchair.

Adaptations for the bedroom – it is important that the bed be easily accessible. In general, it is too low to facilitate transfers. To remedy this, simply extend the legs with pieces of wood.

Adaptations for the kitchen – several important principles must be taken into account for a person who cannot move independently and can participate in certain daily activities only sitting. These principles are:

• work planes (surfaces) will be lowered to a height of 80-85 cm from the ground;
• Under these areas empty spaces will be left free, especially under the sink and under the oven door for washing and cooking;
• Lockers will be suspended at a height appropriate for the patient.

Choice of the wheelchair is determined by a multidisciplinary team composed of: the rehabilitation doctor, physical therapist, occupational therapist, and the orthotic-prosthetic technician.

The doctor decides in terms of: specific pathology, prognosis of the disease and the functionality of the patient.

Occupational therapist completes choice according to:

• Functional abilities of the upper limb and limitations of the body
• The distances to be covered and its use in indoor, outdoor environments and for transportation
• Housing affordability
• Number of hours the patient uses the chair
• Possibilities of transfer
• Family and patient wishes.

The aim is to give the patient maximum independence possible.

Psychosocial therapy

To optimize the long-term rehabilitation treatment, the multidisciplinary team will begin with a full clinical and psychosocial assessment of the patient. The carers must establish a relationship of trust and support with the patient. Before discussing care issues, the initial assessment will be performed, which includes:

• Establishing patient’s perceptions on the disease, providing a basic diagnosis, response to patient’s feelings vis-à-vis the diagnosis, assessment of patient knowledge about the disease, providing details about the diagnosis.
• Comprehensive assessment of clinical and psychosocial factors that may be barriers in selecting appropriate treatment.

The patient’s level of disability, the concomitant diseases, cognitive and mental functions can have a significant impact both on treatment decisions and on outcomes. Cognitive impairment, such as the difficulty in learning and remembering the new information may interfere with the patient’s ability to understand the reason of the therapy and the complex treatment regime.

Education and family involvement in the process of rehabilitation in MS

The multidisciplinary team will develop a care plan in collaboration with the patient and his/her family. This plan must be flexible, dynamic and respond to changing needs and to the preparation level of the patient and of the family.

The family will be actively involved in setting goals and objectives of education as well as in the educational process itself. The perspective of the learner is determined before the learning begins.

Another important aspect is the impact of the disease on children who have a parent with MS – a significant disorder of the parent has a tremendous impact on the development and psycho-social functioning of the child. Stressful life events require accommodation between parents and children. Long term accommodation to chronic illness include time and effort required for each individual and for the family as a group to integrate the physical, mental and social consequences of the disease on intra-psychic and interpersonal reality.

In conclusion, OT with MS patients  uses daily activities (Activities of Daily Living – ADL), both in the assessment process and in the therapeutic intervention, in order to:

• achieve maximum functional independence possible
• prevent possible disability
• improve quality of life.

Sympathetic care of a patient with MS involves the entire multidisciplinary team that will have to assess their own effectiveness as a team and to train their patients to self-evaluate learning acquisitions, which help them to master the disease.

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Correspondence to:
‘Prof. Dr. Alexandru Obregia’ Psychiatry Clinic Hospital Clinic of Paediatric Neurology, Berceni street, Sector 4, Bucharest