THE REHABILITATION TREATMENT IN MULTIPLE SCLEROSIS

Multiple sclerosis (MS) is characterized by the triad disease:

• inflammation,
• demyelination,
• gliosis.

It has a progressive evolution or it advances in evolutionary outbursts. It is characterised by neuromotor abnormalities (paralysis, spasticity, ataxia, tremor, dysmetria, vertigo, neurogenic pain, and decreased muscle strength), eye and cognitive disorders, depression, anxiety, or the contrary: euphoria, exaggerated joy. Rehabilitation treatment addresses both the alternating form, as well as the stationary one.

Functionally, the disease has 4 stages:

Stage I: independence in social and professional life.

Stage II: muscle tone changes, pareses, impaired coordination and balance – the patient becomes partially dependent.

Stage III: motor deficit, cerebellar and vestibular disorders, walking becomes impossible.

Stage IV: severe physical and mental damage, total dependence.

Kurtzke developed a 10-point scale for assessing disability in MS, which will be taken into conside­ration especially in therapeutic prescriptions:

0 = normal neurological exam.

1 = no impairment, but Babinsky+, premonitory signs of ataxia, decreased sensitivity to vibration.

2 = minimal deficit: mild rigidity, mild gait, clumsiness, slight decreases in muscle strength, visual disorders.

3 = monoparesis, hemiparesis, moderate visual disorders, combined dysfunction.

4 = quite severe dysfunction, but the patient can work.

5 = severe dysfunction, gait difficulty, but without support.

6 = walking with a cane or crutches.

7 = use of wheelchair.

8 = patient remains in bed, but is still using the upper limbs.

9 = patient becomes totally dependent.

10 = death can occur.

Recommendation is that rehabilitation should intervene early, when the motor deficit is incipient. (Freeman). The therapist’s attitude to the patient is crucial starting from the first session, because the therapist-patient collaboration depends on it. Treatment success is not determined solely by improving the patient’s possibilities, but rather whether he or she achieves the highest level of activity in each stage of the disease and if he or she reaches the proposed target. (Ashburn, De Souza) In MS, physical therapy requires strict individualization and acts mainly on the disability, without intervention on the lesions or in changing disease progression.

Therapy involves the patient in individual activities based on patient evaluation and it will be based on his or her motivation. (O’Hara, Williams)

Physiotherapy principles: (Ashburn, De Souza)

• Stimulating movement strategies
• Stimulating learning motor skills
• Improving quality of movement patterns
• Reducing muscle tone abnormality
• Increased application of functional physiotherapy
• Providing support to maintain patient motivation and cooperation in therapy
• Implementation of preventive therapies
• Educating the patient in understanding MS symptoms and in how they affect his/her daily life.

Physiotherapy purposes: (Bajenaru)

• Maintaining correct postural stability
• Conservation and improvement of joint mobility
• Prevention of contractures and muscle atrophy
• Improvement of vital signs, especially respiratory ones
• Maintaining body weight within acceptable limits
• Inhibition of unwanted motor schemes
• Preserving of the ability to move as long as possible
• Ensuring autonomy, even in a wheelchair
• Improving coordination
• Improvement of cerebellar disorders
• Proper use of orthotic devices.

Assessment of the patient

a) Fatigue. It is present in 78% of cases (Freal). It is assessed based on fatigue severity scale (Krupp):

• Type of fatigue during the day
• Time of day when patient’s energy is good, reasonable or low
• Activities or opportunities with increased fatigue (eg. At high temperatures)
• Functional impact of fatigue on daily activities
• If fatigue is localized in a particular muscle group (eg. Dorsal flexors of the foot), in a part of the body or in a functional system (speech)
• If central fatigue is the cause of excessive fatigue; Excessive fatigue associated with reduced daily opportunities has negative influences on daily activities.

b) Daily life activities:

• It is important to know the information obtained by the assessment of daily activities. This requires exploring the patient’s social and family environment.
• Fatigue effects are reflected in the activities of daily life, requiring help from family. (Williams)

c) Cognitive assessment:

It is important for cognitive dysfunction in MS, requiring psychologist expertise regarding cognitive and language disorders, depression.

d) Patient self-assessment:

Patient participation in their self-assessment will be encouraged and it should focus on:

• Self-perception of own abilities and limits
• Appreciation of the ability to cope with certain activities
• Desire for change
• Personal priorities and what he/she expects from the therapist.

Physiotherapy intervention:

1. Coordination of therapy:

• When treatment is introduced in the course of the illness
• The length of time therapy is established.

In functional stage I of the MS, specific physiotherapy is not recommended, but the therapist should be part of the team, keeping trace of the patient’s assessments. (Freeman).

• For minimum disability, general toning exercises are recommended together with the posture and fatigue management. (Kiss)

Physical activities in stage II:

• Circulatory gentle massage of the muscles
• Slow passive joint mobilization
• Cryotherapy on tendon
• Mobilization using Kabat’s techniques
• Electrical and vibratory stimulation on muscles antagonist to the spastic ones
• Exercises for the correction of balance disorders
• Relaxation exercises
• Hydrotherapy (water temperature should not exceed 30 degrees)
• To retrain proprioception feedback with acoustic and visual signals is used
• Occupational therapy.

Exercises are performed 1-3 times per day, 15 days consecutively, or one day yes, one does not, at least 5-6 stages a year. (Kiss)

In stages III and IV: (De Souza, Freeman, Kiss)

• the previous programme continues
• prevention of orthopaedic sequelae
• verticalization of the patient for combating circulatory disorders and osteoporosis
• gentle massage
• prevention of bedsores by maintaining hygiene, frequent posture changes
• generally, fatigue during exercise will be avoided.

During the evolutionary crises, the only physical exercises are: (Kiss)

o Passive mobilization 3-4 times a day

o correct posture strengthening in order to:

1. preserve muscle suppleness
2. maintain the tissue trophicity
3. maintain joint mobility
4. prevent muscular-tendinous retractions
5. prevent muscle atrophy
6. secure vital functions, especially in stage IV

2. Types of intervention (Arndt, Bajenaru, De Souza) 

A. Stretching – a valuable procedure to reduce hypertonia

B. Passive-active and active aerobic exercises to maintain mobility

Aerobic exercises are very important for the cardio-vascular effort, they prevent the decrease in muscle strength; the risk caused by physical inactivity is thus reduced.

Warning! The intensity of the exercise should not cause excessive fatigue, they will adapted to patient’s abilities as far as possible. Exercises should not surpass the patient’s endurance!

Particular aspects of physical therapy in cases where the hypertonia syndrome predominates.

Warning! We will not address hypertonia in patients who use spasticity to maintain orthostatic posture, the transfer, or for the balance of the legs when moving with crutches. (De Souza).

In MS, some muscle groups tend to increase spasticity, while the antagonists will have a low tone. This imbalance will lead to contractures, retractions, namely to distortions.

Muscle groups that develop contractions:

Upper limbs:

1. adductor, rotator of the shoulder
2. pronator forearm
3. elbow flexors
4. fist and finger flexors

Trunk:

1. trunk rotators
2. lateral trunk flexors

Lower limbs:

1. hip flexors-femoral joint
2. flexors of the knee
3. foot plantar flexors
4. inversor muscles of the leg

Particular aspects of physical therapy in patients where ataxia elements predominate (Arndt, De Souza, Freeman, Pélissier):

Ataxia is frequently found in MS and is often associated with spasticity, but sometimes with severe sensory disorders, concerning either vision or the sphincter muscles. Ataxic patients demonstrate inability to perform movements that require the muscles to act in a group, namely the contraction. In walking, there are difficulties in unipodal support at the moment of lower limbs muscle contraction, concomitantly with the need for forward projection of the body weight. Compensation is often achieved by walking aids, such as the walker.

Postural deficiencies in ataxia:

1. exaggerated lumbar lordosis
2. pelvic anteversion
3. hip-femoral joint flexion
4. hyperextension of the knee
5. Bodyweight while walking is at heel level
6. curling of toes
7. walking imbalance.

C. Hydrotherapy (is a controversial chapter).

Some authors recommend full immersion in water at 30 degrees Celsius; these procedures would be beneficial to reduce spasticity (Forsythe). Others object to them, saying that they would increase fatigue. There are authors who recommend baths in cold water between 25 – 27 degrees which would favour muscle relaxation or cold clothes at trunk level to reduce fatigue and pain (Pélissier, Pellas). De Souza does not recommend ice applications in patients with poor peripheral circulation. In many cases, however, ice applications on spastic muscle tendons were beneficial.

D. Electrical stimulation (Worthington) 

Low-frequency electrostimulation is applied after a careful selection of patients and in the context complete treatment with active exercises and stretching.

E. Medications (Hauser, Pélissier, Snow) 

• Baclofen (Lioresal) – involves the GABA system, using agents that inhibit the release of neurotransmitters in the motor neuron synapse. Hypertonicity decreases at the level of the receptors from the brainstem and spinal cord. In Romania, it is used per os, in other countries it is frequently administered intrathecally by pump. (very expensive).
  Dose: 20-120mg/day.
• Dandrolen – reduces muscle contraction, especially for fast fibers, reducing the reflex activity and spasticity by subtracting calcium.
  Dose: 25-400mg/day.

According to some authors, baclofen and dandrolen lower muscular strength very much, aggravating the existing deficit. Baclofen can sometimes lead to confusion syndromes with impaired cognitive functions. (Pélissier, Viel).

• Tizanidine (Zanaflex) also reacts to reduce spasticity, but is potentially hepatotoxic.
  Dose: 8-32mg/day.
• Benzodiazepines (diazepam, clonazepam) mainly used against muscle cramps and spasms of the night.
  Dose of diazepam: 2-40mg/day.

F. Infiltration with botulinum toxin, having an effect for 3-4 months, then treatment may be repeated (Snow). It is indicated especially in the spasticity of thigh adductors, psoas iliac, tensor fascia lata.

H. Fortifying the obturator nerve with alcohol solution 66 degrees, after locating the nerve by electrical stimuli.

I. Surgery – thigh adductors tenotomy, neurotomies.

J. Orthotics – lumbar orthosis used for intervertebral joint pain,

– calf and foot orthoses.

The use of crutches and deambulators is questionable (De Souza, Pélissier).

Benefits of walking aids:

• increase stability, security
• reduce the risk of falling
• increase the travel distance
• increase speed
• reduce fatigue.

Disadvantages of walking aids:

• limit the ability of the lower limbs to bear body weight.
• lower leg muscle strength.
• lower equilibrium reactions
• decrease muscle tone
• develop abnormal posture (thigh flexion, lateral flexion of the trunk)
• upper limb function may be compromised.

Preferably, the patient should be advised not to use crutches and the deambulator for as long as possible. We recommend the deambulator when patient maintains upright position. Used daily, it helps maintaining tone, reduces the frequency of muscle spasms, stimulates the activity of extensors. (Brown)

Obviously, when the loss of movement is total, the patient will use a wheelchair.

In the case of homebound patients, physical therapy will focus on:

• correction respiratory deficit
• stimulating coughing, so that secretions, sputum does not accumulate
• achieving muscle contraction and relaxation of the upper limbs
• gentle massage, passive joint mobility movements
• correction and support for sitting and supine posture
• stretching for spastic muscles
• frequent changes of postures
• protective techniques for skin integrity
• stimulation of active muscle contraction
• assisted lifting into sitting and standing position, depending on patient tolerance.

Aims of physiotherapy treatment:

increase in postural stability

• increase of control on the weight centre when body weight is alternating during walking
• improvement of control on the movements from the simple to the complex ones
• encouraging the movements of extremities in relation to body axis (rotations)
• increased proximal stability of limbs
• fostering the coordination of the activities of agonist-antagonist muscle groups
• reducing the need for visual guidance of the movement.

The role of patient’s family

It is essential. The physiotherapist, the occupational therapists, and the psychologist, have an important role in training the family how to handle and stimulate the patient. (Mc Queen)

Conclusions:

MS is one of the most complex and variable diseases encountered by rehabilitation specialists. A multidisciplinary team is tasked to provide continuous care and especially permanent psychological support to the family and to the patient, to win his/her confidence, to teach them to live with the disease, always trying to improve the quality of life.

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