1. DEF:
   1. A chronic inflammatory, demyelinating disease of the CNS
   2. Charcot's Triad
      1. Cardinal Sx of MS:
         1. – Intention tremor – Scanning speech – Nystagmus
2. Epidemiology
   1. Largely affects young adults: 20 – 40
   2. Occurs between 15-50 y.o; peak @ 30 y.o
   3. - Women > Men; 2:1 - Whites > Blacks, Asians & Native Am. - High freq geographical areas > Medium & Low
3. Etiology
   1. Unknown but most widely accepted = autoimmune disease induced by viral/other infectious agent; In particular herpesvirus (I, II, VI) & chlamydial pneumonia
4. Pathophysiology
   1. Attack of the myelin sheath:
      1. - Immune response triggers production of T lymphocytes, macrophages & immuno globin’s (antibodies) - In turn a command/trigger protein, the antigen, is activated producing autoimmune cytotoxic effects within the CNS - BBB sales & myelin sensitivity lymphocyte cells enter & attack myelin sheath that surrounds the nerve
   2. In Adv cases acute & chronic lesions are scattered throughout the CNS (brain, brain stem, cerebellum, and spinal cord) that primarily affect white matter early, with lesions of gray matter evident in more advanced disease. The areas of predilection include:
      1. Optic nerves, Periventricular white matter, Spinal cord ( corticospinal tracts, posterior white columns) Cerebellar peduncles.
5. Clinical Course
   1. Categories of MS
      1. Benign MS
         1. Mild disease in which pts remain fully functional in all neurological systs 15 years after onset
      2. Malignant MS (Marburg's Disease)
         1. Rapid progression leading to significant disability/disease w/in a relatively short time after onset
      3. Relapsing-remitting MS (RRMS)
         1. Relapses with either full recovery or some remaining neurological S&S & residual deficit upon recovery; pds btwn relapses = characterized by lack of disease progression
      4. Primary-Progressive MS (PPMS)
         1. Disease progression from onset, w/o plateaus or remissions or w/ occasional plateaus & temporary minor improvements
      5. Secondary-Progressive
         1. Initial relapsing-remitting course, followed by progression at a variable rate that may also include occasional relapses & minor remissions
      6. Progressive-relapsing MS (PRMS)
         1. Progressive disease from onset but w/o clear acute relapses that may or may not have some recovery or remission; commonly seen in people who develop the disease after age 40
   2. Exacerbating Factors
      1. MS relapses/exacerbations
         1. New & recurrent MS Sxs that last at least 24 hrs & are unrelated to another etiology
      2. Factors that predispose MS pts to relapses:
         1. - The pt’s whose overall health deteriorates - Viral/bacterial infections - Diseases of major organ systems - Stress
      3. Pseudoexacerbation
         1. The temporary worsening of MS Sx; comes & goes quickly usually within 24 hours
            1. anything that raises the body temp can bring on pseudo-attack; usually resolve in 24 hrs of cooling off/end of fever
            2. Adverse rnx to heat=Uthoff's Sx
6. Clinical Manifestations
   1. S & S cheat sheet
      1. early sx typically incld: minor visual disturbances & paresthesias progressing to numbness
      2. Sensory
         1. - Hypoesthesia, numbness - Paresthesias - Disturbances and position sense (LE impairments of vibratory sense)
      3. Pain
         1. - Dysesthesias - Optic or trigeminal neuritis - Lhermitte’s sign - Chronic pain
      4. Visual
         1. - Blurred or double vision - Diminished acuity/loss of vision - Scotoma - Nystagmus
      5. Cognitive
         1. - Memory or recall problems - Decreased attention, concentration - Diminished abstract reasoning - Diminished problem-solving, judgment - Diminished speed of information processing - Diminished visual - spatial abilities
      6. Emotional
         1. - Depression - Pseudobulbar affect - Anxiety
      7. Motor
         1. - Weakness or paralysis - Fatigue - Spasticity - Incoordination - Intention tremor - Impaired balance - Gait disturbances
      8. Bladder
         1. - Urinary urgency, frequency - Nocturia - Incontinence - Urinary hesitancy, dribbling
      9. Sexual
         1. - Impotence - Decreased libido - Decreased vaginal lubrication - Impaired ability to achieve orgasm
      10. Bowel
          1. - Constipation - Diarrhea - Incontinence
      11. Speech & Swallowing
          1. - Dysarthria - Diminished verbal fluency - Dysphonia - Dysphagia
      12. Cardiovascular dysautonomia
   2. Pain
      1. intense, sharp, shooting, electric shock-like & burning
      2. Most common types:
         1. Trigeminal Neuralgia
            1. - Aka tic douloureux -Results from demyelination of the sensory division of the trigeminal nerve innervating the face, cheek & jaw
         2. Paroxysmal Limb Pain
            1. - Presents as abnormal burning, aching pain (dysesthesias) that can affect any part of the body but is more common in the LEs - Most common type of pain in MS & worse at night & after exercise
         3. Headache
      3. Hyperpathia
         1. Hypersensitivity to minor sensory stimuli
   3. Visual Changes
      1. Neuritis
         1. - Inflammation of the optic nerve - Ice-pick like pain behind eye w/ blurring/graying of vision/blindness in 1 eye
      2. Scotoma
         1. Dark spot that occurs in the center of the visual field
      3. Marcus Gunn Pupil
         1. Paradoxical dilation of people in response to ophthalmologic exam using a light test; indicative of unilateral pupillary defect (normal response is constriction as light is shone into the eye)
      4. Nystagmus
         1. - Result from lesions affecting cerebellum or central vestibular pathways - involves involuntary cyclical movements of the eye that developed when pt looks to be sides or vertically or when pt moves ahead
      5. Internuclear Ophthalmoplegia (INO)
         1. (- Produces incomplete eye ADD (lateral gaze palsy) on affected side & nystagmus of opposite ABD eye w/gaze to 1 side - caused by demyelination of the pontine medial longitudinal fasciculus (MLF)
      6. Diplopia
         1. Occurs when muscles of the eyes aren't well coordinated
   4. Motor Dysfnx
      1. Weakness
         1. Pts w/corticospinal lesions
            1. =S&S of UMN involvement:
            2. – Paresis – Spasticity – Brisk tendon reflexes – Involuntary flexor & extensor spasms – Clonus – Babinski's sign – Exaggerated cutaneous reflexes – Loss of precise autonomic control
         2. Movements are slow, stiff & week, the result of loss of orderly recruitment & reduce firing rate modulation of motorneurons
         3. Pts w/cerebellar lesions:
            1. = Asthenia or generalized muscle weakness along w/ataxia
      2. Fatigue
         1. def:
            1. A subjective lack of physical &/or mental energy that is perceived by the individual/caregiver to interfere w/usual & desired activities
         2. Is the result of central activation failure (central fatigue) & failure and excitation-contraction coupling
         3. Precipitating factors:
            1. – physical exertion – exposure to heat & humidity – depression & sleep disorders – low self-esteem & mood disorders – medical conditions & secondary complications of MS
         4. Side effects of medications:
            1. – Analgesics – anticonvulsants – antidepressants – antihistamines – antihypertensive agents – anti-inflammatory agents
         5. Environmental mastery (sense of control)
            1. Pts w/ low sense of environmental mastery reported significantly more fatigue & fatigue related distress
      3. Spasticity
         1. Clinical indications of spasticity incld:
            1. – Impaired voluntary control of movement (abnormal co-contraction) – increased DTRs – clonus, flexion or extension synergy patterns – decreased ROM
      4. Balance & Coordination
         1. Demyelinating lesions in the cerebellum & cerebellar=common in MS, producing cerebellar Sxs:
            1. – ataxia (characterized by dysmetria, dyssnergia & dysdiadochokinesia) – postural tremors (shaking, back & forth oscillatory movements when limb is supported against gravity) – intention tremors (involuntary, rhythmic, shaking movements that occur when purposeful movement is attempted & results from inability of cerebellum to dampen motor movements) – hypotonia – truncal weakness – Dizziness (from lesions affecting cerebellum (archicerebellum) or ventral vestibular pathways)
      5. Ambulation & Mobility
         1. Pts. w/ RR MS=req some form of Assist during walking w/in 15 years of dx
         2. Gait Characteristics:
            1. – Staggering – uneven steps – poor foot placement & uncoordinated limb movements – frequent loss of balance
   5. Speech & Swallowing Dysfnx
      1. – Dysarthria-slurred or poorly articulated speech w/low volume, unnatural emphasis, & slow rate – Dysphonia-changes in vocal quality including harshness, worse, breathiness, or hyper nasal sounds – Dysphagia-difficulty swallowing from poor coordination of the tongue & oral muscles
      2. Signs of Swallowing Difficulty:
         1. – Difficulty chewing & maintaining a lip seal – inability to swallow – spitting or coughing during or after meals
      3. Aspiration Pneumonia
         1. Is a serious complication that can develop if foods/liquids=inhaled into trachea
         2. Signs:
            1. A wet voice quality w/gurgling or sounds of congestion, & fever
   6. Cognitive & Affective Changes
      1. Cognitive Impairments
         1. Are related to specific distribution of the lesions rather than overall severity of disease, its course or pt's disability status
         2. Changes in cognitive fnx incld:
            1. – Impaired attention & concentration – slowed info processing – impaired recent memory – impaired executive functions
         3. – Focal frontal lobe lesions can produce cognitive and flexibility – global dementia = rare but may be seen in rapidly progressing disease or in pts w/ significant cerebral lesions
      2. Depression
         1. Sxs pg 782
      3. Affective Changes
         1. – Pseudobulbar Affect – euphoria
   7. Autonomic Changes
      1. Cardiovascular Dysautonomia
         1. Caused by involvement of the ANS & results in problems w/cardioacceleration & production and BP response during exercise
      2. Bladder Dysfnx
         1. Loss in volitional & synergistic control of the micturition reflex is produced by:
            1. Demyelinating lesions affecting the lateral & posterior spinal tracks unmasking the sacral reflex arc
         2. Types of Bladder Dysfnx in MS:
            1. – Small, spastic bladder (failure to store prob) – flaccid or big bladder (failure to empty prob) – Dyssnergic bladder (prob w/ coordination between bladder contraction & splinter relaxation)
         3. Sxs pg 783
      3. Bowel Dysfnx
         1. Most common bowel complaint=Constipation
            1. lesions affecting control of gastrocolic reflex
      4. Sexual Dysfnx
7. Diagnosis
   1. Imaging
      1. Gd-MRI
         1. – Used to help distinguish new lesions with active inflammation that occurred during the preceding 6 weeks or so – lesions = "bright spots"
      2. T2 scans
         1. – Used to detect more long-term disease activity – lesions = "black holes"; darker the lesion = more extensive the tissue damage
   2. CSF
      1. – MS pts show elevated total immunoglobulin in CSF & presence of oligoclonal IgG bands –Immunoglobulin: PPMS > RRMS pts
   3. Evoked Potentials
      1. – Are abnormal – presence of demyelinating lesions on visual, auditory, somato sensory, or motor pathways produce slowed or abnormal conduction
8. Prognosis
   1. – 74% survived 25 years after onset – @15 yrs, 50% will req use of an AD to walk – @20 yrs, 50% will req W/C
   2. Prognostic factors:
      1. – Sxs: onset w/only 1 sx=strongest indicator of favorable prognosis (+) – Course of Disease: Benign & RRMS > PPMS (more ominous) (+) – Age: young age @ onset > onset after 40 (assoc w/PPMS course) (+) – Neurological findings @ 5 yrs: signif peer middle & cerebellar signs with involvement @ multiple sites at 5 yrs= assoc w/poor prognosis & more severe disability (-) – MRI findings: (+): low total lesion burden, low actie lesion formation & negligible myelin or axon loss (+)
9. Medical Mgmt
   1. Disease-Modifying Agents
      1. Interferons fnx:
         1. - They slowed down the immune system response by reducing inflammation, swelling & rapid proliferation of T & B cells - Block activated T cells from crossing the BBB & damaging Myelin
      2. Synthetic Interferon drugs
         1. – Interferon beta-1b "Betaseron" – Interferon beta 1-a "Avonex & Rebif"
            1. Adverse effects:
            2. – Injection site skin reactions (soreness, redness, pain, bruising, or swelling) – flulike symptoms following injection that lesson over time (fever, chills, sweating, muscle aches, & fatigue) – rarer & more severe adverse rnxs: depression, allergic rnx & liver rnxs
      3. Glatiramer acetate (Copaxone)
         1. immunomodulator that acts as a decoy, clogging T cell receptors
            1. Adverse effects:
            2. – Similar injection site reactions – Initial flushing reaction immediately after injection (anxiety, chest pain, palpitations, SOB) – doesn't cause flu-like symptoms or depression ++
      4. Novantrone
         1. immunosuppresant & has a limited dose to prevent heart damage
            1. Disadvantages:
            2. – Must be closely monitored for serious heart & liver damage – Expensive & not covered by many private insurance plans
      5. these drugs aren't indicated for PPMS
   2. Mgmt of Relapses & Sxs
      1. DRUGS :
         1. Corticosteroid Therapy
            1. Used to treat acute disease relapses, shortening the duration of the episode
            2. Benefits:
            3. - powerful anti-inflammatory & immunosuppressive effects, diminishing swelling within the CNS & temporarily repairing the BBB - may also prevent circulating toxins or amino active cells from entering the CNS
            4. Adverse effects
            5. – Agitation, nervousness, & insomnia – increased sweating, appetite & susceptibility to infection – GI distress including heartburn & diarrhea or constipation
         2. ACTH
            1. Used to provide LT suppression of the immune system, either alone or in combo with steroids
            2. Serious adverse effects:
            3. Suppression of blood production by bone marrow, bleeding disorders, & increased risk of infection
      2. Spasticity
         1. Oral Baclofen
         2. Zanaflex
         3. Dantrium
         4. Valium
         5. Reduction in spasticity must be balanced with possibility of adverse effects with overdosing: sedation (drowsiness), weakness & fatigue
         6. Tegretol
            1. Can be effective in reducing paroxysmal (sudden, sharp onset) spasms
         7. Intrathecal admin of Baclofen directly into CSF of L-spine via Catheter w/programmable implanted pump
            1. Adverse effects: pump failure, infection & lead displacement
         8. Surgical Interventions
            1. – Tendonotomy: severing tendons – Neurectomy: severing nerves – Rhizotomy: severing nerve roots
         9. Phenol Nerve blocks
            1. effective up to 6 mos
         10. Botox
             1. Paralytic agent that can cause temporary blockage of a nerve & muscle w/ limited time frame for effectiveness; repeated injections
      3. Pain
         1. Paroxysmal Pain best responds to:
            1. – Tegretol – Elavil – Dilantin – Valium – Gabapentin
         2. Dysesthesias=managed w/low doses of:
            1. – Elavil – Tofranil – Norpramin
         3. Others:
            1. – Corticosteroids: pain & numbness – Antidepressants (Elavil) – Mild painkillers (acetaminophen or ibuprofen)
      4. Fatigue
         1. Symmetrel
            1. – First line therapy – is an antiviral & dopamine agonist
         2. Provigil
         3. Cylert
            1. CNS stimulant that has undesirable side effects (anorexia, irritability, insomnia)
      5. Tremor
         1. Decrease Tremor
            1. – Ataraz, Vistaril – Klonopin – Propranolol – Buspar – Zofran – Primidone – Severe: neurosurgery (thalamotomy) – Severe: Deep Brain Stimulation (DBS)-involves implanting electrodes into the thalamus
         2. Manage Dizziness & Vertigo w/antinauseant drugs:
            1. Meclizine (Antivert) or Scopolamine patches
      6. Cognitive & Emotional Probs
         1. Manage Cognitive Decline:
            1. Alzheimer's drugs: Aricept
         2. Manage Depression w/antidepressants:
            1. – Prozac – Paxil – Zoloft – *some antidepressants also decrease fatigue
         3. Stimulant meds can be used by may be habit forming
            1. – Ritalin – Cylert – Dexedrine
         4. Manage Pseudobulbar Affect w/antidepressants:
            1. Elavil
      7. Bladder & Bowel Problems
         1. Mgmt Overactive, Spastic Bladder to reg bladder emptying w/Anticholinergic meds:
            1. – Pro-Banthine – Ditropan – Tofranil – Adverse effects: dry mouth, tachycardia, accommodation disturbances
         2. Mgmt Flaccid Bladder:
            1. – Instruction in the Crede Manuver: app of manual downward pressure over the lower abdomen – Intermittent self catheterization (ISC)
         3. Mgmt Dyssynergic Bladder
            1. Alpha-Adrenergic Blocking Agents
            2. – Hytrin – Prazosin – Flow Max
            3. Antispasticity Agents
            4. – Baclofen – Zanaflex
         4. When controlled meds & ISC don't work:
            1. – Continuous catheterization – Surgical urinary diversion (suprapubic catheter)
         5. Mgmt Constipation
            1. – Increased fluid intake & fiber and diet – bulk forming supplements: Metamucil, FiberCon, Citrucel – stool softeners
         6. Mgmt Incontinence
            1. – Avoidance of irritants (caffeine, alcohol) – adjustment of meds used to reduce spasticity which can contribute to the problem – addition of meds to control bowel spasms: Detrol, Pro-Banthine
10. Framework for Rehab
    1. Interventions
       1. Restorative Interventions
          1. – Aimed at remediating or improving impairments, functional limitations & disabilities – early & middle stages = focus on remediating impairments--> improvements and function – indirect impairments from an activity & disuse of comorbidities
          2. Goal & Outcomes=
             1. focus on remediating impairments & regaining functional independence while promoting self-management skills
       2. Preventative Intervention
          1. – Aimed at minimizing potential complications, impairments, functional limitations, or disabilities as the disease progresses
          2. Goal & Outcomes=
             1. focus on promotion of health, wellness, fitness & preservation of optimal function
          3. Includes:
             1. Primary Prevention
             2. Prevention of a disease and a susceptible or potentially susceptible population
             3. Secondary Prevention
             4. Decreasing the duration & severity of Sxs or delaying the emergence of disease sequelae through early detection & intervention
             5. Tertiary Prevention
             6. Minimizing the degree of disability
       3. Compensatory Intervention
          1. – Aimed at modifying the task, activity, or environment in order to allow patient to remain fully functional within the scope of existing impairments & limitations
          2. Goal & Outcomes=
             1. focus on regaining/maintaining function
       4. Maintenance Therapy
          1. A series of occasional clinical, educational, & administrative services designed to maintain the pt's current level of function
          2. – Variety of interventions used to achieve goals & outcomes incld: Limited direct interventions, patient/client related instruction, & supportive counseling – primary focus = teach patients, family & caregiver is the mgmt skills necessary to carry out maintenance program
    2. Clinical Manifestations of inactivity
       1. Musculoskeletal
          1. – Osteoporosis – fibrosis/ankylosis – decreased contractile strength – decreased muscle endurance – atrophy
       2. Digestive
          1. Subtopic 1– Loss of appetite – constipation – poor nutrition/delayed healing
       3. Respiratory
          1. – Decreased vital capacity – decreased respiratory endurance – impaired coughing – increased respiratory infections
       4. Integumentary
          1. – Skin atrophy – Decubiti – chronic sepsis
       5. Cardiovascular
          1. – Decreased physical work capacity – increased heart rate – thrombophlebitis – orthostatic hypotension
       6. Renal
          1. – Urinary stasis – increased urinary infections – renal calculi
       7. Neuromuscular
          1. – Decrease sensory input – decreased motor control – poor coordination – autonomic lability
       8. Psychosocial
          1. – Anxiety/depression – detachment – intellectual deficits
    3. PT Exam
       1. Pt/client Hx
          1. General demographics, medical/surgical hx, social & employment hx, family hx, living environment, general health status, & social & health habits; chief complaints & current functional status, & activity level; coexisting health problems & meds
       2. Systs Review
          1. – Neuromuscular – musculoskeletal – cardiovascular/pulmonary – integumentary
       3. Relevant test & measures
          1. See box 19.3 p. 790
    4. Test & Measures
       1. Cognition
          1. Examine the following:
             1. Memory function, attention, concentration, conceptual reasoning, problem-solving, speed of information processing & effects of fatigue on cognitive performance
          2. Minimal Exam of Cognitive Fnx in MS (MACFIMS)
             1. – 7 neuropsychological tests examining processing speed/working memory, learning & memory, executive function, visual spatial processing & word retrieval – 90 minutes
          3. Mini Mental Status Exam (MMSE)
             1. brief screen of cognitive fnx
       2. Affective & Psychosocial Fnx
          1. Examine:
             1. – Emotional stability – Doc: emotional lability, euphoria, emotional dysregulation; depression; level of stress & anxiety, coping strategies; presence of sleep disorders
          2. the Beck Depression Inventory
       3. Sensation
          1. Examine the following:
             1. – Superficial & deep sensations (touch, pressure, temperature, pain, proprioceptive) – combined cortical sensations (stereognosis, tactile localization, two-point discrimination) – document: presence of acute, paroxysmal pain (Lhermtte's sign, dysesthesias) & chronic pain
          2. McGill Pain Questionnaire or Dallas Pain Questionnaire
             1. Examine the effects of chronic spinal pain on daily activities, anxiety-depression, & social interest
       4. Visual Acuity
          1. Examine:
             1. Acuity, tracking & accommodation
          2. Doc:
             1. Presence of visual deficits (blurred vision, field defects [scotoma], diplopia)
       5. Cranial Nerve Integrity
          1. Doc:
             1. Optic pain, oculomotor dyscontrol, dysphagia, impaired gag reflex, trigeminal neuralgia
       6. ROM
       7. Muscle Performance
       8. Fatigue
          1. Doc:
             1. Frequency, duration, & severity; precipitating factors; activity levels & efficacy of rest attempts
          2. The Modified Fatigue Impact Scale (MFIS)
             1. – Self-report 21 – item questionnaire addressing effects of fatigue on cognitive, physical & psychosocial function – using a 5 point scale; 0= – total score range = 0 – 84 never and 4=almost always – total score range = 0-84
       9. Temperature Sensitivity
       10. Motor Fnx
           1. Examine for:
              1. Presence of corticospinal signs
              2. paresis, spasticity, hyperactive DTRs, positive Babinski sign & involuntary spasms
              3. Presence of Cerebellar Signs
              4. ataxia, intention tremor, nystagmus, dysarthria
              5. The effects of position change may produce an increase in a tactic movements with increased demands for postural stability and should be documented
              6. Presence of Vestibular Dysfnx
              7. (dizziness, vertigo, nystagmus, blurred vision with head & body movements, & postural imbalance
           2. The Amended Motor Club Exam (AMCA)
              1. to examine the nature & degree of motor & fnxal deficits in MS pts
           3. Ashworth Spasticity Scale-->Modified Ashworth Scale
       11. Posture
           1. Static & dynamic postural control
           2. Postural grids, plumb lines, still photography w/LEDs
       12. Balance, Gait, Locomotion
           1. Static & dynamic balance, reactive & anticipatory control, sensory interaction & synergistic strats
           2. Balance:
              1. Clinical Test for Sensory Interaction in Balance
              2. Dynamic Posturography
              3. Berg Balance Scale
              4. Tinetti Performance Oriented Mobility Exam (POMA)
           3. Gait:
              1. 10-m Walk Test or 6 min Walk test
              2. Dynamic Gait Index
              3. Ambulation INdex (AI)
              4. The Rivermead Visual GAit Exam (RVGA)
       13. Aerobic Capacity & Endurance
           1. Examine:
              1. Vitals, Breathing patterns @ rest & during exercise
           2. Doc:
              1. Exertional Sxs & Perceived exertion during & after
           3. The Rating of Perceived Exertion Scale (The Borg RPE Scale)
           4. Dyspnea Scale
       14. Skin Integrity & Condition
       15. Functional Status
           1. Functional Independence Measure (FIM)
       16. Environmental (Home, Community, Work)
       17. General Health
           1. Health Status Questionnaire (SF-36)
           2. The Sickness Impact Profile
           3. Examination of motor and Process Skills (AMPS)
       18. DISEASE-SPECIFIC MEASURES
           1. – Designed to examine attributes common in a specific disease entity – provide information about the disease process & outcomes, & ideally document clinically meaningful change over time
           2. Expanded Disability Status Scale (EDSS) p. 792
              1. – 10 pt scale – pts 1st graded on presenting sx in 7 specific fnxal systs – functional system scores (FSS) are obtained: 0-5 or 6 – based on the grades obtained from the FSS & uses 0-10 scale – focuses on ambulation as the primary indicator of disability
           3. Minimum Record of Disability (MRD)
              1. – 3 subscales: EDSS w/FSS, Incapacity Status Scale (ISS) & Environmental Status Scale (ESS) – addresses impairments (FS & EDSS), disability (ISS) & handicap (ESS) – ISS: 16 items; addres fnxal disability in ADL – ESS: measures social performance
           4. MS Functional Composite (MSFC)
              1. – 21 item test that includes 3 different functional subtests
           5. MS Quality of Life--54 (MSQOL)
              1. – Modification of the generic SF-36 w/additional items relevant to MS – 11 subscales: physical health, role limitations due to physical problems (RLPP), rolled limitations due to emotional problems (RLEP), pain, emotional well-being, energy, health perceptions, social function, cognitive function, help distressed & sexual function)
           6. MS Quality of Life Inventory (MSQLI)
              1. – A battery of 10 self-report scales (138 items) that provide information about health-related quality of life in a MS – 45 minutes to complete – can be reduced to 81 items = 30 minutes
           7. Functional Exam of MS (FAMS)
              1. – 59 item index of health related QOL measure – 6 subscales (mobility,sx, emotional well-being, general contentment, thinking/fatigue & family/social well-being) – strongly correlates with EDSS
           8. MS Impact Scale (MSIS-29)
              1. – Measures the physical & psychological impact of MS
    5. Goals & Outcomes
       1. Preferred Practice Pattern:
          1. 5 E
             1. Impaired Motor Fnx & Sensory Integrity Associated w/Progressive Disorders of the CNS
       2. Examples Box 19.4 p. 793
11. PT Interventions
    1. Mgmt of Sensory Deficits & Skin care
       1. Pt.s w/proprioceptive losses=impairments in motor control & learning:
          1. Tapping, verbal cueing &/or biofeedback=effective augmented feedback
          2. Proprioceptive loading thru exercise, light tracking resistance & Therabands/wts & use of pool
             1. to heighten fnx & improve movement awareness
       2. Pts w/visual loss=interfere w/movement & postural control
          1. Blurred vision
             1. Maintain adequate lighting at all times; reduce clutter; add contrast between items in environment (stair markings)
          2. Dobule Vision
             1. place a patch over 1 eye
       3. Pts w/deficits in superficial sensations=risk damage to insensitive areas of skin
          1. Awareness, protection & care of desensitized parts
    2. Mgmt of Pain
       1. – Regular stretching or exercise, massage & ultrasound – postural retraining & correction – orthotic &/or adaptive seeding devices – hydrotherapy – pressure stockings or gloves – relieve pain, converting sensation of pain to one of pressure – stress management techniques, relaxation training, biofeedback, mediation etc. – TENS (fonflicting results)
    3. Exercise Training
       1. Individuals with min – mod impairments (EDSS scores 1-6) & stable disease demonstrate best exercise tolerance
       2. Factors that req careful attn during exercise:
          1. – Fatigue – spasticity – and coordination – impaired balance – sensory loss & numbness – tremor – heat intolerance – depression
       3. Strength & Conditioning
          1. –exercise scheduled on alt days during optimal times – sub max exercise intensities (50-70% MVC) – resistance training – circuit training: reduced likelihood of the fatigue – discontinuous work (distributed practice) – functional training activities: bal probs: plantigrade, quadruped, supported sitting for more stable postures – group exercise
          2. Precautions:
             1. –to prevent effects of overwork –to monitor effects of fatigue –to manage core body temp & prevent overheating –Impairments where equipment use is unsafe; may need feeback & reminders and posted instructions
          3. Outcome Measures:
             1. – MMT – isokinetic dynanometry – body composition – fatigue (MFIS) – functional tests – quality-of-life measures (HRQL)
       4. Cardiovascular Conditioning (aerobic exercise)
          1. – Physiological responses (HR, BP,VO2) and respiratory responses (RR & minute ventilation) increase in linear fashion in response to increasing workloads – HR & BP may be blunted 2° to cardiovascular dysautonomia
          2. Common Findings of Pts. w/reduced cardiorespiratory fitness secondary to physical inactivity:
             1. – Decreased physical work capacity – decreased vital capacity – increased heart rate at rest & in response to exercise – decreased muscular strength – increased fatigue – increased anxiety – depression
          3. Clinical Exercise Testing p.798
             1. – Upright or recumbent leg cycle ergometer – continuous or discontinuous protocol (3 – 5 minute stages) – submaximal test should be used (70-85 percent HRMax) – increasing workloads: 12-25 W for LE work & 8-12 W for combined UE & LE work – termination: achievement of Peak HR, fatigue, significant BP changes, or decrease and oxygen uptake with increasing work rate – morning is optimal time for testing
             2. Performance Measures:
             3. – HR – ratings of perceived exertion (RPE) – BP – expired gas analysis (VO2)
          4. Exercise Training p. 799
             1. – 3 sessions/week, on alternate days – intensity limited to 60 – 75% peak HR or 50 – 65% peak VO2 – exercise type: cycling, walking, swimming, or water aerobics – circuit training – balance probs=NWB activities – 30 min/session or for more involved pts three 10-min session/day – depression
             2. Outcome Measures:
             3. – Graded exercise testing (GXT) – HR – tests of lung function (FVC) – body composition – RPE – fatigue (FI, MFIS) – functional status – QOL measures (HRQL)
       5. Flexibility Exercises
          1. Both PROM & AROM exercises should be performed daily for short pds
          2. Tai Chi
          3. Outcome measure:
             1. Goniometry
    4. Mgmt of Fatigue
       1. –Aerobic exercise Training – Energy Effectiveness Strategies (ESS) – keeping in daily activity diary – activity pacing – balancing of activity with rest periods interspersed throughout the day – patients with chronic fatigue: rest-activity ratios are developed with periodic rest periods planned in advance – stress management techniques
    5. Mgmt of Spasticity
       1. – Cryotherapy, hydrotherapy, therapeutic exercise, positioning, or any combo thereof – monitor effects of anti-spasticity meds & optimize PT interventions w/dosing cycle – recognize contributing factors that impact tone & respond appropriately – reduce/eliminate all factors that can aggravate spasticity (heat, humidity, stress) – topical cold or hydrotherapy – temporarily reduce spasticity by decreasing tendon reflex excitability & clonus & by slowing conduction of impulses and nerves & muscles –ROM exercises: early on & con't'd daily – intermittent static stretching held a min 30-60 sec applied ideally 5-10 reps – combining stretching movements with rhythmic rotation (gentle rotation of the limb) or PNF (hold-relax active contraction [HRAC], contract-relax active contraction [CRAC] (chap 13) – maintained stretch, held for 30 minutes- 3 hours – active exercises at low/self-selected speeds w/emphasis on contracting the antag thru reciprocal inhibition – E-stim of antags – tai chi, yoga & aquatic exercise combined with cool water temperatures – functional activities: concentrate on trunk & proximal segments (extensor tone predominates) – positioning schedule using varied positions – mechanical positioning devices
    6. Mgmt of Coordination & Balance Deficits
       1. Interventions directed at promoting static postural control should first focus on static control in WB, antigravity postures (sitting, quadruped, kneeling, plantigrade & standing)
       2. Specific Exercise Techniques:
          1. Joint approximation applied through proximal joints (shoulders/hips) or head & spine, & rhythmic stabilization (PNF)
       3. Dynamic postural control can be challenged by incorporating activities such as weight shifting or reaching or stepping
       4. – Practice important functional movements such as bridging, sit to stand, scooting & wall squats – pool: practice static & dynamic postural control in both sitting & standing – water aerobics – platform training (SMART Balance): added biofeedback from visual/auditory feedback displays on machines=useful in pts w/somatosensory deficits – LOS training – proprioceptive loading & light resistance: control of ataxic limb movements (tremor & dysmetria) –*extra weight can increase energy expenditure=fatigue; be careful –Frenkel's exercises (p. 802)-tx pts w/tabes dorsais & probs w/sensory ataxia owing to loss of proprioception – stress management techniques
    7. Locomotor Training
       1. Early gait probs:
          1. Poor balance & heaviness of 1 or more limbs; difficulty lifting legs (hip flexor weakness), week DF (foot drop); circumduction gait
       2. Later gait probs:
          1. Due to Congress, spasticity, sensory loss and/or ataxia; weakness of quads (knee hyperext & fwd trunk flx=lumbar lordosis) & hip ABD'ors (Trendelenburg)
       3. – Exercise program of tone reduction, stretching & strengthening exercises – pool therapy – overhead harness to support bodyweight & motorized treadmill
       4. Orthotics
          1. AFO
             1. – Prescribed for: foot drop, poor knee control (hyperext), min to mod spasticity & poor somatosensation – common type: Polypropylene AFO – Relative Contraindications (AFO/KAFO): severe spasticity, foot edema & weakness (nonfunctional grades of LE muscles, especially hip flexors)
          2. KAFOs
             1. rarely used due to increased energy expenditure
          3. Rocker shoes
             1. to compensate for lost ankle mobility
       5. Cane, forearm crutches or Walker
       6. Wheeled Mobility
          1. Scooter
             1. – Provides needed mobility while conserving energy – For patients with adequate trunk stability, UE fnx, appropriate visual, perceptual & cognitive skills – disadvantage: seeing can't always be customized
          2. W/C
             1. Standard
             2. when postural demands necessitate increased support
             3. Powered
             4. when impairments prevent or limit manual propulsion
    8. Functional Training
       1. Should focus on problem-solving & development of appropriate decision-making skills req'd to meet the challenges of being disabled
       2. PT
          1. Functional Mobility Skills (bed mobility, transfers, locomotion) Training
       3. OT
          1. ADL Training
       4. Speech-Language Pathologist
          1. Communication Skills Training
    9. Mgmt of Speech & Swallowing
       1. – Respiratory muscle training in combo w/ activities to improve trunk stability, had control & sitting balance – PT should focus on diaphragmatic & segmental chest expansion, expiratory training & effective coughing – Oral-motor Exercises-improve malfunction & include specific exercises for lip closure, tongue movements & job control – resistive sucking through a straw – thicker liquids, moist foods, semisolid & puréed foods
       2. To achieve good swallowing & avoid aspiration:
          1. upright pos w/slighly fwd head & chin // to table or slighly tucked
       3. Swallowing Techniques: Power Swallow
          1. Pt. First inhale & then hold breath, thereby closing the airway, then swallows, exhales, & swallows again
    10. Cognitive Training
        1. – May need referral to neuropsychologist to determine patient strength & weakness & to assist and adaptive process – compensator he strategies for memory deficits: memory aids, timing devices & environmental strategies – lists of things to do, memory notebook, reminders, audiobooks – queuing devices: alarm clock, timer went to do certain tasks – structuring & labeling the environment – written down directions/instructions – additional cognitive strategies: mental rehearsal, requesting assistance, maximizing alertness, avoidance of difficult situations, & mental exercises
12. Psychosocial Issues
13. Patient & Family/Caregiver Education