An Innovative Approach to the Treatment of Multiple SclerosisPresented by: Megan Frost PT , MSCS

Megan in a Nutshell• Graduated from the College of St. Scholastica (1999)

• Worked in Sioux Falls, SD (2000-2006)• Patients with spinal conditions

• Moved to the Twin Cities (2006)

• Opened STEP Therapies, Inc. (2007)

Professional Achievements• Starfish Health Care Professional of the Year (2008)

• Healthcare Hero Award (2010)

• MS Certified Specialist (2010)

• Acorda Therapeutics Speakers Bureau (2012)

• Voice in the Community of MS (2014)

3 Highlights Today1) Some symptoms with MS can and will IMPROVE

2) MS patients will TELL you what you need to know to formulate successful goals and treatment plans based on individual needs

3) Choose FUNCTIONAL (ACTIVITY-SPECIFIC) exercises when possible

Innovative Approach to MS Rehab

• Many of the symptoms of MS can and will IMPROVE• Primary Symptoms: Those directly related to the disease; lesion

location, demyelination, axonal damage, etc.• Secondary Symptoms: Those that present themselves as a result

of primary symptoms

• Prognosis is poor with greater levels of demyelination and axonal damage.

So what works?Symptoms are often successfully managed and improved by:

• Exercise and rehabilitation• Physical Exercise

• Training• Mental and cognitive

• Accommodations/Adaptations• Mobility devices, assistive devices, braces, etc

• Medications• For spasticity, pain, bladder control, depression

In PT/OT ClinicsChoose FUNCTIONAL, ACTIVITY-SPECIFIC exercises based on the PATIENTS’ GOALS!

• The power of sit-to-stands and sit-to-stand attempts

• The power of walking

• The power of practicing the task at hand• Assists the brain in recalling unused movement patterns, creating new movement

patterns and/or building old movement patterns

• Design HEP to safely break-down the activity at home

What does NOT work?• General exercises for LE, UE or trunk strengthening

performed lying down or sitting

• General exercises for LE, UE or trunk flexibility performed lying down or sitting

• 4-6 page HEP with generalized exercises

Expectations• Within 4-6 visits: Improvement or a gut feeling by patient

and/or clinician that given time improvement will happen

• Making changes to the treatment

Initial Assessment: Important words defined

• Gait: “A manner or rate of movement or progress”

• Walk: “To move along by foot”

• Orthopedic: “The correction or prevention of skeletal deformities.”

• Neurologic: “…related to disease of the nervous system.”

Walking Assessment Walking is a better definition for assessment with MS

• Many factors go into your walking assessment• Strength, balance, spasticity, fatigue, ataxia, gait

Factors of a Walking Assessment

1) Strength - LE MMT, trunk strength• Strong• Weakness detected: How much? What muscles? Expectations?

2) Balance• AD, mobility device: Why? How long? When? Which hand?

3) Spasticity - Ashworth, Modified Ashworth• 1 mm group• > 1 mm group• Flexion or extension pattern of movement common

Factors of a Walking Assessment

4) Fatigue• Is fatigue a symptom that bothers you? If you overdo it, how long

does it take you to recover? Consider when determining objective measure?

5) Ataxia – uncoordinated movement – sign of cerebellar lesions

6) Gait• Foot drop, toe out, knee hyperextension, trunk weakness, etc• Specific remarks for swing/stance phase not extremely applicable

Walking Assessment

• Many factors go into your walking assessment• Strength, balance, spasticity, fatigue, ataxia, gait

• Gait is a large part of walking but in choosing an appropriate treatment plan, exercise caution in focusing on too many gait components

• Medications: tell us something about the patient and the disease

Walking Assessment Choosing Appropriate Objective Measures

• Not an all-inclusive list: common clinic examples• Dependent on patient goals• 25 FTW: not the BEST indicator of improvement or decline in function• 2 MWT/6 MWT: Endurance, speed• Dynamic Gait Index (DGI): Walking and balance• Tinetti: Walking and balance• ABC: The Activities-Specific Balance Confidence Scale• MSIS-12 or -29: The Multiple Sclerosis Impact Scale

Walking Assessment Choosing Effective Treatment for Better Walking

• Treatment• Any exercise that breaks down the desired outcome and simulates it – use

caution but be aggressive when able

• In a patient with 5/5 LE strength, do NOT expect general strengthening and stretching to improve walking

• Start with 1-2 exercises that you either believe in or have experience with

• Perform a walk (however short or long)

• HEP: I want to know next time if we did enough, too much or you could do more

Balance Assessment• When is balance being lost?• What are you doing when you lose your balance?• Findings to consider when assessing balance

- Strength- Balance- Spasticity- Fatigue- Ataxia- Gait- Somatosensory System

Balance AssessmentFindings to consider when assessing balance

• Somatosensory System- Vision – double vision, optic neuritis (pain)- Proprioception – positional awareness- Vestibular Ocular Reflex – tracking position in space in relation to

what’s around him or her- Dizziness

Balance AssessmentChoosing Appropriate Objective Measures

• Not an all-inclusive list: common clinic examples- Berg – for more static balance issues and a little bit of strength- DGI – for more dynamic balance issues and distraction- TUG – timed up and go – for balance, speed, distraction- Tinetti – walking and balance- Self Reports: ABC, MSIS-29 or -12- For non-ambulatory, non-standing patients

• Standing frame tolerance• Amount of assistance with transfers, STS, style of transfer• Ability to donn/doff pants/shirt? How many attempts?• Time sitting unsupported• Time standing supported and unsupported?• Can he/she reach forward, back, to the side without losing balance?

Balance AssessmentChoosing Effective Treatment for Better Balance

• Treatment- Based on patient goals- Perform the specific tasks that were weak on an objective

measure- Safely encourage exercises that are on the more difficult side for

the BEST results- Use a gait belt – hold it with STEADY and STRONG support- Teach them that the legs move independent of the hands holding

something

Motivation• FIND IT

• Starts with a desire

• GET IT • Ask the questions so you know yourself better• Find a professional that will LISTEN• Schedule,

• KEEP IT• Progress!!!• Realistic goals• Progress as able

Get Motivated

• Get to know your patient by answering a few questions

• Where do you prefer to exercise? • Inside/outside, home/gym

• What time of day is the best?• AM/PM/Mid-day

• What do you like to do?• Walk, bike, swim, yoga, etc.

• What are your goals?• Fitness, strength, ROM, walking, balance

• Might need a professional

MotivationAs professionals…- Set realistic goals based on what the patient tells you

- (REMEMBER: patients tell you what you need to know!)

- Focus on symptoms that you truly BELIEVE can and will improve! (REMEMBER: many symptoms can/will improve!)

- Clinicians involved in MS are in it for the people; our patients keep us engaged making the goals more personalized, keeping the patients engaged!

MotivationFor our patients…- Set realistic goals based on secondary symptoms and get

improvement!

Realistic Goals

ImprovementMotivation

Summary1) MS patients will TELL you what you need to know to formulate

successful goals and treatment plans

2) Many symptoms with MS can and will IMPROVE

3) Choose ACTIVITY-SPECIFIC exercises when possible

4) MOTIVATION IS IMPORTANT: If you stay motivated, your patients stay motivated

Questions?