Physiotherapy plays an important role in the management of MS. In the early stages following diagnosis, there is a strong emphasis on education and self-management with advice on when it is beneficial to request a physiotherapy assessment. The type of physiotherapy approach and the intensity of the therapy will vary depending on the needs of the person with MS and the findings of the physiotherapy assessment. People with MS do not require constant physiotherapy input; however, there are benefits to bursts of rehabilitation following a relapse or a change in functional capacity. Physiotherapy treatment may occur in a variety of settings such as hospital rehabilitation units as either an inpatient or out-patient, or in the community. In some countries rehabilitation at home is available and may be organised by or through the national MS society.
Physiotherapy is beneficial in the treatment of many symptoms of MS and during rehabilitation the physiotherapist will work with the person with MS to achieve functional goals. Some symptoms helped by physiotherapy, often in conjunction with other disciplines, are listed here:
Weakness is a major symptom of MS and leads to a reduced ability in walking, standing and transfers – as well as problems with daily living activities that involve the upper limbs. Physiotherapy techniques to improve strength may involve the physiotherapist handling the person with MS to provide manual resistance for movements; examples include exercises using the weight of the body against gravity, or exercises using weights or elastic bands to provide progressive resistance. During the rehabilitation phase, strengthening exercises are often focused on regaining control of particularly weak muscles and correcting muscle imbalance to restore postural stability.
Weakness is thought to be a factor in fatigue because weak muscles work less efficiently and tire more quickly – therefore strength training helps to reduce fatigue. Weakness also influences balance and co-ordination and recent research into the benefits of strength training have shown improvements with functional tasks.
Reduced motor control (or paralysis) of a leg oran arm may result from damage to the nerve pathway supplying the muscles that control the limb. Recovery of control will be dependent on where the damage occurs and the severity of the damage. Physiotherapy may help restore lost movement when there is still the possibility of nerve impulses activating weak muscles. If restoration of movement is not possible then the physiotherapist may prescribe an external orthopaedic appliance that helps the movement of the limbs (an orthosis) such as a foot splint to improve walking.
Reduced balance occurs when there is a problem with the vestibular system of the brain, or sensory losses, or weakness. Physiotherapists are skilled at assessing the contributing factors to the balance problem and prescribing remedial techniques. Education and promotion of some compensatory strategies are often part of the solution; for example, vision is very important for providing additional information to the brain – therefore, putting on a light when getting up to go to the toilet at night, is very useful in reducing the risk of falling. People with MS who have impaired balance should be assessed by a physiotherapist; without physiotherapy input people often adopt compensatory strategies to reduce the risk of falls. Over time these strategies can lead to greater secondary problems, such as joint strain, increased fatigue, and muscle imbalance.
Spasticity is a symptom experienced by many people with MS caused by changes in the nerve impulses to the muscles resulting in spasms and stiffness. Physiotherapists are involved in teaching people with MS and their carers stretching and positioning techniques which help to relieve spasms and prevent shortening in muscles that are prone to spasms. Often, medication such as baclofen or tizanadine is required to help control the spasticity and physiotherapists are important in monitoring the effectiveness of the prescribed medication over time.
Pain in MS may be related to the areas of the central nervous system that are affected, and is commonly termed neurogenic or neuropathic pain; this is treated by the use of medication such as gabapentin. Other types of pain in MS may be related to muscle spasms and joint strains and can be treated by physiotherapy with success. For people with limited mobility, it is important for physiotherapists to assess the level of seating and postural support required, and to provide advice on adequate pressure relief.
Tremor can be a difficult symptom that limitsfunctional ability. A variety of treatments may be tried, including repetitive patterning movements which aim to improve co-ordination, adding weights to wrists to reduce the amplitude of the tremor, and education about positioning to increase stability of the arm or leg.
Liaison with other disciplines
Ideally physiotherapists work closely with other health professionals on the rehabilitation team. Often there is overlap, with functional goals directed by one discipline helping the goals of another discipline become achievable. A good example of close collaboration is when physiotherapists and occupational therapists perform joint wheelchair and seating assessments; the combined expertise of both disciplines ensures that postural needs, pressure care needs and functional capacity are all met within the same assessment process.
Physiotherapists are responsible for promoting a healthy and active lifestyle to people with MS to help reduce the impact of any relapses and to promote recovery. In the past, people with MS were not encouraged to exercise, particularly those with fatigue; however, more recent research into exercise has highlighted its positive effects and found that fatigue is actually reduced by a more active lifestyle. For people who are no longer able to exercise by themselves, physiotherapists have an important role in teaching carers how to perform regular stretches and positioning techniques.
At the completion of an in-patient rehabilitation period, it is important for physiotherapists to provide a suitable home programme or advice on suitable exercise and activities to promote continued well-being. The physiotherapist plays a primary role in a comprehensive rehabilitation programme.
Physiotherapy is appropriate at different stages of the disease for people with various levels of impairment and can be effective for treating many problems due to or associated with MS.
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