Multiple Sclerosis Symptoms Management: An Integrated Healthcare Approach

At Propel, we use an integrated approach to multiple sclerosis symptoms management that includes physiotherapy and occupational therapy. Evidence has shown that rehabilitation is still the only way to improve functional outcomes in individuals with multiple sclerosis.[i]

Canada has one of the highest rates of multiple sclerosis (MS) in the world, with an estimated 1 in every 385 Canadians living with the disease.[ii]  As the number of Canadians living with MS is expected to grow, there is a need for a better understanding through more research aiming to discover a cure or enhance disease-modifying therapies for all stages of MS.

In the meantime, it is important to continue to educate people on rehabilitation as a valuable treatment option. A recent review of the literature suggests structured rehabilitation programs and physical therapy can improve mobility, muscle strength, aerobic capacity and quality of life.[iii]

In this article, we discuss the different forms of multiple sclerosis and how physiotherapy and occupational therapy help manage symptoms of MS. We also look at other treatment interventions that have been shown to be effective in multiple sclerosis symptoms management, including hydrotherapy, massage therapy, robotic-assisted gait training and PoNS Therapy™.

Table of Contents:

• What is multiple sclerosis?
• Different forms of MS
• How physiotherapy helps manage symptoms of MS
• How occupational therapy helps manage symptoms of MS
• Other treatment interventions
• Conclusion

What is Multiple Sclerosis?

Multiple sclerosis (MS) is a chronic neurodegenerative disease associated with a wide-range of potential symptoms that can be anywhere from mild to causing serious disability.

In MS, the immune system attacks the protective covering, myelin, of the brain and spinal cord, causing inflammation and often damage to the myelin. When this happens, the usual flow of nerve impulses along nerve fibres (axons) is interrupted.

The signs and symptoms of MS vary widely depending on the amount of damage and which nerves are affected. Not all people with MS will experience all symptoms and often the symptoms will improve during periods of remission.

The main symptoms include:

• Fatigue
• Difficulty walking
• Vision problems, such as blurred vision
• Problems controlling the bladder
• Numbness or tingling in different parts of the body
• Muscle stiffness and spasms
• Problems with balance and co-ordination
• Problems with thinking, learning and planning

Different Forms of MS

The earliest form of MS is clinically isolated syndrome, or CIS. CIS refers to a single episode of neurological symptoms suggestive of multiple sclerosis. Often, through MRI investigation there is evidence of abnormality in the brain or spinal cord.

Relapsing-remitting MS is characterized by unpredictable but clearly defined relapses (also known as attacks, exacerbations or flare-ups) during which new symptoms appear or existing ones get worse. In the period between relapses, a person typically returns to their baseline function.

Most people with relapsing-remitting will eventually transition to a phase of the disease called secondary progressive. This phase of the disease has progressive worsening and fewer relapses.

Primary progressive MS is characterized by a slow accumulation of disability, it may stabilize for periods of time, and minor improvement may occur, but there are no periods of remission.[iv]

How Physiotherapy Helps Manage Symptoms of MS

Physiotherapists and exercise therapists can help address the needs of individuals with MS. This can include the treatment of symptoms such as fatigue, balance, weakness and spasticity.

Fatigue can be a debilitating part of MS symptoms, affecting a person’s physical, emotional and social well being. Studies have found that endurance exercise in MS clients can improve walking distance and quality of life measures.[v] Our therapists can help design a tailored and comprehensive exercise program that can alleviate the effects of fatigue.

Balance deficits can lead to an increased risk of falls, gait deviations and decreased independence. MS can cause a wide range of symptoms that can influence balance including decreased coordination, muscle weakness, sensory changes, tremors and dizziness. A systematic review of research has shown significant positive effects of physiotherapy on balance for individuals with MS who have mild to moderate levels of disability.[vi]

Weakness is a common problem in individuals with MS. Resistance training can help improve muscular endurance, strength and power. This in turn can help with functional activities, walking ability and physical independence. Our therapists can help design and execute a resistance training program that helps address areas of weakness an imbalance in the body.

Spasticity is a common symptom is MS that characterized by involuntary stiffness and/or muscle spasms. Spasticity can have a serious effect on a person’s mobility and independence. The effects of spasticity can vary from one MS client to the next. Positioning, stretching, and bracing are all ways to help mitigate the effects of spasticity.

Bowel and/or Bladder Dysfunction occur commonly in MS. Bowel dysfunction can cause a great deal of discomfort and embarrassment, and can aggravate other MS symptoms such as spasticity or bladder dysfunction.[vii]  Symptoms can range from mild to more severe problems, including:.

• Urinary frequency, urinary urgency, urinary incontinence, urinary retention, voiding dysfunction
• Constipation, fecal incontinence

Pelvic floor physiotherapy can be an effective way to help manage various symptoms.

Sexual Dysfunction is frequently associated with multiple sclerosis and can have a negative impact on the sexuality of people of all genders. Most common symptoms include:  

• Erectile and ejaculatory dysfunction, pain with intercourse and pelvic pain

Pelvic floor physiotherapy can be an effective way to help manage various symptoms.

Pelvic Floor Physiotherapy for MS Symptoms

Pelvic floor rehabilitation for bowel, bladder or sexual dysfunction may involve several treatment approaches depending on the individual and symptoms;

• Pelvic floor muscle strengthening
• Pelvic floor muscle relaxation
• Manual techniques for tissue strengthening or relaxation
• Exercise prescription to improve mobility of affected areas
• Biofeedback
• Electrical stimulation of the pelvic floor muscles
• Addressing and discussing lifestyle factors such as sleep, nutrition, hydration, relaxation, toileting, use of lubricant
• Education (pain science, lifestyle influence)

Studies have demonstrated that pelvic floor physiotherapy has the potential to result in significant relief of symptoms and improve quality of life.[viii]

How Occupational Therapy Helps Manage Symptoms of MS

Occupational Therapy (OT) can also address MS symptoms including decreased balance, strength, managing spasticity, fatigue and sensory challenges – lack of sensory discrimination.

Occupational therapists at Propel work in conjunction with physiotherapists to create an exercise program that will help address the challenges faced by the client and the goals thy would like to achieve to improve and/or maintain their current level of function.

They will educate the client on energy conservation, pacing techniques to manage fatigue, and focus on improving the client’s independence in performing activities of daily living (self-care), productivity activities (paid work, volunteering), and leisure activities.

The occupational therapist will also address the needs of any adaptive equipment that may be required to maintain the client’s independence in performing a task.

Other Treatment Interventions

In addition to conventional physiotherapy treatment methods the following interventions have been shown to be effective in MS management.

Hydrotherapy

Hydrotherapy has been shown to have positive effects on physical and mental health. The reduced impact of gravity allows patients with mild to severe paresis in their lower extremities to move more freely and perform standing and walking exercises. Pool therapy can help with pain, muscle spasms and fatigue associated with MS. A systemic review found that hydrotherapy helped improve quality of life for those living with MS.[ix]

Massage Therapy

Massage therapy is used to help with the following:

• improve circulation and range of motion
• decrease tone and spasticity
• improve soft tissue extensibility
• stimulate lymphatic drainage and blood circulation
• as well as decrease pain and ease stiffness.

That is why it is an important technique used in neurological rehabilitation. Massage therapy can also be beneficial in treating stress and stress-related conditions.

Robotic Assisted Gait Training (RAGT)

Robotic assisted gait training allows for repetition of specific movements required for walking without the energy cost. In the MS population RAGT has been found to positively affect gait parameters.

Propel Physiotherapy uses the Keeogo^TM assistive device for walking to effectively help address the unique mobility and gait issues some of our clients face in the community and at home. The evidence-based technology is improving the independence of our clients.

The powered device is designed to help individuals with mobility related challenges that limit their ability to participate in daily activities such as walking, climbing or descending stairs, sitting down or standing up. It is used by individuals with spinal cord injury, Parkinson’s disease, multiple sclerosis, arthritis, brain injury and stroke.

PoNSTherapy

The PoNS™ (Portable Neuromodulation Stimulator) is an innovative medical device that gently stimulates the surface of the tongue, exciting the neural network flowing to the brain. This neural activity is believed to enable neuroplasticity, which has the potential to improve walking and balance in individuals with deficits due to mild to moderate symptoms of multiple sclerosis.

In a clinical study of 20 patients with multiple sclerosis, it was shown that using the PoNS™ device in combination with physical therapy over 14 weeks led to a significant improvement in walking, compared to physical activity alone. Ninety-five percent of all study patients experienced improvement in their walking, however, the PoNS Therapy™ group, on average, had 2x improvement in their walking scores.

Conclusion

Previous concerns that exercise in people with MS would cause more damage and fatigue have been discredited. We now know that the evidence supports that physical activity is a vital component in the treatment of MS. Exercise is beneficial for your physical, emotional and mental health.

For maintaining functional capacity and reducing risk for losing important abilities or independence, rehabilitation interventions should be considered early.[x]  Ask our experienced team of clinicians if an integrated approach to multiple sclerosis symptoms management is right for you and how you can get started.

References

[i] Sutliff MH, Bennett SE, Bobryk P, Halper J, Saslow LA, Skutnik LT, Smith C, Zackowski K, Jones DE. Rehabilitation in multiple sclerosis: Commentary on the recent AAN systematic review. Neurol Clin Pract. 2016 Dec;6(6):475-479. doi: 10.1212/CPJ.0000000000000318. PMID: 28058205; PMCID: PMC5200850.

[ii] StatsCan –Neurological conditions in household population 

[iii] Amatya B, Khan F, Galea M. Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2019 Jan 14;1(1):CD012732. doi: 10.1002/14651858.CD012732.pub2. PMID: 30637728; PMCID: PMC6353175.

[iv] Amatya B, Khan F, Galea M. Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD012732. DOI: 10.1002/14651858.CD012732.pub2. Accessed 03 May 2023.

[v] Dettmers C¹, Sulzmann M, Ruchay-Plössl A, Gütler R, Vieten M. Acta Neurol Scand. 2009 Oct;120(4):251-7. Endurance exercise improves walking distance in MS patients with fatigue

[vi] Paltamaa J¹, Sjögren T, Peurala SH, Heinonen A.J Rehabil Med. 2012 Oct;44(10):811-23. Effects of physiotherapy interventions on balance in multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials.

[vii] Bowel Problems, National MS Society

[viii] Sparaco M, Bonavita S. Pelvic Floor Dysfunctions and Their Rehabilitation in Multiple Sclerosis. J Clin Med. 2022 Mar 31;11(7):1941. doi: 10.3390/jcm11071941. PMID: 35407549; PMCID: PMC8999571.

[ix] Corvillo I, Varela E, Armijo F, Alvarez-Badillo A, Armijo O, Maraver F. Efficacy of aquatic therapy for multiple sclerosis: a systematic review. Eur J Phys Rehabil Med. 2017 Dec;53(6):944-952. doi: 10.23736/S1973-9087.17.04570-1. Epub 2017 Feb 17. PMID: 28215060.

[x] Beer S, Khan F, Kesselring J. Rehabilitation interventions in multiple sclerosis: an overview. J Neurol. 2012 Sep;259(9):1994-2008. doi: 10.1007/s00415-012-6577-4. Epub 2012 Jul 8. PMID: 22772357.

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