Multiple Sclerosis: A Rehabilitation Perspective

Transcription

1 Multiple Sclerosis: A Rehabilitation Perspective MICHELLE H. CAMERON, MD, PT Department of Neurology OHSU & Portland VA TED R. BROWN, MD, MPH Evergreen HealthCare 2012

2 Disclosures Dr Cameron: Has received honoraria from Teva neurosciences Has received consultation fees from DJO LLC and Mettler Electronics, Biogen Idec Has received research support from the National Multiple Sclerosis Society; the Multiple Sclerosis International Federation Currently has research support from the Department of Veterans Affairs Rehabilitation Research & Development Service; Acorda therapeutics; Collins Medical Trust

3 Disclosures Dr. Brown Has received honoraria from Teva Neurosciences, Acorda Therapeutics, Pfizer Has received consultation fees from Acorda, Biogen Idec, Bayer, Zars Pharmaceuticals Has received research support from Lilly and Forest Labs Currently has research support from the Acorda, Biogen and Teva

4 Objectives Understand that MS is caused by an interaction between the immune system and central nervous system Understand common presentations of MS, diagnostic principles and treatments Understand the principles of exercise for people with MS

5 Outline MS pathophysiology and epidemiology MS presentation, diagnosis and treatment Exercise in MS

6 MS Overview Lifelong Progressive No cure Transient disabilities and deficits (relapses) Sustained disability Persistent cognitive dysfunction

7 Pathophysiology of MS CNS disorder (brain, spinal cord, optic nerves) Symptoms separated in time and space Complex immune-mediated disorder

8 MS Plaque/Lesion Locations

9 Symptoms by Lesion Location Poor correlation Brain - Cognitive dysfunction - Double vision - Slurred speech - Tremor Optic nerve - Blurred vision or loss of vision Spinal cord - Weakness, numbness, bladder dysfunction

10 MS: Diagnosis Clinical diagnosis Objective evidence of CNS white matter lesions disseminated in time and space Neurologic history and exam Brain MRI Supportive Spinal MRI CSF: Elevated IgG index, oligoclonal bands

11 Epidemiology of MS 400,000 patients in USA, 2.5 million worldwide, ~1/700 (total 5000) in Oregon, ~ 9,000 in Washington Typical onset age years, average Female:male 2-4:1 Caucasians >> other ethnic groups Genetic predisposition: Identical twins: concordance 25-30% Geographic distribution: Increased prevalence in northern latitudes in N.A. and Europe

12 Prevalence rates per 100,000

13 MS course/sub-types

14 Relapses Usually new symptoms Sometimes significant worsening of an old symptom Lasts at least 24 hours Could be attributed to MS activity Preceded by stability or improvement for at least 30 days Average is 1-2 relapses per year for RRMS 40% of relapses leave residual disability at 3 months

15 Typical presenting symptoms Very varied initial presentation Reduced sensation (33%*) Visual changes vision loss (16%), diplopia (7%) Weakness (13%) Unsteadiness when walking (5%) Poor balance (3%) Multiple symptoms (15%) Also Spasticity Incontinence Cognitive changes

16 Medical Treatment of MS Steroids to shorten clinical episodes but have no effect on long term outcome or recurrence rate Various medications to reduce relapse rate and slow progression of relapsing forms of MS Starting MS drug treatment early is recommended Drugs are less effective for progressive forms of MS Multiple symptomatic treatments

17 MS disease modifying therapies 1 st line, injectable Glatiramer (Copaxone) Interferons (Avonex, Rebif, Betaseron, Extavia) 2 nd line Natalizumab (Tyasbri) Monthly IV infusion Oral Fingolimod (Gilenya)

18 EXERCISE IN MS Good, bad, indifferent? The pros and cons of exercise for people with MS Good, better, best? What works Resources and recommendations

19 Pros and Cons of Exercise in MS Cons Fatiguing Uses up limited energy Overheating Pros Increases fitness Increases energy resource Reduces fatigue in the long run Can avoid overheating with appropriate precautions and exercise

20 Recommendations to Optimize Exercise Progress slowly Stop when performance declines Stay cool swimming, air-conditioning, cold drinks, cool shower before and after Take breaks

21 Benefits of Exercise Short-term the real motivators Reduced stress and tension A break Improved self-esteem and confidence Long-term Reduced fatigue Increased endurance Increased strength Increased flexibility Improved balance Increased cardiovascular fitness, reduced cardiovascular risk Improved mood Weight control Increased participation in activities

22 The Best Exercise for Your Patient Addresses their goals Reduced fatigue Endurance exercise Increased strength Resistance exercise Improved balance Standing exercise Cardiovascular fitness Aerobic exercise What they ll do! Alone, partner, class Indoor, outdoor

23 Clarify Exercise Goals Endurance Work on duration and repetition Resistance Weights, springs, bands Balance Standing, reduced support Fitness Aerobic, increased heart rate

24 Endurance Duration, Repetition

25 Strength - Resistance Exercise

26 Balance Standing Challenges

27 Fitness - Aerobic Exercise

28 Where? Physical therapy Assess goals Assess current abilities and safety Make a specific plan for exercise Home program Gym program Group program Follow to address concerns Gym Clubs Public In physical therapy clinic Groups Mall walking Hiking MS support groups Classes Tai Chi Dance Yoga

29 Why do patients drop out? Lack of motivation Lack of social support Time (perceived) Accessibility Improper exercise program Improper goal setting Exacerbation, illness, injury Fatigue

30 Keep the momentum: How to sustain a program Adequate sleep Exercise when energy is greatest Home program is essential Have indoor and outdoor options If feeling sluggish, reduce exercise for the day Quit smoking Keep track of progress

31 Instructions for staying cool Exercise at cooler times of day Use a fan/ A.C. Wear loose/light clothing Paced exercises Keep hydrated Consider pre-cooling Keep cooling packs/ garments/ ice handy

32 Managing MS fatigue All studies show positive or neutral effect of exercise on fatigue Give rest between exercises Stop when fatigued Teach the 2- hour rule Reduce program on fatigue days

33 Energy Conservation: the 4 P s Planning (organizer, day planner, wk planner, activity station (drop-zone)) Prioritizing (is this task necessary?) Pacing (budget your energy thru the day/wk) Positioning (proper body mechanics/workplace ergonomics)

34 Resources and Recommendations Local community center Gyms and health clubs MS society Books Exercises for Multiple Sclerosis Brad Hamler Websites National MS Society Google MS Exercise

35 Useful exercise precautions for MS patients Avoid exhaustion Avoid overheating Anticipate cognitive impairment High fall-risks

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37 Imbalance and Falls in MS: Epidemiology >75% complain of balance abnormalities >50% fall in 3 months 12% had an injurious fall in 6 months 50% with an injurious fall ever Women with MS have increased risk of osteoporosis and fall-related fractures Balance abnormalities occur in those with minimal or undetectable impairments, as well as in those with significant impairments

38 Imbalance in MS 3 related abnormalities 1. Decreased ability to maintain position 2. Decreased ability to move outside of base of support 3. Delayed responses to postural displacements or perturbations

39 Strategies to Address Proprioceptive Deficits Enhance input TENS, strap or brace on leg Light touch cane Auditory input Tongue stimulation Practice Substitution Increase reliance on vision and vestibular Avoidance Avoid low light Avoid uneven surfaces

40 Canes etc. A cane or hiking poles to provide proprioceptive information more than support

41 Balance Training

42 Home Exercise

43 Safety strategies and home modifications Foot wear Home hazards Lights Trips

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45 Reduce Environmental Hazards

46 Exercise for more disabled people Consider P.T. evaluation for getting started Consider O.T. directed program Stretching is a form of exercise- everybody needs that

47 Mental calisthenics Brain needs to be exercised, too Benefits of cognitive exercise proved in healthy seniors 5 studies in MS: none conclusive More research is needed

48 Mental Calisthenics Key areas Memory Concentration / attention Speed of thinking Reasoning Try to do it every day for at least 30 minutes

49 Assess and Address Speech and Swallowing problems

50 Summary & Conclusions MS is a chronic progressive neurological disease Several immune-based treatments, but no cure High fall-risk! Interventions that address proprioception and central integration are most likely to reduce imbalance and fall risk in MS

51 Conclusions Just do it! The best exercise is any exercise they ll do Clarify goals Remind patients to: Progress slowly but steadily Avoid overdoing and overheating Adapt

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