Spine Care Centre (SCC) protocols for Multiple Sclerosis Update 1 August 2015

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1 Spine Care Centre (SCC) protocols for Multiple Sclerosis Update 1 August 2015 Introduction Multiple sclerosis (MS) affects nerves in the brain and spinal cord, causing a wide range of symptoms including problems with muscle movement, balance, and vision. Each nerve fiber in the brain and spinal cord is surrounded by a layer of protein called myelin, which protects the nerve and helps electrical signals from the brain travel to the rest of the body. In MS, the myelin becomes damaged. Most people with MS only have a few of these symptoms and it is unlikely someone would develop all possible symptoms. The symptoms are unpredictable. Some people's MS symptoms develop and increase steadily over time, while for others, they come and go periodically. These periods when symptoms get worse are known as relapses. Periods when symptoms improve or disappear are known as remissions. This disrupts the transfer of these nerve signals, causing a wide range of potential symptoms, such as: Loss of vision or blurring usually only in one eye Spasticity muscle stiffness that can lead to uncontrolled muscle movements Ataxia difficulties with balance and co-ordination Fatigue feeling very tired during the day Muscle weakness and tightness, for many muscles, including extremities and pelvic floor muscles Numbness and tingling in different regions of the body Bladder problems including difficulty emptying the bladder completely, having to urinate more frequently and having a sudden, urgent need to urinate which can lead to unintentionally passing urine Bowel problems mainly constipation Depression, Vertigo, speech, and swallowing difficulties.

2 SCC Protocol in MS Our primary objective in SCC is to help MS patients living with these symptoms while improving their Quality Of Life (QOL). At SCC we have highly trained therapists, many machines and therapies that can manage many of these problems that MS patient faces everyday. Because multiple sclerosis is a chronic disorder in which there may be intermittent periods of recovery or remission, the indications for and the application of electrical muscle stimulation/ activation (EMS/EMA -Amplitrain) & Motion Lab (ML-Huber) will vary with the symptoms and functional limitations. ML (stretching/reinforcement) may be helpful in the management of spasticity, flexibility, coordination, balance and posture. Amplitrain (EMS/EMA) may be helpful in controlling pain (EMA), respiratory dysfunction, and urinary incontinence (ML/EMS) with resulting improvements in muscle strength, walking ability and performance in daily activities. The number of sessions needed is related to the phase of MS, but spasticity must be treated with ML-stretching before starting EMS/EMA therapy. During this phase we can start using MLstrengthening Global while increasing coordination levels. MS patient must know that Maintenance Program is a Must as this condition is chronic. Maintaining good level of flexibility, coordination, and muscle strength is our aim with MS patients. 6 sessions weekly are recommend in the beginning of the treatment (24-32 sessions depending on the level of disability), 3 sessions per week for maintenance. Management Of Spasticity: ML-stretching has been demonstrated to reduce or eliminate interfering spasticity, or involuntary muscle activity, in multiple sclerosis. The involuntary muscle activity may take the form of spontaneous muscle contractions or it may occur when voluntary

3 movement is initiated. A variety of ML protocols have been employed. Also, minimal intensity EMA, with only a tingling sensation felt by the user is very efficient in spasticity therapy. In other protocols, the intensity of EMS is increased to assist with joint movement. The intensity of EMS should never cause discomfort. Stimulation protocols will vary from one session to another. As a result of SCC-MS protocol, spasticity will be reduced, pain will be less, bowel and bladder function will improve, and walking will be more normal (with longer step lengths and greater walking velocity). Maintaining Or Improving Joint Range Of Motion: ML-strengthening & EMS of muscles can be used to move the joint to the end of the available range or it can be combined with the patient's exercise to be sure the patient is going to the end of the range and stretching just a bit. SCC-MS protocol for this purpose has advantages over vigorous manual range of motion including the use of the individual s muscles to gain the range in a gentle manner without traumatizing the tissues and it can be done several times during the week. When spasticity has contributed to the limitation of joint motion, the movement may improve remarkably as ML/EMS help to reduce the spasticity. Among the advantages of improved joint range of motion are greater ease of positioning and reduced risk for development of pressure sores. Improving Muscle Strength Or Performance: When interfering spasticity is reduced or eliminated, muscles may appear to be stronger in the absence of actual change in the muscle properties. In addition, EMS may improve the timing or recruitment of muscles so that muscles exert force in a more useful and coordinated manner. Exercise home programs, with SCC-MS protocol will improve muscle force production and fatigue resistance. Improving Bladder And Bowel Control: Electrical muscle stimulation has been reported to improve urge incontinence, urethral and anal sphincter control, and constipation. Motion Lab technology has been proven also in pelvic floor muscles rehabilitation in post pregnancy period. Investigators and clinicians have used exercise of the abdominal and pelvic floor

4 muscles in combination with EMS of these muscles with skin electrodes. Some protocols have employed special electrodes made to fit in the anus or vagina. The majority of patients (78 to 85%) reported improvements in their bowel and bladder function, but there is agreement that multiple sclerosis patients do need daily home (vaginal or anal) EMS treatments. Reducing The Risk Of Respiratory Infection: While most people with multiple sclerosis who can walk are not likely to have serious impairment of their respiratory muscle function, those in a wheelchair with decreased arm and trunk activity are at risk for respiratory compromise and infection. One of the most serious problems is the reduction in coughing ability and ML-strengthening & Amplitrain may be useful in contracting the abdominal muscles to assist in coughing and keeping the airway clean. Reduction of spasticity by ML/Amp may improve breathing and coughing by allowing more coordination of the muscles of inspiration and expiration. Improving The Mechanics And Energetics Of Walking: Our protocol has been discussed for the reduction of spasticity as well as improvement in joint range of motion and muscle performance. Maintenance of ankle dorsiflexion range of motion and modulation of ankle plantar flexor spasticity are critical to walking. It is necessary for the body weight to progress over the stance limb in order to take a step with the other leg. If the ankle does not have dorsiflexion range or if the calf muscles contract at the wrong time because they are stretched as the body moves forward, the stance leg will be pulled backward and the patient will have to use crutches and drag their entire lower extremity. These two problems prevent walking for many people with multiple sclerosis. SCC-MS protocol can be employed to rectify these problems and result in much more normal walking. There is evidence to show that people with multiple sclerosis who walk better with EMS will continue to use the EMS device at home for many years. For the MS patient who has a relapsing and remitting course, Maintenance program is recommended. By: Fadi ZEIN EL ABIDINE, MD, MHS, MBA

5 References: Rehabilitation with neuromuscular electrical stimulation leads to functional gains in ambulation in patients with secondary progressive and primary progressive multiple sclerosis: a case series report. Wahls TL1, Reese D, Kaplan D, Darling WG. A randomized trial to investigate the effects of functional electrical stimulation and therapeutic exercise on walking performance for people with multiple sclerosis. Barrett CL, Mann GE, Taylor PN, Strike P. Multiple Sclerosis 2009;15(4): Impact on activities of daily living using a functional electrical stimulation device to improve dropped foot in people with multiple sclerosis, measured by the Canadian Occupational Performance Measure. Esnouf JE, Taylor PN, Mann GE, Barrett CL. Multiple Sclerosis 2010;16(9): Functional electrical stimulation for drop foot of central neurological origin: National Institute for Health and Clinical Excellence. IPG278 public information. London: NICE; Pros and Cons of Functional Electrical Stimulation for MS-Related Foot Drop By Marie Suszynski Reviewed by Niya Jones, MD, MPH National MS Society Mayo clinic / Multiple Sclerosis MS society UK MS Centre, NHS UK ES in Multiple Sclerosis Comfort in Electrical Stimulation ES in Pain Modulation General Considerations in the Clinical Application of Electrical Stimulation ES in the Modulation of Spasticity ES and Muscle Performance