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Title: Promoting Health, Creating Hope

Promoting Health, Creating Hope
  • The Pathology of MSExercise as Treatment
  • Brian Hutchinson, MS PT
  • President, The Heuga Center
  • Charles A. Sourby, MS Ed., CTRS
  • Director, Recreation Therapy
  • Schervier Nursing Care Center
  • Bon Secours New York Health System, Inc.

The Uninvited Guest
  • The vast majority of people who have multiple
    sclerosis (MS) are diagnosed between the ages of
    15 and 55 years. The disease thus affects people
    in their most productive years young adults
    readying themselves to leave home in pursuit of
    academic, vocational, or social goals men and
    women in the process of launching careers and
    families of their own and those in middle age
    who are enjoying their productive years and
    planning for their retirements.

The Uninvited Guest
  • In each of these age groups, the diagnosis of
    a chronic, unpredictable disease has significant
    impact, not only for the individual who receives
    the diagnoses of MS, but also on the family
    members and loved ones whose lives are interwoven
    with that person.
  • Rosalind Kalb, Ph. D.

a to maintain a contest or combat usually
on even terms or with success. b to deal with
and attempt to overcome problems and
difficulties. --Merriam-Websters
Dictionary That sounds simple
enough. Richard. M. Cohen
Key Words
  • Activities of Daily Living, (ADLS)
  • Acute
  • Ataxia
  • Brain Stem Auditory Evoked Potential (BAEP)
  • Central Nervous System (CNS)
  • Cerebral Spinal Fluid
  • Complementary Alternative Medicine
  • Contracture
  • Chronic
  • Clonus
  • Demylelination
  • Exacerbations

Key Words
  • Fatigue
  • Foot Drop
  • Health Related Quality of Life (HRQOL)
  • Impairment
  • Isokinetic Dynamometry
  • Lesions
  • Lehermitttes Sign
  • Magnetic Resonance Imaging (MRI)
  • Nocturia
  • Primary-Progressive MS
  • Progressive Relapsing

Key Words
  • Relapsing MS
  • Secondary Progressive(SP) MS
  • Subjective, Objective, Assessment, Plan (SOAP)
  • Somotosensory
  • Somotosensory Evoked Potential (SSEP)
  • Spasticity
  • Tendelenburg sign
  • Therapeutic Recreation (TR)
  • Visual Evoked Potential

MS Classifications
  • Relapsing-Remitting
  • Primary Progressive
  • Secondary Progressive
  • Progressive-Relapsing

What Triggers MS?
  • Geography
  • Northern Hemisphere age 1-15
  • Genetics/ Heredity
  • Genetic Predisposition
  • Bacterial Infection
  • In combination with virus
  • Viral Infection
  • Herpes or other virus

Pathophysiology of MS
  • Blood brain barrier breakdown
  • Autoimmune/inflammatory response
  • Myelin damage
  • Lesion formation
  • Axonal damage and atrophy

How Does MS Effect the CNS?
  • Invisible vs. Visible MS
  • Like an iceberg
  • Relapses physical disability, (10)
  • Cognitive impairments, brain atrophy, MRI
    lesions, (90 )

Invisible vs. Visible MS
Graphic-Biogen 2001
Invisible vs. Visible MS
Graphic-Biogen 2001
The Invisible vs. the Visible MS Invisible
Brain Atrophy
PhotographBiogen. 2001
The Invisible vs. the Visible MS
GraphicBiogen, 2001
How Does MS Effect the CNS?
  • Oligodenrocyte (forms myelin)
  • Myelin sheath
  • Cytokines formed by Activated T cell
    degrades myelin sheath

GraphiccBiogen, 2001
Extended Disability Scale
  • 2.0-2.5 Least Disabled
  • 4.04.5
  • 6.0-6.5 Cane/Walker
  • 7.0-7.5 Wheelchair user

Extended Disability Scale
GraphicBiogen, 2001
How Does MS Effect the CNS?
  • Inflammatory fluid leaks into the white matter
    causes swelling.
  • Inflammation invasion of white blood cells,
    production on inflammatory proteins-around blood
    vessels contained in the white matter.

The Process of MS Pathology
  • Neuron
  • Axon
  • Myelin Sheath
  • Inflammation
  • Demyelination leads to scarring (or plaques)
  • Axon Loss
  • MRI Lesions

The Process of MS Pathology
GraphicBiogen, 2001
The Consequences of no treatment or medical
  • Relapses
  • Physical Disability
  • Brain Atrophy (7 years)
  • MRI Lesions

The Multidisciplinary Approach to Rehabilitation
  • Provides a more comprehensive integrated care
  • Professionals involved on the rehabilitation team
    often include a physiatrist, nurse, physical
    therapist occupational therapist, orthopedist,
    speech/language pathologist, social worker,
    recreation therapist and psychologist.

The Multidisciplinary Approach to Rehabilitation
  • Other Team members may include
  • Orthotist, rehabilitation technology specialist,
    exercise physiologist, or kinesiologist.
  • Physician referral is required to access
    rehabilitation therapies in all treatment settings

  • Has shown benefits of mild exercise in improving
    disability and handicap in people with MS
  • Kidd, Howard, Losseff, and Thompson (1995)
    Langdon, Hobart, and Thompson (1999) and Solari
    and colleagues (1999), demonstrated improvements
    in functional mobility measures.

  • Freemans study followed individuals for 1 year
    following 6 weeks of inpatient rehabilitation and
    saw improvements in measures of handicap. This
    study consisted of two 45 minute physical
    therapy sessions per day and one 45minute
    occupational therapy session per day over an
    average of 20 days.
  • All individuals had input form doctors and nurses
    during their rehabilitation stays.

  • Solari (1999) divided individuals into two groups
  • One receiving 3 weeks of inpatient rehabilitation
    and one performing exercises at home.
  • The group receiving inpatient treatment
    demonstrated improvements in their disability up
    to nine weeks following their inpatient stay.

  • Health Related Quality Of Life (HRQOL)
  • HRQOL is a measure that includes physical, mental
    and social health variables, and the value a
    person places on their current abilities and/or
  • Patajans (1996) study showed reduced depression
    and anger with regular exercise.

  • Peatajans (1999) study also showed improvements
    in social interaction and emotional behavior.
  • DiFabio, Choi, Soderber Hansen (1997) examined
    individuals with progressive MS, receiving
    ongoing maintenance therapy. These individuals
    showed improvements in many areas of the HRQOL
    with one 5-hour session per week.

Multiple Sclerosis affects families, caregivers
and patients in social or professional settings.
  • Emotional
  • Financial
  • Long Term Planning
  • Assistive Technology
  • Child Rearing
  • Shock
  • Grief
  • Denial
  • Anger
  • Acceptance

Assistive Technology
  • High Tech
  • The Jazzy Scooters
  • Mid Level Tech
  • The Lofstrand crutch
  • Low Tech
  • Canes

Assistive Technology
Photograph Christopher Wittnam,, 2004
Assistive Technology
  • Benefits
  • Increases functional ability
  • Reduces fatigue
  • Equalizes disability

Understanding of the Challenges Facing
Practitioners Patients dealing with Multiple
  • Patient
  • Loss of identity,
  • Loss of physical functioning ability
  • Loss of emotional well being.
  • Practitioner
  • Continuous rehabilitation process.
  • Justification of services to insurance providers

Autoimmune Disorder
  • Immune Response
  • Trigger
  • Blood brain barrier
  • Inflammatory process
  • Myelin damage
  • Lesion formation
  • Axonal damage and atrophy
  • Current Immunomodulating
  • Interferon beta 1a 1996
  • Interferon beta 1b 1993
  • Glatiramer Acetate 1996
  • Mitoxanthrone 2000
  • Rebif 2002
  • Plasmaphoresis
  • Date of FDA Approval

The Story Continues
Medications Used by Patients with MS
  • Amatadine HCL Fatigue
  • Baclofen Spasticity
  • Tricyclic antidepressents Depression
  • Prednisone Acute exacerbation
  • Modafinil Fatigue
  • Selective serotonin Neuropsycholigcal

Complimentary Alternative Medicines
  • Traditional Chinese Medicine Acupuncture
  • Ingested or Injected substances
  • Vitamins, Echinacea, Noni juice,
  • Herbs
  • St. Johns Wort, Evening Primrose Oil Genseng,
    Ginko Bilboa, Melatonin
  • Life-Enhancing Therapies
  • Yoga, Massage, Tai Chi, Reiki, Therapeutic Touch

Complimentary Alternative Medicines
  • Toxic Removal Therapy Chelation therapy
  • Special Diets
  • Swank Low Fat, Gluten free diet, Aspartane free
  • MacDougal Diet

Common Symptoms
  • Fatigue
  • Weakness
  • Spasticity
  • Ataxia/Tremor
  • Parasthesias/Dysethesias
  • Dysarthria/Dysphagia
  • Bowel/Bladder/Sexual Function
  • Cognitive
  • Emotional
  • Visual

Symptom Management
  • Medications
  • Rehabilitation
  • Surgical

Effects of MS on Exercise
  • Primary
  • Secondary
  • Tertiary

Primary Effects of MS on Exercise
  • Blunted Blood Pressure Responses
  • Dampened arterial blood pressure response to
    sustained isometric exercise (Pepin,, 1996
    Ng, et. al., 2000)
  • -Pepin Impaired autonomically mediated pressor
  • -Ng A function of dampened muscle metabolic
  • May affect ability for one to attain target
    zone if an autonomically mediated response

Primary Effects of MS on Exercise
  • Fatigue
  • Central
  • Peripheral
  • Thermosensitivity

Secondary Effects of MS on Exercise
  • Impairments
  • ROM
  • Strength/Weakness
  • Sensation
  • Balance/Coordination
  • Fatigue due to Deconditioning
  • Pain
  • Medication Effects

Secondary Effects of MS on Exercise
  • Disability
  • Mobility
  • -Difficulty achieving desired levels of exercise
    (inability to perform previous activities)
  • Cognitive
  • -Difficulty in initiating or maintaining an
    exercise program

Tertiary Effects of MS on Exercise
  • Emotional
  • Decreased motivation
  • Family/community support
  • Coping skills
  • Accessibility
  • Equipment
  • Location(s)
  • Expertise

Effects of Exercise on People with MS
  • Improvements in Impairments
  • Improvements in Disability
  • Improvements in Quality of Life
  • Improvements in Health Measures

Effects of Exercise on People with MS
  • Improvements in Impairments
  • Improve range of motion
  • Improve strength
  • Improve endurance/decrease fatigue
  • Decrease pain

Effects of Exercise on People with MS
  • Improvements in Disability
  • Improved mobility
  • -Improvement with bed mobility
  • -Improvement with transfers
  • -Improvement with ambulation
  • Improvement with activities of daily living (ADL)

Effects of Exercise on People with MS
  • Improvements in Quality of Life
  • Emotional behavior
  • Social interaction
  • Recreation
  • Home management
  • Reduction in depression
  • Reduction in anger

Effects of Exercise on People with MS
  • Improvements in Physical Health Measures
  • VO2 max
  • Percent body fat
  • Blood lipids

Exercise as Part of Everyday Life
  • Choose fitness that fits.
  • Set realistic goals.
  • Think Safety .
  • Work within individual abilities
  • Time medications with exercises
  • Pace exercise to avoid fatigue

Photographic-National Sclerosis Society--2002
Exercise as Part of Everyday Life
PhotographGail Louis, 2002
PhotographPage Oliver, 2002
Stretch for 30 minutes, 2 times a day or -3
times a day, for 20 minutes.
Exercise as Part of Everyday Life
  • Strategies For Handling Fatigue
  • Plan Ahead take 15 minute nap before preceding
    any demanding exercise
  • Coordinate exercise with body rhythms schedule
    physical activities for a time of day when energy
    is highest
  • Alternate more demanding exercise with activity
    requiring less

Exercise as Part of Everyday Life
  • Apply two Minute rule if feeling to sluggish
    to work out, commit to moderate exercise for just
    two minutes. The activity may generate the energy
    to continue. If fatigue persist, stop and rest.
  • Keep Cool heat leads to poor nerve conduction
    togtincreased fatiguegtincreased weakness and other
    symptoms. For those who are heat sensitive,
    keeping cool is essential.

Exercise as Part of Everyday Life
  • Keep Cool
  • Avoid exhaustion
  • Talk to exercise instructors
  • About MS before starting a
  • Class to avoid embarrassment
  • If you need to stop and rest.

PhotographNational Multiple Sclerosis Society,
Exercises for Spastic Muscles
  • Exercises for Spasticity
  • CautionWhen doing passive exercises, do them
    slowly and apply pressure steadily, especially if
    extreme tightness is present.
  • Ankle dorsiflexion (calf stretch)
  • Bending ankle up Back Lying.
  • Grab the heel, placing the ball of the foot
    against your forearm, and bend the ankle up.
    (Push the toes toward knee.)

Exercises for Spastic Muscles
  • InternalExternal rotation
  • Rolling leg in and out Back lying
  • Abduction-adduction
  • Leg out to side Back lying
  • Knee flexing
  • Front thigh stretch Face lying.
  • Hip extension
  • Leg backward at hip. Face lying.

Exercises for Spastic Muscles
Exercises for Spastic Muscles
  • Hamstring stretch
  • Hip flexion with straight knee Back Lying
  • Hip flexion
  • Knee to chest Buttock Stretch. Back lying

Exercises for Spastic Muscles
Independent Stretching Program
  • Heel Cord Stretch
  • Sit on a mat, the floor, or the be with your legs
    stretched out in front of you. ( If this is
    difficult, sit with your back against the wall.)
    Take a towel and sling it around your foot,
    across the ball of the foot, and pull the
    forefoot up toward you.
  • You should feel the stretch in your calves and up
    behind the knees. Hold for 60 seconds.

Independent Stretching Program
  • Hamstring Stretch
  • Sitting as in first exercise, lean forward, place
    your hands on your calves, and slide them down
    toward your toes, keep you knees straight. You
    should feel a stretch under your thighs.
  • Try to keep your back relatively straight. Hold
    for 60 seconds

Independent Stretching Program
  • Butterfly sit
  • Sit on bed, floor or mat with your knees and hips
    bent and the soles of your feet touching. Clasp
    your ankles with your hands so that your elbows
    rest on the inside of your knees.
  • Push the knees apart with your elbows as you lean
    forward. Hold 60 seconds.

Independent Stretching Program
  • Wall Stretch
  • Lie on your back at the base of the
    wallperpendicular to it (either on the floor or
    a be if it is against the wall.) Your buttocks
    should be all the way up the wall and your legs
    stretched out and up against the wall. Let the
    legs slowly separate and slide out to the side as
    far as possible. Hold for 60 seconds.

Independent Stretching Program
  • Kneel standing
  • Get you knees on a mat or the floor. Then lower
    your buttocks down to the right heel and come
    back up. Then down to the left heel and back up
  • Repeat 5-7 timesprogress as tolerated

Balance and Coordination
  • Kneeling
  • Sitting
  • 4-point Kneeling
  • Maintain equal distribution of weight over the
    four points of contact.

Balance and Coordination
  • Stand Kneeling
  • This position develops increased balance by
    establishing pelvic and hip control.
  • Turning to look behind
  • This exercise challenges the balance system.
  • Taking weight through affected arm

Balance and Coordination
Independent Stretching Program Balance
Strengthening Exercises
  • Knee Extension
  • Quad Set
  • Terminal knee extension
  • Elbow flexion with Theraband
  • Elbow extension with Theraband
  • External rotation with Theraband

Strengthening Exercises
Strengthening Exercises
Strengthening Exercises
  • Shoulder abduction with Theraband
  • Shoulder Adduction with Theraband
  • Exercises for strengthening fingers with use of

Exercises for Speech Difficulties
  • Open close the mouth several times.
  • Pucker lips into a big kiss, hold, then relax.
  • Spread the lips into a big smile, hold, then
  • Pucker, hold, smile, hold, repeat this
    alternating movement.
  • Close the lips tightly together relax.
  • Close lips firmly, slurp all the saliva out to
    the top of the tongue.

Exercises for Speech Difficulties
  • Open the mouth and stick out the tongue be sure
    the tongue comes straight out of the mouth does
    not go off to the side hold, then relax.
  • Stick out the tongue and move it slowly from the
    corner of the lips hold in each corner relax
    be sure the tongue touches each corner, each time.

Exercises for Speech Difficulties
  • Stick out the tongue and try to reach the chin
    with the tongue tip hold at farthest point, then
  • Stick out the tongue pretend to lick a sucker,
    moving the tongue tip from down by the chin up to
    the nose, go slowly and use as much movement as
    possible, then relax.
  • Stick out the tongue and pull it back, then
    repeat as many times as quickly as possible,
    then relax.

Exercises for Speech Difficulties
  • Move the tongue all around the lips in a circle
    as quickly and a completely as possible touch
    all of both the upper lip, lower lip, corner in a
    circle, rest.
  • Open and close the mouth as quickly as possible
    be sure lips close each time rest.

Exercises for Speech Difficulties
  • Say pa-pa-pa-pa as quickly as possible without
    losing the pa sound be sure there is a p and
    an ah each time, rest.
  • Say ta-ta-ta-ta as quickly and as accurately as
    possible, rest, repeat.
  • Say ka-ka-ka-ka as quickly and as accurately as
    possible, rest, repeat.

Exercises for Speech Difficulties
  • Say pataka, pataka, pataka (or buttercup) as
    quickly and as accurately as possible, rest.
  • Pacing and pausing techniques may be helpful if
    speech is slurred or rapid. The pausing is used
    between one or two words.
  • A paceboard initially be used to assist with this
  • Although it sounds relatively simple, it takes a
    lot of practice and learning to monitor oneself.

Exercises for Speech Difficulties
  • Exaggerating (overarticulating) speech sometimes
    will assist in slowing. Each sound within a word
    is pronounced, especially the final sounds.
  • Nonverbal techniques may be used in severe cases
    of specific intelligibility. These may include
    the use of a communication board (letter of
    picture) and a variety of electronic systems.

The Journey With MS
  • Every morning, pre-diagnoses, the patients
    routine included walking his dog. As time went
    on, the patient experienced increasing difficulty
    with this routine. He was continually tripping,
    his gate was unstable and his pace slow. One
    morning, while walking the dog, he fell down in
    the middle of the street. This was the proverbial
    wake-up-call. His wife simply said I wish
    youd see a doctor. Its as though you have
    Multiple Sclerosis or something.

Charles Sourby2001
Individual Therapeutic Recreation (TR) Goals
SubjectiveObjectiveAssessmentPlan (S.O.A.P.)
  • Goal 1 To maintain or improve current leisure
  • Goal 2 To maintain current level of
    socialization activities.
  • Goal 3 To develop skills that promote physical
    functioning, balance, and range of motion.
  • Goal 4 To study, learn and write about Multiple
    Sclerosis, recreation, nature and adoptive

Individual TR Objectives
  • Objective 1 Given the proper equipment,
    resources and opportunities, pt. continues to
    engage in various activities such as gardening,
    paddling, cooking and camping 2-3 times per week.
  • Objective 2 During the course of each day, pt.
    engages in socialization activities such as
    interactive conversation, with friends and
    colleagues for up to 30 minutes per day.

Individual TR Objectives
  • Objective 3 Following physical therapy and
    instruction, pt. independently engages in 30
    minutes stretching exercises two times daily or
    three times per day for twenty minutes.
  • Objective 4 Given the appropriate resources and
    materials, pt, demonstrates learning through
    writing activities and public presentations
    related to MS, therapeutic recreation, adoption
    and nature.

TR Plan
  • Encourage to engage in and adapt to activities
    that interest pt. such as paddling, biking,
    nature study, reading writing.
  • Establish/Maintain mission statement, vision
    statement and philosophy regarding overcoming
  • Follow the prescribed medical plan as directed.
  • Continue to work as appropriate.
  • Rest as necessary.

  • MS and accompanying symptoms can cause difficulty
    with exercise
  • The benefits of exercise outweigh the potential
    difficulties because of the benefits associated
    with reducing disability, improving quality of
    life and improving overall health

  • MS is a chronic often disabling disease
    characterized by the destruction of the myelin
    sheath that surrounds the nerve fibers of the
    CNS. Lesions representing areas of inflammation
    can be present in any part of the brain and
    spinal cord. For definite diagnosis to be
    established, two or more areas of demyelization
    must be detected. MRI, an analysis of
    cerebrospinal fluid for oglioclonal bands are
    used for to support diagnosis. Visual evoked
    potential, Brain stem evoked potential tests are
    important because they confirm the presence of
    suspected or unsuspected lesions.

Multiple Sclerosis Sources and Resources
  • Organizations Websites
  • International MS Support Foundation
  • 9420 e. Golf Links Rd. 291
  • Tucson, AZ 85720-1340
  • Multiple Sclerosis Association of America
  • 706 Haddonfield Rd.
  • Cherry Hill, NJ 08002
  • 1-800-441-7667
  • http//

Multiple Sclerosis Sources and Resources
  • Multiple Sclerosis Foundation
  • 630 North Andrews Ave.
  • Fort Laurerdale FL 33309-2130
  • 1-800-441-7055
  • http//
  • Multiple Sclerosis International Federation
  • http//

Multiple Sclerosis Sources and Resources
  • National Multiple Sclerosis Society
  • 733 Third Ave.
  • New York, NY
  • 1-800-Fight MS (1-800-344-4867 )
  • Web MD
  • Http//
  • MSActive Source
  • http//

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