MS Symptom Management: How PT Can Help
Throughout this series, we have discussed the many symptoms commonly experienced by people with Multiple Sclerosis (MS) and discussed ways to help improve and sometimes wholly resolve those specific symptoms. I thought the best way to give you an overview of what physical therapy can do for you was to provide some case examples. I provided information about how I structured their care plan and included three specific exercise programs. Names and details were changed to protect the patient’s health information!
Case 1: Lisa
Lisa is a 42-year-old female who presented to physical therapy because she had increased difficulty with foot drop. She was diagnosed with relapsing-remitting MS when she was 20 but only starting having trouble with her mobility in the past 3 years after a relapse. Lisa is very active and plays pickleball twice a week. She was having increased falls about 2 times per month due to catching her foot on things or her leg not picking up when running to go after the ball. She also reports experiencing fatigue, and it is much worse in the heat. She has to complete all activities before 1 or 2 in the afternoon, saying it is difficult for her to concentrate/focus after that time.
When she presented to therapy, it was noted that she did have some weakness in her anterior tibialis muscle (on the front of the lower leg). However, her core and hip flexor muscles were very weak, and the more significant contributors to her falls. In therapy, we worked on improving her hip flexor, glute, and core strength. She also purchased a minimal ankle-dorsiflexion assist brace from Amazon, which helped just enough when she got fatigued, and her ankle became weak. We also noted increased tone in her rectus femoris muscle (front of thigh) and her hip adductors (groin). The spasticity was causing her legs to cross when walking and was likely contributing to her feeling of tripping over her own feet. She completed only 5 physical therapy sessions at 1x/week. She was then put on a monthly maintenance program for check-ins and her home exercise program progression. Her program after the initial completion of weekly sessions is listed below.
Lisa’s Exercise Program
Sunday
Rest Day, Daily Stretching Program (hip flexor stretch, calf stretch, hip adductor stretch)
Monday
Cardio: Pickleball, Daily Stretching Program
Tuesday
Strengthening: Tall Kneel Squats (2 sets of 10), Tall Kneel Chops/Lifts (10 reps forward, diagonal), Sit to Stands (2 sets of 10), Daily Stretching Program
Wednesday
Balance: Tandem Stance (3 x30 seconds each leg), Romberg Stance with Head Turns/Nods (2 sets of 10 each), Daily Stretching Program
Thursday
Cardio: Pickleball, Daily Stretching Program
Friday
Strengthening: Hip, Knee and Ankle Flexion on Stability Ball (2 sets of 10 on right), Toe Taps at Step and Step Ups (2x10 each, alternating legs) Soft Tissue Massage to Sole of Foot and Achilles Tendon, Daily Stretching Program
Saturday
Cardio: 30-minute walk (1 rest break halfway for 2-3 minutes, moderate pace), Daily Stretching Program
Case 2: Tom
Tom is a 56-year-old male who presented to physical therapy due to increased difficulty walking short distances, frequent falls in the bathroom, and increasing lower extremity spasticity. He was diagnosed with primary progressive MS 12 years ago. He now uses a power wheelchair as his primary means for mobility, but he does walk short distances in his home. His power wheelchair does not fit through his bathroom or bedroom door, so he still has to walk sometimes, even if he is very fatigued. He uses a rollator walker when walking from room to room but falls 1-2 times every month. It was getting more difficult for him to go from sitting to standing, particularly from the commode. He reports significant fatigue but feels his best first thing in the morning and after a short nap in the afternoon.
In his physical therapy evaluation, we found considerable weakness in his legs, particularly his hip and core muscles. He had spasticity present in his thigh and calf muscles on the left only. He attended physical therapy 2x/week for 1 month and then progressed to monthly check-ins. He demonstrated significant improvements in his gait pattern and distance walked during the 2-minute walk test. After that first month, he could perform a sit-to-stand without pushing up with his arms from his chair (for 10 repetitions). His home exercise program after the initial completion of weekly sessions is listed below.
Tom’s Exercise Program
Sunday
AM: Cardio: Walking with Family Assistance (3x100 feet), Arm Bike for 10 Minutes (low-moderate intensity), Daily Stretching Program (hamstring stretch, quad stretch, calf stretch and hip adductor stretch)
Monday
AM: Balance at Counter with Chair behind: Romberg stance (3x30 seconds), Romberg Stance with Eyes Closed (3x30 seconds) - family assist
PM: Strength Training: Sit to stand (3 sets of 5 without arms), Quadruped Lower Extremity Lifts (3 sets of 5 each leg), Tall Kneel Chops and Lifts (2x5 reps forward and both diagonal, Daily stretching program
Tuesday
Rest Day - Daily Stretching Program Only
Wednesday
AM: Cardio: Walking with Family Assistance (3x100 feet) Arm Bike for 10 Minutes (low moderate intensity), Daily Stretching Program
Thursday
Rest Day - Daily Stretching Program Only
Friday
AM: Balance at Counter with Chair behind: Romberg stance (3x30 seconds), Romberg Stance with Eyes Closed (3x30 seconds) - family assist
PM: Strength Training: Sit to stand (3 sets of 5 without arms), Quadruped Lower Extremity Lifts (3 sets of 5 each leg), Tall Kneel Chops and Lifts (2x5 reps forward and both diagonal, Daily stretching program
Saturday
Rest Day - Daily Stretching Program Only
Case 3: Ashley
Ashley is a 24-year-old female who was just diagnosed with relapsing-remitting MS 6 months ago after experiencing 2 separate issues with her vision. The first being double vision, and then 4 months later, she described a jumping in her vision causing dizziness. On her initial physical therapy evaluation, she reported she had no symptoms but wanted to be proactive with her care. We took baseline measurements of her walking speed, strength, endurance, and balance. We found she had a slight impairment in her gaze stabilization and slight dizziness with position changes from lying down to sitting up and bending over. When she moved in these positions, it left her feeling “swimmy-headed” for a few seconds. At her initial evaluation, we gave her exercises to perform at home to improve her VOR (vestibulo-ocular reflex) to improve gaze stabilization and habituation exercises to reduce her motion sensitivity.
She came in for a follow-up 2 weeks later and reported no dizziness or motion sensitivity. She was given a home exercise program that fit her current exercise routine, with additions to target specific muscles that tend to be problematic in MS for prevention. She checks in with physical therapy every 3 months to ensure no changes to her testing and to progress her home program as needed. Her initial home program after completion of her 1 follow-up visit with physical therapy is listed below.
Ashley’s Exercise Program
Sunday
Daily Stretching Program (quad stretch, hamstring stretch, calf stretch)
Monday
Cardio: 30 minute HIIT (high-intensity interval training) class at YMCA, Daily Stretching Program
Tuesday
Balance Training: Walking in Hallway with Head Turns/Nods (3 passes of each), Tandem Walking, Single-Leg Deadlifts, Yoga (20 minutes at home DVD), Daily Stretching Program
Wednesday
Strength Training: Quadruped Alternating Arms and Legs (2 sets of 10 each), Squats with 15# Kettlebell (2 sets of 10), Half-Kneeling Chops and Lifts with 5# Kettlebell (2 sets of 10), Upper Body Strengthening (she does her own while standing on pillow to engage her core), Daily Stretching Program
Thursday
Cardio: 30 minute HIIT (high-intensity interval training) class at YMCA, Daily Stretching Program
Friday
Balance Training - Tandem Standing with Gaze Stabilization Exercises, Single Leg Balance with Head Turns/Nods (2 sets of 10 each), Yoga (20 minutes at home DVD), Daily Stretching Program
Saturday
Strength Training: Dead Bug Exercise (2 sets of 10), Walking Lunges, Prone Hip Extension with Knee Flexed (2 sets of 10 each leg), Upper Body Strengthening (she does her own while standing on pillow to engage her core), Daily Stretching Program
As you can see, some exercises have made their way into each of the 3 exercise programs. Still, each program was carefully tailored to the individual. For example, those with more fatigue had more rest days and/or exercise broken up throughout the day to allow for rest periods. Our last individual prefers to do some kind of activity every day and not have a particular rest day. Our second client required assistance from his family members for walking/balance safety and stretching, so we tailored it to their schedules. Each of their programs was progressed and/or changed at each follow-up depending on their progress. We also incorporated their previous exercise routine/activities of interest instead of adding on top of it or trying to completely change.
MS is a complicated diagnosis because of the different types, different presentations, and the vast amount of potential symptoms associated with it. It is important to remember that no matter how someone looks or acts, we do not know what is happening inside them. Someone with MS may look like they are functioning completely the same. Still, they may be battling high levels of pain, fatigue, or stress due to cognitive changes, fear of falling, or difficulty keeping up at work in the afternoons.
No matter what your symptoms are, there is help and resources available to you. Make sure you have open conversations with your doctor and include all symptoms, even if you do not think they are relevant. Find a local chapter of the MS society and find a physical therapist, occupational therapist, and/or speech therapist who can support you along the way! Please feel free to contact me directly if you have any questions via email: Cari@movementmatters-pt.com or by phone (704)247-1676. I also have more information on my website at: https://movementmatters-pt.com/multiple-sclerosis
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Disclaimer
This blog is provided for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health providers with any questions you may have regarding a medical condition.
