for 3rd yr and 4th year physiotherpy students useful.

1. MULTIPLE SCLEROSIS
Dr. Ketaki Patani
Associate professor

2. INTRODUCTION
 Multiple sclerosis(MS) is a chronic, often disabling
,demyelinating disease of the central nervous
system(CNS).
 Dr. Jean Charcot in 1868 who defined the disease
of characteristic clinical and pathological findings:
paralysis and the cardinal symptoms of intention
tremor, scanning speech and nystagmus termed as
Charcot’s triad.

4. EPIDEMIOLOGY
 The onset typically occurs between the ages 15 to
50 years with a peak in the third decade.
 It affects an estimated 30 to 80 per 1,00,000 or
250000 to 350000 individual in United states.
 The incidence in females is twice than males.
 It is characterized by multiple signs and symptoms.
 An exacerbation involves a relapse or period of
system flare up , where as remission is a free of
evolving symptoms.

5. ETIOLOGY
 MS is autoimmune disease in which the body’s own
defenses attack the CNS.
 Viral infection initiates immunological insult.
Exposure to common viruses rubella ,canine
distemper.
 The presence of immunoglobulin (Ig G) and
oligoclonal bands in the cerebrospinal fluid (CSF).
 Genetic suspectibility also triggers the MS.

6. CONT….
 Epidemological studies revealed worldwide
distribution it include high frequency areas include
northern United states ,northern europe, southern
Canada, New zealand and southern Australia
 Low frequency prevalence reported in Asians and in
native Americans.

7. PATHOPHYSIOLOGY
 Multiple sclerosis is a chronic inflammatory disease
of the brain, optic nerve and spinal cord mediated
by immune system , it is characterized by lesion of
disseminated focal demyelination accompanied by
variable axon damage and destruction causes
reactive gliosis.
 Most commonly lesion found in the Grey matter it
is significantly involved.

8. CONT…
 Lesion found in gray matter contains demyelination
and loss of neuron without immune system
infiltrates and inflammation characteristics of lesion
in white matter.
 Axon of demyelination and axonal damage interfere
with normal conduction of neural signal leading
disruption of function.

9. CONT…
 Early in the course white matter lesion produce
demyelination causes axonal injury and loss of
oligodendrocytes called plaques.
 Active disease followed by remission with acute
inflammation reduced, causes axonal remyelination
and axonal loss associacted with severity of
inflammation and axon are spared in white matter
lesion.

10. PATHOPHYSIOLOGY
 Viral infection triggers the production of
Lymphocytes (T and B cells) and macrophages
which turn appear to produce cytotoxic effect within
the CNS.
 Reactive astrogliosis results in destruction of
oligodendrocytes and myelin sheath that surrounds
the nerve.
 Myelin serve as an insulator speeding up
conduction along the nerve fiber from one node of
Ranvier to another , it also serve as to conserve
energy for the depolarization .
 Disruption of myelin sheath slows neural
transmission and causes nerve to fatigue rapidly.

11. TYPES OF MULTIPLE SCLEROSIS AND
CLINICAL CHARACTERISTICS
There is four types have been identified:
The initial neurological episode or attack is typically
identified as Clinical isolated syndrome(CIS).
Symptoms must last for at least 24 hours and can be
monoclonal or multifocal.
1. Relapsing remitting MS represents about 85% of
people characterised by exacerbations, that can
last days to months and are typically followed by
improved functions. During remission , function can
return to prerelapse level . It occur around 20 years
or around 40 years of age.

12. TYPES
2) In secondary progressive MS(SPMS) , Relapses
decrease in frequency over time and convert to
study progression of increasing disability or disease
severity. PRMS eventually convert to SPMS 10 to
20 years after diagnosis.
3)Primary progressive MS (PPMS) is less common ,
affecting 10 to 15% of people with MS. From
disease onset progression resulting in a gradual
worsening of symptoms without relapses. It is
diagnosed in late 30s or early 40s.
Progressive myelopathy is commonly associated
with PPMS.

13. TYPES
4)Progressive relapsing MS ( PRMS) is the least
common form(5%). This form of MS typically begins
with progressive course with clear relapses or
exacerbations.
 Benign MS is identified when symptoms occur
once and never recur.

14. CONT….
 With severe fatigue causes conduction block, local
infiltration leads to edema results inflammation and
pattern of fluctuation
 Demyelination undergoes gliosis and refers
proliferation of neurological tissue results glial
plaques and it affects white and grey matter and
affects tract.

16. COMMON SYMPTOMS IN MULTIPLE SCLEROSIS
Clinical symptoms
1. Blurred vision
2. Loss of vision in one eye
3. Slurred or slowed speech
4. Easy fatigability
5. Psychological changes
6. Poor co-ordination
7. Shaking of limb
8. Staggering gait
9. Poor balance
10. Dragging feet
11. Numbness of pins and needle
12. Poor bladder or bowel control.

18. PATTERN OF SYMPTOMS
 Vary greatly from person to person
 Vary over time in which individual affected
 First symptoms usually in young adults
 Early symptoms are usually transient
 Early symptoms usually include problems with
vision problems develop in more than one nervous
system function
 Acute symptoms usually followed by months or
year free of apparent disease.

19. CLINICAL MANIFESTATION
#Fatigue
 People with MS , 65% to 97% report fatigue during
course of the disease.There are two types of
fatigue in people with MS: Primary and Secondary.
 Primary fatigue often called lassitude is caused by
the effects demyelination or axonal destruction .
 Secondary fatigue results deconditioning, infection
,sleep disturbances ,poor nutrition and heat
intolerance.

20. CLINICAL MANIFESTATION
Direct impairment
#Sensory impairments
1.complete loss of single sensation is rare.
2.altered sensation- paresthesia
3.dysesthesias- abnormal burning or aching type of
pain
4.hyperpathia- hypersensitivity to minor sensory
stimuli
5. Most common problem with visual system is optic
neuritis which produces double vision or painful
eye movements and nystagmus.

21. CONT…..
# Trigeminal neuralgia: demyelination of sensory
nerves characterized by stabbing pain and facial
pain.
#Lhermitte’s sign: flexion of neck produces a
sensation like an electric shock running down in
spine and in the lower extremities due to sign of
posterior coloumn damage in the spinal cord.
#demyelinating lesion in spinothalamic tract which
develope prolong posturing results muscle spasm
and muscle strain.

22. VISUAL IMPAIRMENTS
 Involvement of optic nerve produce altered visual
acuity, blindness rare.
 Optic neuritis: inflammation of optic nerve .
 Scotoma: dark spots occur in the center of visual
field.
 Nystagmus
 Internuclear opthalmoplegia: produces
incomplete adduction and demyelination of the
medial pontine longitudinal fasciculus.
 diplopia

23. MOTOR IMPAIRMENTS
 Sign and symptoms of upper motor neuron
syndrome
 Damage to corticospinal tract causes brisk tendon
reflexes, involuntary flexor and extensor spasm,
clonus, babinski’s sign positive, spasticity is
common problem.
 Fatigue is defined as sense of physical tiredness
and lack of energy.
 Fatigue is worsened by stress, vigorous exercise
and depression.
 Fatigue is aggravated by heat and humidity.

24. CONT….
 It causes demyelination of axon of motor and
premotor neurons in the CNS that include
monoparesis , paraparesis and hemiparesis or
quadriparesis.
 Muscle weakness associated with disuse
deconditioning and result muscle atrophy .
 Muscle weakness or loss of motor control results
dysarthria.
 Severity seen as paraplegia, quadriplegia or
hemiplegia.

25. CONT….
 Demyelinating lesion in the cerebellum and in
cerebellar tracts.
 Ataxia used to describe uncordinated movement
characterized by dysmetria , dyssynergia and
dysdiadokinesia associated with postural tremor
and wide based ataxic gait, dizziness and vertigo
common.
 Cerebellar movement associated with dysarthria
associated with scanning speech and dysphagia.

26. COGNITIVE AND BEHAVIORAL DYSFUNCTION
 Impairment in cognitive function include deficit in
memory ,attention and concentration, learning and
conceptual learning.
 Euphoria
 Emotional dysregulation syndrome.

27. BOWEL AND BLADDER DYSFUNCTION
 Spastic bladder
 Flaccid bladder
 Dyssynergic bladder
 Urinary urgency
 Hesitancy in starting urination
 Nocturia
 Dribbling
 incontinence

28. CONT…
 Bowel function impaired by and can be directly
infuenced by gastrocoliec reflex.
 Constipation is common
 Sexual dysfunction is common

29. SEXUAL DYSFUNCTION
It affects 45 % to 85% of women with MS and 50 to
90% of men. It can manifest as erectile dysfunction
,impotence, inability to achieve orgasm.

30. DEPRESSION
 It is three times more common in people with
chronic health condition .26% to 50% of people
experience depression and it is progressive.
 It affects in middle adult often reduction of QOL.
 Suicide is more common.

31. HEAT INTOLERANCE
 Uhthoff phenomenon is a temporary worsening of
MS related problems associated with an increase in
core body temperature. It increases with physical
exertion such as exercise or with change of
enviornment such as hot baths or showers , hot
weather or hot air temperature.

32. PATTERN OF SYMPTOMS
 Vary greatly from person to person
 Vary over time in which individual affected
 First symptoms usually in young adults
 Early symptoms usually include problems with
vision problems develop in more than one nervous
system function
 Acute symptoms usually followed by months or
year free of apparent disease.

33. INVESTIGATION
Kurtzke Expanded Disability Status Scale
The Kurtzke Expanded Disability expanded scale was
developed by Dr. John Kurtzke IN 1950’s to
measure the disability of status of people with
multiple sclerosis. The purpose was to create an
objective approach to quantify the level of
functioning that could widely used to diagnose MS.

34. CONT…
 The scale was modified several times to more
accurately reflect the level of disabilities clinically
observed.
 The scale was renamed the Kurtzke expanded
disability scale (EDSS).
 Total score on scale ranges from 0 to 10 . The first
level 1.0 to 4.5 refer people with high degree of
ambulatory ability and subsequent levels 5.0 to 9.5
refer the loss of ambulatory ability.

35. INVESTIGATION
 MRI findings and EDSS SCALE REVEAL the
complete findings of Multiple Sclerosis.
 EDSS SCALE

36. CONT….
4.0 Fully ambulatory without aid, self-sufficient , up
and above disability consisting of one FS
grade 4 or of previous steps ,able to walk
without aid or rest grater
4.5 Fully ambulatory without aid, up and about much of
the some limitation of full activity or require minimal
assistance usually consisting of one FS grade 4 or
able to walk without aid or rest.
5.0 Ambulatory without aid or rest for about 200 meters
( example : to work full day without special
provision alone, others 0 or 1)
5.5 Ambulatory without aid for about 100 meters
,disabilty FS equivalent to one grade 5 alone.
6.0 Intermittent or unilateral constant assistance (cane,
crutches) with or without resting.

37. CONT….
6.5
7.0 unable to walk beyond approximately 5 meters even
with wheels self in standard wheelchair and transfers
alone .
7.5 unable to take more than few steps ,restricted to
cannot carry on in standard wheelchair a full day ;
may equivalent in combination, grade 4+ system.
8.0 Essentially restricted to bed or chair; preambulated
phase ; retains self care function.
8,5 Essentially restricted to bed much of day .
9.0 helpless bed patient, can communicate and eat.
9.5 totally helpless bed patient, unable to communicate
effortless combination.
10.0 Death due to MS.

38. EDSS
 Excludes cerebral function grade 1.
 EDSS 1.0 to 4.5 refer patient fully ambulated.
 In addition eight subscale measurements called
Functional system (FS) scores.
 The level of function refer eight functional system
affected by MS.

39. EIGHT FUNCTIONAL SYSTEM
 Pyramidal (p)- weakness or difficulty in moving
limbs.
 Cerebellar (c11)- ataxia,loss of coordination ,tremor.
 Brainstem (BS)- problems with speech, swallowing,
nystagmus.
 Sensory (s)- numbness or loss of coordination.
 Bowel and bladder (BB)
 Visual (v)
 Cerebral or mental (cb)
 Other(o)

40. ASSESSMENT
 According to , the site of lesion the clinical picture
can present a broad spectrum of dysfunction.
Damage can occur anywhere in the brain or spinal
cord resulting malfunction of any neurological
mechanism.
 In a complex condition it is not related to motor
problem but it is also related to limited sensation
and perception which leads to agnosia and
apraxia.
 Symptoms and general information needed to make
thorough assessment of neurological impairment
can be divided into various section.

41. ASSESSMENT
 Joint range: recorded the any restriction of
movement.
 Soft tissue shortening: a special note is
taken about any tightness or about
shortening.
 Sensory disturbance: disturbances such
as paresthesia or numbness and tingling
are frequently early clinical signs.
 Vision: impaired vision and nystagmus are
complication where eyes may have
substitute for proprioceptive loss.
 Tone : alteration in tone may be due to

42. ASSESSMENT
 Voluntary movement: once tone is normalized the
active movement itself vary in strength and co-
ordination . Quality of movement recorded and
determine the functional activities of isolated
movement .
 Muscle chart show actual grading and strength it is
helpful.
 Involuntary movement: it is present isolated for
one joint or limb.
 Posture and balance mechanism: postural
reaction can not be separated from voluntary
movement , re-educate he necessary postural
reactions .

43. ASSESSMENT
 Prevailing abnormal postures: abnormal postures
may be as a direct result of abnormal tone or because of
excessive use of influence of reflex pattern or attitudes
results adaptive shortening of tissues.
 Perception: As perceptual processes are involved with
motor performance and considered about impairment.
 Memory: a memory deficit necessitate for adaptation to
the programme physical management.
 Behavioral and intellectual disturbance: due to
inadequate emotional and social experience increased
anxiety, irritability or changes of mood from time to time.

44. ASSESSMENT
 Balance: it can be assessed by functional reach
test, Tinetti performance assessment scale,
Dynamic gait index
Dizziness handicap inventory.
# for upper extremity: box and block test.
Use of mobility assisted technology,
Use of splints AFO and HKAFO according to
requirement.

45. MEDICAL MANAGEMENT

46. PRINCIPLES OF PHYSIOTHERAPY
 Role of physiotherapist in the general management
of long term disability has undergone a change in
emphasis.
 Prevention of secondary complication.
 Every attempt must be made to facilitate normal
movement or co-ordination which have been lost
during exacerbation or period of immobility.

47. SYMPTOM MANAGEMENT
1. fatigue: it is divided into the primary and secondary
causes,it is due to heat intolerance , lassitude or
psudoexacerbation other causes like poor nutrition
,reduced activity level, infection other causes are
depression or sleep disturbances.
Fatigue can be assessed by
Modified fatigue impact scale.
Fatigue severity scale

48. MODIFIED FATIGUE IMPACT SCALE
 Fatigue is a feeling of tiredness and lack of energy ,
but people with MS experience stronger feeling of
fatigue and with greater impact on others.
 Instruction for scoring MFIS
It can be aggregated into three subscales (Physical,
cognitive and psychosocial).
All items are scaled so that higher scores indicate
greater impact of fatigue on person’s activities.

49. FATIGUE DURING PAST 4 WEEKS
1. I have been less alert.
2. I have had difficulty paying attention for long period
of time.
3 . I have been unable to think clearly.
4. I have been clumsy and uncoordinated.
5.. I have been forgetful.
6.I have had to pace myself in my physical activities.
7. I have been less motivated to do anything that
requires thinking.
8. I have been less motivated to participate in social
activities.

50. CONT…
9. I have been limited in my ability to do things away from
home.
10. I have been trouble in maintaining physical effort for
long period of time.
11. I have had difficulty making decisions.
12. I have been less motivated to do anything that requires
thinking.
13. My muscles have felt weak.
14. I have been physically uncomfortable.
15. I have had trouble finishing task that require thinking.
16. I have had difficulty organizing my thoughts when
doing things at home or at work.
17. I have been less able to complete that require
physical effort.

51. CONT…
18. My thinking has been shown down.
19. I have had trouble in concentrating.
20. I have limited physical activities.
21. I have needed to rest more often for longer period
of time.
PHYSICAL SUBSCALES
This scale can range from 0 to 36. it is computed by
adding raw scores on following items:
4+6+7+10+13+14+ 17+20+21.

52. CONT….
#Cognitive subscales:
This scale can range from 0 to 40 . It is computed by
adding raw scores of the following items:
1+2+3+5+11+12+15+16+18+19.
# Psychosocial subscale
This scale range from 0 to 8 . It is computed by
adding raw scores on following items: 8+9
Total MFIS score:
Total MFIS score from 0 to 84. it is computed by
adding scores on physical, cognitive and
psychosocial subscales.

53. FATIGUE SEVERITY SCALE(FSS)
 The fatigue severity scale is a method of evaluating
fatigue .
 A low value is 1 and high value is 7 for every
question.
 FSS Questionnaire: disagree to agree (1 to 7)
 During the past week I Have found that:
1. My motivation is lower when I am fatigued.
2. Exercise brings on my fatigue.
3. I am easily fatigued.
4. Fatigue interferes with my physical functioning.

54. CONT….
 Fatigue causes frequent problem for me.
 My fatigue prevents sustained physical functioning.
 Fatigue interferes with carrying out certain duties
and responsibilities.
 Fatigue is among my three most disabling
symptoms.
 Fatigue interferes with my work, family and social
life.
The scoring is done about calculate the average
response of answer of the questions.

55. REHABILITATION MANAGEMENT
 People with multiple sclerosis often experience
physical or cognitive impairments that can lead to
increased by inactivity . Deconditioning and disuse
reduced activity level.
 Physical impairment cognitive
impairment
disuse/deconditioning

56. REHABILITATION
 Rehabilitation for people with MS in every setting :
inpatient and outpatient clinics, skilled nursing
facilities, home care nursing and community.
 International classification of functioning(ICF)
useful for assessment and management of MS.

57. ASSESSSSING BODY SYSTEM PROBLEMS
WITH ACTIVITY LIMITATION
 SPASTICITY: Spasticity measured by Modified
Ashworth Spasticity Scale .
 Ataxia and Inco-ordination: It is test by
assessment and rating of Ataxia(SARA) .
 Vestibular Dysfunction: technique is used for
vestibular nuclei or cerebellum or cranial nerve
lesion mostly used benign paroxysmal positional
vertigo (BPPV) .
- Computerized platform Posturography(CPP) in
people with minimal to mild disability.

58. CONT……
 Cognition: National MS society , is a test for
cognitive impairment used for Audio Recorded
cognitive screen (ARCS) appears to develop
people for dementia .
 Fatigue: fatigue related self report measures help
the rehabilitation commonly used scales are
Modified fatigue impact scale and Fatigue severity
scale.

59. ASSESSING ACTIVITY PERFORMANCE AND
PARTICIPATION
 Balance: it focus on
#Stationary and static tasks which include single leg
stance, Romberg test with eyes open and closed,
tandem stance then functional reach test.
# Tinetti performance oriented mobility assessment:
(POMA) :
Tinetti tool score: less than 18 : risk of fall high
19-23: moderate
more than 24: low
# berg balance scale
# sensory organization test .

60. CONT…..
 Dizziness: Dizziness handicap inventory(DHI) :
Three domains related to dizziness:
Physical,emotional and functional.

62. CONT….
#Gait: 6 minute walk test
Timed up and go test

63. BOX AND BLOCK TEST
 # Upper extremity test of function
Box and block test

64. NINE HOLE PEG TEST

65. ASSESSING QUALITY OF LIFE
 QOL measures are patient report tools that
evaluate the value of person places on his or her
abilities and limitation and how these affects the
social ,emotional and physical well being.
 It includes Health status Questionnaire, sexual
satisfaction survey , bladder control scale, bowel
control scale, Impact of visual impairment scale,
Perceived deficits questionnaire, Mental health
inventory and Modified social support survey.

66. DISEASE SEVERITY MEASURES
 Disease severity of measures of disablement.
Intervention change the function and can reduce
the disability.
 Disease progression may used to assess the
impact of intervention on the patient’s perceived
level of disability.

67. GOALS
 Maximize and maintain function and prevent
complication.
 To increase or maintain ROM.
 To diminish abnormal spastic movement pattern
 To prevent contractures ,deformity.
 To increase or maintain strength.
 To facilitate maximal coordination and function of
extremities.
 To maintain maximal level of ADL.
 To maintain the ability to work and participate in
leisure activities.

68. CONT…
 To assist in psychosocial adjustment.
 To provide patient and family education and
support.

69. OCCUPATIONAL THERAPY
 Occupational therapy focuses on the following
seven areas:
 Energy conservation and work simplification
methods
 Assistive equipment /technology.
 Home and community management.
 Wheelchair and seating assessment
 Sensation or vision loss compensation training.
 Architectural modification.

70. EXERCISE
 It is based on EDSS scale, level of disability and
individual capacity.
LEVEL OF DISABILITY EDSS LEVEL TRAINING PROGRAM
NO FATIGUE OR
LIMITED FATIGUE
Minor balance and gait
problem
0
1-2
Full exertion,aerobic and
resistance exercise.
It includes strengthening
and endurance training.
Limited gait, have
spasticity,weakness
,ataxia and balance
problem. MODERATE
LEVEL.
3-5 Strengthening and
endurance training
,walking
cycle,ergometry.

71. CONT…..
LEVEL OF
DISABILITY
EDSS LEVEL TRAINING
PROGRAM
SEVERE: CANNOT
Participate `in ADL
,short distance aided
walking only.
6-7
Movement
preservation,
stretching,strengtheni
ng, task-specific
training
Bedridden
8-9
Primarily passive
movement to maintain
motion, breathing
exercise.

72. SKIN CARE PRINCIPALS ARE:
1. The skin should be kept clean and dry. Soiled skin
should be cleansed and dried promptly.
2. The skin should be inspected regularly with
particular attention to persistent areas of redness
and over bony prominences.
3. Clothing should be breathable and comfortable .
Seams, buttons and pockets should not press on
the skin , particularly in weighbearing areas.
4. Regular pressure relief is essential . Patient
should instructed to change their position
frequently.

73. CONT…
 Typically every 2 hours in bed and every 15 minutes
when sitting on wheelchair. Wheel chair push ups or
repositioning maneuver should be taught to relieve
pressure.
 Pressure relieving devices (PRDs) may be necessary
to protect insensitive areas and should be implanted as
appropriate.
 These can include mattresses (water, gel, air or
alternating pressure) to distribute body weight and
reduce shear and friction in bed.
 Sheepskins, air or foam cushions ,cuffs or boots may be
necessary to protect body areas prone to breakdown
ischial tuberosities, sacrum, trochanter, knees ,malleoli.

74. MANAGEMENT OF PAIN
#Musculoskeletal strain or joint mal alignment from
chronically weakened muscle are important for
physical therapy consideration.
#Patient may experience relief of pain with regular
stretching exercise , massage, and ultrasound.
#Postural retraining and correction of faulty
movement patterns along with orthotic or adaptive
seating devices reduce mal alignment and pain.
# stabbing pain from Lhermitte’s sign may be relived
with a soft collar to limit neck flexion.
# hydrotherapy beneficial using lukewarm water
effective for painful dysesthesias.

75. CONT….
 Stress management technique ,relaxation training,
biofeedback ,meditation are helpful for reducing
anxiety and pain.
 Use of transcutaneous electrical stimulation (TENS)
to modulate pain in patient with MS with some
experiencing improvement and some worsening
symptoms.

76. SPASTICITY
 Several rehabilitation strategies to manage
spasticity including ROM, stretching, cold therapy,
stroking, electrical stimulation and education.
 Cold can be applied in a number of ways :
baths,towels or cooling garment .
 Prolonged stretching lasting with braces and
splints.

77. BALANCE AND POSTURAL CONTROL
 Balance is the ability to stay upright and perform
dynamic movements
 It is frequent problem in people with MS and result
limiting participation in home, work and leisure
activities.
 Balance training include reduction in falls and
improvement in strength and improvement in
walking.

78. CONTROL OF ATAXIC MOVEMENT CAN BE
DONE BY FOLLOWING STRATEGIES:
1. Increasing proprioceptive loading .
2. PNF techniques by rhythmic stabilization
3. Light weight (weight cuffs) added to the distal part
of extremities.
4. Latex resistance bands
5. Weighted boots,jacket and belts
6. Weighted canes and walkers
7. Weighted spoons and forks while eating
8. External devices such as splints.
9. Air splints and soft cervical collars.

79. MOBILITY
 Gait pattern is adversely affect in people with MS.
 Lesion in brain and spinal cord produce wide
variety of potential impairment that can adversely
affect gait.
 Different therapeutic intervention used to improve
ambulation.
 Task-specific gait training evaluated in people
with MS.
 Therapeutic intervention to restore function ,mobility
assistive device ,canes, crutches, walkers,splints,
wheelchairs and scooters are used to enhance
mobility.

80. BLADDER DYSFUNCTION
 Urinary incontinence and retention is common
problem and often embarrassing problems for
people with MS.
 Patient may advised to avoid bladder irritant include
caffeine ,alcohol ..
 Physical therapist work with assess to bladder
dysfunction by retraining hyperactive or weak pelvic
floor muscles using biofeedback technique .

81. EXERCISE TRAINING
 Muscle weakness and decreased endurance are
common finding in patients with MS
 The benefits are producing meaningful
physiological and psychological changes to improve
function which enhancing the quality of life.
 STRENGTH AND CONDITIONING:
1. Maximal muscle force during sustained isometric
and isotonic kinetic exercise to lower for person to
reduce ability to activate muscles.
2. Prescription of exercise related to intensity of
exercise, type of exercise ,frequency of exercise
and time and duration of exercise.

82. THE FOLLOWING GUIDELINES CAN BE USED:
1. Exercise session can be scheduled on alternate days
and during optimal times such as body core temperature
to be lowest or before fatigue sets in it.
2. Submaximal exercise intensities are tolerated where
maximal exercise are not generally tolerated.
3. Resistance training modes can include weight
machines, pully weights,elastic resistance bands or
isokinetic machines.
4. Circuit training in which improved work capacity is
developed through the various stations that alternate
work between upper and lower extremities.
5. Progression is slower than the health individuals.

83. CONT…
6. Precautions should be taken to prevent the effect
of overwork and fatigue.
7.Precaution should taken to manage core body
temperature and overheating. Additional cooling can
be achieved by using fans, AC cooling or with aquatic
exercises.
8. Precaution should be taken with cognitive and
memory impairments.
9. Functional training activities used to promote
strength and functional endurance.
10 . Group exercise can promote valuable motivation
and social support.

84. CARDIOVASCULAR CONDITIONING
 Individuals with MS EXPECTED PHYSIOLOGICAL
RESPONSES to submaximal aerobic exercise
related to HR, BP , oxygen uptake in response to
increase in workloads.
 Exercise tolerance and maximal aerobic power are
reduced in individulas with reduced cardio-
respiratory fitness secondary to physical inactivity.
 Decreased muscular strength, increased fatigue,
increased anxiety and depression are common
finding.
 For clinical exercise testing preferred mode is
upright or recumbent cycle ergometer.

85. CONT…
 A submaximal test should be used to achieve 70 to
85 percent age predicted maximal heart rate(HR
max).
 Precaution should be taken to monitor HR and BP
response during exercise.
 Precaution should be taken to monitor the effect of
fatigue and overwork.
 Morning is the optimal time for testing..
 Circuit training best for optimizing training.
 Individulas with balance problem or sensory loss
require non weight bearing activities.

86. FLEXIBILITY EXERCISES
 Stretching and ROM exercises necessary to ensure
the effect of spasticity.
 Sedantary or inactive person who are dependent on
wheelchair develop tightness in hip flexors
,adductors or in hamstrings.
 Patient confined to bed typically with tightness in
hip/knee extensor and planterflexors.
 Supported position should be decrease to impact of
balance problem.
 More active patients from TAI CHI provides
additional benefits of relaxation and balance
training.

87. MANAGEMENT OF FATIGUE
 Fatigue is the most debilitating symptom characterized
by overwhelming of sleepiness, tiredness and sense of
weakness.
 Aerobic capacity and energy effective strategies(ESS)
are intervention to plan lessen of fatigue.
 Patient instructed to keep activity diary in which that
they record how they slept night before.
 Energy conservation refers to adoption of strategies that
reduce overall energy requirement of task and all
fatigue. It modifying the completion in daily activities.
 Activity pacing refers to the balancing of activity with
rest periods interspersed throughout the day.

88. PARESIS
 Muscle weakness varies considerably from patient
to patient.
 Patient with corticospinal lesion demonstrate
reduce strength, power and endurance and
impaired reciprocal relationship in association with
spasticity and other UMN signs.
 With cerebellar lesion may demonstrate asthenia
or generalized muscle weakness.
 Strengthening of unaffected muscle allows effective
for compensatory strategies e.g. for upper extremity
push-up transfer and wheelchair use.

89. CONT…..
 Strengthening should focus on muscles needed for
effective use of assistive devices.
 Submaximal exercise intensities are tolerated,
where maximal exercise is not.
 Stretching exercise may be necessary to decrease
spasticity and ensure adequate flexibility.
 Resistance training modes can include isokinetic
dynamometry or progressive resistance exercises.
 PNF patterns are ideal because of their emphasis
on diagonal pattern on combining their synergistic
action of muscle group.

90. CONT…
 Patterns and activities can be resisted with weight
cuffs, elastic resisted bands or manual resistance.
 The use of group classes and self-paced exercises
can be a valuable component of a rehabilitation
program.

91. COGNITIVE TRAINING
 Compensatory strategies include for memory deficit
pattern which include the use of memory aids ,
timing devices, memory book,audio tapes.
 Cueing devices such as an alarm clock,bell timer or
watch alarm help patients to do certain tasks.
 Structuring and labelling also be an effective
strategies to assisting memory.
 Directions for functional tasks should be carefully
written , additional cognitive strategies helpful to
include mental rehearsal, maximizing alertness
,avoidance of difficult situation and mental exercise.

92. DYSPHAGIA AND DYSARTHRIIA
 Dysphagia or difficulty in chewing and swallowing
become more prevalent in people with MS.
 Fascilitate proper swallowing with exercise will improve
posture to prevent aspiration and strengthen the
muscles of mastification.
 Dysarthria from the disruption of muscular control in the
central and peripheral speech mechanism leads
abnormalities in speed ,strength ,sound and accuracy in
speech movement.
 Program include exaggerating articulation, increasing
voice volume and increase strength of oral musculature.
 Exercise increase strength of respiratory muscle and
improve the voice of quality of production.

93. ORTHOTICS AND ASSISTIVE DEVICE
 Ankle –foot orthosis: for foot drop, poor knee
control , minimal spasticity and poor
somatosensation.
 Functional electrical stimulation: for treatment and
compensation who having foot drop . It improve
locomotor training.
 Knee- foot –orthosis: Used for poor knee control .

94. PSYCHOSOCIAL ISSUES
 Depression is most common; uncertainity with
emotional and cognitive stresses ,patient feel out of
control themselves.
 Self-efficacy is the belief of an individual will be able
to deal with particular situation that may contain
novel,unpredictable and stressful element.
 A positive ,affirming attitude can effectively
influence patients attitude.
 Personal and family counselling should be provided
early in the course of the disease and continued
with later episodes of care as needed.
 A positive approach generally prove most helpful.

95. RECENT ADVANCES
 Role of physiotherpy and practice of Judo as an
alternative method of treatment in multiple sclerosis
.
By Kartyxyna Wiszinewaska from UK ; Journal of
Physiotherapy .
Submitted : sep 2020
Published : jan 2021
Use of judo,tai-chi and kick boxing helpful for to
improve motor and cognitive function ,increase
proprioception . It is used for 8 weeks ,twice a week
for 20 min. in this they has to use different position
like ukemi,osakemi waza ,uke,randorin ne waza
and assess with MS impact scale

96. REFERENCES:
 Adam’s neurology
 O’sullivan 6th edition.
 Darcy Umphred and Margaret Roller for
neurological rehabilitation 6th edition.
 Lorraine Pedretti’s occupational therapy for fourth
edition.
 Glady for neurological conditions.