Rehabilitation in Multiple Sclerosis
In spite of the development
and use of disease modifying therapies, most individuals with MS will have limitations.
Although rehabilitation does not directly impact the pathologic processes involved
in MS, rehabilitation techniques can be highly effective in treating MS symptoms
and in improving quality of life. Rehabilitation is an active process intended
to help the patient recover and/or maintain the highest possible level of functioning
and realize his or her optimal physical, cognitive, and social potential despite
the limitations of physical disability. A major goal of rehabilitation in MS is
to intervene in ways that will help people regain a sense of control over their
bodies and their lives, and increase their self-esteem.
From the time of diagnosis,
and even before symptoms of disability occur, the rehabilitation team can provide
education and treatment designed to promote general conditioning and to reduce
fatigue. As the disease progresses, team members become more active, designing
problem-focused interventions that can help the patient and family to:
- Manage MS symptoms.
- Enhance physical and
mental functioning.
- Facilitate activities
of daily living.
- Identify and learn how
to use appropriate assistive devices and environmental modifications.
- Prevent injury and unnecessary
complications.
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Rehabilitation techniques can directly improve the pathological processes involved
in MS.
The rehabilitation team focuses
on impairments such as spasticity, movement disorders, weakness, imbalance, fatigue,
muscle paralysis or weakness, bowel and bladder problems, visual disturbances,
pain, sensory changes, speech and swallowing problems, and cognitive impairment.
Although rehabilitation interventions cannot reverse neurological damage caused
by the disease process, they reduce disability by lessening the impact of impairments
on daily functioning, and enhancing the patient’s ability to carry out daily
activities and participate to the fullest extent possible in life roles.
Rehabilitation professionals
face certain challenges in caring for the patient with MS that are different
than working with people with other types of physical disabilities.
- First, MS is a
chronic disease and to date there is no cure available. The rehabilitation
team must measure their success not by their ability to cure the patient,
but rather by their ability to help the patient with optimum function and
to maximize the person’s life quality despite progressive physical impairments.
The challenge posed by a chronic illness such as MS is to maintain a positive,
hopeful outlook in the face of disease progression. An important role for
the rehabilitation team is to help the patient to acknowledge his or her limitations
and to establish personal goals that are realistic and achievable.
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Maximizing
life quality despite progressive physical impairments is a major challenge in
MS rehabilitation.
- Second, MS is
characterized by variability and unpredictability. MS symptoms can vary significantly
from one patient to the next and episode to episode in the same patient. The
variability of MS has an impact on treatment compliance. The person with relapsing
MS may find it very hard to comply with a treatment program during times of
remission, due to a wish to believe that the MS has disappeared. Likewise,
during periods of exacerbations, patients may find it hard to comply with
treatment due to increased fatigue, other distressing symptoms, and feelings
of hopelessness and despair.
- Third, MS is associated
with high levels of profound and debilitating fatigue. In fact, fatigue is
the most common symptom reported by persons with MS. In addition to fatigue
brought on by the disease process itself, sleep disturbances, aerobic and
muscular deconditioning, neuromuscular fatigue, medications, and depression
can heighten fatigue, and the energy demands of disability. Just doing basic
activities of daily living may demand more energy than the patient has. In
addition, some patients with MS may resist using assistive devices that would
help them manage fatigue because they do not want to "give in" to
the disease or view assistive devices as indicators of progressive disability.
- Fourth, depression
is common in MS and may directly impact the patient’s ability to effectively
participate in a rehabilitation program. Clinical depression is more common
in MS than in other chronic diseases. It is thought that MS related depression
is caused not only by the stresses caused by the disease, but also by neurologic
changes in the brain’s mood control centers. Adequate assessment, diagnosis,
and treatment of depressive symptoms are essential for the patient with MS
to be able to participate in a rehabilitation program.
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MS
related depression is thought to be caused by neurological changes in the brain’s
mood control center and by the stresses caused by the disease.
- Fifth, cognitive
dysfunction occurs in approximately 60% of patients with MS. About 10% of
these individuals will experience changes severe enough to interfere significantly
with daily function. The most commonly occurring cognitive problems include:
memory impairment, attention problems, slowed information processing, impairments
in executive functioning (the ability to plan, organize, and problem-solve),
visual-spatial deficits, and word-finding and communication difficulties.
The degree of cognitive impairment is unrelated to the severity of physical
disability. A person with significant physical impairment may remain cognitively
intact while a person with no physical limitations might demonstrate significant
cognitive deficits. Also, cognitive impairment can occur very early in the
disease, as one of the presenting symptoms, or appear much later in the disease
course. Communication style, teaching strategies, and intervention methods
must all take into account the person's cognitive functioning level.
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If
cognitive impairment occurs in MS, it tends to occur late in the progression
of the disease.
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