Multiple Sclerosis Physiotherapy Guidelines

Multiple sclerosis physiotherapy guidelines will help you to achieve and maintain your maximum physical, psychological, professional, and social, as well as a quality of life that is compatible with your physical injury, life goals, and environment. Achieving and maintaining optimal function is essential for progressive diseases such as multiple sclerosis (MS).

Multiple Sclerosis Physiotherapy Guidelines (Image credit: Medicon)


Multiple sclerosis (MS) is the leading cause of neurological problems in young and middle-aged adults. It is common in women and almost twice as often as in men, and can occur at any age, from childhood to old age, but peaks between the ages of 25 and 35.

Multiple sclerosis in brief

What is multiple sclerosis?

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) characterized by demyelination, chronic inflammation, neuronal loss, and gliosis (Scarring). The process can be repeated or gradual.

MS lesions usually occur at different times and locations in the central nervous system (ie, they spread in time and space). Multiple sclerosis (MS) affects approximately 350,000 people in the United States and 2.5 million people worldwide.

What is multiple sclerosis?

In Western society, MS is the second leading cause of neurological dysfunction that begins in early or mid-adulthood after trauma.

The manifestations of MS range from benign diseases to rapidly developing disabling diseases, requiring thorough lifestyle adjustments.

What causes multiple sclerosis?

The cause of multiple sclerosis is unknown. Scientists believe that multiple sclerosis is caused by several factors. To find out the cause, researchers tried to find the cause of multiple sclerosis. Possible causes of multiple sclerosis include:

  • Immunological factors
  • Environmental factors
  • Infectious factors
  • Genetic factors

Here we will describe the factors below in brief.

What causes multiple sclerosis?

Immunological factors

The etiology of MS autoimmunity is supported by laboratory models of experimental allergic encephalomyelitis (EAE) and studies of the immune system of MS patients.

  • Auto reactive T lymphocyte: Myelin basic protein (MBP) is also an important antigen in EAE T cells and possibly in human MS. Activated MBP-reactive T cells have been identified in blood, fluid (CSF), and multiple sclerosis foci. In addition, DR2 binds with high affinity to the MBP fragment, which stimulates T cell responses to this autoimmune protein, which can influence the autoimmune response.
  • Cytokines: Cytokines and chemokines appear to regulate many cellular interactions that play a role in MS. Inflammatory cytokines TH1, including interleukin (IL) 2, tumor necrosis factor (TNF) and interferon (IFN), play an important role in the activation and maintenance of autoimmune responses.
  • Humeral Autoimmunity: In experimental models and in human MS, cell activation and antibody response also appear to be necessary for the full development of demyelinating lesions. In MS lesions and CSF, a greater number of clonally expanded B cells have the memory properties of the post-germinal center or antibody-producing lymphocytes. Myelin-specific autoantibodies have been detected, some of which are directed against myelin oligodendrocyte glycoprotein (MOG), which bind to vesicle myelin fragments on EM plaques. In CSF, elevated levels of locally synthesized immunoglobulin’s and oligoclonal antibodies derived from clonal-restricted plasma cell expansion are also characteristic of MS. Some bands recognize EBV antigen.
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Multiple Sclerosis Physiotherapy Guidelines

Environmental factors

Although the cause of MS is still unclear, scientists are learning more about the environmental factors that contribute to the risk of MS. There is no single risk factor for MS, but it is believed that several factors contribute to the overall risk.

  • Gender: The incidence of MS in women is approximately three times that of men. The age of onset is usually between 20 and 40 years (males are slightly later than females), but the disease can occur for life. Approximately 10% of cases start before the age of 18, and extreme cases are described as early as one to two years or as late as 80 years of age.
  • Geographic gradients: Geographical gradients have been repeatedly observed in multiple sclerosis (MS), with increasing prevalence in high latitudes. The highest known MS prevalence (250 per 100,000 people) occurs in the Orkney Islands in northern Scotland, and similarly, high incidences have been found in Northern Europe, the northern United States, and Canada. In contrast, Japan (6 per 100,000 people), other parts of Asia, Equatorial Africa, and the Middle East have lower prevalence.
  • Lack of Vitamin D: One proposed explanation for the latitude effect in MS is that latitude has a protective effect from sun exposure. The sun’s ultraviolet rays are the main source of vitamin D for most people, and low vitamin D levels are common in high-altitude areas with little sun exposure especially in winter. Prospective studies show that vitamin D deficiency is associated with an increased risk of multiple sclerosis. The immune-modulatory effects of vitamin D may explain this possible link.
  • Migration: Migration studies and the identification of potential infectious diseases provide additional support for environmental influences on the risk of multiple sclerosis. Migration studies show the clinical impact of MS in childhood and pre-MS. In some studies, moving early from a low-risk to a high-risk area increases the risk of multiple sclerosis, and conversely, moving from a high-risk area to a low-risk area decreases the risk of multiple sclerosis. The most striking example of a possible pinpoint epidemic occurred in the Faroe Islands in northern Denmark after the British occupation in World War II.
  • Obesity: A few examinations have shown that obesity in youth and adolescence, particularly in young girls, expands the danger of developing multiple sclerosis later in life. Other research suggests that obesity in early adulthood may also increase the risk of developing multiple sclerosis. In addition, obesity in people previously diagnosed with multiple sclerosis can increase inflammation and activity in multiple sclerosis.
  • Smoking: There is also growing evidence that smoking plays a role in the development of multiple sclerosis. Research has linked smoking to an increased risk of developing multiple sclerosis and an accelerated progression of more serious diseases and conditions. Fortunately, evidence suggests that smoking cessation before and after the onset of multiple sclerosis is associated with a slower progression of the disease.

Infectious factors

Most interestingly, many epidemiological and laboratory studies support evidence that remote Epstein-Barr virus (EBV) infection plays a role in MS. The increased risk of infectious mononucleosis (associated with relatively late EBV infection) and higher antibody titers against the incubation period-related EBV nuclear antigen are associated with MS; in contrast, people who have never been infected with EBV are at risk for MS Lower.

However, at this time, the causal role of EBV or any specific infectious agent in MS is still uncertain.

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Multiple Sclerosis Physiotherapy Guidelines

Genetic factors

MS is not a genetic disease, which means it is not a disease that is passed on from generation to generation. However, there is a genetic risk that can be inherited in MS. In the general population, the risk of MS is about one in 750-1000. If one twin has multiple sclerosis, the other twin’s risk of developing multiple sclerosis increases by a quarter.

Other first-degree relatives (parents, siblings, or children) suffer from multiple sclerosis, but much less frequently than identical twins. Approximately 200 genes have been identified, and they have little effect on the overall risk of developing MS. Research is ongoing to better understand the genetic risks and other factors that lead to the development of multiples sclerosis (MS).

Multiple sclerosis symptoms

There are many serious symptoms and signs of MS. But most common symptoms of MS are-

  • Visual problems
  • Neurological deficit
  • Fatigue
  • Cerebellar disease
  • Muscle hypertonia
  • Muscle weakness
  • Sexual dysfunction
  • Brisk reflexes
  • Gait disturbances
  • Symptoms are exacerbated by heat and cold
  • Psychiatric and psychological disturbances
  • Bowel and bladder incontinence
  • Problem with learning, thinking and planning

General weakness and fatigue are almost the same symptoms. In fact, fatigue may be the current symptom of MS patients. The first two symptoms of MS are a visual problem and neurological deficit.

Visual problems

Visual loss or double vision is the first symptom of multiple sclerosis. This is the most common single symptom is acute or subacute vision loss in one or, in rare cases, both eyes. This is how 25% of patients behave, which is often accompanied by eye pain and discomfort.

A typical symptom of damage to the optic nerve is invisible coloration. Blurred vision persists, followed by shooting in the center (blind spot) and loss of vision. Improvement usually begins spontaneously over days or weeks. About 30% have fully recovered, but the rest report decreased or impaired vision.

After the development of optic neuritis, the nipple becomes pale and atrophic (optic atrophy). More than half of people with optic neuritis have other signs of multiple sclerosis. People without episodes of inflammatory demyelination or other conditions.

Diplopia is a very common symptom that can result from muscle weakness caused by the 3rd, 4th, or 6th cranial nerves or connective nerves. Between the nuclei of the brainstem.

The most common disease is internuclear ophthalmoplegia, caused by damage to the medial dependent fascia, in which the abduction of the eye, activated by the lateral gaze, does not work with abducted nystagmus. Multiple sclerosis can be effectively diagnosed in young people with bilateral ophthalmoplegia.

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Multiple Sclerosis Physiotherapy Guidelines

Neurologic deficit

The second most common symptom is the onset of a well-defined neurological deficit, which can occur alone or with other people, such as:

  • Weakness
  • Numbness
  • Instability, imbalance, clumsiness
  • Difficulty speaking
  • Nystagmus
  • Intention tremor
  • Trigeminal neuralgia.

Numbness, weakness, or tingling can affect one or more of your limbs. Symptoms can develop rapidly within a few minutes, or they can develop over a long period of weeks or months, but more typically they develop over a period of hours or days.

This manifestation, with or without sphincter involvement, usually indicates an area of ​​spinal cord demyelination. Lhermitte phenomenon, the sensation of shooting toward the back and legs when the neck is bent, is similar to an electric shock and is a symptom of irritation of the cervical spinal cord.

It is usually described when the cervical spinal cord is demyelinated. The disease may begin with the signs and symptoms of cerebellar dysfunction, leading to instability, imbalance, clumsiness, and dysarthria (slurred speech).

The examination may reveal that the patient has nystagmus, intentional tremor, and cerebellar dysarthria. These combinations are called Charcot’s triad and are one of the typical features of MS.

These symptoms are caused by demyelination that occurs in the brainstem, and there are various brainstem syndromes that cause cranial nerve abnormalities and signs of long fascicles. Other signs include trigeminal neuralgia or tic pain in young people, which indicates the presence of brain stem disease.

Multiple Sclerosis Physiotherapy Guidelines

When people with multiple sclerosis experience a loss of motor ability or functional activity, it is often referred to seek physiotherapy. Not all patients get much worse, but once this stage is reached, the disease causes irreversible damage to the central nervous system, which leads to several exacerbations and severe and permanent disability. Although this section focuses on progressive disease, MS health care standards recommend early intervention for people with mild disabilities. Successful treatment should not be aimed at improving the patient’s condition, but at achieving the highest level of vital activity at each stage of the disease and attaining the patient’s own goals. The physiotherapy guidelines of Multiple sclerosis are described below.

Approaches to Physiotherapy

Physiotherapy for people with multiple sclerosis will primarily work at a disability level and will not change the course of injury or illness. For most people with multiple sclerosis, physical therapy is probably one of several treatments, so disability needs to be addressed based on individual needs and needs to be set different treatment goals. Thus, physiotherapy is patient-centered and requires the patient to actively participate in the treatment. This includes advising on decision making and sharing information on goal setting and providing information to patients to receive feedback on their progress and knowledge of their skill level.

Principles of Physiotherapy

The treatment plan should be flexible, change from time to time, and meet the needs of the patient. The principles of physiotherapy are as follows-

  • Improve the quality of patterns of movement
  • Minimizes muscle tone disturbances.
  • Facilitate the development of movement strategies.
  • Facilitates the learning of motor skills.
  • Emphasizes the functional use of physiotherapy.
  • Implement preventive therapy
  • Motivates and supports collaboration and improves treatment.
  • Helps patient better understand the symptoms and impact of multiple sclerosis on their daily life.

Assessment of MS patient

The effectiveness of physical therapy depends on the ability to assess and analyze the root causes of the patient’s problems. Hence, it is an important component for both the patient and the physiotherapist.

Firstly, you need to learn more about the nature, severity, frequency, and history of the problem.

Secondly, you need to collect information about which symptoms have worsened or diminished, about previous treatments or examinations, and about other neurological symptoms that have occurred. It is also important to be aware of the problems that patients may face in their daily life.

Finally, you should ask what the patient expects from physiotherapy and what results in he expects.

But for multiple sclerosis patients, you have to focus on some specific problems to assess the patient.

Fatigue assessment: As mentioned above, fatigue is a proven symptom of multiple sclerosis. This is reported to occur in 78% of patients. It has nothing to do with disability level or mood. The assessment of fatigue should include:

  • Daily fatigue pattern
  • Times of the day when energy is high, reasonable, and low
  • Activities or events that aggravate or reduce fatigue (eg. hot weather)
  • Daily functional effects of fatigue
  • Whether fatigue is localized to specific muscle groups, a body part, or a functional system.
  • Whether central fatigue is causing overall excessive tiredness.

Cognitive assessment: The importance of cognitive impairment and the assessment of multiple sclerosis has attracted the attention of both clinical and research readers.  A detailed cognitive assessment is best done by a physician with experience in the field.

Physiotherapists should make these assessments as accessible as possible because the identified limitations allow treatment. In the absence of a specific cognitive assessment and diagnosis, a physical therapist can help with a brief overall assessment of memory, mood, and visual-motor behavior.

Activities of daily living assessment: It is important to know exactly what information is needed for ADL assessment. If the information required refers to what a person with MS can generally do, then the assessment requirement is one of the person’s physical ability to complete the task on the ADL instrument.

However, if the information needed is about what the person does every day, it is necessary to explore the person’s social, family, and cultural roles. Likewise, effects of fatigue can have a profound impact on the way decisions are made. For example, a person may choose to wash and dress in the morning to save energy on commuting, or they may choose to shop to have enough time and energy to pick up their children from school.

Many families and social activities performed by young people are not reflected in the available standardized ADL assessments.

Physiotherapy treatment guidelines

Physiotherapy is a treatment method widely used for MS patients. They often need it and have high hopes for its value. Although many comments have been made, few studies indicate which types of physical therapy should be included in the treatment program. The physiotherapy treatment of MS is-

Stretching: Multiple sclerosis (MS) often means fighting symptoms that affect movement and consume energy. Strategies for relieving these symptoms: Stretch every day. Stretching along with regular exercise only takes a few minutes a day and can produce impressive results.  

The fact that your shoes aren’t cramped or that you can’t walk around the parking lot without spasms makes these things easier, gaining flexibility, strength, energy, and freedom of movement. Of the 156 patients with multiple sclerosis interviewed by the Australian Disability and Rehabilitation Study, 56% had impaired mobility or contraction of joints in at least one large joint.

Even if joint contractions occur early in the disease, they can affect the development of multiple sclerosis. Stretching is one way to increase the range of motion, according to the authors, but more research is needed.

Active exercise: Active exercise is recommended for treating multiple sclerosis, but there are several reasons. It has been suggested for functional retraining, muscle strengthening, and balance and coordination, and ROM maintenance.

Although physical activity is recommended for multiple sclerosis, there is little research on its use. One reason for general agreement may be that physical therapists prefer exercise programs with different conditions. However, chronic muscle use in multiple sclerosis has been shown to cause extreme weakness and fatigue, as doe’s normal muscle.

This may mean that vigorous exercise can help maintain and improve muscle strength and endurance, but this should be studied in people with multiple sclerosis. In addition, the group that received more treatment had significant improvements in function, balance, and daily activity. This study is one of the few that provides scientific evidence for the effectiveness of a multiple sclerosis physical therapy program.

Aerobic exercise: Like other neuropathies, aerobic exercise is a relatively new approach to the treatment of multiple sclerosis. Currently, available evidence suggests that this is beneficial for patients, especially those with mild disabilities.

This therapeutic approach aims to increase overall physical and cardiovascular performance, prevent general weakness, and reduce health risks from disinfection and abuse. Aerobic exercise programs with MS have been shown to significantly increase endurance, improve mood, and increase cardiovascular needs for up to six months.

An increase in activity has also been reported. Recently, an anaerobic exercise program (5 * 30 minutes per week biking) in MS patients reported increased activity, decreased malaise, and improved perceived health. Easily mediated in just 4 weeks.

Weight resisted exercise: Alexander and Costello (1987) recommended weight-resisted exercise for MS, although most patients were found to have worsened early (Russell and Palfrey, 1969). This type of treatment does not seem suitable for inclusion in a physical therapy plan.

Walking aids: Many authors (e.g., Burnfield and Frank, 1988) have found that physical therapy is beneficial for maintaining lower extremity mobility, but have failed to reach an agreement on the use of braces for the lower extremities. Previous authors have also widely recommended the use of walking aids, but care must be taken to avoid postural instability and deformity during prolonged use. Therefore, if necessary, people seem to generally approve of patients’ use of assistive tools, but warn against over-reliance.

Electrical stimulation: Low-frequency neuromuscular electrical stimulation may be beneficial for some MS patients (Worthington & De Souza, 1990), but emphasizes the need for careful selection of this type of treatment for patients because it is not beneficial for all MS patients. In addition, neuromuscular stimulation is recommended as a supplement to other physical therapies, mainly active exercises and muscle stretching.

Hydrotherapy, heat, and cold: There are many anecdotal reports about the usefulness of hydrotherapy and hot and cold therapy. Burnfield (1985), as a doctor and MS patient, recommends avoiding hydrotherapy because “it makes things worse and causes fatigue.” In contrast, Alexander and Costello (1987) pointed out that pool exercises may be beneficial; however, these reports lack specificity because they do not mention any specific symptoms or signs that are affected by the treatment.

Regarding heat and cold, another MS doctor, Forsythe (1988), reported that hot baths help muscle stretching exercises. However, Burnfield (1985) found cold water baths to be beneficial but also described cases where this treatment produced “catastrophic” results.

No description of the benefits or the composition of the disaster is given, but these anecdotal reports help to highlight individuals. Block and Kester (1970) clearly warned against using heat therapy in MS.

They believed that heat therapy would lead to severe deterioration of clinical and subclinical defects, while De Souza (1990) warned against using ice or ice water in patients with circulatory disorders. , Because this will cause the blood vessels to constrict and further reduce circulation.


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