Overview

Definition of multiple sclerosis (MS)

Multiple sclerosis (MS) is a chronic autoimmune, inflammatory neurological disease that affects the central nervous system.¹ The immune system mistakenly detects the myelin that surrounds neuronal axons as foreign, so it destroys it. The loss of myelin causes problems in the connections between neurons. This results in the symptoms that are seen in MS, which include:

• Fatigue
• Difficulty walking
• Dizziness
• Bladder complications
• Affected balance and coordination
• Impacted cognitive function (thinking, memory, concentration, learning)
• Muscle spasms (tremors)

These symptoms can affect patients differently and some patients might suffer other additional symptoms.² Approximately 50% of patients require help to walk within 15 years after the disease begins to express itself.³

MS is the most common disabling disease that affects young adults. MS affects almost 1 million people in the United States, this number is almost twice the estimate from previous studies.⁵ Its cause is currently not fully understood. Several factors can play a role, including genetics, low vitamin D, smoking, childhood obesity and infection with the Epstein-Barr virus.

Purpose of physical therapy (PT) in MS

Physical therapy (PT) is a type of treatment used to help people restore their limbs' movement and function after injury or an illness. This way patients are directly involved in their rehabilitation. PT is commonly used to help MS patients, as it offers several benefits that can help them manage their symptoms, improving their quality of life. PT increases patients’ mobility by improving leg flexibility and stability and therefore increases their independence in their day-to-day lives.

Benefits of physical therapy for MS patients

PT includes several exercises that target different muscle groups and improve different aspects of mobility. Some of the benefits that MS patients see with PT include:

• Improved mobility and independence: PT includes exercises that target leg strength, flexibility, and stability. This helps patients maintain their independence as much as possible as the disease progresses
• Management of stiff muscles and pain: stretching exercises prevent stiffness, and improve the range of motion and flexibility of these patients. Stretching the affected muscles can also help prevent future painful contractions.⁶ Massage techniques can also be useful to ease muscle tightness and the pain that comes with it
• Enhanced balance and coordination: through balance training, and focusing on coordination, reaction times and muscle control, patients can regain balance, making it easier for them to walk. PT has shown positive effects in reducing falls in patients with MS⁷
• Reduction of fatigue: PT can include low-impact aerobic exercises such as cycling, swimming, or walking that can improve cardiovascular health and reduce the feeling of fatigue. This allows patients to do everyday life activities with less exhaustion
• Improved mental health: PT helps improve people’s mental health as doing sports releases endorphins, which can boost a person’s mood.  It can also make patients feel more in control of their condition, making them feel more confident and reducing stress and anxiety
• Prevention of secondary complications: MS can result in secondary complications like muscle atrophy, joint contractures and pain. PT can reduce the likelihood of these events occurring by increasing muscle strength, flexibility and mobility. This way the disease can be managed in the long term, reducing its progression

Types of physical therapy interventions

Exercise therapy

The World Health Organization (WHO) recommends doing any physical activity of moderate intensity for 30 minutes a day, 5 days a week, or 20 minutes a day for 3 days a week with high intensity.⁸ Strength training is one of the basic exercises of physical activity used to treat MS patients. Several different types of strength training are used, some include weights, weight machines, and body weight in different positions, both standing and not standing. Different exercises target specific muscle groups. This ultimately reduces muscle weakness and spasticity, improving the issues that these patients have with becoming easily fatigued. Strength exercises can be complemented with stretching exercises, which include yoga and pilates, and have shown to have equally positive effects as other PT exercises.⁸

Aquatic therapy

Low-impact aerobic exercises such as swimming can help improve endurance and reduce joint pressure. Aquatic physical therapy permits patients to practice balanced and coordinated movements in a facilitating environment thanks to being found in the water⁹.

Gait training

Gait training is an additional PT method where patients can be assisted to walk on the treadmill or balance boards. This can also include more specific exercises such as helping patients get in and out of a car or go up and down stairs to regain these skills. Mobility aids can be used such as walkers or canes to help patients before they can do the exercises in the absence of these aids.

Balance and coordination training

Balance and coordination exercises are another alternative that has shown positive effects on MS patients. Step training programs can be done at home and are a feasible, safe, and effective method for improving stepping, standing balance, coordination and functional performance in people with MS¹⁰. Exercises using materials such as stability balls, foam pads, and other tools can be used to improve coordination.

Electrical stimulation

Functional electrical stimulation (FES) is sometimes used to stimulate muscle contraction and reduce rigidity by applying electrical stimulation to cause muscle contractions that can make a foot lift, for example.¹¹ It can help patients regain the strength to walk and it has shown improved quality of life, where patients have said to feel more confident, less stressed and participate more in everyday life activities.¹²

Collaborative care and customized PT plans

Multidisciplinary approach

PT is not the only form of treatment that MS patients can access, and it does not work as efficiently if it is the only one used. For this reason, the occupational therapists who are helping patients with PT have to coordinate with neurologists, physicians, nurses, speech and language pathologists, patients, families and other caregivers who are treating these patients.¹³ This allows the people involved to have a better understanding of the disease progression and how these patients can be helped based on their needs.

Personalised treatment plans

Personalised treatment plans are a good option for MS patients as they focus specifically on the patient and tailor the therapy based on their specific symptoms and the severity of these. Additionally, it is a good option as patients are regularly assessed, to ensure that the exercises that they are doing are the appropriate ones for their needs. It is also very important to make sure that the recommended exercises are followed consistently and at home, as not doing them regularly will greatly reduce their effects, just like is seen when missing weeks of going to the gym, for example. Patients have to try to maintain simple daily routines that keep them moving and maintain their strength.

Challenges and limitations of physical therapy in MS

Although PT shows multiple benefits to MS patients, the complexity of the disease presents challenges and limitations to this treatment approach. Individuals with MS experience a highly variable clinical course, in which symptoms can vary daily. This has a strong impact on the patients’ functional ability¹⁴ by affecting a person’s cognitive processing, walking speed and distance and postural control¹⁵. This unpredictability makes it difficult for therapists to develop and implement consistent, long-term rehabilitation strategies. The reason why these symptoms vary so much is still not fully understood, which adds another level of complexity.

A key aspect of PT is that it must be done consistently for it to show the necessary improvements. Regular exercises are essential for increased strength, flexibility, and mobility in MS patients. However, the variability of MS symptoms can make it difficult for patients to adhere to a consistent therapy schedule, leading to periods where they may be unable to perform exercises at the same intensity or frequency. This means that physical therapists need to constantly modify treatment plans to accommodate the patient's changing physical state, making it difficult to maintain a consistent, progressive plan.

Conclusion

MS is an autoimmune disorder. PT is beneficial for MS patients as it improves mobility, enhances muscle strength and flexibility, improves balance and coordination, reduces fatigue and offers many other benefits. PT is crucial to improving their life quality, increasing their level of independence in their day-to-day lives. There are multiple PT options available to patients, which include exercise therapy, aquatic therapy, gait training, balance and coordination training, and electrical stimulation. PT can have many long-term benefits if patients are consistent with these exercises and follow the advice of specialists. Although presented with some challenges due to a lack of understanding of MS, PT is an essential tool for managing MS symptoms. As research on this disease progresses, this treatment method will undoubtedly be more beneficial for patients. 

FAQs

What is multiple sclerosis (MS)? 

Multiple sclerosis (MS) is a chronic autoimmune, neurological disease that affects the nervous system. The immune system wrongly attacks the protective myelin that covers nerve fibres. This results in problems in the communication between the brain and the rest of the body, causing individuals with MS to suffer from fatigue, difficulty walking, muscle spasms, and many other symptoms.

How can physical therapy (PT) help individuals with MS? 

Physical therapy (PT) helps MS patients by improving mobility, increasing strength, enhancing balance and coordination, and managing pain and stiffness. PT is especially effective in helping patients maintain independence by targeting leg strength and stability, reducing the risk of falls, and minimising fatigue.

What types of exercises are used in PT for MS patients? 

PT for MS patients includes a variety of exercises such as:

• Exercise therapy: strength training to improve muscle strength and stretching exercises such as yoga and pilates to increase flexibility and prevent stiffness
• Low-impact aerobic exercises: for example, swimming or cycling to reduce fatigue in everyday tasks and improve cardiovascular health
• Balance and coordination training: To enhance walking stability and coordination
• Gait training: To assist with walking and everyday movements like climbing stairs
• Electrical stimulation: electrical impulses are used to cause muscle contractions, which can help with muscle strength and reduce muscle rigidity

How is a physical therapy plan personalised for an MS patient? 

A physical therapy plan is personalised by assessing the specific symptoms, severity, and individual needs of each MS patient. Therapists work closely with patients, regularly evaluating their progress and adjusting exercise routines to ensure the therapy is effective and that it meets the needs of the patient at every particular stage of the treatment plan.