Multiple Sclerosis (MS)

OT Dude Academy’s Free NBCOT® Exam Prep Course Neurology Multiple Sclerosis (MS)

  • Multiple sclerosis (MS) is a progressive disease of the central nervous system (CNS) that causes significant disability.
  • 135 in 10,000 people in the US have MS.
  • Most are diagnosed between the ages 20 and 50.1 
  • Characterized by lesions in the white matter of the brain and spinal cord.
  • A chronic inflammatory demyelinating disease.
  • Symptoms: muscle stiffness, muscle spasms, spasticity, clonus, paralysis, impaired balance, sensory loss, impaired coordination, fatigue, cognitive impairment, psychological problems (e.g., depression), visual impairment, speech and swallowing impairments, cerebellar dysfunction, and bowel and bladder problems.2 1 3 
  • Cognitive impairments: attention, information processing, executive function, processing speed, new learning, and memory.4 
  • Other symptoms: sexual dysfunction, heat intolerance
  • 80% of patients with MS report fatigue in the first year of disease onset.5 
  • Fatigue impacts quality of life and reduces the capacity to perform occupations.6 
  • Relapse – attack or exacerbation
  • Remission – symptoms partially or completely disappear

Disease Progression

  • Clinically Isolated Syndrome (CIS) – a first episode of neurologic symptoms caused by inflammation and demyelination. Lasts at least 24 hours but does not yet meet the criteria for diagnosis of MS; some may not go on to develop MS.
    • CIS accompanied by lesions on MRI has a high likelihood of a second episode of neurologic symptoms and diagnosis of RRMS.
  • Relapse-remitting MS (RRMS) – most common (85% of cases) and characterized by clearly defined attacks and remissions (symptoms disappear)
  • Secondary progressive MS (SPMS)  – follows an initial relapsing-remitting course; some transition from RRMS to SPMS; characterized by a progressive worsening of neurological function
  • Primary progressive MS (PPMS) – worsening neurologic function from the onset of symptoms without relapses or remissions7 

Medications

  • Spasticity:8 
    • Botox injections into muscles
    • Baclofen – muscle relaxant; baclofen pump
    • Zanaflex (Tizanidine – muscle relaxant)
    • Valium (diazepam – promotes sleep due to nighttime spasms)
  • (Brochure) List of Disease-Modifying Therapies for MS – FYI, don’t need to memorize

Outcome Measures

  • Modified Fatigue Impact Scale (MFIS)
  • Fatigue Severity Scale (FSS)
  • FIM
  • CARE Tool
  • Beck Depression Inventory (BDI)
  • 9-Hole Peg Test
  • 2-point discrimination
  • Semmes-Weinstein Monofilament
  • Functional Dexterity Test9 
  • Stroop Test (visual-perception)
  • Modified Ashworth Scale (spasticity) 10 
  • Canadian Occupational Performance Measure (COPM) 11 
  • Goal Attainment Scaling (GAS) 12 

OT Intervention

Purpose: enable individuals to participate in self-care, work, and leisure activities they want to perform.13 

  • Physical activity program14 
    • Endurance training
    • Strengthening
    • Motor training
    • Weightbearing (spasticity) 2 
  • Cognitive training (home-based, individualized, computerized, e.g., RehaCom, Video Games) 15 16 17 
  • Activity participation1 
  • Sensory reeducation9  and/or compensation
  • ADLs, IADLs
    • Self-catherizing18 
  • Energy conservation
  • Environmental modifications
  • Time management
  • Proper body mechanics and optimal task performance
  • Use of assistive devices3 
  • Cognitive Behavioral Therapy (CBT) – telephone or group-based19 20 
  • Mindfulness21 
  • PAMs: Electrical stimulation, Cryotherapy, Vibration 2 
  • Yoga and Stretching (spasticity: prolonged static stretching) 2 
  • Driver rehabilitation – screening, evaluation, referral to CDRS
  • Assistive technology22 
  • Fall prevention
  • Pain management: TENS, hydrotherapy23 
  • Stress management: daily diary, relaxation breathing, progressive muscle relaxation24 
  • Coping strategies: positive attitude, socializing25 
  • Ergonomics and accommodations26 
  • Aquatic therapy27 
  • Avoiding heat-induced fatigue and staying cool – precooling, water immersion, cooling garments, cold beverages, applying ice packs, taking cold showers.28 29 30 31 32 33 

OT Recommendations

Sources22 34 

Bathing

  • Tub bench, hand-held shower, grab bars
  • Avoid hot water
  • Practice safe transfer techniques

Toileting

  • Bedside commode, armrest near toilet
  • Practice safe transfer techniques

Dressing

  • Clothing selection for weather
  • Long shoe-horn, velcro closures, button hook, dressing stick
  • Lower closet bar
  • Sit while dressing
  • Dress the weaker side first

Eating

  • Plate guard, specialized utensils, wrist support
  • Stabilize with the elbows
  • Hold objects with two hands

Cooking

  • Microwave oven
  • Wheeled utility/food cart
  • Electric can opener
  • Pot stabliizer
  • Sit whenever possible
  • Slide objects across rather than lifting
  • Cook smaller portions

Chores

  • Reachers
  • Electric appliances and assistive technology (e.g., robot vacuum cleaners)
  • Spread tasks out over time
  • Do heavier chores when there is higher energy
  • Plan ahead
  • Take breaks
  • Ask for help

Home Safety and Fall Prevention

  • Check entryways, thresholds, doors, stairs.
  • Install ramps, railings, and reflective, non-skid strips.
  • Clear doorways or widen them.
  • Consider a raised toilet seat.
  • Apply non-skid or non-slip pads in the shower or tub.
  • Avoid throw rugs or tack them down.
  • Ensure proper lighting, use nightlights.
  • Avoid exposure to hot water.
  • Keep phone by the bed.
  • Be aware of pets and avoid tripping over them.
  • Store frequently used items at a level that avoids excessive movement.
  • Put lightweight items on top shelves.
  • Use contrasting colors for visual problems.
  • Clean up spills immediately.
  • Avoid carrying objects up or down stairs.
  • Clear clutter and keep trip hazards out of walking paths.
  • Wear flat or low-heeled shoes.
  • Have a friend accompany you for longer trips.
  • Avoid carrying too much weight when walking.
  • Use the recommended mobility device and orthotic.
  1. Yu, C. H., & Mathiowetz, V. (2014). Systematic review of occupational therapy–related interventions for people with multiple sclerosis: Part 1. Activity and participation. American Journal of Occupational Therapy, 68(1), 27-32.[↩][↩][↩]
  2. Hughes, C., & Howard, I. M. (2013). Spasticity management in multiple sclerosis. Physical medicine and rehabilitation clinics of North America, 24(4), 593-604.[↩][↩][↩][↩]
  3. Steultjens, E. E., Dekker, J. J., Bouter, L. M., Cardol, M. M., Van den Ende, E. C., & van de Nes, J. (2003). Occupational therapy for multiple sclerosis. Cochrane Database of Systematic Reviews, (3).[↩][↩]
  4. Mitolo, M., Venneri, A., Wilkinson, I. D., & Sharrack, B. (2015). Cognitive rehabilitation in multiple sclerosis: a systematic review. Journal of the Neurological Sciences, 354(1-2), 1-9.[↩]
  5. L. E. Van den Akker, H. Beckerman, H. E. Collette et al., “Effectiveness of cognitive behavioural therapy for the treatment of fatigue with multiple sclerosis: a systematic review and meta-analysis,” Journal of Psychosomatic Research, vol. 90, pp. 33–42, 2016.[↩]
  6. H. Kooshiar, M. Moshtagh, M. A. Sardar, M. Foroughipour, M. T. Shakeri, and B. Vahdatinia, “Fatigue and quality of life of women with multiple sclerosis: A randomized controlled clinical trial,” The Journal of Sports Medicine and Physical Fitness , vol. 55, no. 6, pp. 668–674, 2015.[↩]
  7. National MS Society. (n.d.). Types of MS. Retrieved from https://www.nationalmssociety.org/What-is-MS/Types-of-MS
  8. Malignant MS – 10% experience a malignant course.((Gholipour, T., Healy, B., Baruch, N. F., Weiner, H. L., & Chitnis, T. (2011). Demographic and clinical characteristics of malignant multiple sclerosis. Neurology, 76(23), 1996-2001.[↩]
  9. Ratini, M. (2020). Spasticity and MS: How to Control Your Muscles. Retrieved from https://www.webmd.com/multiple-sclerosis/controlling-muscle-spasms-multiple-sclerosis[↩]
  10. Kalron, A., Greenberg-Abrahami, M., Gelav, S., & Achiron, A. (2013). Effects of a new sensory re-education training tool on hand sensibility and manual dexterity in people with multiple sclerosis. NeuroRehabilitation, 32(4), 943-948.[↩][↩]
  11. Forwell, S. J., Copperman, L. F., & Hugos, L. (2008). Neurodegenerative diseases. In M. V. Radomski & C. A. Trombly Latham (Eds.), Occupational therapy for physical dysfunction (6th ed., pp. 1079–1105). Baltimore: Lippincott Williams & Wilkins.[↩]
  12. Kos, D., Duportail, M., Meirte, J., Meeus, M., D’hooghe, M. B., Nagels, G., … & Nijs, J. (2016). The effectiveness of a self-management occupational therapy intervention on activity performance in individuals with multiple sclerosis-related fatigue: a randomized-controlled trial. International Journal of Rehabilitation Research, 39(3), 255-262.[↩]
  13. Hanssen, K. T., Beiske, A. G., Landrø, N. I., Hofoss, D., & Hessen, E. (2016). Cognitive rehabilitation in multiple sclerosis: a randomized controlled trial. Acta Neurologica Scandinavica, 133(1), 30-40.[↩]
  14. Tipping L. Multiple Sclerosis. In: Turner A, Foster M,
    Johnson SE editor(s). Occupational therapy and physical dysfunction. 4th Edition. New York: Churchill Livingstone, 1994:497–512.[↩]
  15. Bjarnadottir, O. H., Konradsdottir, A. D., Reynisdottir, K., & Olafsson, E. (2007). Multiple sclerosis and brief moderate exercise: A randomised study. Multiple Sclerosis, 13, 776–782. http://dx.doi.org/10.1177/1352458506073780[↩]
  16. Goverover, Y., Chiaravalloti, N., & DeLuca, J. (2008). Selfgeneration to improve learning and memory of functional activities in persons with multiple sclerosis: Meal preparation and managing finances. Archives of Physical Medicine and Rehabilitation, 89, 1514–1521. http://dx.doi.org/10.1016/j.apmr.2007.11.059[↩]
  17. Campbell, J., Langdon, D., Cercignani, M., & Rashid, W. (2016). A randomised controlled trial of efficacy of cognitive rehabilitation in multiple sclerosis: a cognitive, behavioural, and MRI study. Neural plasticity, 2016.[↩]
  18. De Giglio, L., De Luca, F., Prosperini, L., Borriello, G., Bianchi, V., Pantano, P., & Pozzilli, C. (2015). A low-cost cognitive rehabilitation with a commercial video game improves sustained attention and executive functions in multiple sclerosis: a pilot study. Neurorehabilitation and neural repair, 29(5), 453-461.[↩]
  19. Hentzen, C., Turmel, N., Chesnel, C., Miget, G., Le Breton, F., Charlanes, A., … & Amarenco, G. (2020). What criteria affect a patient’s choice of catheter for self‐catheterization?. Neurourology and urodynamics, 39(1), 412-419.[↩]
  20. Mohr, D. C., Likosky, W., Bertagnolli, A., Goodkin, D. E., Van Der Wende, J., Dwyer, P., & Dick, L. P. (2000). Telephone-administered cognitive–behavioral therapy for the treatment of depressive symptoms in multiple sclerosis. Journal of consulting and clinical psychology, 68(2), 356.[↩]
  21. Graziano, F., Calandri, E., Borghi, M., & Bonino, S. (2014). The effects of a group-based cognitive behavioral therapy on people with multiple sclerosis: a randomized controlled trial. Clinical rehabilitation, 28(3), 264-274.[↩]
  22. Salomè, A., Sasso D’Elia, T., Franchini, G., Santilli, V., & Paolucci, T. (2019). Occupational therapy in fatigue management in multiple sclerosis: an umbrella review. Multiple sclerosis international, 2019.[↩]
  23. Bain, L, Schapiro, R, Bennett, S. (2016). Managing MS Through Rehabiliation. [Brochure] Retrieved from https://nmsscdn.azureedge.net/NationalMSSociety/media/MSNationalFiles/Brochures/Brochure-Managing-MS-Through-Rehabilitation.pdf[↩][↩]
  24. Amatya, B., Young, J., & Khan, F. (2018). Non‐pharmacological interventions for chronic pain in multiple sclerosis. Cochrane Database of Systematic Reviews, (12).[↩]
  25. Artemiadis, A. K., Vervainioti, A. A., Alexopoulos, E. C., Rombos, A., Anagnostouli, M. C., & Darviri, C. (2012). Stress management and multiple sclerosis: a randomized controlled trial. Archives of Clinical Neuropsychology, 27(4), 406-416.[↩]
  26. Goretti, B., Portaccio, E., Zipoli, V., Hakiki, B., Siracusa, G., Sorbi, S., & Amato, M. P. (2009). Coping strategies, psychological variables and their relationship with quality of life in multiple sclerosis. Neurological Sciences, 30(1), 15-20.[↩]
  27. Persechino, B., Fontana, L., Buresti, G., Fortuna, G., Valenti, A., & Iavicoli, S. (2019). Improving the job-retention strategies in multiple sclerosis workers: the role of occupational physicians. Industrial health, 57(1), 52-69.[↩]
  28. Corvillo, I., Varela, E., Armijo, F., Alvarez-Badillo, A., Armijo, O., & Maraver, F. (2017). Efficacy of aquatic therapy for multiple sclerosis: a systematic review. European journal of physical and rehabilitation medicine, 53(6), 944-952.[↩]
  29. Davis, S. L., Wilson, T. E., White, A. T., & Frohman, E. M. (2010). Thermoregulation in multiple sclerosis. Journal of Applied Physiology, 109(5), 1531-1537.[↩]
  30. Bassett SW , Lake BM. Use of cold applications in the management of spasticity: report of three cases. Phys Ther Rev 38: 333–334, 1958.[↩]
  31. Boynton BL , Garramone PM , Buca JT. Observations on the effects of cool baths for patients with multiple sclerosis. Phys Ther Rev 39: 297–299, 1959.[↩]
  32. Grahn DA , Murray JV , Heller HC. Cooling via one hand improves physical performance in heat-sensitive individuals with multiple sclerosis: a preliminary study. BMC Neurology 8: 14, 2008.[↩]
  33. Scherokman BJ , Selhorst JB , Waybright EA , Jabbari B , Bryan GE , Maitland CG. Improved optic nerve conduction with ingestion of ice water. Ann Neurol 17: 418–419, 1985.[↩]
  34. Watson CW. Effect of lowering of body temperature on the symptoms and signs of multiple sclerosis. N Engl J Med 261: 1253–1259, 1959.[↩]
  35. Frankel, D, Schneider, D. (2019). Minimizing Your Risk of Falls. [Brochure] Retrieved from https://nmsscdn.azureedge.net/NationalMSSociety/media/MSNationalFiles/Brochures/Brochure-Minimizing-Your-Risk-of-Falls.pdf[↩]
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