Occupational Therapy and Multiple Sclerosis: Treatment Tips and Strategies
When working in occupational therapy, have you noticed as you gain clinical experience that there is no “one size fits all” approach to intervention, particularly with patients with multiple sclerosis (MS)?
Although these patients share a common diagnostic code, there is so much underlying variation in how MS affects their lives. With that being said, we are going to share a few tips for occupational therapists who are still trying to get their footing in working with patients with multiple sclerosis.
What Exactly is Multiple Sclerosis?
Multiple sclerosis (MS) is a condition in which the body’s immune system attacks itself in the form of damage to the brain and to the spinal cord (Mayo Clinic, 2020). Specifically, the immune system attacks the myelin sheath (white matter) of neurons, which inhibits proper motor and sensory communication between the brain and the body.
This explains why individuals with MS may have difficulty with coordinating fine and gross motor movement and sometimes lose the ability to ambulate altogether. Depending on the type of MS and medication routines, damage to nerve tissues can worsen and become permanent.
What are the Different Types of MS and How Does Each Impact Function?
Multiple sclerosis can affect any and all portions of the brain and spinal cord in any nonsensical pattern and rate. That is why it can be so difficult for affected individuals to get an immediate diagnosis. However, the International Advisory Committee on Clinical Trials of MS (2013) have identified four types:
1. Clinically Isolated Syndrome (CIS)
CIS describes the very first episode of neurological symptoms that could go on to develop into MS, but not in all cases. If an individual presents with neural inflammation and lesions as revealed by an MRI, they are more likely to have MS in the future. CIS classifies an initial episode that lasts for at least 24 hours and can cause dizziness, balance and coordination issues, difficulty in walking, muscle stiffness or spasms, and sexual dysfunction to name a few.
2. Relapsing Remitting MS
This is the most common type of MS, making up approximately 85% of MS cases (National Multiple Sclerosis Society, 2020). An individual will experience periods of relapse (symptom exacerbation) followed by periods of remission where some symptoms disappear completely for a time. Researchers have not identified a consistent progression of the disease in this type.
Everyone experiences a different batch of functional problems, but some include: balance and coordination issues, muscle weakness or stiffness, pain, fatigue, trouble focusing, eye pain or visual problems, sexual dysfunction, pain and tingling sensations running through the spine, dizziness, and depression (WebMD, 2020).
3. Secondary Progressive MS
Some individuals who were initially diagnosed with relapsing remitting MS will eventually progress into having secondary progressive MS. There are still periods of relapse and remission. However, a notable increase in disability begins to appear and worsen with time (Multiple Sclerosis Society, 2020). Functional problems are similar to those experienced in relapsing remitting MS, but have worsened to the point of causing disability.
4. Primary Progressive MS
PPMS makes up approximately 15% of all MS cases and is usually diagnosed later in life than the other disease types. Nerve damage is the primary issue, particularly in the spinal cord. This type does gradually worsen with time without the exchange of relapse and remission periods (WebMD, 2020). Common functional problems can include trouble walking, overall muscle weakness, fatigue, pain, swallowing problems, visual deficits, and incontinence.
What Areas are OTs Forgetting to Evaluate?
As mentioned previously, multiple sclerosis can be kind of a mixed bag of dysfunction and not every patient will respond well to the exact same therapy intervention schedule. Cater your initial occupational therapy evaluation to the specific needs of your patient, despite the official diagnosis. Look at areas you may not commonly think about until later down the therapy road.
Individualized patient goals
First and foremost, inquire about the patient’s actual goals. Ask them about where they would like to see themselves at the end of therapy and what progress means for them.
Medication and impact on function
Although advanced MS medications delay disease progression and remediate debilitating symptoms, each medication comes with its own challenging side effects. Thus, OT treatment will have to be adapted around the medication schedule. Some side effects include flu-like symptoms, symptoms similar to those experienced by patients on chemotherapy (i.e. nausea, vomiting, bladder infections, etc.), and changes in heart rate.
Cognition and mental health
More than 50% of persons with MS develop cognitive problems. Common issues may include deficits in memory, attention, concentration, executive function, visual perception, and verbal fluency (National Multiple Sclerosis Society, 2020). Make sure your evaluation screens for potential cognitive reduction and how it impacts daily activity participation.
Common visual problems associated with MS include optic neuritis (optic nerve inflammation), diplopia (double vision), and nystagmus (involuntary eye movement). Whatever the diagnosis, visual disruption often goes unnoticed until after several therapy sessions or until an actual problem occurs (i.e. falls, decreased activity participation, spills, etc.). Catch it early and modify your intervention planning as needed.
Exhaustion sets in at different times and varying levels of intensity. Help the patient track their periods of fatigue in order to optimize therapy around those times.
Pain is a strong motivator to avoid therapy. In order to plan accordingly, collaborate frequently with the patient about their pain: the location, the intensity, at rest, with activity, and which activities tend to exacerbate episodes.
Functional mobility can range from completely independent to total assist depending on the type and severity of MS cases. Knowing levels of mobility will give you an idea about what approach to take: remediative (strengthening, functional activity tolerance) or compensatory (crutches, walkers, manual chairs, power chairs, etc.).
Besides Energy Conservation, What Other OT Interventions Can We Use?
Oftentimes when OTs don’t quite know what to do with a patient with MS, our first copout strategies are energy conservation techniques. Although this does appropriately address common fatigue in MS, this restricts our ability to see the entire picture. Explore additional interventions depending on your patient’s individual needs and desires:
- Pain management: Physical agent modalities, manual therapy techniques
- Muscle strengthening and elongation: Therapeutic exercise, yoga, Tai-Chi, dance, swimming, weightlifting
- ADL management: IADL and ADL participation, compensatory and adaptive equipment strategies
- Home modification and fall prevention: Equipment installation, rearrangement of the home environment
- Mobility: Transfer training, wheelchair management and training
- Fine and gross motor coordination: Table-top tasks, arts and crafts, games, handwriting, utensil and tool manipulation.
- Cognitive training: Memory games, attention and focus activities, planning and organizing activities
- Visual compensation: Visual adaptive strategies
- Incontinence interventions: Bowel and bladder strengthening, compensatory strategies, improving mobility for toileting tasks
- Sexual dysfunction and intervention strategies: Positional strategies for intercourse
When working with a patient with multiple sclerosis, OTs should be approaching intervention the same way they would with any patient: with outside-the-box thinking and individualized intervention planning. Avoid over-categorizing your patients because the truth is that no patient will have the same level of dysfunction or the same goals.
Consult with fellow mentors and do a little bit of research and continuing education on your own in order to better understand and work with your patients with MS.
Multiple Sclerosis: Overview (2020). Mayo Clinic. Multiple sclerosis – Symptoms and causes – Mayo Clinic.
Primary Progressive Multiple Sclerosis (2020). WebMD. Primary-Progressive Multiple Sclerosis (PPMS): Symptoms & Treatment (webmd.com).
Types of MS: Overview. (2020). National Multiple Sclerosis Society. Types of MS | National Multiple Sclerosis Society (nationalmssociety.org).
My father was diagnosed with MS in his mid 30’s and as a young child into my teenage years, I watched it progress. It started with his R hand and then eventually the entire arm. Weakness and then the inability to hold a pen or utensil to cut meat. Next came the foot drop with his R leg, and he compensated by using his stronger side which was totally unaffected. He did have some falls, only a few sporadically. Eventually he used a cane to help with ambulation. We lived on a farm so there was alot of work to be done. His Cognitive abilities never diminished throughout the illness. He was as sharp as a tack. It wasn’t until my dad reached his late 50’s to early 60’s that his strength to stand quickly diminished and was then completely bedridden. To perform any ROM exercises required TD as he was unable to lift his LUE and both legs required TD to reposition in bed to avoid pressure sores. He did develop Cataracts, which were corrected in his R eye allowing him the ability to see more clearly, but restrictions and limitations for transporting with Medicare his L eye was not done. And again his Cognition did not diminish. He could figure out his banking and bills faster than I could using a calculator. His cognition remained in tact until his passing Nov.2014 at the age of 79. And I miss him so much.
Thank you so much for sharing your experience about your dad, Eileen!