Fatigue, weakness and spasticity in MS… a self-management challenge! Thomas R. Holtackers, PT

1. Fatigue, weakness and spasticity in MS… a self-management challenge!Thomas R. Holtackers, PT

2. Self-Management Challenges • Progression of the disease • Overlapping grieving processes • Cognitive issues • Depression and apathy • Lack of health literacy • Life’s stresses • Lack of support/follow-up

3. Self-Management Concepts “The most consistent aspect of MS, is its inconsistency!” “Rely on delayed-gratification more than instant-gratification” “Stretch the stiffness; Strengthen the weakness; Endure the fatigue.” “Activity rest; activity rest; activity rest…”

4. Fatigue • Not a single entity - many components • 1 ˚ nerve fatigue (demyelination, sclerosing process & axonal damage) • muscle, emotional, cognitive • “MS” fatigue • Interaction of other symptoms • spasticity/tone • weakness/muscle imbalance • Other possible contributors • poor balance/ataxia/tremor • cognitive dysfunction • bladder dysfunction

5. Other Factors • Autonomic Nervous System dysfunction • diminished sweat response • heart rate/blood pressure change not concomitant with increases in activity • Sleep deprivation • Bladder dysfunction • Restless legs • Dehydration • Diminished activity • Heat sensitivity!

6. Variables of Increased Core Body Temperature • Activity/exercise • Ambient temperature/humidity • Poor sweat response • “Diurnal” temperature change • Temperature of food/drink • Radiant energy/direct sunlight • Heavy/warm clothing • Thermogenesis of digestion

7. Fatigue Management • Managing other symptoms • Practice heat sensitivity management skills • Sleep management • Practicing good nutritional habits • Use of adaptive equipment • Prioritizing energy expenditure • Pacing activities • Finding a balance between exercise, activity and inactivity • Adopting the concept of… activity, rest; activity, rest; etc

8. Spasticity/Tone Spasticity is velocity related Postural tone Mild to severe Often co-exists with weakness More apparent in the lower extremities

9. Pain/discomfort Contractures  energy-cost  sheer forces  skin breakdown  safety  work for caregiver May interfere with: - ADL’s - hygiene -bowel/bladder - sexual activity - gait/transfers - general mobility - posture - sleep - breathing Spasticity/ToneNegative Consequences

10. Spasticity/TonePositive Consequences • Possible advantages of spasticity • Good vs. bad spasticity • Maintains muscle tone/bulk • Helps support circulatory function • May prevent formation of deep vein thrombosis • May assist with postural control • May assist in activities of daily living, i.e. transfers, dressing, gait

11. Spasticity/ToneManagement • Stretching (primary) - intensity} moderate - duration} short - repetition} many - frequency} often

12. Positioning/change in position • Activity (“motion is lotion”) • Strengthen antagonist muscle groups • Other considerations: • rotatory trunk movements • reciprocal movements • vibration • topical heat vs cold • reciprocating electrical stimulation

13. Spasticity/ToneMedical Management • Medical intervention • Baclofen • Zanaflex/valium/catapres • Baclofen pump • Botox injections • Nerve blocks • Surgical intervention • Neurotomy • Tendinotomy

14. Weakness • Primary (organic) • Due to MS plaques in the CNS • results in physiological muscle fatigue, paresis, or paralysis • Secondary • 2º disuse, deconditioning, compensatory movements, pain, contractures, proprioceptive loss, tendonitis, etc. • 2º spasticity & fatigue

15. Weakness Management • Primary weakness - Strengthening exercise to maintain - Be aware of overuse - May require compensatory intervention (mobility aids, electrical stimulation, bracing, etc.)

16. Secondary weakness - Often overlooked - May be minimized with early intervention - emphasize posture/stability - correct compensatory gait - reduce lifestyle risk factors - incorporate energy management strategies

17. Weakness Management • Strengthening exercises - Positioning to reduce effects of tone & spasticity - Isometric vs Isotonic - Functional antigravity muscle groups - “Core” groups - Quality of repetitions - Relaxation between reps - Number of repetitions - Speed of contractions

18. Treatment Considerations Lower Extremity FWS Functional considerations • Gait/standing/transfers • Wheelchair/sitting posture to help reduce extensor/flexor/adductor tone • Bed positioning to help reduce same • Driving: gassing/braking

19. Ankle/Foot • Weak dorsiflexion vs. strong, spastic plantar flexion vs. extensor tone • Stretch ankle into dorsiflexion • Strengthen anterior tib with knee flexed • Strengthen anterior tib with knee in extension • If a walker, consider rocker bottom shoe; use the toe test • Consider extensor tone during gait on ankle/knee/hip synergy • AFO to help prevent foot drop; consider weight increase/influence on hip flexion; disuse atrophy • FES of anterior tib; consider over stimulation/fatigue/spasticity; disuse atrophy

20. Knee • Quadriceps/hamstring strength/spasticity inequities vs. extensor/flexor tone • Stretch and strengthen both • Consider stretch of antagonist prior to strengthening agonist • Position to reduce tone • When strengthening use a circuit of alternating between knee extension and knee flexion

21. Hip • Hip flexor/extensor imbalance • Stretch and strengthen • Positioning/posture considerations • Hip abductor/adductor imbalance • Stretch and strengthen • Positioning/posture considerations • Trunk instability/“core” weakness • Get “on the ball” • Pilates concepts

22. Other Considerations • Asymmetry of weakness/spasticity • Increased work of mobility with gait aids; cane, crutches, walkers • Wheelchair use • Other MS symptoms - pain, tremor, sensory dysfunction, central ataxia, cognitive dysfunction, emotional dysfunction • Other diseases: Cardiopulmonary/vascular, arthritis, etc

23. Conclusions • Fatigue, weakness and spasticity (FWS) are common symptoms of MS • FWS are manageable through physical and medical interventions • Self-management of FWS is challenging and requires effort, consistency and support

24. For professionals 1-866-MS-TREAT www.nationalmssociety.org/PRC.asp Healthprof_info@nmss.org (bulletin) For clients 1-800 FIGHTMS MS Society Resources