by Meghann Koppele
Multiple Sclerosis is a complex disease with varying courses and treatments. Before we explore strategies to successfully work with clients with MS, it is important to understand the pathology.
First of all, MS is a chronic inflammatory disease of the central nervous system, which includes the brain, spinal cord, and optic nerves. MS is also considered an autoimmune disease due to the faulty immune response that attacks the myelin sheath of the nerves. Myelin, the lipid and protein rich layer protecting the nerve is necessary for proper nerve conductivity to occur. In MS, the immune response produces inflammation that damages the myelin producing scars or lesions along the nerve. This damage will delay or completely block nerve conductivity, affecting the muscles that the nerve innervates. To simplify a complex process, think of a computer cord. A computer cord is composed of many small wires to which an electric signal is carried. If one of the wires is damaged the electric signal will not get to the computer and thus the computer will not work. Also, the location of the damage will determine how well the computer will work. For example, if the internet cord is damaged but the power cord is not, the computer will still work but you will not get internet access. The body of an MS client is similar to this because the location of the demyelination and scarring will determine the symptoms that the client will experience. This can be seen in my client who has developed a syrinx (a hole that can fill with fluid) due to severe demyelination in her T8 vertebrae. Her doctors have concluded that the location of the syrinx causes the “MS Hug” or banding, which is extreme pressure around the rib cage like a tight hug. When working with her we concentrate on deep lateral breathing to open the intercostal muscles. While this offers temporary relief it will not reverse the demyelination at T8
A major challenge in treating MS is that demyelination is unpredictable and can occur at various sites producing a large range of symptoms and disability. Symptoms can include loss of balance, muscle spasms, clonus, excessive tone, numbness in affected areas, tingling or burning sensation, lack of movement in joints, trouble walking, inflammation, coordination problems, and excessive fatigue. MS can also affect the bowel, bladder, eyes, and brain. If the brain is affected, the client can experience more cognitive problems such as decreased attention span, poor judgment, depression, and difficulty problem solving. Unfortunately symptoms that the clients may experience are varied and complex. Clients can also have compensatory problems steaming from the list of symptoms above. It is not uncommon for a client to experience low back pain or SI Joint pain due to lack of mobility and stability in other joints. Let these compensatory symptoms guide your programming choices because that is where we as fitness professionals can make the biggest impact.
Now that we understand what MS is let’s explore the different courses that the disease can take. MS clients will experience one of the four disease courses: relapse remitting, primary progressive, secondary progressive, or progressive-relapse. While they are all similar in the basic pathology, they are all different in how the client experiences symptoms.
- Relapse–Remit, the most common course, will experience clearly defined attacks or exacerbations where they experience worsening neurologic function. The exacerbations will be followed by complete recovery or a partial recovery. In my experience most clients will have lingering affects after the exacerbation even if they are in a recovery period or remission. Clients can go for long periods of time without an exacerbation and the exacerbations can range from minor to very severe.
o When a client is having a relapse it is probably wise to avoid sessions until they are feeling better and get doctor’s approval.
o A client’s symptoms with relapse-remit can vary greatly. Many clients can present as symptom free while others exhibit severe symptoms.
o In my experience clients that do not appear to have physical impairments can often have mental impairments such as disorientation, confusion, and problems focusing and understanding.
- Primary-Progressive, there are no distinct relapses or remissions. Instead they will experience steady worsening neurological function over time. They may however experience occasional plateaus and improvements due mostly to their treatment plan. Clients with primary progressive can be described to have a different illness physically and emotionally than other MS sufferers due to the steady decline with no remission and the fact that there is no successful treatment plan. Also primary-progressive clients will develop more lesions on the spinal cord rather than the brain. Due to the increased spinal lesions it is more common for them to loose the ability to walk as well as have bladder, bowels, and sexual dysfunction. Currently there is research using stem cell treatments because the disease modifying treatments that I will discuss later are usually not successful for treatment of primary progressive.
- Secondary–Progressive will start with a period of relapse-remit but develop a secondary progressive disease course similar to primary progressive. Clients with relapse-remit can gradually change into secondary. This transition is often difficult to recognize, however relapses will no longer fully go away. Luckily disease-modifying treatments for relapse-remit clients have slowed down this transition. Symptoms that may indicate you are progressing to Secondary-Progressive include:
o Increase in weakness and incoordination
o Stiff, tight leg muscles
o Bowel and bladder problems
o Greater fatigue, depression, and problems thinking
- Progressive-Relapse is the least common of all courses. Clients will experience a steady decline, like primary progressive, but will also experience attacks of worsening neurological function. Similar to primary progressive, they may experience some recovery, but they will never be in remission.
Finally, there are many experimental treatment options but the standard treatments are broken down into disease modify treatments, relapse treatments, and symptom management. The most common disease modifying treatments are beta interferons such as Aubagio, Avonex, Betaseron, Copaxone, Extavia, GilenyaNovantrone, Rebif, Tecfidera, and Tysabri. Studies have shown they can reduce the frequency of exacerbations of MS, reduce the amount of activity seen on MRI scanning, and may slow the progression of MS. However, this group of drugs have significant side effects including injection site reactions, flu-like symptoms, CNS disturbances including depression and suicidal ideation, low white cell count, elevated liver enzymes and severe hypersensitivity reactions. A common side effect is feeling ill on the day of injection, with flu-like syndrome consisting of fever, chills, headache, muscle pains, joint pains, nausea, and perhaps vomiting and diarrhea. I find it is best to avoid sessions for at least 3-5 days following treatments. Every client has a different experience so let the client be the guide and I recommend a light session with a lot of mobility work the week after the treatment while they are still recovering. It is also important to understand that some of the side effects can be confused with a MS related symptom. In addition to the disease modifying drugs, when a client has a relapse doctors usually suggest a corticosteroid treatment since the relapse is due to the increased inflammation in the CNS causing damage to the myelin. Doctors will often prescribe a 3 to 5 day high dose corticosteroid to reduce the inflammation. As for managing symptoms there is an array of drugs available and doctors will prescribe the necessary drugs to help with each individual symptom.
In conclusion, it is important to understand that the autoimmune response of the CNS and rise of inflammation is the major factors in MS. It is important to understand that clients will vary greatly but if you understand the underlying mechanism of what is happening in the body it will help you as a practioner help your client.
Works Cited List
Gelfand, Jeffrey M. “Multiple Sclerosis: Diagnosis, Differential Diagnosis, and Clinical Presentation.” Handbook of Clinical Neurology 3rd ser. 122 (2014): 269-74. PubMed. Web.
Kutzelnigg, Alexandra. “Pathology of Multiple Sclerosis and Related Inflammatory Demyelinating Diseases.” Handbook of Clinical Neurology 3rd ser. 122 (2014): 45-47. PubMed. Web.
“Learn About Multiple Sclerosis.” Treatments for Multiple Sclerosis. N.p., Feb. 2014. Web. 15 Mar. 2014.
“Optic Neuritis.” Definition. Mayo Clinic, n.d. Web. 16 Mar 24. 2014.
“What Is MS?” National Multiple Sclerosis Society. N.p., n.d. Web. 24 Mar. 2014.