[ARTICLE TYPE]

Manuscript title
Sailaja Nandennagari, Annam Preethi, Annam Reshma, Krupavaram Bethala *

1. Medicine, Avalon University School of Medicine, Willemstad, Curacao

[email protected]

2. Medicine, Avalon University School of Medicine, Willemstad, Curacao

[email protected]

3. Medicine, Avalon University School of Medicine, Willemstad, Curacao

[email protected]

*Corresponding author: Third Author, Address; [email protected]

ABSTRACT

INTRODUCTION
Multiple sclerosis is a chronic autoimmune progressive disease of demyelination of the
central nervous system with subsequent axonal damage. The symptoms are due to loss of
oligodendrocytes, but CNS diseased effects are often controlled through rehabilitation. 

OBJECTIVE OF THE STUDY

The goal of this study is to see if early physiotherapy rehabilitation combined with
immunosuppressants can suppress and minimize symptoms while also slowing down the
illness process from the first day of hospitalization to six weeks, which normally causes the
patient's condition to deteriorate.

METHOD
The patient is required to follow the physiotherapy guidelines for a period of six weeks.
Based on their symptoms, the patient's interventions were gradually increased each week.
The functional independence measure (FIM) and the Short Form survey-12 were used to
assess the patient's everyday quality of life in the first week and then again in the seventh
week (SF-12).

RESULTS
There is a variation in the value of outcome measures after the 7th re-assessment. The FIM
level has risen from 3-moderate assistance with assistance to 6-modified independence
without assistance. The SF-12 physical score improved significantly from 48.020307 to
56.57706, whereas the SF-12 mental score changed just slightly.

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CONCLUSION
Multiple sclerosis disease impairment is mostly caused by disease progression, but it can also
be exacerbated by decreased physical activity, which causes muscle weakness, limited range
of motion, and stiffness. Exercise and training have demonstrated improvement of the above-
mentioned deteriorations in multiple sclerosis patients.

Keywords: Multiple sclerosis, exercise, rehabilitation, disability, intervention, spasticity

Introduction
Multiple sclerosis is a chronic, progressive disease that mainly affects young adults
but can be diagnosed through 20 to 50 years of age according to NMSS, National Multiple
Sclerosis Society. About 400,000 people in the United States and 2.5 million people
worldwide have been diagnosed with multiple sclerosis. The diseased effect is very different.
There is no known cure for this disease, but it can be well controlled with treatment and
rehabilitation. Physical therapists help people with multiple sclerosis to regain and maintain
general fitness, flexibility, and lead an active and productive quality of life (1). There is a
remarkable advance in the treatment of all forms of multiple sclerosis, especially the
recurrent disease that has positively changed the long-term outlook for many patients. There
was also a conceptual shift in our understanding of the immunopathology of MS, away from
the pure T cell-mediated model to the understanding that B cells play an important role in the
etiology. With the advent of highly effective drugs that require less frequent dosing, these
options have become the preferred choices for tolerability and adherence. Many experts
recommend this, as first-line therapy for many patients in the early stages of the disease
before permanent disability is identified.
This article describes the effectiveness of early physiotherapy along with medical
management of a patient with acute multiple sclerosis. The aim of this article describes
effective short-term physiotherapy outpatient treatment for a duration of 6 weeks which
improves the disability of multiple sclerosis patients by reducing their impairment on the
early stage of rehabilitation (2).
Functional independence measure (FIM) and short-form survey-12 (SF-12, a health-related
questionnaire) were used to evaluate the effective outcome measure of the patient following a
course of physiotherapy treatment for 6 weeks from the day of hospitalization. Due to the
immunomodulatory changes, it is difficult to quantify the progress of the patient with
multiple sclerosis, but it is highly recommended to start with mild aerobic exercises,
isometrics, range of motion exercises, neuromuscular facilitation exercises, proprioception
exercises along with multidisciplinary rehabilitation team approach for a duration of initial 6
to 8 weeks (2), (3).

Case Presentation

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 In this article, a 46-year-old woman came to the clinic with pain in the leg
compartments on sides, malaise, visual impairment, frequent tingling, numbness in various
parts of the body, and frequent instability with reported learning and planning issues. She
recently lost her husband and wants to investigate further thereby she suffers from anxiety
and depression. She doesn’t have any comorbid conditions, and after the initial neurological
physical evaluation is done, she was referred to a neurologist, alongside neurologist
evaluation and MRI (Magnetic Resonance Imaging) was done to confirm multiple sclerosis.
Classical Charcot’s triad (nystagmus / INO, internuclear ophthalmoplegia, intentional tremor,
scanning speech) is observed in this patient with the most common clinical course, relapsing-
remitting type. MS eventually enters a secondary progressive phase (4). After we confirmed
her diagnosis, she revealed that she experienced similar kinds of symptoms when she was 40
years old, the time when she lost her husband.
As per the recommendation of the neurologist, the patient was advised to have a short stay in
the hospital where she was treated with steroid injections for a period of 3 to 5 days. The
patient is also educated about short-term improvement with steroids and prolonged steroid
medications that might lead to weight gain, osteoporosis, and type 2 diabetes and the patient
confirmed that she understood completely.
Further after the hospital discharge, the patient was advised to take 8 weeks of physiotherapy
sessions with 4 sessions per week in the outpatient department. During the first day of the
visit, the patient is evaluated through neurological, physical, and functional examinations and
evaluations and interventions were planned and explained to the patient.

Intervention
A physical therapist’s primary role in helping a person with multiple sclerosis is
optimizing his/her mobility, function, and quality of life with respect to the disease and
improving overall health and wellness in every aspect of life. The patient performed 6 weeks
of intervention every day under the supervision of a physiotherapist. Intervention includes
strengthening, aerobic conditioning, flexibility exercises, coordination exercises, balance
exercises, gait training using assistive devices, sensory training, functional training, bowel,
and bladder control. Interventions gradually progressed up to the patient every week
according to their symptoms (5,6,7,8,9,10,11, 13). After 6 weeks, patients were re-assessed
using the outcome measures. The progression of intervention is described in Table: 1 as
follows,
Table: 1

WEEKS INTERVENTIONS

Pain management:

Electrotherapy- Ultrasound, TENS

Hydrotherapy

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 Orthotics

Flexibility exercises:
Week-1
Stretching

ROM (upper limb, lower limb)

Sensory re-education

Strengthening:

Isometrics exercises

Respiratory muscle training:

Breathing exercises

Chest mobility exercises

Progressive resisted exercise:

Modes of resistance training: body resistance,

free weights, weight machines, resistance
bands.

Week-2 Flexibility training

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 Fatigue management

4 Ps: Pacing, planning, prioritizing,

positioning, Task Simplification, Adaptive
equipment/assistive devices, Environmental
modifications, Strategic rest breaks.

Aerobic training:

Modes of Exercise - Swimming, stationary

bike, walking, arm bike

Week-3
Flexibility training

Coordination exercises:

Frenkel’s exercise

Week-4 Strengthening

Functional training:

Push/pull/lunge/bend

Balance training:

Single leg balance with eyes off should be

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 progressed

Balance training:

Gait training: Using assistive devices

Week-5
such as crutch, walker

Progression of strengthening exercises

Flexibility training

Balance exercise – heel walk, toe walking, etc.

Week-6

Outcome Measures
Clinically used outcome measure is to check the decrease in progression of the
disability and the effectiveness of the treatment (12). Pre and post-assessments are done using
functional independence measure, which is an instrument that measures disability  in an
individual with a variety of issues (14). It includes measures of independence for self-
care, i.e. sphincter control, transfers, locomotion , communication , and social cognition.
The tool is used to assess a patient's level of disability as well as change in the patient’s
status in response to rehabilitation . And the quality of life is measured using sf-12 which
is a health-related questionnaire consisting of 12 questions that measure eight health
domains to assess physical and mental health (15). After the 6 weeks of interventions,
post-assessments were done, and it has been shown there is a difference in the value of
outcome measures.

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Scores through FIM and Health survey scale are documented as Table 2:

Outcome measure Preintervention Postintervention

FIM, Functional 3-- Moderate Assistance (>= 50%): 6-- Modified, Independence

Independent Helper-Modified Dependance (Device): No Helper
Measure (in scales)

SF-12, Quality of PCS-12 (Physical Score): 48.020307 PCS-12 (Physical Score): 56.57706
life measure
MCS-12 (Mental Score): 59.04606 MCS-12 (Mental Score): 60.75781

Conclusion
Multiple sclerosis disease impairment is primarily a consequence of disease progress,
but it can be aggravated by reduced physical activity. Exercise has been shown to improve
various aspects of the physiological profile of Multiple sclerosis patients and inactivity-
related impairment can be alleviated by exercise as well. The patient will benefit from
physiotherapy services in increasing the function of the upper as well as lower
extremities, increasing balance, managing fatigue, optimizing gait pattern, and
improving the patient’s attitude towards the future delay and maintaining disability level
than progressing and improvement as well in their quality of life and functional independence
as per table 2. Whilst some studies have considered their leads in terms of disability
levels, none have been made on progressive Multiple sclerosis.
To date, there has not been a printed review examining the evidence of physiotherapy for
the rehabilitation of people with progressive Multiple sclerosis. This article will be the
first consideration of it. In conclusion, the evidence within this report demonstrates that
physiotherapy could also be effective in the rehabilitation of individuals with progressive
MS.
Further investigation, with appropriately powered studies and consistency in outcome
measures among studies are required to strengthen this evidence-based study and to
conduct a meta-analysis of the evidence.

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Recommendations:

This case study reveals the importance of short-term physiotherapy, which is highly
recommended to implement physiotherapy intervention with many of early diagnosed
multiple sclerosis patients to check it’s effectiveness, to analyze data and to generalize the
results.

Limitations:

Study done with a single patient. Only active exercise-based interventions are given
predominantly. Investigator’s thoughts may influence the study, termed as research bias.
Outcomes may not be similar in similar types of patients. Generalization is not possible with
a single case study.

Author Contributions (as necessary)

[Insert text here.]

Conflict of Interest

[Insert text here.]

Acknowledgements (as necessary)

[Insert text here.]

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