Fatigue, weaknessFatigue, weakness and spasticity in MS… and spasticity in MS…

a self-management challenge!a self-management challenge!

Thomas R. Holtackers, PTThomas R. Holtackers, PT

Self-Management Challenges Self-Management Challenges

• Progression of the diseaseProgression of the disease• Overlapping grieving processesOverlapping grieving processes• Cognitive issuesCognitive issues• Depression and apathyDepression and apathy• Lack of health literacyLack of health literacy• Life’s stressesLife’s stresses• Lack of support/follow-upLack of support/follow-up

Self-Management ConceptsSelf-Management Concepts “ “The most consistent aspect of MS, The most consistent aspect of MS,

is its inconsistency!” is its inconsistency!”

““Rely on delayed-gratification Rely on delayed-gratification

more than instant-gratification” more than instant-gratification”

““Stretch the stiffness; Stretch the stiffness;

Strengthen the weakness; Strengthen the weakness;

Endure the fatigue.”Endure the fatigue.”

““Activity rest; activity rest; activity rest…”Activity rest; activity rest; activity rest…”

Fatigue Fatigue • Not a single entity - many componentsNot a single entity - many components

– 11 ˚ nerve fatigue (demyelination, sclerosing process & axonal ˚ nerve fatigue (demyelination, sclerosing process & axonal damage)damage)

– muscle, emotional, cognitivemuscle, emotional, cognitive– ““MS” fatigue MS” fatigue

• Interaction of other symptomsInteraction of other symptoms– spasticity/tonespasticity/tone– weakness/muscle imbalanceweakness/muscle imbalance– Other possible contributorsOther possible contributors

•poor balance/ataxia/tremorpoor balance/ataxia/tremor•cognitive dysfunctioncognitive dysfunction•bladder dysfunctionbladder dysfunction

Other FactorsOther Factors•Autonomic Nervous System dysfunctionAutonomic Nervous System dysfunction

– diminished sweat responsediminished sweat response– heart rate/blood pressure change not heart rate/blood pressure change not

concomitant with increases in activityconcomitant with increases in activity•Sleep deprivationSleep deprivation

– Bladder dysfunctionBladder dysfunction– Restless legsRestless legs

•Dehydration •Diminished activityDiminished activity•Heat sensitivity!Heat sensitivity!

Variables of Increased Core Body Variables of Increased Core Body TemperatureTemperature

• Activity/exerciseActivity/exercise• Ambient temperature/humidityAmbient temperature/humidity• Poor sweat responsePoor sweat response• ““Diurnal” temperature changeDiurnal” temperature change• Temperature of food/drinkTemperature of food/drink• Radiant energy/direct sunlightRadiant energy/direct sunlight• Heavy/warm clothing Heavy/warm clothing • Thermogenesis of digestionThermogenesis of digestion

Fatigue Management Fatigue Management • Managing other symptoms Managing other symptoms • Practice heat sensitivity management Practice heat sensitivity management

skillsskills• Sleep management Sleep management • Practicing good nutritional habitsPracticing good nutritional habits • Use of adaptive equipment • Prioritizing energy expenditure Prioritizing energy expenditure

– Pacing activities Pacing activities – Finding a balance between exercise, Finding a balance between exercise,

activity and inactivityactivity and inactivity– Adopting the concept of… activity, rest; Adopting the concept of… activity, rest;

activity, rest; etc activity, rest; etc

Spasticity/ToneSpasticity/Tone

• Spasticity is velocity related Spasticity is velocity related • Postural tone Postural tone • Mild to severe Mild to severe • Often co-exists with weaknessOften co-exists with weakness• More apparent in the lower extremities More apparent in the lower extremities

Spasticity/ToneSpasticity/ToneNegative ConsequencesNegative Consequences

• Pain/discomfortPain/discomfort• ContracturesContractures energy-costenergy-cost sheer forces sheer forces skin breakdownskin breakdown safety safety work for work for

caregivercaregiver

• May interfere with:May interfere with:- ADL’s- ADL’s- hygiene - hygiene -bowel/bladder -bowel/bladder - sexual activity- sexual activity- gait/transfers- gait/transfers- general mobility- general mobility- posture- posture- sleep- sleep- breathing - breathing

Spasticity/ToneSpasticity/TonePositive Consequences Positive Consequences

• Possible advantages of spasticityPossible advantages of spasticity– Good vs. bad spasticityGood vs. bad spasticity– Maintains muscle tone/bulkMaintains muscle tone/bulk– Helps support circulatory functionHelps support circulatory function– May prevent formation of deep vein May prevent formation of deep vein

thrombosisthrombosis– May assist with postural controlMay assist with postural control– May assist in activities of daily living, i.e. May assist in activities of daily living, i.e.

transfers, dressing, gaittransfers, dressing, gait

Spasticity/ToneSpasticity/ToneManagementManagement

• Stretching (primary)Stretching (primary)- intensity} moderate- intensity} moderate- duration} short- duration} short- repetition} many- repetition} many- frequency} often- frequency} often

• Positioning/change in positionPositioning/change in position• Activity (“motion is lotion”)Activity (“motion is lotion”)• Strengthen antagonist muscle groupsStrengthen antagonist muscle groups• Other considerations: Other considerations:

– rotatory trunk movementsrotatory trunk movements– reciprocal movementsreciprocal movements– vibration vibration – topical heat vs coldtopical heat vs cold– reciprocating electrical stimulation reciprocating electrical stimulation

Spasticity/ToneSpasticity/ToneMedical ManagementMedical Management• Medical interventionMedical intervention

– BaclofenBaclofen– Zanaflex/valiumZanaflex/valium/catapres /catapres – Baclofen pumpBaclofen pump– Botox injections Botox injections – Nerve blocksNerve blocks

• Surgical interventionSurgical intervention– NeurotomyNeurotomy– Tendinotomy Tendinotomy

Weakness Weakness • Primary (organic)Primary (organic)

– Due to MS plaques in the CNSDue to MS plaques in the CNS– results in physiological muscle fatigue, results in physiological muscle fatigue,

paresis, or paralysisparesis, or paralysis• SecondarySecondary

– 2º disuse, deconditioning, 2º disuse, deconditioning, compensatory movements, pain, compensatory movements, pain, contractures, proprioceptive loss, contractures, proprioceptive loss, tendonitis, etc.tendonitis, etc.

– 2º spasticity & fatigue2º spasticity & fatigue

Weakness Weakness Management Management

• Primary weaknessPrimary weakness- Strengthening exercise to - Strengthening exercise to

maintainmaintain- Be aware of overuse- Be aware of overuse- May require compensatory - May require compensatory intervention (mobility aids, intervention (mobility aids, electrical stimulation, bracing, electrical stimulation, bracing,

etc.)etc.)

• Secondary weaknessSecondary weakness- Often overlooked- Often overlooked- May be minimized with early - May be minimized with early intervention intervention

- emphasize posture/stability- emphasize posture/stability- correct compensatory gait- correct compensatory gait- reduce lifestyle risk factors- reduce lifestyle risk factors- incorporate energy - incorporate energy management strategies management strategies

Weakness Weakness Management Management

• Strengthening exercisesStrengthening exercises- Positioning to reduce effects of - Positioning to reduce effects of tone & spasticity tone & spasticity- Isometric vs Isotonic- Isometric vs Isotonic- Functional antigravity muscle groups- Functional antigravity muscle groups- “Core” groups- “Core” groups

- Quality of repetitions- Quality of repetitions- Relaxation between reps- Relaxation between reps- Number of repetitions- Number of repetitions- Speed of contractions- Speed of contractions

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

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

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

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

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

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

MS Society Resources MS Society Resources

•For professionals 1-866-MS-TREATFor professionals 1-866-MS-TREAT•www.nationalmssociety.org/PRC.asp•Healthprof_info@nmss.org (bulletin)• For clients 1-800 FIGHTMSFor clients 1-800 FIGHTMS