Multiple sclerosis

--What is multiple sclerosis?

MS is an incurable, unpredictable but commonly progressive, life-long neurological condition, affecting approximately 26,000 people in Australia⁴, and 2.8M people around the world⁵. Three quarters of people with MS are women, and most people are diagnosed between their early 20s and 40s. Most people start with a relapsing-remitting disease course, and approximately two-thirds move to the progressive form of the disease.

Within approximately 15 years of first being diagnosed with MS, around 50 per cent of people are unable to walk without an aid and 25 per cent of people will eventually depend on a wheelchair. An important reason for this progression in disability is impaired mobility, balance and strength. Reduced balance, mobility and deficits in strength are reported by around 75 per cent of people with MS. Other problems experienced by people with MS including high levels of fatigue, thinking and memory problems, mood changes, visual problems, and problems with bladder and bowel functioning.

MS has a high impact on the individual and on society. Often people with MS need to stop or reduce employment^{6, 7}, or their usual social behaviours, in particular participation in exercise, and other forms of physical activity⁸.

--How is MS diagnosed?

The complexity of MS can sometimes make it difficult to diagnose. In MS, the immune system mistakenly attacks tissues in the brain, spinal cord and optic nerve. Collectively this is the central nervous system (CNS). These localised attacks on the CNS are known as lesion, which are seen with a brain scan (magnetic resonance imaging or MRI). It is with MRI and imaging of these lesions that a clinical diagnosis of MS is made.

There should be evidence of multiple attacks at different times, and in multiple locations in the CNS. There needs to be a careful combination of clinical examinations, MRI scans and a diagnostic test before a definite diagnosis of MS is made.

--Importance of physiotherapy in MS management

Expert advice shows that health care professionals, including physiotherapists, are the preferred source of information on physical activity and maintaining function.

Neurological physiotherapists are a vital part of health management for people living with MS and are trained in central nervous system conditions. When working with people living with MS, they work in partnership with persons with MS, and their families, to help them to move safely and efficiently.

Physiotherapists can help persons with MS to maintain healthy behaviours towards movement, fatigue management and physical activity. They may also assist with any strength, mobility, balance, bladder and bowel concerns. Physiotherapists are also essential in helping people with MS at times of relapse and during time of minimal disease activity^{1, 2}. Further physical activity encouraged by a neurological physiotherapist can assist with improving cognition, managing pain, and may help slow disease progression.³

--Who are neurological physiotherapists and how can they help MS?

Neurological physiotherapists are experts in movement, and in particular altered movement as a result of neurological symptoms. They are also trained in helping with of movement education, physical activity and can prescribe an exercise program to help you keep active.

Neurological physiotherapists understand that every day is different, and that sometimes the symptoms of MS, such as fatigue, make it difficult to be as physically active every day. Your neurological physiotherapist can help with fatigue, and physical activity.

• When seeing a neurological physiotherapist, you might ask questions such as:
• What type of exercise and how much exercise should I be doing?
• What can I do about fatigue, and when my symptoms are quite bad?
• I’d like to work towards a big physical activity goal next year. Can you guide me on the small steps I can take to get there?
• Because I spend most of the day in a wheelchair, can you suggest what I can do to improve my upper body, posture and breathing?

--What are some of the symptoms of MS?

There are a range of symptoms people with MS may experience. These symptoms may be quite mild or quite debilitating.

Evidence indicates that fatigue, balance and co-ordination problems are particularly common, with many people with MS experiencing muscle spasticity, altered sensation, visual problems and abnormal speech. Mood changes, such as low self-esteem, low confidence and symptoms of depression might be experienced.

--What lifestyle modifications can be made with MS?

A number of modifiable lifestyle factors influence disease progression and disability. There is evidence to suggest the progression of some symptoms of MS can be substantially reduced through changes in behaviours or living environment. More information can be found via MS Research Australia’s website, for clinician’s here⁹ and for people with MS and their family or friends here. The details below are listed in the MS Research Australia’s guidelines, with links to relevant sources.

Smoking:

Approximately 27 per cent of people at the earliest stage of MS smoke. Smoking is associated with faster MS progression and worse symptoms of MS. Smoking increases the risk of MS progressing by around 55 per cent. People with MS who smoke experience lower quality of life, along with increased risk of depression and anxiety. There is an increased risk of early death in people with MS who smoke compared with people with MS who have never smoked. Smoking is the most important modifiable risk factor.

Physical activity:

Exercise can help with mobility, fatigue and pain in MS, however, many people with MS have low levels of physical activity.^{8, 10} There is recent evidence that people with MS may have reduced physical activity levels as a result of crises, such as the Australian Black Summer bushfires¹¹ and as a result of the pandemic.^{11, 12}

Exercise is safe for people with MS. There is also growing evidence that exercise could potentially slow the disability progression associated with the condition. Examples of exercise for persons with MS may include moderate aerobic exercise two to three times per week along with strength training exercises two to three times per week. For people who are already active, the recommendation is to practice moderate to vigorous aerobic exercise five times per week along with strength training exercises two to three times per week. Other exercise, including breathing activities, and arm-based activities may also be recommended.¹³ For tailored advice on exercise for your condition, be sure to contact your healthcare provider.

People with MS and MS healthcare providers should consider comorbidities (such as cardiovascular issues) and symptom fluctuations when exercising and aim to achieve goals sensible for you. For people with more progressive disability, expert evidence recommends consulting with experts such as a neurological physiotherapist.

Diet and nutrition:

There is not enough evidence to support a specific diet to improve outcomes in MS. People with MS should follow the nutritional guidelines for the general population outlined in the Australian Dietary Guidelines and follow a balanced diet with a wide variety of nutritious foods. Speaking with a dietitian may help implement these guidelines in daily life.

--What healthcare professionals can help with MS?

A range of healthcare professionals can help manage the symptoms, and consequences of MS.

While availability and accessibility of some healthcare providers may vary, generally a multidisciplinary healthcare team involves a MS nurse and neurologist working alongside a range of allied healthcare specialists. 

Physiotherapists and occupational therapists can assist with function, community participation, and physical goal achievement.

Dieticians are key to maintaining a healthy diet, and for some patients’, speech and language specialists are key to maintaining communication and swallowing.

With changes in mood common in MS, psychologists are important to help persons with MS manage their emotions and consider ways to help maintain positivity.

--Where can you go for more information

MS Research Australia’s information on lifestyle for people with MS and their family or friends

The National MS Society of America’s Review of physical activity and exercise for people with MS

The MS Trust’s story from Fee on staying active

MS Australia’s website on wellness

The MS Trust’s suggestion to keep a symptoms diary can help people with MS work with their neurological physiotherapist

Exercise is Medicine’s advice on exercise

--References

1. Motl RW, Sandroff BM (2015) Benefits of Exercise Training in Multiple Sclerosis. Curr Neurol Neurosci Rep 15:62. https://doi.org/10.1007/s11910-015-0585-6
2. Learmonth YC, Ensari I, Motl RW (2016) Physiotherapy and walking outcomes in adults with multiple sclerosis: systematic review and meta-analysis. Phys Ther Rev 21:160–172
3. Dalgas U, Langeskov-Christensen M, Stenager E, et al (2019) Exercise as Medicine in Multiple Sclerosis—Time for a Paradigm Shift: Preventive, Symptomatic, and Disease-Modifying Aspects and Perspectives. Curr Neurol Neurosci Rep 19:88. https://doi.org/10.1007/s11910-019-1002-3
4. Campbell JA, Simpson S, Ahmad H, et al (2019) Change in multiple sclerosis prevalence over time in Australia 2010-2017 utilising disease-modifying therapy prescription data. Mult Scler Houndmills Basingstoke Engl 1352458519861270
5. King R (2020) Atlas of MS 3rd edition. PART 1: Mapping multiple sclerosis around the world key epidemiology findings. Multiple Sclerosis International Federation, London
6. Palmer AJ, Colman S, O’Leary B, et al (2013) The economic impact of multiple sclerosis in Australia in 2010. Mult Scler J 19:1640–1646. https://doi.org/10.1177/1352458513488230
7. Chen J, Taylor B, Palmer AJ, et al (2019) Estimating MS-related work productivity loss and factors associated with work productivity loss in a representative Australian sample of people with multiple sclerosis. Mult Scler J 25:994–1004. https://doi.org/10.1177/1352458518781971
8. Marck CH, Learmonth YC, Chen J, van der Mei I (2020) Physical activity, sitting time and exercise types, and associations with symptoms in Australian people with multiple sclerosis. Disabil Rehabil
9. Zarghami et al Learmonth (2020) Modifiable lifestyle factors and MS: A guide for healthcare professionals. MS Res Aust
10. Kinnett-Hopkins D, Adamson B, Rougeau K, Motl RW (2017) People with MS are less physically active than healthy controls but as active as those with other chronic diseases: An updated meta-analysis. Mult Scler Relat Disord 13:38–43
11. Marck C, Hunter A, Heritage B, et al (2021) The effect of the Australian bushfires and the COVID-19 pandemic on health behaviours in people with multiple sclerosis. Mult Scler Relat Disord Press
12. Kalron A, Dolev M, Greenberg-Abrahami M, et al (2021) Physical activity behavior in people with multiple sclerosis during the COVID-19 pandemic in Israel: Results of an online survey. Mult Scler Relat Disord 47:102603. https://doi.org/10.1016/j.msard.2020.102603
13. Kalb et al (2019) Exercise and lifestyle physical activity recommendations for people with multiple sclerosis throughout the disease course. MSJ