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Multiple Sclerosis: Improving Physical Therapy Outcomes by Minimizing Neurogenic Fatigue and Maximizing Neuroplasticity

My first educational session at my first physical therapy conference was on what seems like a very challenging condition to manage in the clinic – Multiple Sclerosis.

Hebert Karpatkin began his talk by stating his main goal – to “change the way you treat MS”.

Why are these patients difficult to treat? Here are Karpatkin’s thoughts:

  • Unique neurologic diagnosis – can have effects at multiple regions of the CNS, therefore many neuro symptoms possible
  • Unique presentation – no two patients look alike
  • Therapeutic Nihilism – why even bother, what can I do? (extreme pessimism)
  • Disease of unknowns – progression, severity, and recovery are all so variable!

Dr. Karpatkin then went on to suggest four main areas to consider for successful management of your patients with MS.

1. Fatigue

As stated by the injury charges law firm serving in Canada, this is the most commonly reported symptom of patients with MS (74-89% of patients). The origin of fatigue is separated into two categories:

  • Primary fatigue – due to disease itself – either as motor fatigue specific OR lassitude genreal
  • Secondary fatigue – body’s response to the disease – arises from disuse, sedentary lifestyle, pain, movement compensation, infection, depression, sleep disorder

PT can help by intervening with four of the  secondary fatigue sources – disuse, sedentary lifestyle, pain, movement compensation = GET THEM MOVING!!! For the best stress-relief centers, outpatient rehab Huntsville AL can be checked out!

2. Thermoregulation

Another commonly reported symptom is thermosensitivity. Simply meaning that symptoms become more severe with higher temperatures. This is a fundamental problem as it limits the amount of exercise patients can perform.

How can therapists can intervene?

  • Cooling garments applied before therapy
  • Simply turning on the A/C in your clinic.

3. Intermittent Training

A patient with MS once said:

“Trying to get better makes me worse”

This quote really hit home because it highlights the main problem: the exercise itself is making me fatigued, how do I get better!?!?!

You need your patients to reach a critical dosage of exercise to improve, but how? Intermittent training:

  • Develop a “feel” for when to take breaks
  • Provide rest at first signs of movement difficulty
  • Vital signs (blood pressure / heart rate) are not very telling

Dr. Karpatkin the provided preliminary data that demonstrated that in four patients their 6 minute walk time performance was better with an intermittent protocol (1158) as opposed to a continual exercise protocol (966). To get a better reading of one’s status when it comes to health goals, an app like the tdee calculator comes to mind.

It was also suggested that PTs could apply this protocol to gait, strength, balance, functional activities as well.

4. Secondary Deficits

Posture and stretching

Posture can be poor in patients with MS. One of Dr. K’s patients was given PT 1-2 x/week +home exercise program and this significantly improved his posture and gait. Why was this not addressed with previous therapists? It was suggested that maybe those other PTs neglected posture because of a bias towards his condition.

Foot drop is a common presentation in gait with MS. Dr. K suggested plantarflexor stretching. This ca

n be done during sleep using a night splint.

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Healthy People 2020: Physical Therapists in Health and Wellness

CSM kicked off with a talk about how physical therapist’s can fit into the Healthy People 2020 initiative . Further, the roles and potential roles of physical therapists in health, wellness, health promotion, and public health. Source can help you to get a clear idea about healthcare like how to overcome from addiction .You can read it below

  • Work towards health focused practices
  • Health as an outcome
  • Physical Therapy is about movement and function
  • Address societal needs of movement, function, living with disability, and health/wellness
  • Ethics > Meet the health needs of people locally, nationally, and globally
  • Link to our work to individual patient’s, societal needs, overall healthcare
  • How to obtain reimbursement for preventive care?

The speakers gave broad information about health promotion and physical therapists. Each gave some interesting case examples. Each advocated for physical therapy in serving the societal needs of not only health, but living with disability. I absolutely agree! But…

Especially in private practice how do we not only incorporate health promotion, but make it fiscally sustainable and or profitable? Sometimes it is difficult enough to obtain reimbursement and or private pay for a current condition let alone chronic health conditions such as hypertension control, obesity, healthy exercise habits, and smoking cessation. Understanding the protein needed per day can help guide nutritional advice.

But, on the other hand, the personal fitness and health industry (i.e. weekend trained personal trainers at 24 hour fitness) is booming. How can PT’s obtain a slice (or a big chunk) of this market?

I think they speakers brought a good point that we need a critical mass of not just PT’s, but legislators, public policy makers, patients, and other healthcare professionals committed to societal health in various practice settings. And a recognition of rehabilitation and physical therapy as essential parts of not only health care, but health promotion. To define narcissist and understand the narcissism as a condition we have a long way to go in terms of educating ourselves about it.

Why aren’t we moving in that direction? Do we all need to broaden our view of our professional role? What is the SWOT [Strengths, Weakness, Opportunities, and Threats] Analysis of the PT profession, and each us as individual practitioners, in regards to health?  I think there are a lot of opportunities, but many, many barriers.

Do we have what it takes to step up to the plate? Or, at least get a place at the table?

  • How do we measure health and outcomes related to health?
  • How do we market and spread the word to: patients, physicians, legislators, payors (ha!), the media, educators, public health professionals, and thus society?
  • What role does technology play in our promotion of health and wellness?
  • Can we leverage technology to achieve and spread the above goals and ideas?

I think the first talk brought up many, many questions, problems, and ideas…

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Medicare Physician Compare Fail

This scathing blog post by Michael Millenson concerning the U.S. Government’s new site to help patients locate Medicare providers caught my eye. Medicare’s new Physician Compare was designed to allow consumers to learn more about their providers. Here’s a little background on the site.

After reviewing the site and doing some searching for physical therapists, I have to concur with Millenson. The site is a bust. It should be re-named, “Pointless Partial List of Participating Providers.” I know they are planning to add more content over the next few years, but why start out with such nothing to begin with? It lacks patient-centric factors or any potential interactivity like maps or web-sites. It certainly doesn’t compare anything.

Sites like Healthgrades.com do a much better job of providing some form of information that’s useful, but where are physical therapists on these sites? Consumers are presently lacking a good site to compare providers of physical therapy. As a profession, we can’t leave it up to big Physician sites or the federal government. We need to actively reach out to consumers and show them who we are. Thoughts?

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iPad: PT’s New Best Friend?

By Bronwyn Spira, PT, and Tejal Ramaiya, DPT, CSCS

The iPad is quickly transforming the way business is conducted in the media, entertainment and education sectors. But what about health care? What are the specific benefits of the iPad for physical therapists and what should you be cautious about? As a clinic that has actively been using the iPad for about 6 months now, we have found a number of tangible benefits. Documentation is much faster and happens in real time with each visit. We can track and log the time of each modality, which is especially useful for insurance billing. The small, flat screen is less obtrusive than a laptop – We always felt the screen created a physical and potentially emotional barrier between my patients and myself. We also like that the ipad can be easily handed to the patient for demonstration of a video exercise or other visual aids.

A couple of notes of caution – the iPad doesn’t have a USB port or printer connection so document management is challenging. Current battery life is shorter than the 12-hour workday and common flash-based applications don’t work.

The other issues we face when evaluating the iPad as a medical tool are fragility (it will break if dropped) and hygiene since it cannot be sterilized. The latter is probably less of an issue for physical therapists than other medical professionals, but certainly bears mentioning.

The true future of iPad use within physical therapy clinics will depend on the availability of medical apps for clinicians. It seems inevitable that as our world becomes more and more technology focused we will have to start thinking about how to maneuver our own clinical landscape.

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Bronwyn Spira, PT, and Tejal Ramaiya, DPT, CSCS authored this guest post. They can be found at Force Therapeutics or Twitter.com/ForceTherEx.

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APTA 2010: Boston Wrap

Image courtesy werkunz via Flickr The Annual Conference and Exposition of the APTA was recently held in Boston. It was a fun time and had the highest attendance in the past 4 years! Boston is a great city.

My personal conference highlights included a an amazingly constructed and delivered McMillan Lecture by Dr. Andrew Guccione, and getting to catch up with some of my former classmates and professors from Quinnipiac University. I also had the opportunity to present two educational sessions. One session was with Dr. Tim Noteboom from Regis University on Collaborative Web Tools, and another was with Rachael Lowe on the future of text books and Physiopedia.

Head on over to Physiopedia to check out our slides from that presentation! I’ll be posting the slides from the web tools talk in a day or so.

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Medieval Therapy Techniques?

Graston ToolsDo PTs today practice medieval therapy techniques? An ABC affiliate in San Francisco seems to think we use medieval tools, anyway. The technique reported on is the Graston Technique,® an aggressive form of soft tissue mobilization aimed at breaking up adhesions between fascia and muscle fibers using specialized tools. In theory, this treatment is essentially the same as aggressive STM; the difference lies in the use of the specialized tools.

So do the tools really make the technique more effective than traditional STM? The literature results are extremely limited. Only one study directly compared STM and the Graston Technique ®:

Burke et al. compared Graston Techniques ® to regular STM provided by the therapist’s hands for the treatment of Carpal Tunnel Syndrome. They resulted no clinical differences between the two groups, but did substantiate the clinical efficacy of conservative treatment for mild to moderate CTS.

Perhaps the effectiveness of the Graston Technique ® occurs from the ability to detect adhesions better than manual palpation alone. Users report feeling vibrations or hearing clicks as they move the tools over adhesions that were not detected by palpation. There are a few case studies that report solely on the effectiveness of the Graston technique.

Hammer reports on the ability of the Graston Technique ® user to both feel and target treatment on areas of degenerated tissues in three cases involving plantar fasciitis, Achilles tendonosis, and supraspinatus tendonosis.

Aspergren et al. effectively used thoracic (HVLAT) manipulation and the Graston Technique ® to treat a collegiate volleyball player with acute costochondritis. Although the authors did not compare to thoracic manipulation plus manual STM, pain and functional levels improved.

Other foreseeable benefits include the ability to really dig-in during STM and saving your own joints as a PT, benefits that may also be found in simple massage tools. The side effects include being too painful for many patients and causing bruising in some patients. In all, more research needs to be performed comparing the technique to regular STM by independent examiners.

Bottom line: for now, trust in your hands – they have been around since before medieval times, and are the most powerful tool a PT possesses.

1. Burke J, Buchberger DJ, Carey-Loghmani MT, et al. A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. J Manipulative Physiol Ther. 2007;30(1):50-61.

2. Hammer WI. The effect of mechanical load on degenerated soft tissue. J Bodyw Mov Ther. 2008;12(3):246-256.

3. Aspegren D, Hyde T, Miller M. Conservative treatment of a female collegiate volleyball player with costochondritis. J Manipulative Physiol Ther. 2007;30(4):321-325.

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Capitol Hill Day

Today, hundreds of physical therapists, members of the APTA’s Othopaedic section, and members of AAOMPT, are spending the day on Capitol Hill meeting with as many legislators as we can.

In today’s rapidly changing healthcare arena, the timing of this event couldn’t be better. Providing input from the physical therapist’s perspective is important as so many decisions are about to be made. The day has started out well, with some excellent breakfast at the Russell Senate Office Building. Present were the leadership of representative organizations. Left to right: Jay Irrgang (APTA-Orthopaedic section) Scott Ward (APTA) and Bob Rowe (AAOMPT).