Power in Numbers
A patient's prognosis in physical therapy can often be highly predictable, especially when coming in after a common surgical procedure. Most patients in the United States receiving therapy after common procedures such as rotator cuff repairs or knee replacements, it's pretty easy from the beginning to know how many days they'll stay in the hospital, how many times therapy treatments will occur before going home, and how many weeks of rehab they'll need to be right as rain. These are all determinations made, not on the needs of the patient per se, but by the statistical power of high volume procedures and largely standardized medical practices made to fit the parameters of what insurance will comfortably reimburse for.
Lord have mercy on you if your particular case doesn't fit into the statistical average of the data pool. Need some extra days in rehab to meet your goals? Need an additional month of outpatient therapy to battle some nagging stiffness? You can't always count on it. Insurance reimbursement is a finely tuned machine, and when patient progress doesn't fit the typical time-lines, getting additional care often means putting up a fight. This is the conundrum for any medical condition that is an outlier or with difficult prognosis.
Multiple Sclerosis, or MS for short, falls into this category. MS is a disease with a highly individualized presentation. Also typical is frequent and unpredictable exacerbation with recovery that is difficult to predict both in duration and in quality. This is frustrating in a world where patients have fewer PT visits in their insurance plans and high co-pays and deductibles. One year a person with MS may need no PT at all, and in another, they may be hospitalized 3 separate times, requiring weeks of rehab each time. Where do we leave room for preventative therapies in this mess?
My name is Dr. Allan Buccola, PT, DPT. I am a physical therapist and owner of Impetus Physical Therapy in Greensboro, NC. This blog post will describe how physical therapy benefits individuals living with Multiple Sclerosis and how I think we as a nation could be doing better job serving this population. Let's dive right in!
What is Multiple Sclerosis?
I know not all readers will have a strong familiarity with MS so I'll first go into some details about this disease. Multiple Sclerosis or MS, is a chronic auto-immune-mediated neurological disease, which is to say that its a disease without a cure, effecting the brain and/or spinal cord, wherein these cells are attacked by the body's immune system. The resultant degeneration of the central nervous system (brain or spinal cord) creates changes in how one’s body feels or functions.
As aforementioned, MS is a disease that currently has no cure, however many successful treatment options are available and new, highly effective drugs are being created each year. The disease process is characterized by any combination of alternating periods of slow progressive degeneration, acute exacerbation of symptoms, and periods of remittance. Because MS progresses unpredictably, clinical presentation is unique to each person. Early symptoms can often include changes to vision and often progress to moderate fatigue and focal weakness.
functional stages of ms
Although not everyone will experience MS the same way, here are three simplified stages to describe how MS may progress. Because this post is written from a physical therapy perspective, this staging schema is largely described in changes of mobility or physical functioning; however, in some individuals, there may also be changes that occur in terms of affective or psychiatric characteristics. Whereas I am sensitive to these changes, they remain outside the scope of this article.
This is the period wherein first symptoms are often intermittent and difficult to diagnose. Noticing changes in vision is typical, as is loss of fine motor control (discrete, controlled movements), which is often perceived as clumsiness. Feelings of tingling in various parts of the body may be present as well.
In this stage, physical therapy is important in identifying less apparent changes in strength, balance, and coordination, that can be addressed to halt any additional loss of function. Early symptoms may be discrete and not immediately noticed; however, PT is good at identifying these changes. This is also a prime time to educate patients on the importance of maintaining a lifestyle with healthy amounts of physical activity.
In this stage, symptoms are more consistent and predictable and may extend to focal weakness in the trunk, arms, and/or legs. Sensation changes are more persistent. Loss of gross motor control (standing, walking, balance) may begin to affect the ability to participate fully in daily activities like work or leisure. It is also typical for individuals to experience frequent periods of fatigue in late afternoon.
In this stage, physical therapy is critical in helping teach individuals effective use of assistive devices such as canes, walkers, etc (when they are warranted). Physical therapy is also of benefit in helping prescribe a plan to maintain general physical fitness as high as possible to maximize overall wellness. Certain types of exercise are clinically validated to modulate the immune system, protecting the nervous system and helping make some medications more effective. PTs also teach strategies for preventing additional exacerbation when possible.
In the most severe or progressed cases, partial or total loss of mobility may occur. Some individuals lose the ability to control their bladder. Another common occurrence is chronic muscle tightness or muscle spasm in various muscle groups.
In this stage, physical therapy teaches strengthening, stretching, education, and mobility training as daily tasks become more difficult. Energy conservation skills are critical to daily life. Often the final goals of PT are related to maintaining as much patient independence as possible, as well as helping to maintain a high quality of life.
best treatment follows current research
As a PT who has not been out of school for very long, I remain intimately connected to current treatments available in the latest research. As a student, the focus remains on the latest and the greatest, but once in the workplace, treatments available are dictated by available equipment. Treatment time frames are guided by what the patient's insurance will cover. The unpredictable nature of MS often results in some patients not getting enough PT either because their covered sessions are limited or because they have an unusually high number of exacerbation in a given year.
The other frustration on my end lies in the fact that so much of the current evidence shows promise in the role of wellness and prevention education with these patients, but often our healthcare system is more reactive than it is proactive. It's hard knowing that patients could be doing better if I saw them sooner, especially when their benefits often don't support that notion.
This is one reason I modeled my clinic as it is, allowing affordable treatment options for everyone regardless of their benefits. Billing directly to the patient gives the power back to the patient in regards to when they come and how often, especially in terms of preventative and wellness services. Individuals who are recently diagnosed with MS are often highly motivated to do whatever they can to preserve their function and quality of life, but unfortunately, our current healthcare system hasn't found a way to serve them...until they are on the mend.
For a person living with MS, it seems ludicrous that a physician need deem any physical therapy services "medically necessary" simply to be covered by a particular plan. It seems logical that these individuals are smart enough to be able to make that call independently. After all, this is a condition they live with daily, and their awareness of changes in their functional independence are far more sophisticated than what modern medicine has to offer.
reasons to remain active with MS
Here is just a smidgen of what research has shown on how physical activity can improve the lives of those living with MS. Physical therapy can help with all of these.
-with improved and/or maintained general mobility, the incidence of secondary health problems such as osteoporosis, obesity, and cardiovascular disease declines rapidly.
-primary problems with MS such as spasticity or weakness are actually mediated by sedency and physical inactivity, and improve with exercise.
-individually prescribed exercise is noninvasive, relatively safe, and has been shown to be tolerated well specifically in persons with MS.
-endurance training has been shown to improve both upper and lower body strength in persons with MS.
-resistance training has been shown to reduce fatigue in persons with MS, and to improve their functional capacity (amount of activity they tolerate.)
-gait (walking) training programs have been shown to improve quality of walking.
-more extensive aerobic training programs have demonstrated the ability to improve balance, and reduce fatigue, depression, and fear of falling.
-whereas strenuous sport-like activity may have a negative effect on persons with MS, moderate exercise has been shown to improve immune system function, but the benefit may only last for 3-24 hours post workout, hence regular activity is critical.
-in a study that just came out this year, BDNF, a chemical in the brain responsible for neural growth and protection was shown to be 20% lower in persons with MS when compared to healthy control subjects. More importantly, this level declined further with the sedentary group, and increased 16% with the exercise group, all in the course of 24 weeks.
I hope this post brings to light a few ideas. Firstly, this should have created a greater awareness of MS in the general population. These people are in and around our lives each day and need our support. Secondly, as I feel as though PTs are well suited to serve more in the role of educators to this unique population, with intent to improve their self-efficacy and reduce the progression of disease. Thirdly, this is just another perfect example of another group of people under-served by the reactionary nature of our healthcare system. As it stands, work must be done to be able to provide more wellness services and community education.
If you found this post helpful, please check out another piece I recently wrote about the benefits of exercise for MS. For more information about Impetus PT and services offered check out our site, and for more info about MS, there's a site for that too!
Thanks for reading! Until next time, don't stop moving!