Defining and Describing Multiple Sclerosis
Multiple sclerosis (MS) is a chronic disease that affects the central nervous system, which includes the brain and spinal cord. It is responsible for receiving, processing, and transmitting information throughout the body. Surrounding the neurons of the central nervous system is myelin, which is a substance that forms a protective covering around the nerve fibres. It acts like an insulator on an electrical wire, helping to speed up the transmission of electrical impulses and allowing them to travel more efficiently throughout the body. In people with MS, the myelin is damaged, preventing the accurate transmission of nerve signals (Dobson et al, 2019).
The myelin, sometimes known as the myelin sheath, is often characterized as analogous to the insulation around an electrical wire. Just as the insulation prevents the electrical current from leaking out of the wire and allows it to flow efficiently to its destination, the myelin sheath insulates and protects the nerve fibres, allowing electrical impulses to efficiently travel along the nerve pathway. If the insulation around the wire becomes damaged or lost, the electrical current may leak out and become less efficient. Similarly, when the myelin is damaged or lost, signals do not properly transmit between the brain and the rest of the body, which can cause a variety of neurological symptoms seen in people with MS such as fatigue, muscle weakness, balance and coordination problems, vision changes, and cognitive impairment.
Prevalence of MS in Canada
The current estimate suggests that a considerable number of individuals, ranging between 77,000 and 100,000 Canadians, are presently living with MS. According to the Multiple Sclerosis Society of Canada, MS affects 1 in every 385 Canadians, which places Canada in the category of countries with some of the highest rates of MS worldwide. The exact reasons behind the relatively high prevalence of MS in Canada are uncertain, but numerous factors, such as environmental elements like vitamin D levels and latitude, genetic components, and other factors, could play a role in its development. Because of these unknowns, and the fact that there is no cure for MS, MS continues to be a significant health concern in Canada with ongoing research efforts focused on discovering its causes and potential treatments (MS Society, 2019).
The Role of Occupational Therapy in Helping People with MS
Occupational therapy (OT) plays a vital role in helping people with MS manage their symptoms, maintain their independence, and improve their overall quality of life. OT continues to be one of the most impactful healthcare professions that use a client-centred approach to assist people to participate in meaningful activities and achieve their goals.
OT can offer a variety of interventions for people with MS that are intended to target particular symptoms and enhance overall functioning. OT interventions include energy conservation techniques, adaptive equipment, functional mobility training, and cognitive rehabilitation. These treatments can aid MS patients in managing their fatigue, enhancing their functional mobility, such as transferring on and off a toilet and enhancing their capacity to carry out daily tasks like getting dressed and preparing meals. Additionally, OT can assist MS patients with navigating workplace difficulties by recommending modifications or accommodations, assistive technology, and job coaching. By offering these services, OT can assist MS patients to live independent and fulfilling lives.
Understanding The Effects of Multiple Sclerosis
It is crucial to remember that MS symptoms can differ greatly from person to person and evolve with time. For instance, some MS patients may occasionally experience numbness or tingling in their limbs, while others may struggle to walk or become paralyzed. Additionally, while some MS patients may experience cognitive changes or mood swings, others may not. Because MS is a complicated condition, each person may experience different symptoms, and the way these symptoms impact day-to-day living, also varies greatly from person to person. Having a team of medical experts with different specialties can provide comprehensive care and support for people living with MS. For example, a team may include a neurologist to manage MS symptoms, a Physical Therapist to help with mobility and balance, and an Occupational Therapist to help improve the ability to perform daily activities.
Some common symptoms of MS include:
Fatigue: It is frequently described as an exhausted feeling that is not alleviated by rest or sleep. Up to 80% of MS patients who experience it report it as one of the disease's most prevalent symptoms.
Muscle weakness: This can affect any part of the body, and can range from mild to severe. Mobility, strength, and coordination may be affected.
Spasticity: This is a condition in which muscles become stiff and difficult to control. It may result in pain, uncontrollable movements, and muscle spasms.
Balance and coordination issues: MS-related damage to the cerebellum, which is the part of the brain that controls balance and coordination, can result in difficulty with walking, standing, and maintaining balance.
Vision changes: MS can lead to optic nerve inflammation and damage, which can cause double vision, blurred vision, or even the loss of vision in one or both eyes.
Dysfunction of the bladder and bowel: MS-related damage to the nerves that regulate the bladder and bowel can cause issues with incontinence.
MS can also lead to cognitive impairment, which includes challenges with memory, attention, language, and problem-solving, in addition to these physical symptoms.
Approximately 50% of individuals with MS experience some degree of cognitive impairment, and this can significantly impact their ability to work, perform daily activities, and participate in social and recreational activities.
Occupational Therapy and Multiple Sclerosis
How Occupational Therapists Help Manage MS Symptoms and Maximize Independence
Occupational therapy can play an important role in helping individuals with MS manage fatigue, which is one of the most common and debilitating symptoms of the disease. OT interventions for MS-related fatigue are designed to help individuals conserve energy, prioritize activities, and develop strategies for managing daily tasks.
Energy conservation is about finding a balance between work, rest, and leisure to reduce the strain on your body and decrease energy demand. The 4 Ps of energy conservation are a set of guiding principles that can help individuals manage energy levels and reduce fatigue. These principles include:
Prioritize: Decide what is most important for the day and prioritize your tasks. Start with the essential items to ensure it gets done, and save the less important things for later in the day or the following day.
Plan: Plan your activities ahead of time to avoid unnecessary trips. Gather all the supplies you need before starting a task and alternate heavy and light tasks throughout the week. Don't hesitate to reach out to family and friends for help with tasks that may be too demanding.
Pace: Maintain a slow and steady pace and take frequent breaks. Breathe slowly and steadily, and don't be afraid to ask for help when needed. Listen to your body, know your limits, and avoid excessive activity or overexertion.
Position: Minimize bending and reaching to reduce fatigue and shortness of breath and consider proper body positioning. Use tools like a reacher or long-handled shoehorn to reduce bending and maintain an upright posture while sitting and standing. Sitting can also help conserve energy, reducing energy use by 25%.
By incorporating these principles into daily routines, individuals with multiple sclerosis can reduce fatigue and conserve energy to better manage their symptoms and maintain their daily activities.
Symptom: Muscle Weakness
OT interventions for muscle weakness are designed to improve strength, endurance, and coordination. OT practitioners can develop individualized exercise programs that are tailored to the individual's specific needs and goals. These exercises may involve performing specific movements designed to target weak muscles. Another approach that OT practitioners may use is functional training or task-specific training. This involves practicing specific tasks or activities that are meaningful and relevant to the individual's daily life, with the goal of improving overall function and performance.
Let's take a look at an example. Task-specific training in the context of cooking for an individual with muscle weakness might be practicing chopping vegetables with a knife. The therapist might work with the individual to develop a customized chopping board with suction cups to prevent it from sliding around during use. The therapist may also provide adaptive equipment such as a knife with a wider handle for a better grip. Guiding the individual through a series of progressively challenging chopping exercises, starting with softer vegetables like tomatoes and building up to harder vegetables like carrots, can help to safely progress and strengthen muscles in a controlled manner. Through regular practice and feedback, the individual would develop increased strength, endurance, and coordination specific to the task of chopping vegetables, which would translate to improved overall function and performance in the kitchen.
Symptom: Balance and Coordination Issues
One approach that OT practitioners use to address balance and coordination difficulties is balance training. This involves a series of exercises that are designed to improve an individual's ability to maintain their center of gravity and stay upright during movement. Balance training exercises may involve standing on one leg or performing dynamic movements that challenge the body's ability to maintain equilibrium. The primary aim of these exercises is to focus on improving the strength of muscles and augmenting the sensory feedback mechanisms that are crucial for maintaining balance. These sensory feedback mechanisms include proprioception, which is the ability to determine one's body position in space, and vestibular function, which is the sense of balance that originates from the inner ear.
For example, suppose somebody with MS has difficulty standing and dressing on their own. In that case, the therapist and client might start practicing weight-shifting and standing balance activities. Next, the therapist might introduce a piece of clothing and guide the individual through a series of exercises focused on standing on one leg and reaching for clothing while maintaining a stable standing position. The therapist might also work with the individual to use adaptive equipment such as a dressing stick or reacher to pick the clothing up instead of bending and reaching. If balance continues to be a concern and the risk of a fall is high, perhaps learning to dress while sitting using a sturdy chair or other support surface is the next best approach.
Symptom: Bladder and Bowel Dysfunction
OT interventions for bladder and bowel dysfunction are designed to improve bladder and bowel management and reduce incontinence. Often, this begins by providing education on the anatomy and function of the bladder and bowel, including how they work, how they can be affected by MS, and how to recognize signs of dysfunction. The OT may discuss various techniques for improving bladder and bowel management, such as timed voiding and double voiding.
During timed voiding, an individual sets a schedule for when they will go to the bathroom to urinate. This schedule is typically based on the individual's usual patterns of urination, as well as the frequency and severity of their symptoms. For example, an individual may schedule bathroom breaks for every two hours during the day and every four hours at night. Double voiding is a technique that can help individuals fully empty their bladder to reduce the risk of urinary tract infections and other complications. After urinating, an individual waits a few minutes and then attempts to urinate again to ensure the bladder is fully emptied. An individual may use double voiding before leaving the house, before starting a long car ride, or before going to bed to minimize the need to urinate during inconvenient times. Often, double voiding is used in combination with a timed voiding schedule.
Pelvic floor muscle exercises, also known as Kegel exercises, can help improve bladder control in people with bladder dysfunction, including those with MS. By strengthening these muscles, individuals can improve their ability to control their bladder and reduce the frequency and severity of urinary incontinence. Performing Kegel exercises involves contracting and relaxing the muscles that regulate urine flow. Here are the steps for doing Kegel exercises (Harvard Health, 2015):
Identify the pelvic floor muscles: To locate the pelvic floor muscles, try stopping the flow of urine when using the bathroom. The muscles used to do this are the same ones that need to be contracted during Kegel exercises.
Get into position: Once you have identified the pelvic floor muscles, find a comfortable position to do the exercises. This can be done sitting or lying down.
Contract the muscles: Tighten the pelvic floor muscles, squeezing as if trying to stop the flow of urine. Hold the contraction for 3-5 seconds, or as long as possible without straining.
Relax the muscles: Release the contraction and allow the muscles to relax for 3-5 seconds.
Repeat: Repeat the contraction and relaxation process 10-15 times in a row, 3-4 times per day.
It's important to note that Kegel exercises should be done consistently over time to see results. It may take several weeks or even months to notice a significant improvement in pelvic floor strength and urinary symptoms.
Another approach that OT practitioners often recommend is the use of assistive devices or adaptive equipment. For example, using a bedside commode can be beneficial for individuals who have difficulty getting to the washroom on time. Commodes provide a convenient and safe way for people to use the bathroom during the night. Occupational therapists teach individuals how to transfer safely and independently by using proper body mechanics and strategies such as hand placement and weight shifting.
In cases where the bladder cannot be emptied naturally, a catheter may be necessary to remove the urine and prevent retention, which often leads to discomfort, infections, and other complications. A catheter is a medical device that is used to empty the bladder when a person is unable to do so on their own. It is a thin, flexible tube that is inserted through the urethra into the bladder, allowing urine to flow out.
By working with an occupational therapist, individuals can learn how to use and care for their catheters properly. Occupational therapists can also provide information on maintaining good hygiene, such as washing hands before and after using the catheter, and properly cleaning and sterilizing the equipment after use. They can educate people on emptying their catheter bags and properly reconnecting the hosing. Furthermore, the therapist can help the individual develop a routine for catheter care that fits their daily schedule and offer support and advice for any issues or complications that may arise.
Symptom - Cognitive Impairment
MS can cause cognitive impairment, which refers to difficulties with various aspects of cognitive functioning such as memory, attention, language, and problem-solving. Occupational therapy can play an important role in addressing cognitive impairments in individuals with MS.
Some treatment interventions include:
Cognitive training: This involves practicing specific cognitive skills to improve overall function, such as memory exercises or attention tasks.
Environmental modifications: Modifying the environment to reduce distractions and improve organization can make it easier for individuals with cognitive impairments to complete daily tasks.
Compensatory strategies: Strategies such as using external aids like reminder devices or memory aids can help individuals with MS cope with cognitive deficits and maintain independence.
Here is an example of using compensatory strategies. Pretend somebody has difficulty remembering important tasks or appointments. The OT could recommend a memory aid, such as a notepad or a whiteboard, to write down important information, like phone numbers, names, or appointments. The OT may also suggest using a colour coding system or pictures to make it easier to remember specific details. Depending on the severity of the impairment, an OT may also recommend a smartphone app that sends reminders for tasks like taking medication or attending appointments. The individual can set up reminders based on their schedule and the type of tasks they need to remember. By using strategies to compensate for cognitive impairments, individuals with MS can feel more confident and in control of their daily activities.
Recap - Key Takeaways
MS is a chronic disease that affects the central nervous system.
MS can cause physical and cognitive symptoms that impact daily life.
MS is relatively common in Canada, affecting approximately 1 in 385 individuals.
Occupational therapy can be an effective intervention for individuals with MS.
OT can help manage a variety of MS symptoms, including fatigue, muscle weakness, spasticity, balance and coordination difficulties, and bladder and bowel dysfunction.
OT interventions for MS are designed to be individualized and may include approaches such as activity pacing, energy conservation, exercise, and functional training.
OT can help individuals with MS maintain their independence, improve their daily functioning, and achieve their goals.
OT provides tailored interventions, education and training, and support and guidance to help individuals with MS overcome challenges and achieve their full potential.
Online Resources for People With MS
The Multiple Sclerosis Society of Canada:
National organization for people with MS, their families, and caregivers
Provides education and awareness programs, financial assistance, and advocacy efforts
The National Multiple Sclerosis Society:
US-based organization for people with MS, their families, and caregivers
Offers research funding, education and awareness programs, and support groups
The Multiple Sclerosis Association of America:
US-based organization providing programs and services to individuals with MS
Offers educational resources, financial assistance programs, and a helpline for support
Provides programs to manage MS symptoms and improve quality of life
Dobson R, Giovannoni G. Multiple sclerosis - a review. Eur J Neurol. 2019 Jan;26(1):27-40. doi: 10.1111/ene.13819. Epub 2018 Nov 18. PMID: 30300457.
MS Society of Canada, 2023, https://mssociety.ca/about-ms
Step-by-step guide to performing Kegel exercises - Harvard Health. (2015, January 16). Harvard Health. https://www.health.harvard.edu/bladder-and-bowel/step-by-step-guide-to-performing-kegel-exercise