Primary Progressive Multiple Sclerosis

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SMART Goals

Fine motor

In 4 weeks, patient will score less than 33.3 seconds total on the 9-hole peg test to indicate improvement in hand dexterity and make strides towards typing with both hands

Range of Motion

In 3 weeks, patient will improve dorsiflexion active range of motion by 5 degrees, to help prevent foot drop and thus fall risk during gait.

Deficits of PPMS

Loss of smell

Neurophysiology: damage to white matter in subcortical structures may affect smell due to the connections that the olfactory tract makes with the limbic system (amygdala, hypothalamus)

Neuroanatomy: limbic system, olfactory cortex

Objective measure: MMT and ROM of anterior tibialis, extensor hallucis longus, extensor digitorum longus, as well as muscles of the shoulder, brachium and antebrachium

Guides POC to see extent of patient's weakness and to set intensity and modality of exercises given to pt

Neuroplasticity: use it and improve it, use it or lose it, intensity matters, interference

If the patient has a steppage gait due to foot drop, it would interfere with learning a new gait pattern that involves active use of the weak dorsiflexors

Making sure that the exercises that work the weaker muscles aren't too easy, and the patient feels challenged

If you don't target the weak dorsiflexion and hemiparesis, it will atrophy and get worse

Focusing on the weaker side of the body to improve its functions and recruitment

Neurophysiology: the corticospinal tract travels through CNS white matter structures that may be damaged due to MS, in the spinal cord and brainstem

Efficacy of muscle contractions depend on this tract running through myelinated structures

Neuroanatomy: Corticospinal tract

Left arm hemiparesis

Foot drop

Ambulation (dynamic balance)

The training for dynamic balance should be blocked at first to improve her foundations of gait then be transferred to random to mimic a variety of surfaces she'll encounter in her environment

Outcome measure: DGI

Determine what other parts of ambulatory activities the patient struggles with

Walking on level surface, changing gait speed, gait with horizontal and vertical head turns, gait with pivot turn, stepping over and around obstacles, walking up stairs

Neuroplasticity: salience matters, transference,

When patient improves dynamic balances over firm surfaces, we can transfer her over to compliant surface ambulation to help her deficit of ambulating over uneven surfaces outside of the clinic.

Emphasizing that if ambulation improves, patient will be able to do more independent tasks by herself such as grocery shopping and socializing with friends.

Neurophysiology: if there are problems processing information from the sensory tracts, the motor tracts will have problems integrating the proper ambulation pattern. In addition, with possible damage to the corticospinal tract, the patient experiences hemiparesis which further impedes gait skills.

Neuroanatomy: corticospinal tract, DCML tract

Fine motor skills

Outcome measure: nine-hole peg test

Measures hand dexterity; patient is timed and places the pegs in the holes as quickly as possible

Neuroplasticity: specificity, repetition matters, age matters

Taking her age into account, though it is possible to make neuroplastic changes, it may take a while compared to a younger patient

Professionally educate the patient about a realistic timeline and what it would take for how long it would take to achieve her goal to type with two hands

Including exercises that target the specific fine motor deficits that she struggles with

Incorporating a good HEP to get extra repetitions in for her fine motor exercises especially because this is one of her main goals

Neurophysiology: damage to the connections between the motor planning or coordination structures to the cortex, can cause discrepancies in fine motor skills. This input damage would be located to the area of the primary motor cortex that is in charge of moving the fingers.

Neuroanatomy: motor cortices, basal ganglia, thalamus, cerebellum

Cognitive (Dual tasking)

At first we should break the dual tasking into parts, and then slowly integrate practicing both at the same time as a whole

Outcome measure: TUG and TUG cog (compare the two)

Measures cognitive dual tasking; patient starts from sit, stands up, and walks 3 meters and back while doing a cognitive task (ex: counting backwards from 100 by 5s), then sits down as quickly as possible

Neuroplasticity: Salience matters, time matters, use it or lose it, interference

Since the patient has trouble with doing both cognitive and motor tasks at the same time, they compensate by stopping one task to complete the other. Slowly integrate dual tasking into treatment parameters.

Stimulating this area during PT will prevent further decline in cognitive processing

It is important to note that she has been diagnosed with MS since 2010, so her brain will not make neuroplastic changes as easily as someone with a fresher brain injury

However this means that we need to start working on more neuroplastic changes ASAP because the sooner the better

Make exercises functional to reinforce the Papez circuit and help with processing

Neurophysiology: Papez circuit located in the limbic system is involved with learning, the secondary motor areas help with external and internally guided movements, finally, the prefrontal cortex coordinates and controls these aspects of dual tasking via being in charge of working memory and attention.

Neuroanatomy: motor cortices, basal ganglia, limbic system, prefrontal cortex

Loss of taste

Neurophysiology: damage to the higher centers of gustation such as the cranial nerve 7 nuclei in the pons or the gustatory cortex will impede the patient's ability to sense taste.

Neuroanatomy: gustatory cortex, pons cranial nerve 7 nucleus

Static balance

Objective measure: dermatome testing

To figure out if the lack of balance is due to lesions to corticospinal tract or DCML

Neuroplasticity: repetition matters

Providing the pt a HEP that allows her to safely practice static balance in order to get the proper amount of repetitions in to make neuroplastic changes

Neurophysiology: with UMN lesions, the sensory input from the LMN cannot be processed, and the patient will have trouble with balance because the corticospinal tract is unable to receive proper information for how to engage muscles.

Neuroanatomy: DCML tract, corticospinal tract

Practice parameters

Distributed practice conditions should be utilized to ensure the patient's fatigue doesn't interfere with her treatment

Objective measure: assessing RPE at the end of every exercise

To determine extent of fatigue and to set parameters of how intense exercises should be in regular POC and what the progression would look like; Follow up with questions about what type of fatigue the patient is feeling

Neuroplasticity: intensity matters, transference, specificity

Working on endurance and managing fatigue symptoms will transfer over to improving her ability to attend longer social events

Including exercises and patient education in the pt's program that specifically addresses and helps improve fatigue

The exercises should adequately challenge the patient, yet not overfatigue them

Neurophysiology: saltatory conduction

Saltatory conduction makes neurons fire faster, without this myelination from the upper motor neurons, not as many action potentials will get through to the lower motor neurons, decreasing endurance of those structures.

Neuroanatomy: myelin sheaths

Primary Progressive Multiple Sclerosis

Participation

Activities of daily living

Showering

Shower has 2 grab bars

Dressing

Can only wear sports bras and shirts that can be pulled on

Cleaning

Struggles with hanging clothes

Cooking

Has special kitchen appliances that help with this

Recreational sports or activities

Negotiating stairs

Unable to have stairs in the home

Ambulating uneven surfaces

Community ambulation

Can't go to the store by herself

Activities

Typing

Reading

Driving

Sleeping

Sitting

Using the restroom

Balance

Gait

Body structures

Specific structures

Spinal cord white matter

Corticospinal tract

Hemiparesis

Foot drop

AFO

Fasciculus cuneatus/gracilis

DCML

Loss of sensation (fine touch, vibration)

Problems with proprioception and balance

Thalamic nuclei

Ventrolateral

Problems with active movements of the contralateral side

Pons

Cranial nerve nuclei 5-8

CN 7: facial nerve

Taste loss

Micturition/storage centers

Bowel, bladder issues

Optic nerve

Vision problems

Limbic system + frontal cortex

Olfaction problems

Motor deficits

Gross motor

Fine motor

Trouble with processing, learning, and memory

T-cells destroy oligodendrocytes

Demyelination in the CNS

Slower action potentials

Weakness

Fatigue

Personal

First degree relatives with MS

Obesity

Smoking

Diagnosis of RRMS

Initially diagnosed with RRMS 2010 befrre PPMS

Age

Sex

Female

Environment

Hot climates

Family lives in Florida, doesn't want to move up North, so just stays indoors during hot weather

Access to proper healthcare

Low access to vitamin D

House or apartment with stairs

Is unable to have stairs in the home

Occupation with physical or cognitive demands