THERAPY-Magazin
Motor therapy for multiple sclerosis
Discover how targeted training improves motor function in MS patients with paresis, ataxia and somatosensory disorders. Learn evidence-based neurorehabilitation strategies to enhance mobility, balance, and quality of life—even in severely affected individuals.
Sabine Lamprecht
MSc Neurorehabilitation,
Owner of the practice HSH Lamprecht
Paresis, fatigue, Uhthoff’s phenomenon and spasticity in multiple sclerosis (MS) – the two preceding parts of the expert report by physiotherapist and neurorehabilitation expert Sabine Lamprecht covered these themes. The focus of the concluding part will be ataxia and somatosensitivity disorders, together with neurorehabilitation of severely-affected MS patients.
Review
MS sufferers are functionally most affected by paresis. In combination with motor fatigue and Uhthoff’s phenomenon, paresis and weakness are the reason why exertion is often avoided in MS therapy, despite the fact that this avoidance means a continuous decline in functions for those affected with MS [3]. Contrary to what is commonly believed, exertion does not trigger relapses. The temporary worsening of symptoms is not permanent damage. It is a sign of the MS-specific pathophysiology and not a reason to cut down on regular training.
MS patients should engage in targeted and long-term training with an effective training stimulus and a suitably high number of repetitions in order to strengthen the affected muscles. Training weak muscles should also be at the forefront of spasticity therapy, because it can improve function while reducing spasticity. Increased activity can actually achieve a sustained reduction in spasticity.
The most important qualities, particularly for walking, are stamina and speed. While stamina is improved through targeted interval training, speed can be trained up to the limit of capability in a fall-safe environment, including with the aid of a gait trainer such as the THERA-Trainer e-go. Effective gait rehabilitation also includes targeted training of the affected muscles and targeted balance training. Stamina and strength training improve functional abilities without increasing spasticity; on the contrary, they generally reduce spasticity. [1]
MS sufferers are functionally most affected by paresis. In combination with motor fatigue and Uhthoff’s phenomenon, paresis and weakness are the reason why exertion is often avoided in MS therapy, despite the fact that this avoidance means a continuous decline in functions for those affected with MS [3]. Contrary to what is commonly believed, exertion does not trigger relapses. The temporary worsening of symptoms is not permanent damage. It is a sign of the MS-specific pathophysiology and not a reason to cut down on regular training.
MS patients should engage in targeted and long-term training with an effective training stimulus and a suitably high number of repetitions in order to strengthen the affected muscles. Training weak muscles should also be at the forefront of spasticity therapy, because it can improve function while reducing spasticity. Increased activity can actually achieve a sustained reduction in spasticity.
The most important qualities, particularly for walking, are stamina and speed. While stamina is improved through targeted interval training, speed can be trained up to the limit of capability in a fall-safe environment, including with the aid of a gait trainer such as the THERA-Trainer e-go. Effective gait rehabilitation also includes targeted training of the affected muscles and targeted balance training. Stamina and strength training improve functional abilities without increasing spasticity; on the contrary, they generally reduce spasticity. [1]
Tests and therapeutic approaches to ataxia
Ataxia is commonly used as an umbrella term for damage to the cerebellum and/or cerebellar pathways. Atactic movement disorders occur in over 80% of MS patients and are therefore a widespread phenomenon. [4]
Ataxia is commonly used as an umbrella term for damage to the cerebellum and/or cerebellar pathways. Atactic movement disorders occur in over 80% of MS patients and are therefore a widespread phenomenon. [4]
They require a targeted approach. Fundamentally, the usual ataxia tests should be performed. These include the following:
- Finger-nose test
- Finger-finger test
- Heel-knee test (or extended heel-knee test incl. shin edge)
- Dysdiadochokinesia test
- Rebound test
- Romberg’s test
- Unterberger’s stepping test
- Tightrope walker’s gait
- Finger-nose test
- Finger-finger test
- Heel-knee test (or extended heel-knee test incl. shin edge)
- Dysdiadochokinesia test
- Rebound test
- Romberg’s test
- Unterberger’s stepping test
- Tightrope walker’s gait
If a patient has very slight balance problems, he or she can be tested for single-leg stance. MS patients, in particular, often show problems of afferent information due to spinal or sensory ataxia, which worsens without visual checking and is caused by spinal plaques in the afferent cerebellar pathways. For therapists, therefore, it is important to distinguish whether the difficulties occur with open or closed eyes. The background to this distinction is that if there are increased difficulties without visual checking, the afferent pathways to the cerebellum (= posterior column pathways or spinocerebellar pathways) are affected. Only these can be compensated via the visual acuity. If the afferents are to be trained, no compensation from visual acuity should be permitted.
For example, if a patient can stand well with eyes open in the Romberg’s test, but wobbles markedly when eyes are closed, the patient needs to practise balance including without visual and tactile checking. The usual balance training should therefore be carried out either with eyes closed or at least with change of gaze. As far as possible, the patient should not hold onto the Thera bands or ropes, or should use them only as an aid.
Afferent information can also be improved by increased perceptual and sensory input, e.g. by having pimples and other strong sensory stimuli on the sole of the foot and for proprioception.
The same procedure applies for the upper extremity: if, for example, the finger-nose test with visual acuity check can be performed much better than without, it must be practised without a visual acuity check.
For example, if a patient can stand well with eyes open in the Romberg’s test, but wobbles markedly when eyes are closed, the patient needs to practise balance including without visual and tactile checking. The usual balance training should therefore be carried out either with eyes closed or at least with change of gaze. As far as possible, the patient should not hold onto the Thera bands or ropes, or should use them only as an aid.
Afferent information can also be improved by increased perceptual and sensory input, e.g. by having pimples and other strong sensory stimuli on the sole of the foot and for proprioception.
The same procedure applies for the upper extremity: if, for example, the finger-nose test with visual acuity check can be performed much better than without, it must be practised without a visual acuity check.
Ataxia therapy
Therapeutic approaches to ataxia are characterised by the pathophysiology of ataxia. If the afferent pathways are affected, this results in difficulty with depth sensitivity or proprioception for the patient. This should be repetitively trained as described above without visual checking with a lot of peripheral input.
Overall, the same principles apply to balance training in ataxia patients as in the usual balance training: from easy to difficult, from large to small support surface, from hard to soft. Balance must always be practised while standing or walking, and always at the limit of performance. The patient must be brought out of balance or fight to maintain balance. If possible, dual-task exercises should also be included - meaning that the patient should not concentrate on balance, but as far as possible should perform two or more things at the same time. For example, standing on one leg and talking, performing a calculation or searching for something. In most cases, balance training is practical in MS patients excluding visual acuity or with change of gaze, whereby the patient should not be holding onto anything. This can be specifically trained in the THERA-Trainer balo balance trainer. Here, the patient is in a safe environment. The less the patient leans on the device, the greater the challenge.
The problem of dysdiadochokinesis shows the coordination difficulties in atactic movement disorders. Reciprocal movements, in particular, need to be trained specifically. In terms of coordination, fast movements are easier than slow ones. Ataxia patients should therefore be trained from fast to slower, preferably reciprocal, movements. This is easier for ataxia patients if they are able to perform a guided movement. For that reason, upper and lower extremity exercise trainers are ideal, as are Cross Walkers or other closed systems.
Cerebellar damage is always associated with a general reduction in strength and tone. For that reason, dynamic strength and endurance training is practical. Resistances make it easier for the patient to perform the movements. Therefore, it is easier for them to train with a little more weight or resistance. As training increases, weight and resistance are reduced. Weights can also be used as an aid. This refers to weight vests and weights on the upper and lower extremities, for example.
Movement transitions from low to higher positions should also be practised. Crawling can be a purposeful self-training for many ataxia patients, as they are not afraid of falling and at the same time exercise the muscles of the whole body in a reciprocal manner. This is also possible with an exercise trainer such as the THERA-Trainer tigo, using rhythmic pedalling with agonistic/antagonistic change of leg or arm activity. Even with strong ataxia, this allows for effective training.
As mentioned earlier, ataxia patients also train more easily here at high speed and against resistance. To increase the training, resistance and speed can be purposefully reduced. These two parameters can be accurately dosed on the THERA-Trainer tigo, while normal ergometers are set differently due to their watt-controlled training. Here, more resistance is given at slower revolutions, but MS patients need less resistance at slower speeds – regardless of whether they become more tired through paresis and motor fatigue or are specifically training coordination in the case of ataxia.
For ataxia patients, too, it can be useful to specify the revolution speed, so that the patient cannot exercise at above the pre-set speed. This can also be set with the THERA-Trainer tigo, using the corresponding program.
Even severely-affected ataxia patients can move in a balance trainer such as the THERA-Trainer balo. Here too, training with more resistance is easier and safer than training with reduced resistance.
Therapeutic approaches to ataxia are characterised by the pathophysiology of ataxia. If the afferent pathways are affected, this results in difficulty with depth sensitivity or proprioception for the patient. This should be repetitively trained as described above without visual checking with a lot of peripheral input.
Overall, the same principles apply to balance training in ataxia patients as in the usual balance training: from easy to difficult, from large to small support surface, from hard to soft. Balance must always be practised while standing or walking, and always at the limit of performance. The patient must be brought out of balance or fight to maintain balance. If possible, dual-task exercises should also be included - meaning that the patient should not concentrate on balance, but as far as possible should perform two or more things at the same time. For example, standing on one leg and talking, performing a calculation or searching for something. In most cases, balance training is practical in MS patients excluding visual acuity or with change of gaze, whereby the patient should not be holding onto anything. This can be specifically trained in the THERA-Trainer balo balance trainer. Here, the patient is in a safe environment. The less the patient leans on the device, the greater the challenge.
The problem of dysdiadochokinesis shows the coordination difficulties in atactic movement disorders. Reciprocal movements, in particular, need to be trained specifically. In terms of coordination, fast movements are easier than slow ones. Ataxia patients should therefore be trained from fast to slower, preferably reciprocal, movements. This is easier for ataxia patients if they are able to perform a guided movement. For that reason, upper and lower extremity exercise trainers are ideal, as are Cross Walkers or other closed systems.
Cerebellar damage is always associated with a general reduction in strength and tone. For that reason, dynamic strength and endurance training is practical. Resistances make it easier for the patient to perform the movements. Therefore, it is easier for them to train with a little more weight or resistance. As training increases, weight and resistance are reduced. Weights can also be used as an aid. This refers to weight vests and weights on the upper and lower extremities, for example.
Movement transitions from low to higher positions should also be practised. Crawling can be a purposeful self-training for many ataxia patients, as they are not afraid of falling and at the same time exercise the muscles of the whole body in a reciprocal manner. This is also possible with an exercise trainer such as the THERA-Trainer tigo, using rhythmic pedalling with agonistic/antagonistic change of leg or arm activity. Even with strong ataxia, this allows for effective training.
As mentioned earlier, ataxia patients also train more easily here at high speed and against resistance. To increase the training, resistance and speed can be purposefully reduced. These two parameters can be accurately dosed on the THERA-Trainer tigo, while normal ergometers are set differently due to their watt-controlled training. Here, more resistance is given at slower revolutions, but MS patients need less resistance at slower speeds – regardless of whether they become more tired through paresis and motor fatigue or are specifically training coordination in the case of ataxia.
For ataxia patients, too, it can be useful to specify the revolution speed, so that the patient cannot exercise at above the pre-set speed. This can also be set with the THERA-Trainer tigo, using the corresponding program.
Even severely-affected ataxia patients can move in a balance trainer such as the THERA-Trainer balo. Here too, training with more resistance is easier and safer than training with reduced resistance.
Somatosensory disorders
Somatosensory disorders are a common symptom in MS patients. Depth sensitivity has already been treated in the ataxia section. But surface sensitisation disorders similarly occur in about 80% of MS patients. The treatment approach is to desensitise, because strong sensory stimuli can influence feelings of furriness. However, it must be ensured that this can also be carried out by the patient in self-training. Stretching exercises, too, can often have a positive influence on somatosensory disorders.
Somatosensory disorders are a common symptom in MS patients. Depth sensitivity has already been treated in the ataxia section. But surface sensitisation disorders similarly occur in about 80% of MS patients. The treatment approach is to desensitise, because strong sensory stimuli can influence feelings of furriness. However, it must be ensured that this can also be carried out by the patient in self-training. Stretching exercises, too, can often have a positive influence on somatosensory disorders.
Lhermitte’s sign
With rapid flexion of the head, a sudden pain may be experienced, which radiates along the spinal column to the arms and/or legs, known as Lhermitte’s sign. The cause of Lhermitte’s sign is suspected to be dura immobility due to plaques. Whole-body extensions in the sense of neurotension, giving special consideration to the flexion of the cervical spine, can therefore be used in therapy. Similarly, this is the case with many yoga exercises.
With rapid flexion of the head, a sudden pain may be experienced, which radiates along the spinal column to the arms and/or legs, known as Lhermitte’s sign. The cause of Lhermitte’s sign is suspected to be dura immobility due to plaques. Whole-body extensions in the sense of neurotension, giving special consideration to the flexion of the cervical spine, can therefore be used in therapy. Similarly, this is the case with many yoga exercises.
Neurorehabilitation for patients with severe MS
In severely-affected MS patients with an Expanded Disability Status Scale (EDSS) of 7 or above (patient can still walk five metres), the focus is similarly on activity [3]. If walking is still possible, walking should be further trained – every step counts. Here, gait quality is subordinate. What is crucial is that the patient walks several times a day. The number of steps per day should be determined with a pedometer, for example, and increased steadily. Appropriate provision of aids or provision with sufficient walking aids is enormously important. If patients can no longer stand upright for any time, a standing trainer for the home is absolutely necessary.
In severely-affected MS patients with an Expanded Disability Status Scale (EDSS) of 7 or above (patient can still walk five metres), the focus is similarly on activity [3]. If walking is still possible, walking should be further trained – every step counts. Here, gait quality is subordinate. What is crucial is that the patient walks several times a day. The number of steps per day should be determined with a pedometer, for example, and increased steadily. Appropriate provision of aids or provision with sufficient walking aids is enormously important. If patients can no longer stand upright for any time, a standing trainer for the home is absolutely necessary.
Dynamic standing trainer THERA-Trainer balo
The THERA-Trainer balo is not only suitable for standing, but is also ideal as a training device for dynamic balance training. Since the right intensity is crucial and the patient should be exercising daily for at least one hour in the vertical, the patient should have a standing device at home.
The THERA-Trainer balo is not only suitable for standing, but is also ideal as a training device for dynamic balance training. Since the right intensity is crucial and the patient should be exercising daily for at least one hour in the vertical, the patient should have a standing device at home.
The benefits of standing include:
- Cardiovascular prophylaxis
- Contracture prophylaxis
- Thrombosis prophylaxis
- Pneumonia prophylaxis
- Activation of the pelvic floor
- Improved alertness and cognition
The standing trainer can be used not only for standing, but also for stretching, strengthening, to improve balance and in therapy as a targeted therapy device.
Self-training using a movement trainer (e.g. THERA-Trainer tigo) is a practical addition. It should be ensured that, even with strong spasticity, a certain resistance is set, so that not only a reduction in spasticity, but also increased activation of the muscles is achieved at the same time. If the patient is unable to actively pedal, he or she should think about pedalling, as mental training.
It is also advisable to always include the upper extremity in the exercise training, as patients who rely on walking aids or the wheelchair need strong arms and a correspondingly strong shoulder girdle for coping with daily activities.
Any physical activity is recommended for severely affected patients. Care should be taken to ensure that the training is fun for the patient. Self-training using the THERA-Trainer balo software is a practical option for activity; particularly if the therapist chooses suitable biofeedback exercises. But any form of cycling in or outside the house, e.g. with a tricycle, a hand-bike or a wheelchair front attachment are pleasant leisure activity options. Moving in a wheelchair outdoors, even with residual power boosting (e-motion), or in an electric wheelchair, brings many benefits.
- Cardiovascular prophylaxis
- Contracture prophylaxis
- Thrombosis prophylaxis
- Pneumonia prophylaxis
- Activation of the pelvic floor
- Improved alertness and cognition
The standing trainer can be used not only for standing, but also for stretching, strengthening, to improve balance and in therapy as a targeted therapy device.
Self-training using a movement trainer (e.g. THERA-Trainer tigo) is a practical addition. It should be ensured that, even with strong spasticity, a certain resistance is set, so that not only a reduction in spasticity, but also increased activation of the muscles is achieved at the same time. If the patient is unable to actively pedal, he or she should think about pedalling, as mental training.
It is also advisable to always include the upper extremity in the exercise training, as patients who rely on walking aids or the wheelchair need strong arms and a correspondingly strong shoulder girdle for coping with daily activities.
Any physical activity is recommended for severely affected patients. Care should be taken to ensure that the training is fun for the patient. Self-training using the THERA-Trainer balo software is a practical option for activity; particularly if the therapist chooses suitable biofeedback exercises. But any form of cycling in or outside the house, e.g. with a tricycle, a hand-bike or a wheelchair front attachment are pleasant leisure activity options. Moving in a wheelchair outdoors, even with residual power boosting (e-motion), or in an electric wheelchair, brings many benefits.
Overall summary
Multiple sclerosis should not be equated with other neurological conditions. The disease must be diagnosed and treated individually and symptomatically. Motor symptoms of MS can be very well targeted for therapy and improved with specific training, which should be based on the latest findings in neurorehabilitation. New findings regarding the illness make physiotherapy procedures and occupational therapy procedures even more important than in the past.
Especially in the rehabilitation of MS patients, the following holds good: Exercise and activity are effective, passive therapies, protection from and fear of over-exertion are completely outdated and can lead to deconditioning and further deterioration.
However, it is important to train in a targeted way and to structure the training in a practical manner. We therapists should create a personalised training program for patients, based on a targeted finding that includes strength testing and targeted balance tests, so that patients benefit from their training. MS patients require strength and strength-endurance training of the affected muscles.
The basis of the therapy must be strength, endurance, gait and specific balance training. In walking patients, improving the gait is often the main focus. Here, endurance training should be used specifically to increase the walking distance and/or speed training used to increase speed. Even for severely affected patients, every step counts. The focus should be on the number of steps, and not on the manner of walking.
Likewise, balance must be specifically tested and practised accordingly. Here, differentiation between balance training with opened or closed eyes is required, to specifically improve the afferent pathways and proprioception.
Daily standing is fundamentally important for severely-affected patients who sit in a wheelchair. Patients who can no longer stand independently must be verticalised. When standing, many activities can then be specifically trained again. Especially for patients who have been severely affected, activities outside the home are enormously important, in addition to standing. Ideal activities are cycling using adapted bicycles, or simply active use of the wheelchair in the fresh air. The fact that social contact can be encouraged and depression reduced when doing so can be an important side-effect. In addition, if properly adjusted, exercise trainers can not only loosen up and avoid contractures, but can also very specifically build up strength and effectively reduce spasticity as a result.
In addition, the patient should perform additional “sports” depending on the symptoms and severity of the condition. These should be fun and have a specific effect on the motor deficits. Possibilities include Nordic Walking, Tai Chi, archery, wheelchair dancing, climbing or diving.
The Medical Training Therapy offers a wide range of training that people with MS can effectively use. Hippotherapy is a recommended additional therapy option. [2]
Multiple sclerosis should not be equated with other neurological conditions. The disease must be diagnosed and treated individually and symptomatically. Motor symptoms of MS can be very well targeted for therapy and improved with specific training, which should be based on the latest findings in neurorehabilitation. New findings regarding the illness make physiotherapy procedures and occupational therapy procedures even more important than in the past.
Especially in the rehabilitation of MS patients, the following holds good: Exercise and activity are effective, passive therapies, protection from and fear of over-exertion are completely outdated and can lead to deconditioning and further deterioration.
However, it is important to train in a targeted way and to structure the training in a practical manner. We therapists should create a personalised training program for patients, based on a targeted finding that includes strength testing and targeted balance tests, so that patients benefit from their training. MS patients require strength and strength-endurance training of the affected muscles.
The basis of the therapy must be strength, endurance, gait and specific balance training. In walking patients, improving the gait is often the main focus. Here, endurance training should be used specifically to increase the walking distance and/or speed training used to increase speed. Even for severely affected patients, every step counts. The focus should be on the number of steps, and not on the manner of walking.
Likewise, balance must be specifically tested and practised accordingly. Here, differentiation between balance training with opened or closed eyes is required, to specifically improve the afferent pathways and proprioception.
Daily standing is fundamentally important for severely-affected patients who sit in a wheelchair. Patients who can no longer stand independently must be verticalised. When standing, many activities can then be specifically trained again. Especially for patients who have been severely affected, activities outside the home are enormously important, in addition to standing. Ideal activities are cycling using adapted bicycles, or simply active use of the wheelchair in the fresh air. The fact that social contact can be encouraged and depression reduced when doing so can be an important side-effect. In addition, if properly adjusted, exercise trainers can not only loosen up and avoid contractures, but can also very specifically build up strength and effectively reduce spasticity as a result.
In addition, the patient should perform additional “sports” depending on the symptoms and severity of the condition. These should be fun and have a specific effect on the motor deficits. Possibilities include Nordic Walking, Tai Chi, archery, wheelchair dancing, climbing or diving.
The Medical Training Therapy offers a wide range of training that people with MS can effectively use. Hippotherapy is a recommended additional therapy option. [2]
Neurorehabilitation for multiple sclerosis means:
- interdisciplinary thinking and acting
- intensive specific training
- individual therapeutic procedures geared to everyday and symptom-oriented actions
- therapy goals must be at the level of activity and participation
Targeted activities – targeted training – no fear of over-exertion, and most important of all: training that’s fun. Depending on the symptoms, an individual concept geared to the long term should be developed together with those affected and their relatives, because therapy, sports, and self-help are the pillars of therapy for patients with MS.
Missed the first two parts of our expert report and want to catch up?
Contact us! We’ll be happy to send you the two issues of THERAPY by email.
- interdisciplinary thinking and acting
- intensive specific training
- individual therapeutic procedures geared to everyday and symptom-oriented actions
- therapy goals must be at the level of activity and participation
Targeted activities – targeted training – no fear of over-exertion, and most important of all: training that’s fun. Depending on the symptoms, an individual concept geared to the long term should be developed together with those affected and their relatives, because therapy, sports, and self-help are the pillars of therapy for patients with MS.
Missed the first two parts of our expert report and want to catch up?
Contact us! We’ll be happy to send you the two issues of THERAPY by email.
Ambulante Rehabilitation
Fachkreise
Stationäre Rehabilitation
Therapy & Practice
THERAPY 2019-I
THERAPY Magazine
Sabine Lamprecht
MSc Neurorehabilitation,
Owner of the practice HSH Lamprecht
Sabine Lambrecht completed her physiotherapy examination in Berlin in 1982. Since then, she has participated in various advanced training programs. In 2006, she earned a Master of Science in Neurorehabilitation from Danube University Krems, Austria. Starting in 1983, she worked as a senior physiotherapist at the Neurological Clinic Christophsbad, where she helped establish the physiotherapy department. In 1987, she and her husband opened their own practice. She has been a lecturer at the University of Applied Sciences in Heidelberg and is currently a lecturer at Dresden International University in Fellbach.
References:
- Ada, L./Canning, C./Low, S.-L.: Stroke patients have selective muscle weakness in shortened range, Brain 2003, 724-731.
- Boswell, S./Gusowski, K./Kaiser, A./Flachenecker, P.: Hippotherapie bei Multipler Sklerose – eine prospektive, kontrollierte, randomisierte und einfachblinde Studie; Akt Neurol 2009; 36-P537.
- Lamprecht, S./Dettmers, Ch.: Sport bei schwer betroffenen Patienten mit Multipler Sklerose, Neurol Rehabil 2013, 19 (4): 244-246.
- Mattle, H./Mumenthaler, M. (Hg.) (2013): Neurologie. Stuttgart: Georg Thieme Verlag.
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