In the video of this episode Dr. Poorva Kulkarni, PT DPT MHS explains to us in this episode how physical therapy can help you with your symptoms.

Physical Therapy for MS

Dr. Poorva: Thank you so much for giving me this opportunity to be here. It is heartfelt to hear all your stories and what you guys have been going through. It definitely helps me to be a better physical therapist knowing what struggles you go through. So I hope this will help explain the role of what physical therapy is and when it can help.

No Two MS patients are the same

So, basically what is MS? I’m not going to spend a lot of time on this because a lot of you already know. But what I do want to say is that it affects everyone differently depending on which part of your brain and which nerves are damaged. And thus it will present itself in a different way for each of you. If you do a Google research on MS, it can be overwhelming to see that there are so many symptoms out there. Know you will not experience all of them. Everybody is going to go to a different level of progression and have a different evolution.

The only thing I do want to mention is how physical therapy (PT) can help.

The Role of PT for MS

So when does PT come in? What will help to improve your strength, your endurance, your balance, and decreasing spasticity? Things such as managing it in a better way. For example, having a stretching program will make sure that your spasticity is much more under control and easier deal with it. Another example is coping with fatigue.

Because coping with fatigue is vital. There’s a lot of research out there about fatigue induced weakness. So what if you push yourself to a limit?  It is too much. The next day you’re going to feel it and you’re going to feel that weakness. And so just being aware of your limits, which could change, is important. Knowing your limits and not reaching them.  I always tell my patients to imagine a zero-to-ten scale. Zero being you’re not tired, 10 being you’re very tired. You don’t want to reach ten. You want to keep yourself at a solid five to six range. If you feel like you are do something, pushing it into an eight or nine, you’re going to feel that weakness may be that day or next. And most times, that is not worth it, so always try watching your thresholds.

Apart from stretching and watching your fatigue levels, PT for MS supports you with exercises. It’s hard to generalize what can really benefit as each of you presents symptoms differently. But, some things that help are endurance training, walking, and biking. These are especially good in the morning. If you feel like you know you’re tight and it’s hard for you to get going – the bike definitely helps to relief that muscle tightness that you feel.

As for balance and coordination training, PT works a lot with those issues. If you’re noticing that you have fallen two or three times and are having a little trouble with balance, we can definitely help you with that.

Again, something that I want to stress so much because it is so important is to learn to gauge your fatigue. And I stress this because I know it is hard for you to gauge how much is too much. You need to learn your limits. In physical therapy, I offer my patients an activity log. That way you can plan ahead. Sometimes the log will work and you might have days, that it might not. But even if it works 90% of the time, it’s still a good thing. So if you feel like you have to do A, B, C, and D things, just plan ahead. Plan taking little rest breaks in the middle so you’re not pushing yourself to the limit where you’re going to be so tired the next day.  That has really worked well with patients – having that activity log as a reminder.

Also, split your activities out during the week, or delegate it. Getting an idea of your fatigue is key. It will definitely help. Also, if you go to a gym on your own, just be aware to exercise within that fatigue level too. Have somebody initially give you a guided exercise program so you know your limit and how to progress.

Aquatic exercise is another option of physical therapy for multiple sclerosis. There is new research that shows that pool therapy is really good for patients with MS. It helps to relax the muscles. The biology of the water basically helps you. And it is nice to not be afraid that you’re gonna fall. It’s a good place to stretch out. Also, physical therapy in a pool can put you in positions that would be hard for you to do on the table or a mat.

The thing that you want to remember is you are not going into a heated pool. You want it at 80 degrees, which is a therapeutic temperature that is important with MS. So you want it to be at 80 to 85, a good therapeutic range that relaxes the muscles and makes it easier out. So much more so than on land.

When can Physical Therapy for MS help?

Everyone with MS goes through many different stages and PT can help in all of them. It could be at the time of diagnosis, when you are in remission, and during a relapse or progression. Know that PT can help with MS at each of these stages.

1. At the Time of Diagnosis

So, to begin, at the time of diagnosis, it can help educate you on what is out there. And that is key. It’s definitely scary because it’s new and overwhelming to just have the diagnosis. And if you don’t have enough information, you could be misled, as there is so much out there on the internet. And PT has a treatment for each of the symptoms that present themselves at the onset. The earlier you start, the better you’re able to deal and cope with it. One of the basics, which is most important from the beginning, is teaching you the energy conservation techniques. What I kind of explained to you with making sure that you’re planning your activities, you’re taking rest breaks, etc. And that’s the key. If you start sooner and if you know what this is, it’s easier to get in the routine and help stabilize you.

2. In remission / stability

Then your PT can check up on you at 6 months. You would review your home exercise program. See if everything fine. Is there a change? The idea behind that is that you’re catching the problem before it happens. If you’re kind of slowly noticing that maybe you’re having a little issue with your foot or you’re dragging it, we can work with that. It can be fixed.

Even when you are in a stable phase, you can come in for a tune-up, do a reassessment, and overall see where you are at.

3. During or after a relapse

During a relapse, working on things that are affecting you and getting the treatments to address the symptoms. Is there a need for assistance advice at that point? We are assessing your balance and seeing if that relapse has done anything that might make you more susceptible to falling or things like that.

4. Disease Progression

And then with the progression, if you are in that phase, we might assess if you need a standing frame if it’s hard for you to stand for too long.

We evaluate the need for each stage. Whether we need to use any device just to make sure you’re safer or if we need to brace. Things like that will help you live that much better.

Questions on Using PT for MS

Question: If we did start needing an aid, even temporarily, would we be able to come to you with that aid and you could show us how to use it physically, therapeutically and make sure we’re using it right?

Dr. Poorva: Yeah, totally. Because it’s the technique we use. It could be a walking stick. We assess what might be best for you? It could be a cane or you could do better with a walking stick or a walker if you need to. A physical therapist can show you which device could work best for you at that point. Aids require technique and it can be hard if you haven’t used it.

We have mobility clinics that can help out if you need a wheelchair or things like that. Know that you can get a customized wheelchair if need be, which is way better than getting a rental one which is not your size. You don’t want to get pressure sores. So things like that. So just knowing that you have that source out there too, which is a mobility clinic where they evaluate you, they customize a wheelchair or a standing frame based on you.
There are definitely options out there for you to know that if you are in that phase as well.

And then again managing your symptoms at that point too. If there are things that are getting harder for you, we can definitely address those changes. So some things, when you’re aware of them through the activity log, we can address things like using an ice vest. If you’re a person who gets overheated too much and then your symptoms get really hard to manage, especially with the heatwave that we had, there’s an ice vest that you could get which helps you not get overheated.

Many of the patients will describe tingling or numbness in the hand. And if you’re cooking, you don’t want to cut yourself with a knife. That could happen if you’re not feeling your hand. So there are these weighted spoons would you can get even on Amazon and things like that. The idea with that is that the weight helps you to realize that you have something in your hand so it helps your brain. What we called proprioception. Even with the tremors, it helps. I use weights a lot for patients who don’t know where their feet are. It gives your brain extra feedback. And it will help you not cut to the finger too.

Question: I know the cold season’s coming and I know we’re all basically just like Goldilocks is, we need perfect temperatures. If we are going to exercise outside, should I be wearing like warmer stuff even though I get hot? I guess the temperature thing has been a bit concerned. Should I be going out for long walks? Or should I be going to the pool where it’s warmer, where I can stretch?

Dr. Poorva: Definitely. Again, it depends on every individual, but usually, if you walk in extreme heat, those symptoms trigger. Like you might feel like you’re getting fatigued a lot. So choose the time when you go for walks.

Question:  As I mentioned earlier, my shoulders are really starting to hurt.  It feels like I don’t really even have the strength to build them up at this point. So is that something that you think would be better?

Dr. Poorva: If there is pain, we need to address that pain first. We’d definitely show you some techniques on how to spread and transfer your weight. And then if at that point, if we determine that you are having trouble with your daily activities, I refer you to OT. Occupational therapy can help you learn about the cool devices out there for you. And there are so many now that can make your life easier. We always tag team with other therapists, splitting the sessions so that you get the support you need. You don’t have to be concerned with knowing what kind of physical therapy you need.

Audience member:  We have a real advantage in this community because there aren’t a lot of outpatient neuro PT clinics in the country and she (Dr. Poorva) has a lot of really specific things that will help you adapt and help you. Whatever stage you’re at. I mean you can, it doesn’t really matter whether you’re primary progressive relapsing, remitting or secondary progressive there you can make changes at any stage.

Dr. Poorva: After you have completed your physical therapy, I usually like my patients to go to the classes offered at the clinic. We can always talk about which one you might benefit from.

There are these PEP classes that take place or you could be going off into the community doing senior fitness classes or going into the pool doing one of their programs. The idea behind that is that you’re doing something once a week where you are having somebody there for you. And they can catch things, notice changes, and refer you back to PT. So you can stay in the loop that way. It’s quicker to catch things that way.

Question: Do we need to ask our doctor to refer us? I feel like, every time I go see my doctor, I ask but then they don’t send through a referral.

Dr. Poorva: I would follow up and see if they have. They don’t always call you. Sometimes they say that if they don’t call by such and such date, call them. If they say no, you get back to your doctor and say I didn’t get my referral. Exactly. Yeah, that’s pretty much it. I can also check in our files if your doctor sent us a referral for you.

Member of the audience:  I just wanted to say, I didn’t think I would benefit from physical therapy because I was operating on a basic level, but you showed me stuff that I didn’t even realize! The brain is amazing, and some of the stuff that my body was doing in order to protect me was actually causing me longer-term damage. For instance, I didn’t realize that I wasn’t really looking left and right when I was walking because it made me dizzy. And, and then, getting more confident in being able to look around.  That has helped me feel safer going on walks at night. There was a point there where I was feeling really uncomfortable because I go if you’re coming on my left I was like Zoo Lander…couldn’t turn left!

I’m now a big advocate. Thanks. Thanks to your work. I didn’t realize. I didn’t understand all of the stuff I was doing. Like, I wasn’t even using my knees right. I’ve had these for 32 years! I just didn’t know. It really has helped. And, for example, the pools that they use. Just that light bit of compression that you get from being in the water. Cause I’m always pressing on myself, and the pressure of laying in the pool makes my arms feel so much better. I just didn’t know. The water is amazing, it really is. It definitely helps. So you might not realize that you might be compensating by training your body when you are looking and not turning your head at the onset of that dizziness. PT for MS helps you to learn that. And, Dr. Poorva, you made me sit up straighter!. I’ve been sitting up straight and it makes me look skinny (laugh)!

Dr. Poorva: Thank you.

References

Dr. Poorva Kulkarni, Physical Therapist specialized in neuro, Dominican Hospital Rehabilitation and Therapy Services, Santa Cruz, CA.

Rohrig, mandy. (2018). Physical Therapy in Multiple Sclerosis. National Multiple Sclerosis Society.