Neurorehab2 Ms

Front 1

MS: A Chronic Disease of the ____

Immune mediated
 Inflammatory and
degenerative process
 Brain, brainstem, spinal
cord, optic nerves
 Damage to the myelin
sheath and axon
 Interrupted nerve
impulses
 Multiple lesions leading
to “multiple scarring”
 Cause is unknown
 Environmental factors
 Genetic factors

Back 1

CNS

Front 2

Pathophysiology/
Etiology/Epidemiology
 Abnormal ____ response to infection or
environmental trigger in genetically
susceptible individuals
 Activated peripheral ____ breach
blood/brain barrier
 Inflammatory response against myelin,
axons and ____
 Neurologic signs result from conduction
blocks and axonal transection

Back 2

immune

t-cells

oligodendrocytes

Front 3

Pathophysiology/
Etiology/Epidemiology

Immune Steps Leading to Neurological
Deficits

“Activated” T cells…

…cross the ___…

…launch attacks on ____ &
nerve fibers...

…to obstruct nerve signals.

Back 3

blood-brain barrier

myelin

Front 4

Nerve Damage and Myelin Loss

(A) Normally, axons have a protective myelin coating
 (B) In MS, the ___ destroys myelin, resulting in
inflammation of the affected areas
 (C) Exposed axons may then be severed…
 (D) …leading to permanent loss of the ____
 (E) The result is permanent loss of nerve function

Back 4

immune system

axon

Front 5

Pathophysiology/
Etiology/Epidemiology
What is the ____ factor?
– 1/1000 risk of MS in the general population
– 2-5/100 for person with a close relative with
MS
• 1/50 for daughter of a mother with MS
• 1/100 for son of a father with MS
• 1/20-50 for a sibling of a person with MS
• 1/3 for an identical twin

Back 5

genetic

Front 6

Incidence
■ > 2.6 million individuals worldwide
■ 500,000 in the United States
■ Higher prevalence in ___ 3:1
■ Onset 15 - 50 years of age (average 30 years)
■ Every week 200 individuals are diagnosed with MS
■ 10,000 new cases annually
■ Most common cause of neurologic disability in
young adults in the U.S.

Back 6

women

Front 7

relapsing-remitting - 85%
primary-progressive - 10%
Secondary-progressive - 58%
Progressive- relapsing - 5%

Back 7

cool

Front 8

Diagnosis of MS: Basic Principles
 Clinical observation + history + neurological
examination
 Laboratory tests to exclude other diagnoses
 Tests to support the diagnosis:
 MRI
 ____ analysis
 Evoked potentials

Back 8

Cerebrospinal fluid (CSF)

Front 9

Diagnosis
 ____ definitive diagnostic test
 Diagnosis is clinically based on medical
history, signs, and symptoms
 Definite diagnosis requires:
– Evidence of lesions in at least
___ distinct areas of the CNS
– Evidence that lesions occurred
at discrete points in time
– No better explanation

Back 9

No single

two

Front 10

Diagnosis
____ abnormal in 95% of people with
MS
Lumbar puncture: CSF ____
 Visual evoked potentials

T1 with Gadolinium

Brain Atrophy - huge ventricles

Back 10

MRI

oligoclonal
bands

Front 11

Principles of Management
 Delay progression to disability
 Reduce frequency and severity of
relapses
 Treat relapses when they occur
 Manage symptoms
 Maintain functional independence
 Improve and facilitate an acceptable
quality of life and promote Hope
A wellness philosophy is the focal point of comprehensive care

Back 11

ok

Front 12

Disease Modification
 Goal is to alter the ___ of
the disease
 Decrease relapses
 Delay disability
 Classes of disease-modifying
medications
 Immunomodulators
 Immunosuppressants

Back 12

natural course

Front 13

Immuno____

 Methylprednisolone
 Mitoxantrone (Novantrone)*
 Cyclophosphamide (Cytoxan)
 Azathioprine (Imuran)
 Methotrexate
* FDA Approved for use in MS = Mitoxantrone (Novantrone)*

Back 13

Immunosuppressants

Front 14

Immuno_____
 Interferon beta
 Avonex
 Rebif
 Betaseron

 Antigen-specific
 Copaxone

 Adhesion molecule inhibitors
 Natalizumab (tysabri)

Back 14

Immunomodulators

Front 15

How MS Therapies Work

 ____
 Increases suppressor lymphocytes and
inhibits stimulation of other immune cells

 Copaxone
 Converts inflammatory immune cells to antiinflammatory
cells in the CNS

 Mitoxantrone (Novantrone)
 Attacks all rapidly dividing cells; decreases
ability to fight infection

 Monoclonal Antibody (Tysabri)
 Inhibits WBC from crossing the BBB

Back 15

Interferons

Front 16

Long-Term Safety and Tolerability Issues

______

 Flu-like symptoms
 Injection-site reaction
 Abnormal liver function
Pregnancy category C
Neutralizing antibodies

Back 16

Interferons

Front 17

Long-Term Safety and Tolerability Issues

___

 Post-injection reaction
 Injection-site reaction
Pregnancy category B

Back 17

Glatiramer Acetate (Copaxone)

Front 18

Long-Term Safety and Tolerability Issues

____

 Cardiotoxicity
 Acute myelogenous leukemia (AML)

Back 18

Novantrone

Front 19

Long-Term Safety and Tolerability Issues

____

 Progressive Multifocal
Leukoencephalopathy (PML)

Increased risk of certain infections

Back 19

Tysabri

Front 20

MS ____ or New Symptom?
 New onset of symptoms may indicate an
exacerbation (relapse) or pseudo--exacerbation
 Relapses or Exacerbations
 New symptom lasting >24 hours in the
absence of infection
 Could indicate a new lesion in the brain or
spinal cord
 Questions the patient regarding presence of
physical or emotional stress, injection side effect
 Consult physician for treatment with high-dose
steroids

Back 20

Exacerbation

Front 21

Most Common Presenting Symptoms
 ____ symptoms in arms/legs 33%
 Unilateral vision loss 16%
 Slowly progressive motor deficit 9%
 Diplopia (double vision) 7%
 Acute motor deficit 5%
 Multiple symptoms at onset 14%
 Others 16%

Back 21

Sensory

Front 22

Prognostic Indicators
 Factors associated with more
____ course:
– Female
– Onset before age 35
– Monoregional vs. polyregional lesions
– Sensory vs. motor symptoms
– Complete recovery after exacerbation

Back 22

favorable

Front 23

Prognostic Indicators
 Factors associated with ___ course:
– Male
– Onset after age 35
– Cerebellar symptoms (tremor,
nystagmus, dysarthria, ataxia)
– Poor recovery following exacerbations
– Frequent attacks

Back 23

less
favorable

Front 24

MS REHABILITATION

Rehab in MS is a process that helps a person
achieve and maintain maximal physical,
psychological, social and vocational potential,
and quality of life consistent with physiologic
impairment, environment, and life goals.
Achievement and maintenance of optimal
function are essential in a _____
disease such as MS.

Back 24

progressive

Front 25

Rehabilitation Principles
MS rehab is a philosophy of care
(traumatic injury vs. chronic illness)
• ____ approach with close
collaboration among team members
• Patient centered
• Intermittent and ongoing
• Teaching/learning
• Promotes wellness behaviors

Back 25

Multidisciplinary

Front 26

Rehab Can...
 Minimize the impact of existing
impairments on day to day
functioning
• Improve mobility
• Improve ADL’s/IADL’s
• Improve QOL
• Prevent complications
• Reduce health care utilization
• Improve safety/promote ____

Back 26

independence

Front 27

____ Intervention
 Focus on prevention of secondary
effects of the disease
 Education to empower the individual
and manage symptoms
 Support and motivate the individual
to follow treatment plan
 Looks to have a positive change in
behaviors

Back 27

Early

Front 28

Goal Setting
 Restorative after an exacerbation or a
decline to regain previous functional
abilities
 Preventative to maintain maximum function
in the face of a disease that may be
progressive
 Treatment goals should be developed to
meet individual needs and be consistent
with their priorities
 Goals must be attainable, realistic and
____ based

Back 28

functionally

Front 29

Rehab Assessment
 Rehab interventions can only be as good as
the assessments on which they are based
 Multidisciplinary evaluation is best
 Important to obtain baseline information to
track changes over time
 Periodic reassessments to revise treatment
plan and promote adherence
 Driven by patient identified priorities
 Use ____ tools as
often as possible

Back 29

standardized assessment

Front 30

Rehab Evaluation
 Ambulation/mobility
 Posture
 Balance
 Transfers
 Speech/swallowing
 Cognitive function
 Pain
 Vocational
 Bed mobility H ki /S lf
 ROM
 Strength
 Tone
 Coordination
 Sensation
 Proprioception
 Vision
 Homemaking/Self
Care
 Driving
 Home assessment
 Leisure skills
 Safety
 Equipment
 Endurance
 Communication

Back 30

ok

Front 31

Rehab Evaluation:
Other Considerations
 Fatigue
 Bladder/bowel disturbances
 Visual deficits
 Emotional concerns/depression
 Social support
 Environmental factors
 Other medical problems/diagnoses
 Medications and possible side effects
 ____ of evaluation

Back 31

Time of day

Front 32

Rehabilitation Assessment
_____ in MS
 Expanded Disability Status Scale
(EDSS)
 MS Functional Composite (MSFC)
 MS Quality of Life-54 (MSQOL-54)
 MS Quality of Life Inventory (MSQLI)
 Minimal Assessment of Cognitive
Function in MS (MACFIMS)

Back 32

Standardized Measures

Front 33

Other Rehab Assessments
 Box and Block Test of
Manual Dexterity
 MMT
 Grip
 Pinch
 Ashworth and Modified
Ashworth Spasticity Scale
 Modified Fatigue Impact
Scale
 6 minute walk
 9 Hole Peg Test
 Grooved Peg Test
 Barthel Index
 FIMS
 MVPT
 Symbol Digit
 MOCA
 Timed Up and Go
 Berg Balance Scale
 Functional Reach Test
 Tinetti Assessment Tool

Back 33

wow!

Front 34

EDSS (Expanded Disability Status Scale)
still remains ___ for research

 MSFC (Multiple Sclerosis Functional
Composite) recommended by the Task
Force on Clinical Outcomes Assessment
of the NMSS

Back 34

gold standard

Front 35

Progression to Disability—
Expanded Disability ____

10.0 = Death due to MS
9.0 - 9.5 = Completely dependent
8.0 - 8.5 = Confined to bed or chair
7.0 - 7.5 = Confined to wheelchair
6.0 - 6.5 = Walking assistance is needed
5.0 - 5.5 = Increasing limitation in ability to walk
4.0 - 4.5 = Disability is moderate
3.0 - 3.5 = Disability is mild to moderate
2.0 - 2.5 = Disability is minimal
1.0 - 1.5 = No disability
0 = Normal neurologic exam

Back 35

Status Scale

the gold standard for research = EDSS

Front 36

MS Functional ____

Developed in response to the
limitations of existing clinical
rating scales
• 25 foot walk
• 9 hole peg test
• Paced Auditory Serial Addition Test
(PASAT)

Back 36

Composite Measure

Front 37

Effects of ____
 Increased leg strength with increased gait speed,
decreased fatigue (White et al., 2005)
 Decreased time in functional skill (chair transfer)
with lower extremity weight training program
(Harvey et al., 1999)
 Improvements in functional tasks and increased
strength with resistive exercise program (Kraft et
al., 1996)
 Increased strength with lower body resistance
training program (Svensson et al., 1994)
 Improvements in muscle strength and endurance
with water exercise program (Gehlsen et al., 1984)

Back 37

Strength Training

Front 38

______ to Exercise
 Aerobic response is influenced by level of
impairment, but all individuals are able to
achieve a greater level of fitness
 During maximal exercise conditions, some
individuals with MS display a blunted HR
response
 Exercise endurance was not enhanced in
a “water” environment, but the perception
of muscle stress is less in water
 Positive impact on factors related to
quality of life
 Exercise did not result in an increased
_____

Back 38

Aerobic Responses

exacerbation rate

Front 39

Effects of Aerobic Training
 Improvements in ____ threshold and
QOL measures with 4 week aerobic
training program (Mostert et al., 2002)
 Improvements in aerobic capacity but no
improvement in gait parameters (Rodgers
et al., 1999)
 Increased aerobic capacity, increased
strength, decreased fatigue/anger and
depression (Petajan et al., 1996)

Back 39

anaerobic

Front 40

____ Cardiovascular
Reflexes in MS
 With minimal to moderate impairment,
cardiovascular responses during exercise
are not affected
 With moderate to severe impairment,
cardiovascular responses can be
adversely affected, HR and BP are
attenuated
 Sweat response abnormal in 42% to 60%
of individuals with MS

Back 40

Autonomic

Front 41

Interventions

 ____ skills training
 Therapeutic exercise with emphasis on home
exercise program or referral to community
based program
 Balance activities
 Coordination activities
 Gait skills
 Postural exercises
 Respiratory exercises
 Relaxation exercises
 Equipment recommendations/procurement
 Education/support/referral

Back 41

Functional

Front 42

Stretching
 Evaluate for
restrictions/____/
instability
 Tool for spasticity
management
 Recommend daily
stretching program

Back 42

spasticity

Front 43

Strengthening

 Determine which muscle groups are deficient
and what is the most appropriate form of
strengthening for that muscle group (active,
active-assisted or resistive)
 Determine which muscle groups, if
strengthened, will help attain the individual’s
functional goals
 Screen/educate regarding exercise philosophy
 Repetitions to ____
 Watch for joint instability secondary to muscle
weakness
 Recommend 3 to __ times per week

Back 43

fatigue

5

Front 44

Aerobic Training

 Determine exercise (patient interest,
availability)
 Instruct patient in perceived exertion scale
 Educate regarding ___ and
adapt environment or conditions as able
 Recommend 3 to 5 times per week

Back 44

heat sensitivity

Front 45

Precaution: ___ Sensitivity
 ___% of patients develop increased
symptoms with an increase in their
___ temperature
• Cool environment (AC, fans, pool, Schwinn
Air-dyne bike)
• Cooling vest or other cooling devices
• Ice slurry
• Use normal circadian rhythm (lowest core
temp in AM)
• Recognize “red flags” - blurry vision, numbness, tingling, dysarthria, vertigo, neurological s/s, sudden behavioral changes

Back 45

Heat

80%

core

Front 46

Key to MS Symptom
Management
 Signs and symptoms vary from person to
person or within the individual
 Fluctuation is based on ___
 Many symptoms have a cascade effect on
functioning
 Careful management can improve quality of
life
 Management must be individualized and
flexible in light of a dynamic condition

Back 46

circumstances

Front 47

FACTORS TO CONSIDER
WHEN SYMPTOMS CHANGE
 Infection
 Noxious Stimuli (i.e. pressure sores,
constipation)
 ____ (i.e. from
overheating)
 Exacerbation/progression
 “Current state of the neurological
system”

Back 47

Pseudoexacerbation

Front 48

AREAS MOST COMMONLY
ADDRESSED BY REHAB
 Mobility
 Fatigue
 Balance
 Cognition
 Spasticity
 Sensory changes
 Weakness
 Pain
 Tremor
 ADL’s/IADL’s
 Speech/swallowing
dysfunction

Back 48

ok

Front 49

FATIGUE
 Reported by up to ___% of individuals with
MS
 >50% report that it is their most ___
 ___ correlation between level of
impairment, gender, MRI findings or
clinical subtype
 Does correlate moderately with
depression and cognitive function

Back 49

90%

disabling
symptom

No

Front 50

Types of Fatigue
 Normal fatigue
 Neuromuscular fatigue or “short
circuiting”
 Depression related fatigue
 _____
– An overwhelming sense of tiredness
that cannot be attributed to an
identifiable cause

Back 50

Lassitude

Front 51

Measuring Fatigue
 Fatigue Severity Scale (FSS)
 Fatigue Impact Scale (FIS)
 Modified Fatigue Impact Scale (MFIS)
 Visual Analog for Fatigue

Back 51

ok

Front 52

Fatigue Management
 Light to moderate ____
 Cooling
 Energy effectiveness strategies
 Spasticity management
 Interspersed rest periods throughout the day
 Address sleep patterns
 Appropriate use of assistive devices
 Promote healthy lifestyle changes (stop smoking,
good nutrition)

Back 52

exercise

Front 53

Sensory Symptoms
 Numbness,
tingling
 Burning pain
 Dysesthesias
 Loss of sensation
 ____ sensation
around thorax

Back 53

Bandlike

Front 54

Sensory Symptoms
 Medications
 Sensory retraining
 Exercise
 Education

Back 54

i'm assuming this is tx

Front 55

COGNITION
 Estimates range from 45 to 60%
experience changes
 Only ___% suffer from severe
impairment
 Cognitive changes are often missed in
a standard neurological exam

Back 55

10%

Front 56

Cognitive Dysfunction Pie Chart

None = 50%
Moderate to severe = 10%
Mild = ___%

Back 56

40%

Front 57

Prevalence by Cognitive
Domain
Domains
 Memory ___%
 Information Processing 25%
 Problem Solving 20%
 Visual Spatial Abilities 20%
 Attention/concentration 10%
 Verbal fluency 10%
One domain: 50%
Multiple domains: 22%

Back 57

30%

Front 58

Managing Cognitive Changes
 Disease modifying
agents
 ____
strategies
 Neuropsychologic
al evaluation
 Cognitive
rehabilitation
 Patient and family
support

Back 58

Compensatory

Front 59

Depression
 Depression is common during the course of
MS: ___%
 Depression is a term applied to a wide
variety of mood disorders in MS
 Evidence suggests that depression may be a
result of the disease process
 Brain lesions in specific areas may increase risk
of depression
 Depression may occur at any time, even
when life is going well
 Suicide rate is ___ times higher in MS
population

Back 59

70%

7x

Front 60

Evaluating Depression
 The important factor in management is to
“recognize and acknowledge” the problem and
begin treatment
 Evaluation: ___ Depression Index II
 Sadness
 Sleep: change in sleep pattern
 Interest: less interest in pleasurable things
 Energy: change in energy level; fatigue
 Problems with thinking or concentration
 Appetite: Eating too much or too little
 Suicide: life is not worth living;
contemplating ending life
Consider any possible contributing medical causes!

Back 60

Beck

Front 61

Treatment of Depression
 Identification of the problem
 Evaluation of concurrent treatments
 Pharmacologic management (___,
tricyclic antidepressants)
 Counseling
 Ongoing assessment and reassessment
 Exercise is shown to improve mood and
sense of well being.

Back 61

SSRI

Front 62

PSYCHOSOCIAL IMPLICATIONS OF
MS SYMPTOMS

___ = perception of self: damaged, weak, giving in, less intelligent, less competent

___= fear of drinking fluids, fear of leaving home, embarrassment

____= misinterpreted as drunkenness or lack of intelligence

Back 62

Use of assistive device

bladder dysfunction

dysarthria

Front 63

SPASTICITY
 >___% of individuals with MS will have some
degree of spasticity
 Velocity-dependent increased resistance of
the muscle to passive movement
 Not always a negative sign if the individual
uses spasticity to assist with function

Back 63

>60%

Front 64

Assessment
 Assess impact of ____ on
– gait
– seating
– hygiene
– comfort level
– energy level/energy costs
– sexual activity

Back 64

spasticity

Front 65

______ Measures
 Ashworth/Modified Ashworth Scale
 Spasm Frequency Scale

Back 65

Spasticity

Front 66

___ Scale
SCORE CRITERIA
1 No increase in tone
2 Slight increase in tone
3 Marked increase in tone, but easily
flexed
4 Considerable increase in tone,
passive ROM difficult
5 Affected parts rigid in flexion or
extension

Back 66

Ashworth

Front 67

____ Scale
Score Criteria
0 No increased tone
1 Slight increased tone (catch and release at end of ROM)
1+ Slight increase in tone manifested by a catch followed by
min. resistance throughout the remainder of the ROM
(less than half the ROM)
2 Marked increase in tone through most of ROM but
affected part(s) move easily
3 Considerable increased tone, passive movement difficult
4 Affected part(s) rigid in flexion or extension

Back 67

Modified Ashworth

Front 68

____ Scale
0 No spasms
1 No spontaneous spasms except with vigorous
stimulation
2 Occasional spontaneous spasms and easily
induced spasms
3 More than 1 but less than 10 spontaneous
spasms per hour
4 More than 10 spontaneous spasms per hour

Back 68

Spasm Frequency

Front 69

Outcomes
 Prevent complications such as joint
____, pressure sores
 Ease pain
 Insure safety during mobility
 Improve posture
 Improve hygiene
 Improve ease of
movement/endurance

Back 69

contractures

Front 70

____ Management

 Stretching/ROM
 Aerobic conditioning
 Positioning
 Yoga
 Weight bearing
 Modalities
 Air splint
 Relaxation techniques/biofeedback
 Orthotics/Splinting
 Give feedback to medical team regarding effectiveness of
medication schedule
 Education

Back 70

Spasticity

Front 71

ITB (Intrathecal ____)
SynchroMed® Infusion System
Components

Pump - infuses drug at
programmed rate

Catheter - delivers drug to
the intrathecal space of
the spinal cord

Programmer - allows for
precise, adjustable
dosing

Back 71

baclofen

Front 72

Mobility Aids
• ___ (AFO’s, KAFO’s, etc..)
• Assistive Devices
• Canes (straight canes, small or large base quad
canes, Sure Foot)
• Loftstrand (forearm) crutches
• Walkers (standard, 2 wheeled, 4 wheeled)
• Manual wheelchairs/transport chairs
• Power mobility (scooters, power wheelchairs)
• Car/van modifications (left foot accelerator, hand
controls, etc..)

Back 72

Orthotics

Front 73

Walk-Aide Wireless FES
www.walkaide.com
 Needs to be fitted and customized
by a trained professional.
 System programmed using
software called “Walk Analyst”.
 Walk-Aide communicates with Walk
 Battery-operated single channel
 Utilizes a “tilt sensor” to control
Analyst using Bluetooth wireless
technology.
stimulation during normal gait.

Back 73

ok

Front 74

NESS L300™
Neuroprosthesis
www.bioness.com
 “L-300” --New wireless FES
 3 components: electronic
orthosis, control unit, and gait
sensor.
 Heel pad in shoe connects via
wire to clip on outside of shoe.
 Small stimulator is encased in
washable cuff around calf.
 Remote device is programmed by
a PDA (can be set for exercise or
walking)

Back 74

ok

Front 75

PAIN
 Until the 1980’s MS was often considered a painless
disease.
 It is now known that two thirds of all people with MS
experience pain at some time during the course of
the disease.
 Pain is a result of the disease itself as well as a
consequence of the disability it produces.
 Pain is not a ____ for poor disease outcome.

Back 75

predictor

Front 76

pain

Associated Symptoms
 Insomnia
 Anxiety
 Depression
 Weight loss
 Decreased quality of life
 Disturbed relationships
 Altered role

Back 76

ok

Front 77

____ Syndromes
 Trigeminal neuralgia
 Glossopharyngeal neuralgia
 Episodic facial pain
 Paroxysmal limb pain
 Tonic seizures
 Headache

Back 77

Acute Pain

Front 78

Subacute and ___ Pain
 Caused by the disease process or
acute worsening of MS symptoms
 Treating the cause usually alleviates
the pain
 Examples: optic neuritis, infection,
UTI, urinary retention, flu, pressure
sores

Back 78

Secondary

Front 79

____ Pain
 Pain caused by MS therapies
 Examples: flu like symptoms,
headache, injection site reactions
associated with interferon treatment,
steroid induced pain of osteoporosis,
avascular necrosis
 Treatment: ____

Back 79

Iatrogenic

Prevention

Front 80

Chronic Pain
____ extremity
pain
Spasticity
Musculoskeletal pain

Back 80

Dysesthetic

Front 81

____ Musculoskeletal Pain
 Causes
– weakness
– stress on bones, joints and
muscles
– immobility
– use of compensatory muscles

Back 81

Chronic

Front 82

Treatment for Musculoskeletal Pain
 Physical therapy assessment
 NSAID’S
 Ice
 Exercise
 Position change
 Support
 Prevention
 Pressure ___

Back 82

stocking or glove

Front 83

____ Problems
 Those who are less mobile may be
susceptible to respiratory complications
 Problems are not necessarily correlated
to disease course
 Sleep apnea and pneumonia have been
associated with MS
 Don’t forget to address respiratory status
early in the disease.

Back 83

Pulmonary

Front 84

CAM
 Herbs
 Vitamins
 Diet
 Acupuncture
 Massage
 Tai Chi
 Exercise/Yoga
 Meditation/Centering
 Homeopathy
 Hypnotherapy
 Biofeedback
 Chiropractic Medicine
 Electromagnetic Therapy
 Hyperbaric Oxygen

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CAM: Herbs
 Cranberry: Prevention of UTI
 Ginko Biloba: May improve cognition
 Kava Kava: May improve anxiety
 St. John’s Wort: May improve mild
depression
 Valerian: May improve insomnia

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CAM Treatments With Possible
Immunostimulating Effects
 Alfalfa
 Astragalus
 Betacarotene
 Ginseng
 Goldenseal
 Grape seed extract
 Cat’s Claw
 Coenzyme Q10
 DHEA
(dehydroepiandro
esterone)
 Echinacea
 Garlic
p
 Licorice
 Melatonin
 Saw plametto
 Selenium
 Vitamin A, C, and E
 Zinc

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____ AND MS
 General health and wellness are often
neglected in multiple sclerosis
 It is important to recognize that people
with MS often face other acute or chronic
problems
– Disease states such as hypertension,
osteoporosis, allergies, diabetes,
cancer, arthritis, cardiac dysfunction
and others must be considered in the
rehab plan

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WELLNESS

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PREGNANCY AND MS
 Pregnancy has a positive effect on
exacerbation rates. As a pregnancy
progresses the exacerbation rate ___.
 After delivery the exacerbation rate
increases for the first ___ months.
 Resuming their MS medications
immediately after delivery is
recommended and may impact a woman’s
ability to breast feed.

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declines

3 – 6

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Wellness Promotion
 Encourage “well” visits
 Promote smoking cessation
 Good nutrition/maintain healthy weight
 Adequate rest/sleep patterns
 Emotional well-being/stress management
 Spiritual
 Balance

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The Take Home Message:
Hope
 Realistic hope
 Informed decision
making
 Empowerment
 Self-efficacy
 Wellness-seeking
behaviors

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