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Referat general Ligia Robnescu Tratamentul de reabilitare n scleroza

Referat multipl
general

Tratamentul de reabilitare n scleroz multipl


The rehabilitation treatment in multiple sclerosis

Ligia Robnescu1, Cristina Bojan2


Rezumat

Scleroza multipl (SM) este cauza major a dizabilitilor neurologice ale adolescenilor i adulilor de vrst medie.
Impactul SM asupra vieii celor afectai este considerabil, pe de o parte din cauza faptului c evoluia acestei maladii este
imprevizibil, iar pe de alta parte din cauza c efectele i simptomele sunt extrem de variabile.
Pentru pacienii cu MS, fizioterapia va fi una din multiplele componente ale tratamentului i cuprinde stratching, exerciii active
aerobe, hidroterapie, electrostimulri, infiltraii cu toxin botulinic, ortezare etc.
Este foarte important s se analizeze informaiile necesare evaluarii activitilor cotidiene, deci specialistul n terapie ocupaional
are un rol important n echipa terapeutic.
MS se asociaz i cu tulburri cognitive, afective, de comportament, n proporie semnificativ. Psihologul face de asemeni parte
din echipa responsabil de procesul de reabilitare.
Cuvinte cheie: scleroza multipl, fizioterapie, terapie ocupaional, reabilitare psihic.

Abstract

Multiple sclerosis (MS) is the major cause of neurological disability in young and middle aged adults.
The impact of MS upon the lives of those affected can be enormous, partly because the course of the illness is unpredictable and
partly because its effects and symptoms are so protean.
For the people with MS, the physiotherapy will be one of several treatments. Type of intervention: stratching, active aerobic
exercices, hydrotherapy, electrical stimulations, injections of botulinum toxin, orthotics, a.s.o.
It is important to know exactly what information is required from an assessment of activities of daily living, therefore the oc-
cupational therapist has a role as part of the care team.
MS are associated with cognitive, affective and behavioural deficits in a significant proportion. The neuropsychologist works
within a team, particularly in rehabilitation settings.
Key words: multiple sclerosis, physiotherapy, occupational therapy, neuropsychological rehabilitation.

1 Medic specialist recuperare medical, Bucureti Scleroza multipl (SM) este afeciunea caracteri-
2 Kinetoterapeut, Bucureti zat prin triada: - inflamaie, demielinizare, glioz.
Adres de corespon:
Are o evoluie progresiv sau n pusee evolutive.
Spitalul Clinic de Psihiatrie Prof. Dr. Alexandru Obregia Prezint tulburri neuromotorii (paralizii, spastici-
Clinica de Neuropediatrie, oseaua Berceni, Sector 4, Bucureti tate, ataxie, tremor, dismetrie, vertij, dureri neurogene,
scderea forei musculare), tulburri oftalmologice,
1 MD, medical rehabilitation, Bucharest cognitive,depresie, anxietate, sau dimpotriv: euforie,
2 Kinetotherapist, Bucharest veselie, exacerbate.
Tratamentul de reabilitare se adreseaz att formei
Correspondence address:
Prof. Dr. Alexandru Obregia Psychiatry Clinic Hospital
alternante, ct si celei staionare.
Clinic of Paediatric Neurology, Berceni street, Sector 4, Bucharest Funcional, boala are 4 stadii:

Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 3 41
Ligia Robnescu Tratamentul de reabilitare n scleroza multipl Referat general

Stadiul I: independen n viaa socio-profesional. accentuarea aplicrii fizioterapiei funcionale


Stadiul II: se modific tonusul muscular, apar pa- furnizarea de suport pentru a menine motivaia
reze, tulburri de coordonare, de echili- i cooperarea pacientului la terapie
bru bolnavul devine semidependent. implmentarea terapiilor preventive
Stadiul III: deficit motor, tulburri cerebeloase i educarea pacientului pentru nelegerea simp-
vestibulare, mersul devine imposibil. tomatologiei SM i cum i afecteaz aceasta viaa
Stadiul IV:  deteriorare fizic i psihic grav, de zi cu zi.
depende total. Scopurile fizioterapiei: (Bjenaru)
Kurtzke a realizat o scal cu 10 puncte de apreci- meninerea stabilitii posturale corecte
ere a dizabilitilor n SM, de care se va ine seama n conservarea i ameliorarea mobilitii articulare
prescripiile terapeutice: prevenirea contracturilor i atrofiilor musculare
0 = examen neurologic normal. ameliorarea funciilor vitale, mai ales a respiraiei
1 = fr disfuncii, dar Babinsky pozitiv, semne meninerea greutii corporale n limite acceptabile
premonitorii ale ataxiei, scade sensibilitatea inhibarea schemelor motorii nedorite
la vibraie. conservarea pe ct posibil a posibilitii de deplasare
2 = deficit minim: uoar rigiditate, uoare tulbu- asigurarea unei autonomii, chiar n fotoliul rulant
rri de mers, nendemanare, uoare scderi ale ameliorarea coordonrii
forei musculare, tulburri vizuale. ameliorarea tulburrilor cerebeloase
3 = monoparez, hemiparez, tulburri oculare utilizarea corect a ortezelor.
medii, disfuncii combinate.
4 = disfuncie relativ sever, dar bolnavul poate munci. Evaluarea bolnavului
5 = disfuncie sever, mers dificil, dar fr sprijin.
6 = mers cu baston sau crje. a. Fatigabilitatea
7 = utilizeaz scaun cu rotile. Este prezent n 78% din cazuri (Freal)
8 = bolnavul rmne la pat, dar se folosete de Evaluarea n funcie de scala severitii fatigabili-
membrele superioare. tii (Krupp):
9 = devine total dependent. tipul de fatigabilitate n timpul zilei
10 = exitus. perioada din zi cnd energia pacientului este
Recomandarea este ca reabilitarea s intervin pre- bun, rezonabil sau sczut
coce, cnd deficitul motor este incipient. (Freeman). activitile sau ocaziile cu fatigabilitate crescut
Atitudinea kinetoterapeutului fa de bolnav este (de ex. la temperaturi ridicate)
crucial din prima edin, de acest moment depinde  impactul funcional al fatigabilitii asupra
colaborarea terapeut-bolnav. activitilor zilnice
Succesul tratamentului nu e determinat numai dac oboseala este localizat la un anumit grup
de mbuntirea posibiliilor pacientului, ci mai muscular (de ex. flexorii dorsali ai piciorului), o
degrab dac acesta realizeaz cel mai nalt nivel al parte a corpului sau un sistem functional (vorbirea)
unei activiti n fiecare etap a bolii i dac inta pe dac fatigabilitatea central este cauza unei exce-
care i-a propus-o este realizat. (Ashburn, De Souza) sive oboseli. Oboseala excesiv asociat cu posi-
Kinetoterapia necesit o strict individualizare n biliti zilnice reduse are influene nefaste asupra
cazul SM i acioneaz n special asupra dizabilit- activitilor zilnice.
ii, neintervenind asupra leziunilor sau n schimbarea b. Activitile vieii cotidiene:
progresiei maladiei. Este important cunoaterea informaiilor obi-
Terapia antreneaz pacientul n activiti individu- nute de ctre evaluarea activitilor cotidiene, aceas-
ale bazate pe evaluarea bolnavului i se va constitui n ta necesitnd explorarea mediului social i familial al
funcie de motivaia acestuia.(OHara, Williams) bolnavului.
Principiile fizioterapiei: (Ashburn, De Souza) Efectele fatigabilitii i pun amprenta asupra ac-
stimularea strategiilor de micare tivitilor vieii cotidiene, necesitnd ajutor din par-
stimularea nvrii abilitilor motorii tea familiei. (Williams)
mbuntirea calitii modelelor de micare c. Evaluarea cognitiv:
diminuarea anormalitii tonusului muscular Este important n disfunciile cognitive din SM,

42 Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 3
Referat general Ligia Robnescu Tratamentul de reabilitare n scleroza multipl

necesitnd expertiza psihologului viznd tulburri n timpul puseelor evolutive nu se fac dect: (Kiss)
cognitive, lingvistice, depresii. o mobilizri pasive de 3-4 ori pe zi
d. Autoevaluarea pacientului: o posturare corect pentru:
Participarea bolnavului la evaluarea proprie va fi 1. conservarea supleei musculare
ncurajat i intereseaz: 2. meninerea troficitii esuturilor
percepia proprie asupra abilitii i limitelor sale 3. meninerea mobilitii articulare
aprecierea de a face fa unor activiti 4. prevenirea retraciilor musculo-tendinoase
dorina de schimbare 5. prevenirea atrofiilor musculare
prioritile personale i ce dorete din partea te- 6. asigurarea funciilor vitale, mai ales n stadiul IV.
rapeutului. 2. Tipurile de intervenie (Arndt, Bjenaru, De
Souza):
Intervenia fizioterapiei: A. Stratching o procedur valoroas pentru re-
ducerea hipertoniei
1. Coordonarea terapiei :
B. Exerciii aerobe pasivo-active i active pentru
cnd se institue terapia n cursul bolii
meninerea mobilitii
ct timp se institue terapia.
Exerciiile aerobe sunt foarte importante pentru
n stadiul funcional I al SM, nu se recomand
efortul cardio-vascular, previn scderea forei muscu-
fizioterapie specific, dar kinetoterapeutul trebue s
lare, se reduce riscul provocat de inactivitatea fizic.
fac parte din echip, urmrind evalurile pacientului.
Atenie! Intensitatea exerciiilor s nu provoace obo-
(Freeman).
seal accentuat, acestea se vor adapta posibilitilor pa-
- Pentru dizabilitile minime se recomand exer-
cientului.
ciii generale de tonificare, managementul posturii i
Nu se vor practica exerciii sub rezisten!
al fatigabilitii. (Kiss)
Aspecte particulare ale kinetoterapiei n cazuri-
n stadiul II se execut:
le unde predomin sindromul hipertonic:
masaj circulator blnd al musculaturii
Atenie! Nu vom combate hipertonia la bolnavii
mobilizri pasive lente
care folosesc spasticitatea pentru a-i menine ortos-
crioterapie pe tendon tatismul, transferul, sau pentru balansul membrelor
mobilizri n cadrul schemelor Kabat inferioare n cazul deplasrii cu crje. (De Souza)
stimulri electrice i vibratorii pe musculatura n SM unele grupe musculare au tendina de a
antagonist celei spastice amplifica spasticitatea, n timp ce antagonitii vor
exerciii pentru corecia tulburrilor de echilibru avea un tonus sczut. Aceast imbalan va duce la
exerciii de relaxare contracturi, retracii, deci deformri.
hidroterapie (temperatura apei s nu depeasc Grupele musculare care dezvolt contracturi:
30 de grade) Membrele superioare:
pentru reantrenarea propriocepiei se folosete a. adductori, rotatori ai umrului
feed-back cu semnalizare acustic i vizual b. pronatori antebra
terapie ocupaional. c. flexori cot
Exerciiile se execut de 1-3 ori pe zi, 15 zile con- d. flexori pumn i degete
secutiv, sau o zi da, una nu, minimum 5-6 etape pe Trunchi:
an. (Kiss) a. rotatori trunchi
n stadiile III i IV: (De Souza, Freeman, Kiss) b. flexori laterali ai trunchiului
programul anterior se continu Membre inferioare:
profilaxia sechelelor ortopedice a. flexori articulaia coxo-femural
verticalizarea bolnavului pentru combaterea b. flexori ai genunchiului
tulburrilor circulatorii i a osteoporozei c. flexori plantari picior
masaj blnd d. inversori picior
prevenirea escarelor prin meninerea igienei, Aspecte particulare ale kinetoterapiei la bolna-
schimbarea frecvent a posturilor vii unde predomin elementele ataxice (Arndt, De
n general se va urmri evitarea apariiei oboselii Souza, Freeman, Plissier):
n timpul exerciiilor. Ataxia se ntlnete frecvent n SM i se asociaz

Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 3 43
Ligia Robnescu Tratamentul de reabilitare n scleroza multipl Referat general

deseori cu spasticitatea, alteori cu tulburri senzitive, special pentru fibrele rapide, diminund activi-
vizuale sau sfincteriene. tatea reflex i spasticitatea prin scderea valo-
Pacienii ataxici demonstreaz inabilitate n a re- rii clcului.
aliza micrile care solicit muchilor o aciune de Doza: 25-400mg/zi.
grup, anume contracia. Dup unii autori, baclofenul i dandrolenul scad
n mers exist dificulti n sprijinul unipodal n mult fora muscular, agravnd deficitul existent.
momentul contraciei muchilor membrelor inferi- Baclofenul poate genera uneori sindroame confuzi-
oare, concomitent cu necesitatea proieciei greutii onale, cu alterarea funciilor cognitive. ( Plissier, Viel).
corpului spre nainte. Tizanidin (zanaflex) acioneaz tot pentru
Compensarea se realizeaz deseori prin ajutoare scderea spasticitii, dar este potenial hepa-
de mers, de exemplu cadrul de mers. totoxic.
Deficiene posturale n ataxie: Doza: 8-32mg/zi.
a. lordoza lombar exagerat Benzodiazepine (diazepam, clonazepam)
b. anteversia pelvisului utilizate n special mpotriva crampelor
c. flexia articulaiei coxo-femurale i spasmelor musculare din timpul nopii.
d. hiperextensia genunchilor Doza de diazepam: 2-40mg/zi.
e. greutatea corpului n mers este la nivelul F. Infiltraiile cu toxina botulinic, cu efect 3-4
clciului luni, care se pot repeta (Snow). Sunt indicate
f. grifa degetelor piciorului mai ales pentru spasticitatea adductorilor coap-
g. dezechilibru n mers. sei, psoas iliac, tensorul fasciei lata.
C. Hidroterapia (este un capitol controversat). G. Alcoolizare a nervului obturator cu soluie al-
Unii autori recomand imersii n apa la maximum cool 66 de grade, dupa reperarea nervului prin
30 de grade, proceduri ce ar fi benefice pentru dimi- stimuli electrici.
nuarea spasticitii (Forsythe) H. Tratament chirurgical tenotomia adductori-
Alii le contest, motivnd c ar crete senzaia de lor coapsei, neurotomii.
oboseal. I. Ortezare - se folosesc lombostate n cazul dure-
Sunt autori care recomand bi n ap rece ntre rilor la nivelul articulaiilor intervertebrale, orte-
25 de grade 27 de grade care ar favoriza relaxarea ze gamb-picior.
muscular, sau mbrcmite rece la nivelul trunchiu- Folosirea crjelor i a deambulatorului este discu-
lui, pentru reducerea fatigabilitii i a durerii (Plis- tabil (De Souza, Plissier).
sier, Pellas). Avantajele ajutoarelor pentru mers:
De Souza nu recomand aplicaiile de ghea la cresc stabilitatea, sigurana
pacienii cu circulaie periferic precar. reduc riscul cderii
n multe cazuri ns, aplicaiile cu ghea pe ten- mresc distana de deplasare
doanele muchilor spastici au fost benefice. mresc viteza de deplasare
D. Stimulrile electrice (Worthington) reduc fatigabilitatea.
Electrostimulrile de joas frecven se aplic Dezavantajele ajutoarelor pentru mers:
dup o selecie atent a pacienilor i n contextul tra- scad capacitatea membrelor inferioare de a su-
tamentului complet cu exerciii active i stratching. porta greutatea corpului.
E. Tratamentul medicamentos (Hauser, Plissier, Snow) scad fora muscular a membrelor inferioare.
Baclofen (lioresal) - implic sistemul scad reaciile de echilibru
GABA, utiliznd ageni inhibitori ai eliberrii scad tonusul muscular
neurotransmitorilor sinapsei la nivelul moto- apar anomalii de postur (flexia coapsei, flexia
neuronilor. Scade hipertonia la nivelul recepto- lateral a trunchiului)
rilor din trunchiul cerebral i mduv. La noi funcia membrelor superioare poate fi compromis.
se utilizeaz per os, n alte ri se administreaz Este preferabil ca bolnavul s fie sftuit s nu folo-
foarte frecvent intratecal prin pomp. (foarte seasc deambulatorul i carjele pe ct posibil.
costisitor). Se recomand ns verticalizatorul, unde bolnavul
Doza: 20-120mg/zi. menine ortostatismul. Folosit zilnic ajut la menine-
Dandrolenul reduce contracia muchilor, n rea tonusului, reduce frecvena spasmelor musculare,

44 Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia 2012 vol. 15 nr. 3
general study Ligia Robanescu Rehabilitation Therapies in Multiple Sclerosis

stimuleaz activitatea extensorilor. (Brown) n timpul mersului


Evident c la pierderea total a deplasrii se va fo- ameliorarea controlului micrilor de la cele
losi fotoliul rulant. simple la cele mai complexe
n cazul pacienilor nedeplasabili, fizioterapia se ncurajarea micrilor extremitilor n relaie
va concentra asupra: cu axul corpului (rotaii)
corectarea deficitului respirator creterea stabilitii proximale a membrelor
stimularea tusei, pentru a nu se acumula ncurajarea coordonrii activitii grupelor
secreii, sput musculare agonist-antagonist
realizarea contraciei i relaxrii musculaturii reducerea necesitii de ghidare vizual a
membrelor superioare micrii.
masaj blnd, micri pasive pentru mobilitate Rolul familiei bolnavului
articular Este esenial. Fizioterapeutul, ergoterapeutul, psi-
corecie i suport pentru postura eznd i de- hologul, au un rol important n instruirea familiei
cubit dorsal pentru manipularea bolnavului i stimularea acestuia.
stratching pentru musculatura spastic (Mc Queen)
schimbri frecvente ale posturilor
Concluzii:
tehnici protective pentru integritatea tegumentelor
stimularea contraciei musculare active SM este una din cele mai complexe i variabile
ridicri asistate n eznd i ortostatism, n afeciuni ntlnite de specialitii n reabilitare.
funcie de tolerana pacientului. O echip multidisciplinar are sarcina de a oferi o
Obiectivele tratamentului fizioterapic: ngrijire continu i mai ales un suport psihologic per-
creterea stabilitii posturale manent familiei i pacientului, s-i ctige ncrederea
creterea controlului centrului de greutate n acestuia, s-l nvee s triasc cu maladia, ncercnd
momentul alternrii greutii corpului permanent mbuntirea calitii vieii.

*
* *
Multiple sclerosis (MS) is characterized by the Kurtzke developed a 10-point scale for assessing
triad disease: disability in MS, which will be taken into conside
- inflammation, ration especially in therapeutic prescriptions:
- demyelination, 0 = normal neurological exam.
- gliosis. 1= no impairment, but Babinsky+, premonitory
It has a progressive evolution or it advances in evo- signs of ataxia, decreased sensitivity to vibration.
lutionary outbursts. It is characterised by neuromo- 2 = minimal deficit: mild rigidity, mild gait, clum-
tor abnormalities (paralysis, spasticity, ataxia, tremor, siness, slight decreases in muscle strength, vi-
dysmetria, vertigo, neurogenic pain, and decreased sual disorders.
muscle strength), eye and cognitive disorders, depres- 3 = monoparesis, hemiparesis, moderate visual dis-
sion, anxiety, or the contrary: euphoria, exaggerated orders, combined dysfunction.
joy. Rehabilitation treatment addresses both the alter- 4 = quite severe dysfunction, but the patient can work.
nating form, as well as the stationary one. 5 = severe dysfunction, gait difficulty, but without
Functionally, the disease has 4 stages: support.
Stage I: independence in social and professional life. 6 = walking with a cane or crutches.
Stage II: muscle tone changes, pareses, impaired 7 = use of wheelchair.
coordination and balance - the patient 8 = patient remains in bed, but is still using the
becomes partially dependent. upper limbs.
Stage III: motor deficit, cerebellar and vestibular 9 = patient becomes totally dependent.
disorders, walking becomes impossible. 10 = death can occur.
Stage IV: severe physical and mental damage, to- Recommendation is that rehabilitation should
tal dependence. intervene early, when the motor deficit is incipient.

Journal of Romanian Child and Adolescent Neurology and Psychiatry 2012 15th vol. no. 3 45
Ligia Robanescu Rehabilitation Therapies in Multiple Sclerosis  general study

(Freeman). The therapists attitude to the patient is If fatigue is localized in a particular muscle group
crucial starting from the first session, because the (eg. Dorsal flexors of the foot), in a part of the
therapist-patient collaboration depends on it. Treat- body or in a functional system (speech)
ment success is not determined solely by improving If central fatigue is the cause of excessive fatigue;
the patients possibilities, but rather whether he or Excessive fatigue associated with reduced daily
she achieves the highest level of activity in each stage opportunities has negative influences on daily
of the disease and if he or she reaches the proposed activities.
target. (Ashburn, De Souza) In MS, physical therapy b) Daily life activities:
requires strict individualization and acts mainly on - It is important to know the information obtained
the disability, without intervention on the lesions or by the assessment of daily activities. This requires ex-
in changing disease progression. ploring the patients social and family environment.
Therapy involves the patient in individual activi- - Fatigue effects are reflected in the activities of
ties based on patient evaluation and it will be based daily life, requiring help from family. (Williams)
on his or her motivation. (OHara, Williams) c) Cognitive assessment:
Physiotherapy principles: (Ashburn, De Souza) It is important for cognitive dysfunction in MS,
Stimulating movement strategies requiring psychologist expertise regarding cognitive
Stimulating learning motor skills and language disorders, depression.
Improving quality of movement patterns d) Patient self-assessment:
Reducing muscle tone abnormality Patient participation in their self-assessment will
Increased application of functional physiotherapy be encouraged and it should focus on:
Providing support to maintain patient motiva- Self-perception of own abilities and limits
tion and cooperation in therapy Appreciation of the ability to cope with certain
Implementation of preventive therapies activities
 Educating the patient in understanding MS Desire for change
symptoms and in how they affect his/her daily life. Personal priorities and what he/she expects from
Physiotherapy purposes: (Bajenaru) the therapist.
Maintaining correct postural stability
Conservation and improvement of joint mobility Physiotherapy intervention:
Prevention of contractures and muscle atrophy
Improvement of vital signs, especially respira- 1. Coordination of therapy:
tory ones W hen treatment is introduced in the course of
Maintaining body weight within acceptable limits the illness
Inhibition of unwanted motor schemes The length of time therapy is established.
Preserving of the ability to move as long as In functional stage I of the MS, specific physio-
possible therapy is not recommended, but the therapist should
Ensuring autonomy, even in a wheelchair be part of the team, keeping trace of the patients as-
Improving coordination sessments. (Freeman).
Improvement of cerebellar disorders - For minimum disability, general toning exercises
Proper use of orthotic devices. are recommended together with the posture and fa-
tigue management. (Kiss)
Assessment of the patient Physical activities in stage II:
Circulatory gentle massage of the muscles
a) Fatigue. It is present in 78% of cases (Freal). Slow passive joint mobilization
It is assessed based on fatigue severity scale (Krupp): Cryotherapy on tendon
Type of fatigue during the day Mobilization using Kabats techniques
Time of day when patients energy is good, rea- Electrical and vibratory stimulation on muscles
sonable or low antagonist to the spastic ones
Activities or opportunities with increased fa- Exercises for the correction of balance disorders
tigue (eg. At high temperatures) Relaxation exercises
Functional impact of fatigue on daily activities Hydrotherapy (water temperature should not

46 Journal of Romanian Child and Adolescent Neurology and Psychiatry 2012 15th vol. no. 3
general study Ligia Robanescu Rehabilitation Therapies in Multiple Sclerosis

exceed 30 degrees) Muscle groups that develop contractions:


To retrain proprioception feedback with acous- Upper limbs:
tic and visual signals is used a. adductor, rotator of the shoulder
Occupational therapy. b. pronator forearm
Exercises are performed 1-3 times per day, 15 days c. elbow flexors
consecutively, or one day yes, one does not, at least 5-6 d. fist and finger flexors
stages a year. (Kiss) Trunk:
In stages III and IV: (De Souza, Freeman, Kiss) a. trunk rotators
the previous programme continues b. lateral trunk flexors
prevention of orthopaedic sequelae Lower limbs:
verticalization of the patient for combating cir- a. hip flexors-femoral joint
culatory disorders and osteoporosis b. flexors of the knee
gentle massage c. foot plantar flexors
prevention of bedsores by maintaining hygiene, d. inversor muscles of the leg
frequent posture changes Particular aspects of physical therapy in patients
generally, fatigue during exercise will be avoided. where ataxia elements predominate (Arndt, De
During the evolutionary crises, the only physi- Souza, Freeman, Plissier):
cal exercises are: (Kiss) Ataxia is frequently found in MS and is often asso-
o Passive mobilization 3-4 times a day ciated with spasticity, but sometimes with severe sen-
o correct posture strengthening in order to: sory disorders, concerning either vision or the sphinc-
1. preserve muscle suppleness ter muscles. Ataxic patients demonstrate inability to
2. maintain the tissue trophicity perform movements that require the muscles to act
3. maintain joint mobility in a group, namely the contraction. In walking, there
4. prevent muscular-tendinous retractions are difficulties in unipodal support at the moment of
5. prevent muscle atrophy lower limbs muscle contraction, concomitantly with
6. secure vital functions, especially in stage IV the need for forward projection of the body weight.
2. Types of intervention (Arndt, Bajenaru, De Compensation is often achieved by walking aids, such
Souza) as the walker.
A. Stretching - a valuable procedure to reduce Postural deficiencies in ataxia:
hypertonia a. exaggerated lumbar lordosis
B. Passive-active and active aerobic exercises to b. pelvic anteversion
maintain mobility c. hip-femoral joint flexion
Aerobic exercises are very important for the car- d. hyperextension of the knee
dio-vascular effort, they prevent the decrease in mus- e. Bodyweight while walking is at heel level
cle strength; the risk caused by physical inactivity is f. curling of toes
thus reduced. g. walking imbalance.
Warning! The intensity of the exercise should not C. Hydrotherapy (is a controversial chapter).
cause excessive fatigue, they will adapted to patients Some authors recommend full immersion in water
abilities as far as possible. Exercises should not surpass at 30 degrees Celsius; these procedures would be ben-
the patients endurance! eficial to reduce spasticity (Forsythe). Others object to
Particular aspects of physical therapy in cases them, saying that they would increase fatigue. There
where the hypertonia syndrome predominates. are authors who recommend baths in cold water be-
Warning! We will not address hypertonia in pa- tween 25 - 27 degrees which would favour muscle
tients who use spasticity to maintain orthostatic pos- relaxation or cold clothes at trunk level to reduce fa-
ture, the transfer, or for the balance of the legs when tigue and pain (Plissier, Pellas). De Souza does not
moving with crutches. (De Souza). recommend ice applications in patients with poor pe-
In MS, some muscle groups tend to increase spas- ripheral circulation. In many cases, however, ice ap-
ticity, while the antagonists will have a low tone. This plications on spastic muscle tendons were beneficial.
imbalance will lead to contractures, retractions, name- D. Electrical stimulation (Worthington)
ly to distortions. Low-frequency electrostimulation is applied after

Journal of Romanian Child and Adolescent Neurology and Psychiatry 2012 15th vol. no. 3 47
Ligia Robanescu Rehabilitation Therapies in Multiple Sclerosis  general study

a careful selection of patients and in the context com- limit the ability of the lower limbs to bear body
plete treatment with active exercises and stretching. weight.
E. Medications (Hauser, Plissier, Snow) lower leg muscle strength.
Baclofen (Lioresal) - involves the GABA lower equilibrium reactions
system, using agents that inhibit the release decrease muscle tone
of neurotransmitters in the motor neuron develop abnormal posture (thigh flexion, lat-
synapse. Hypertonicity decreases at the lev- eral flexion of the trunk)
el of the receptors from the brainstem and upper limb function may be compromised.
spinal cord. In Romania, it is used per os, Preferably, the patient should be advised not to
in other countries it is frequently adminis- use crutches and the deambulator for as long as pos-
tered intrathecally by pump. (very expensive). sible. We recommend the deambulator when patient
Dose: 20-120mg/day. maintains upright position. Used daily, it helps main-
Dandrolen - reduces muscle contraction, espe- taining tone, reduces the frequency of muscle spasms,
cially for fast fibers, reducing the reflex activity stimulates the activity of extensors. (Brown)
and spasticity by subtracting calcium. Obviously, when the loss of movement is total, the
Dose: 25-400mg/day. patient will use a wheelchair.
According to some authors, baclofen and dandro- In the case of homebound patients, physical ther-
len lower muscular strength very much, aggravating apy will focus on:
the existing deficit. Baclofen can sometimes lead to correction respiratory deficit
confusion syndromes with impaired cognitive func- stimulating coughing, so that secretions, spu-
tions. (Plissier, Viel). tum does not accumulate
Tizanidine (Zanaflex) also reacts to re- achieving muscle contraction and relaxation of
duce spasticity, but is potentially hepatotoxic. the upper limbs
Dose: 8-32mg/day. gentle massage, passive joint mobility move-
Benzodiazepines (diazepam, clonazepam) ments
mainly used against muscle cramps and spasms correction and support for sitting and supine
of the night. posture
Dose of diazepam: 2-40mg/day. stretching for spastic muscles
F. Infiltration with botulinum toxin, having an frequent changes of postures
effect for 3-4 months, then treatment may be protective techniques for skin integrity
repeated (Snow). It is indicated especially in the stimulation of active muscle contraction
spasticity of thigh adductors, psoas iliac, tensor assisted lifting into sitting and standing posi-
fascia lata. tion, depending on patient tolerance.
H. Fortifying the obturator nerve with alcohol Aims of physiotherapy treatment:
solution 66 degrees, after locating the nerve by increase in postural stability
electrical stimuli. increase of control on the weight centre when
I. Surgery - thigh adductors tenotomy, neurotomies. body weight is alternating during walking
J. Orthotics lumbar orthosis used for interver- improvement of control on the movements
tebral joint pain, from the simple to the complex ones
calf and foot orthoses. encouraging the movements of extremities in
The use of crutches and deambulators is question- relation to body axis (rotations)
able (De Souza, Plissier). increased proximal stability of limbs
Benefits of walking aids:
fostering the coordination of the activities of
increase stability, security
agonist-antagonist muscle groups
reduce the risk of falling
reducing the need for visual guidance of the
increase the travel distance
movement.
increase speed The role of patients family
reduce fatigue. It is essential. The physiotherapist, the occupation-
Disadvantages of walking aids: al therapists, and the psychologist, have an important

48 Journal of Romanian Child and Adolescent Neurology and Psychiatry 2012 15th vol. no. 3
general study Ligia Robanescu Rehabilitation Therapies in Multiple Sclerosis

role in training the family how to handle and stimu- ists. A multidisciplinary team is tasked to provide
late the patient. (Mc Queen) continuous care and especially permanent psycho-
logical support to the family and to the patient, to
Conclusions: win his/her confidence, to teach them to live with
the disease, always trying to improve the quality
MS is one of the most complex and variable of life.
diseases encountered by rehabilitation special-

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