Rehabilitation in multiple sclerosis: mobility, fatigue and cognition

The NHS describes MS as a condition affecting the brain and spinal cord, with symptoms that include fatigue, vision problems, numbness, balance and coordination difficulties, muscle spasms and stiffness, bladder problems and trouble with memory or concentration. Symptoms may come and go in relapses and remissions or, in progressive forms, worsen over time. Because the picture changes, rehabilitation is repeated rather than one block of treatment.

NICE recommends a coordinated multidisciplinary approach involving MS nurses, consultant neurologists, physiotherapists and occupational therapists with MS expertise, speech and language therapists, psychologists, dietitians, social care, continence specialists, specialist pharmacists, rehabilitation medicine consultants and the primary care team. MS Trust explains that people with MS may see rehabilitation specialists that others with MS do not, depending on their needs, and that goals should be tailored to health needs.

NICE says people with MS and mobility problems should be able to have an assessment to set individual goals, usually involving rehabilitation specialists and physiotherapists with MS expertise. It suggests considering vestibular rehabilitation for people whose fatigue or mobility problems are linked to limited standing balance, and supervised exercise programmes that combine moderate progressive resistance training and aerobic exercise.

MS Trust describes physiotherapy as particularly useful for stiffness, balance, spasticity and spasms. Approaches include tailored strengthening exercises, advice on posture and activity levels, manual therapy, electrotherapy, and in some places hydrotherapy. Exercises are normally given to do at home between sessions. MS Trust also points out that physiotherapy is a protected title and that registration with the Health and Care Professions Council can be checked.

Where drop foot is the issue, NICE points to its interventional procedures guidance on functional electrical stimulation. A decision about walking aids, orthoses or a wheelchair is made with the person and revisited as symptoms change.

The NICE position is encouraging. People with MS should be encouraged to exercise and told that regular exercise may have beneficial effects on their MS and no harmful effects on it. When there is more than one suitable intervention, services should choose according to what the person prefers and whether they can keep going after the supervised programme ends. Teams are asked to help people continue exercising, for example by referring them to an MS physiotherapist or an exercise referral scheme, and to encourage long-term habits.

• Aerobic, resistive and balance exercises, including yoga and pilates, may help MS-related fatigue.

• For moderately impaired mobility, a supervised programme of aerobic and moderate progressive resistance activity combined with cognitive behavioural techniques can be considered.

• There is no evidence that a specific diet improves MS fatigue, though a healthy diet supports general health.

NICE advises asking about fatigue and not assuming it is always caused by MS. Other contributors include poor sleep, pain, spasticity, bladder dysfunction, medicine side effects, infections, anaemia, thyroid dysfunction, anxiety and depression, all of which can be treated.

Self-management is offered as a personalised discussion covering goals and priorities, energy conservation, a review of diet and exercise, and stress management approaches such as mindfulness and cognitive behavioural techniques. Vitamin B12 injections and hyperbaric oxygen are not recommended for fatigue. A medicine such as amantadine, modafinil or an SSRI may be discussed with a specialist, using shared decision-making and regular review, with extra precautions for modafinil in pregnancy.

Spasticity is suspected when there are muscle spasms, stiffness, painful restriction of certain movements, or a change in mobility or hand function. NICE asks teams to look for aggravating factors, such as pressure ulcers, bladder and bowel problems, infection, poor posture and pain, before changing treatment. It also notes that some people use their spasticity to help them stand, walk or transfer, so a muscle relaxant can reduce function as well as discomfort.

If simple measures are not enough, oral baclofen is the usual first drug option for people with specific goals such as mobility or comfort, with gabapentin as a second-line choice and combinations in some cases. Referral to a multidisciplinary spasticity team is advised when problems with mobility, posture or function persist. Musculoskeletal pain is common in MS and is usually secondary to immobility, spasticity and posture, so treatment targets those causes.

Cognitive problems, including memory difficulty, may not be immediately linked to MS by the person. NICE recommends assessing cognition during the comprehensive review, checking for the effects of anxiety, depression, sleep difficulties, fatigue and medicines, and considering referral to an occupational therapist or neuropsychologist for persistent problems.

Emotional lability, involuntary laughing or crying linked to a frontal lobe lesion, can be treated, and amitriptyline is among the options NICE names. Psychological support is part of routine rehabilitation, not an optional extra.

MS Trust says you can discuss rehabilitation with your GP or neurologist, who can refer to services such as cognitive rehabilitation, speech therapy, physiotherapy, continence services or occupational therapy. Care may take place at home, in hospital or in community settings. NICE guidance asks services to review needs regularly, with the frequency set by the person's needs and the treatments involved, and the new NICE guideline on neurological rehabilitation expects a holistic needs assessment, a rehabilitation plan and a single point of contact.