The MS rehabilitation process is multidimensional and dynamic. In areas requiring assessment and intervention, members of the rehabilitation team work with the person with MS to enhance or preserve function. The frequency, intensity and setting of the rehab intervention must be based on individual needs, and goals should be established early and revised as needed. Reference our clinical bulletins for more guidance on rehabilitation, including speech-language pathology (Dysarthria
and Swallowing Disorders
), Physical Therapy (PT)
, Occupational Therapy (OT)
and Assistive Technology
The international classification of functioning, disability and health (ICF)
While each rehabilitation specialty has its own assessment protocols, they share a common model to describe functioning and disability. This model is defined by the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF)
. Within this framework, assessment is required for a specific impairment and the effect of that impairment on a person’s participation in daily activities, while taking into account environmental and personal factors.
To help translate ICF to clinical practice, WHO has created ICF core sets
, a list of relevant functional categories for specific health conditions. Both the full length ICF Core Set for MS and the Brief ICF Core Set are available here
. WHO also maintains a comprehensive list of ICF educational resources, including:
Assessment, intervention and outcomes
A thorough assessment provides baseline information about the person’s physical status and present level of function. Periodic reevaluation and outcomes assessment allow for comparison of function over time and determining if the intervention used was effective. The following diagram and outline illustrate the rehabilitation process in MS.
The initial evaluation should include a baseline assessment of symptoms
currently affecting the individual’s performance as well as their current and prior level of function. The evaluation focuses on the following areas:
- Early intervention - Early intervention, in conjunction with disease-modifying therapies, can help people maintain or improve their level of function, perform activities of daily living efficiently and prevent premature workforce retirement.
- Restoration, modification and compensation - Restoration of function may or may not occur following an exacerbation. If restoration is not possible, teach effective ways to compensate for impairments and make adaptations to behavioral and environmental modifications to maintain function.
- Education, support and motivation - A major focus of the interaction between the rehabilitation specialist and the person with MS is motivational. The specialist’s role is to educate the person about the connection between the intervention being prescribed (e.g., exercise regimen, assistive device, environmental modification, etc.) and the person’s own goals. The specialist also provides support and alternatives to circumvent barriers.
- Skills training and adaptive equipment - A primary objective of interventions is to help people with MS learn to manage their disease through education, skills training and the proper use of adaptive equipment.
Assessment and intervention in occupational and physical therapy share many of the same concepts. PTs and OTs may treat the same problem, though in general, PT focuses on impairments involving gross motor skills, balance and endurance, while OT focuses on impairments involving fine motor skills, fatigue, functional cognition, functional vision and adaptive equipment. Our Assessments and Interventions in MS Rehabilitation
chart outlines the overlap in the evaluation and treatment strategies used by PTs and OTs.
Another member of the rehabilitation team is the speech-language pathologist (SLP). Cognitive assessment and intervention by a speech therapist can appear to overlap with that of OT but assessment and treatment is directed very differently. SLPs will assess and treat all domains of cognition while OTs will focus on functional cognition. SLPs will also assess and treat muscle weakness associated with speech articulation and swallowing.
The following factors influence which specialist evaluates/treats a particular person with MS:
- the person’s insurance plan, which may not cover all specialties
- the background and training of the OT, PT and SP at a facility
- the availability of rehabilitation specialists in a facility or geographic area
- institutional variation
The disease is always changing so rehabilitation must be flexible. Recent relapses, disease progression or other factors may influence goal setting at any point in time. Some individuals with MS may focus on goals that are unattainable, so it is important to provide alternatives to unrealistic goals:
- Unrealistic goal setting: The client wishes to walk unassisted to the library, which is something they have not done in five years.
- Realistic goal setting: The client will walk with a walker independently to and from the library to attend story hour with her daughter.
Goals may also need to include the care partner/family:
- The person with MS sometimes requires assistance with activities of daily living (ADLs). Their care partner needs to be educated when the patient needs assistance and when they do not. The care partner is instructed on proper body mechanics, necessary equipment and techniques for assisting in transfers, activities of daily living, etc. The care partner should be encouraged to follow up with the healthcare provider as the functional situation of the individual with MS changes.
Use shared decision-making when developing goals to avoid misaligned patient and therapist goals. The role of the therapist is to educate on realistic goal setting, offer an alternative plan of care to unattainable goals, or break down the goal into more manageable steps. If attempts at shared decision-making are unsuccessful, suggest the referring healthcare provider to reassess for alternative treatment options.
Reviewed by Sue Kushner, PT, MS, Diane Meyer, PT, MSCS and Brian Hutchinson, PT, MSCS, February 2021