A Step Toward Wellness: The Benefits of Early Rehab in MS

This transcript has been edited for clarity.

Patricia Bobryk, MHS, PT, MSCS, ATP: Hi. My name is Patty Bobryk, and I'm a physical therapist. I work at Yampa Valley Medical Center, which is part of UCHealth in beautiful Steamboat Springs, Colorado. I have been doing multiple sclerosis (MS) work for over 30 years, and I am an MS-certified specialist. I have the great pleasure of being joined for this discussion by a distinguished colleague in the MS community, Colleen Harris.

Colleen J. Harris, MN, NP, MSCN, MSCS: Hi, everyone. My name is Colleen Harris. I am a nurse practitioner at the University of Calgary MS Clinic, where I, too, have been involved in MS care for more than 30 years and have been fortunate enough to work with a multidisciplinary rehabilitation team.

Bobryk: We're going to be talking this morning about comprehensive rehabilitation for early MS. Are there benefits? To set the stage, I wanted to talk a little bit about medical intervention for MS early in the disease trajectory. It has become standard of care that early use of disease-modifying therapies (DMTs) to maintain neurologic reserve is what we all strive for.

That neurologic reserve is two points: brain reserve, which is kind of brain volume, and cognitive reserve, which is our brain's ability to process information and act on it. We know that DMTs decrease relapse rate, and they decrease the chance of brain atrophy. We even have data to show that, if someone is identified as having clinically isolated syndrome and we initiate DMTs, we can delay the onset of clinically definite MS.

These are all positive things about early intervention with medical treatment, but that's not the case for rehabilitation. Rehabilitation has been traditionally more reactive than proactive. To give you some information about the comprehensive rehabilitation team, I'd like to identify the main players. We usually think about the core team and the comprehensive team to include physical therapists, occupational therapists, and speech and language pathologists.

Physical therapists, like myself, are the mobility specialists. We look at movement, walking, and strength. We're the key people that initiate exercise programs for not only strengthening, but also fitness and endurance. There are subspecialties within physical therapy — for instance, vestibular rehabilitation and pelvic health — that can address symptoms of MS also.

Occupational therapists are the clinicians that address activities of daily living. They are functional skills people. They look at life's desired roles for an individual and try to help them maintain independence in those life roles. There are also subspecialties in this type of therapy, such as driving and visual retraining. Occupational therapists are also involved in cognitive retraining and cognitive strategies.

Speech and language pathologists are the clinicians that work on communication and also swallowing and dysphagia. Dysphagia can happen in approximately one third of our patients. It can happen early on, and I think treatment for it is very underutilized. Speech and language pathologists also work with cognitive retraining.

Having said all the wonderful things that a rehabilitation team can provide, Colleen, would you please tell us why you think that we should be advocating for early referral to the rehabilitation team?

Harris: My involvement with MS care dates back to before DMTs, when we did very little other than diagnose the disease and try and manage relapses. With the introduction of DMTs that actually impact the course of the disease, the world of MS opened up wide as far as treatment options.

In the early days, rehabilitation came much later than it does now, and it was used to help with functional limitations, postrelapse, or progressive phases of the disease. We very soon got on board, not only treating the disease with the DMTs but also treating the whole person. I was able to witness these multidisciplinary MS centers develop over the course of a couple of years because we were seeing so many more patients since we had good introductory treatments for them.

We learned very quickly that we need rehabilitation not just for relapses, but also for promoting wellness as a whole. It is so beneficial to be able to have patients have a thorough rehabilitation assessment at the beginning of their MS journey. If they were to develop issues as they go along in the trajectory of their illness, then we are able to evaluate how they're doing, how much functional loss they have at that point in time, and where our goals are to do better.

Starting rehabilitation at the beginning, when the disease is first diagnosed, helps a patient build their healthcare team. The healthcare team in MS is not just a physician or a neurologist. It's composed of the nurses that take care of them, other medical disciplines like the urologist, as well as the rehabilitation team. As Patty very eloquently pointed out, there is a full complement of specialists now available and treating MS.

Our goal is to maintain the comprehensive care model and get them involved in patient care right at the beginning so we can promote a wellness-based model, along with getting patients on effective DMTs.

Bobryk: We're learning more and more, Colleen, about the actual physiologic benefits of early referral. Although there isn't a huge body of literature to support that, many wonderful trends are now emerging. I'd just like to share a few of those benefits that we're seeing.

Most of the work these days has been done on the role of exercise with MS. Certainly, as I talk about what benefits there are, you can see how that might translate to all members of the team and the interventions they provide for their patients. In regard to individuals with MS who exercise vs those individuals who don't exercise, we know that there's actually a lower relapse rate of about [27%] among folks with MS who exercise

When we think about exercise, we shouldn't be thinking about exercise only in the realm of fitness and wellness, but also exercise as medicine and the medical plan. They're looking more and more now at biomarkers and what exercise does in our central nervous system in MS.

There's a negative chemical, a pathogenic molecule in our brain, matrix metalloproteinases-2 (MMP-2), which breaks down the blood-brain barrier. In exercise, we know that MMP-2 is lowered. There might even be an anti-inflammatory effect of exercise on the brain. If we look at MRI data on those folks that exercise, there's a trend toward increased cortical thickening and decreased brain atrophy, which is huge. We're trying to preserve that neurologic reserve.

When we're looking at some of the chemicals that are released when we exercise, brain-derived neurotrophic factor (BDNF) comes to the forefront. We know in healthy individuals, in the presence of BDNF, there is better motor acquisition, better skill acquisition, and better retention of those skills, and also improvement in cognition. This is another wonderful thing that exercise can do.

One more point that I wanted to bring up is that some studies have looked at the brain connections—how our synapses work in the presence of exercise. For folks who do exercise, there's improved synaptic efficiency. When we're dealing with a disease that is all about transmission, that becomes very important.

That's the data in the world of exercise. From a more practical approach, also, when we think about the early intervention by the rehabilitation team, especially for those therapists who have training in MS, we can identify problems or symptoms early in the disease so they don't become so problematic later on.

The example I always like to use is if someone develops a little bit of weakness in dorsiflexion, the muscles that lift the foot up, that will change somebody's walking pattern and their gait efficiency would be decreased. They would put stress and strain on joints and structures that aren't meant to have these strains on them. Theoretically or hypothetically down the line, a patient can end up with a knee, hip, or back problem, which they will then have to go to an orthopedist to treat.

If we could have prevented that at the start of the disease trajectory or done some intervention, then we would have saved healthcare dollars. The same is true for early intervention with speech and identifying swallowing issues. If we can identify early on and treat swallowing problems and prevent aspiration pneumonia, that's huge not only for someone's quality of life but also in the realm of healthcare dollars.

We know that people who have many comorbidities don't do as well with their MS. If we can, as you said, Colleen, have this holistic approach and treat the whole person, in the end they'll do better.

Knowing all of this now, Colleen, what do you see as some of the barriers to early referral?

Harris: In the very beginning, it can sometimes be the patient not wanting to come to terms with the diagnosis and not wanting to think that they need rehabilitation because, unfortunately, there's still a bit of stigma associated with the term "rehabilitation" and we can't get them to the service.

They're not ready to accept that we would like to know their baseline, and we want to be able to get them to rehabilitation so we can encourage them to live this healthy lifestyle and to develop a home-based exercise routine. Patient acceptance, sometimes, is the biggest barrier. Although now we temper it with wellness and the fact that we all, as healthy adults, should be looking at daily fitness.

If we can temper a new diagnosis with the fact that this is really what everyone else should be doing anyway — a healthy approach to life, making sure they get enough activity during the day, not sitting around too much, going for a walk, watching their weight, watching what they eat —that often helps with the very first barrier. The most important barrier is the patient's perception.

Then we have to look at the types of rehabilitation programs that are out there and the types of practitioners that you have access to. I've been very lucky to have a wonderful multidisciplinary rehabilitation program at my clinic for some time. I have seen it make a huge difference in the way we're able to keep people healthy together with medication. We're also getting people active. They're joining fitness groups.

They have a different outlook. They know that it's not just about drugs. It's about living well. It's about taking care of their health. So, we have to refer patients to the healthcare professionals who are trained in treating and managing MS, and that pertains to occupational therapists and physical therapists. The types of swallowing issues patients may experience are quite specialized, and we need therapists that are geared and are educated to the MS approach.

Then there is the struggle we all have with ongoing funding. Even if we have the availability of these wonderful therapists in the community or in our institution, can we get them funded? Can we get them funded for our program? Since we started our rehabilitation program in my clinic some 20 years ago, we still fight yearly for funding, to maintain that funding, and we want to make sure that we're not forgotten.

We all have to be advocates. Whether you're a nurse, doctor, occupational therapist, physical therapist, or speech and swallowing therapist, we all advocate to keep our services because we know that we need each other. We can do a really good job, as you pointed out Patty, and it can be cost-effective if we maintain our comprehensive multidisciplinary teams.

I'm quite proud of how far we've come with multidisciplinary MS care. We are truly making a big difference. It's enjoyable to be a practitioner in MS care because we can have so much more influence on the outcomes of the patients that we take care of.

Bobryk: Agreed. I think the takeaway point is that early rehabilitation keeps our patients healthier, gives them better outcomes, and can have an impact on what's happening in the brain. The comprehensive team, if it's well trained, can provide those services early on and throughout the course of the disease.

Thank you for joining us.

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