Multiple Sclerosis (MS) is a chronic, often progressive and debilitating disease that affects over a million Americans.
Typically, management includes a comprehensive medical and pharmacologic regimen and sometimes, physical and occupational therapy. Depending on the severity of symptoms, inpatient rehabilitation can help patients with MS build strength and remain in the home longer, said Dr. Scott Bleakley, director of therapy at Encompass Health Rehabilitation Hospital of Sewickley in Pennsylvania.
During inpatient rehabilitation, patients participate in a minimum of three hours of therapy, five days a week, with a combination of physical, occupational and speech therapy. Historically, some health care providers were concerned that intense rehabilitation might increase the risk of exacerbating the disease process. Bleakley said current research as well as his experience has shown that if managed by an experienced team, rehabilitation can be highly beneficial for people with MS without the negative side effects that were at one time associated with it. Bleakley said acute rehabilitation can be a safe setting where the patient can build their strength back up and regain some of their independence.
“The challenge we have is that some hospitals look at the patient and see that they're not able to stand or walk, so they can't participate in three hours of therapy,” he said. “They have complex needs, but our programs can be adjusted to meet those needs; they're tailored to the patient's specific needs.”
What is MS?
MS is a chronic disease that impacts the central nervous system, disrupting the flow of information in the brain, according to the National Multiple Sclerosis Society.
While no two patients' symptoms are the same, the most common ones include:
- Fatigue
- Difficulty walking and poor coordination
- Numbness in the face or other parts of the body
- Weakness
- Muscle spasms
- Blurred vision
- Vertigo and dizziness
What are the different types of MS?
There are four types of MS, each affecting the body differently overtime. They are:
- Relapsing-Remitting MS (RRMS). This is the most common form of the disease. It's characterized with temporary relapses followed by periods of remission. An MS relapse, or flare up, can cause a range of symptoms from severe fatigue to loss of balance.
- Secondary-Progressive MS (SPMS). Symptoms worsen more steadily overtime with or without relapses.
- Primary-Progressive MS (PPMS): Symptoms worsen over time without periods of relapse and remission.
- Progressive-Relapsing MS (PRMS): Symptoms steadily worsen with relapses but no remissions.
How inpatient rehabilitation can help MS patients
The goals for rehabilitation are highly individualized and depend on the individual needs of the patient and their caregivers. Following a detailed assessment of the patient, the patient and rehabilitation team develop a plan of care tailored to meet those goals and the current state of the disease. Depending on the goals, the treatment plan can consist of a mix of physical therapy, occupational therapy and speech therapy.
Physical therapy treatments may include exercise, endurance training, gait training, balance and education. One unique tool for improving gait (walking) is the Vector overhead support system. On the Vector, the patient is partially suspended and walks along a track without the risk of falling, Bleakley said. Occupational therapists often focus on improving self-care as well as alternative ways to return to independence and resume previous roles in and out of the home. Activities of Daily Living (ADLs) are a powerful tool occupational therapists use to reinforce skills and teach new ones.
Similar to exercising a muscle, speech therapy engages the brain in a similar way and is a great form of mental exercise, as well. Speech therapists work to improve cognitive skills or teach adaptive techniques, again, focused on meeting the patient's rehabilitation goals.
As the clinicians focus on building the patient's strength and the ability to perform everyday tasks, their case manager is working to identify tools and programs in the community to assist the patient after they leave the hospital.
“Our goal is to return people to their community, stronger, more independent and equipped to stay that way,” Bleakley said.
What is dysphagia?
Like aphasia, it can be caused by neurological conditions such as brain injuries and stroke, but it also can stem from muscle disorders, certain cancers and blockages/strictures in the throat.
Depending on the cause, dysphagia can be temporary or long-term.
Conditions commonly associated with dysphagia include:
- Parkinson’s disease and multiple sclerosis
- Neck and throat cancers
- Late-stage Alzheimer’s disease and other dementias
- Cervical neck surgeries
Stages of dysphagia
There are three phases of swallowing that are impacted with dysphagia:
- Oral: This is the process of chewing food and mixing it with saliva to form a bolus in order for it to be moved from the front of the mouth to the back of the mouth. A person with dysphagia in this phase could have trouble breaking down the food enough to properly move it to the back of the mouth to trigger the swallowing reflex. This stage is also where tongue weakness or decreased sensation may impact the ability to clear food from the sides of the mouth causing it to pocket in the cheeks.
- Pharyngeal: This is where the swallowing reflex begins, and pharyngeal muscles push food down the throat to the esophagus. The epiglottis (a cartilage) inverts to protect the airway and sends the bolus towards the esophagus. This is when the upper esophageal sphincter opens to allow food to travel into the esophagus. A person with dysphagia in this phase might feel like the food is “entering the wrong pipe,” Delashaw said, because the muscles in the pharynx and/or larynx are not operating properly to prevent food or liquids from entering the airway.
- Esophageal: This is when the bolus is taken from the upper esophageal sphincter that has opened, allowing it to enter the esophagus. Peristalsis (muscle contractions) carries the bolus from the upper esophagus towards the stomach. In this phase, a person with dysphagia may feel like food is stuck in their throat or chest.
Symptoms of dysphagia
Dysphagia symptoms could include:
- Coughing or choking during or shortly after eating or drinking
- Heartburn or indigestion
- Feeling that food is stuck in the throat or chest
- Painful swallowing
- Regurgitation
- Food sitting in the mouth or being pocketed in the cheeks
- Unexplained weight loss
- Reduced desire to eat
Diagnosing dysphagia
Dysphagia is diagnosed by a healthcare provider. Speech-language pathologists diagnose dysphagia with a comprehensive oral exam and swallowing examination, which should include swallowing tests such as a FEES or MBS exam.
- FEES: FEES stands for fiberoptic endoscopic evaluation of swallowing. This is an exam where a speech-language pathologist inserts a small thin scope with a camera through the nose and allows visualization of the throat, larynx and vocal cords to assess swallow function as you eat and drink certain foods.
- MBS: During a modified barium swallow study, a speech-language pathologist will give you food and liquids covered in a small amount of barium. As you swallow, X-rays are performed to view your swallow in real-time.
Treatment of dysphagia
After a dysphagia diagnosis, a speech-language pathologist can help determine what consistency of food and liquids is safest to eliminate risk of choking or aspiration. They can also provide therapy and exercises to help strengthen the muscles used during the different stages of swallowing.
Treatment should always involve a discussion with the individual to determine their wishes regarding oral intake and development of dysphagia treatment.
“If difficulty is noted in the oral phase, we can design an exercise program to target movement for the muscles used when breaking down the food,” Delashaw said. “Say you had a stroke that impacted lip muscles, and you can’t hold food in your mouth. We’re going to work on increasing the control and strength of the lip muscles, so you do not lose liquids or foods out of the mouth.”
In addition to exercises, Delashaw said neuromuscular electrical stimulation could also be used to increase muscle awareness in the different stages of dysphagia.
In the esophageal stage, your speech-language pathologist could suggest obtaining a referral from your primary care doctor to a gastroenterologist for further evaluation.
Recovery from dysphagia
Depending on the diagnosis and related conditions, dysphagia could improve over time. If swallowing difficulty is related to a neurological condition, inpatient rehabilitation could help develop adaptive techniques and diet plans to meet your needs and quality of life standards.
The multidisciplinary approach in this setting also allows for other symptoms related to your condition to be addressed through intensive therapy. In addition to working with a speech-language pathologist, your therapy team would also include a physical therapist and occupational therapist to address mobility and strength as well as activities of daily living and quality of life.