#PTonICE Daily Show – Wednesday, July 26th, 2023 – Multiple sclerosis & the vestibular system

In today’s episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses  how treating individuals with sensory-based approaches at an early stage of their disease progression may help prevent or delay limitations later on. Alex suggests incorporating a variety of sensory challenges into treatments for individuals with Multiple Sclerosis (MS). These challenges include exercises that activate the inner ear and engage the eyes, aiming to improve proprioception and challenge the integration of sensory information. Alex emphasizes the importance of carefully dosing and scaling the exercises, taking into account the limitations of fatigue, in order to maximize the benefits of these interventions. Furthermore, Alex encourages starting the sensory-based approach in individuals with MS in their 20s and 30s, as it may potentially prevent or delay the onset of limitations later in the course of their disease progression. This approach focuses on enhancing sensory fitness and training the visual system through ocular motor training. By utilizing central vestibular system outcome measures and incorporating a variety of sensory challenges, clinicians can effectively identify and address the sensory integration component in their treatments for individuals with MS.

Take a listen to learn how to better serve this population of patients & athletes.

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00:00 INTRO
What’s up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today’s episode, let’s chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they’ve made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can’t miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you’re make sure to use the code ICEPT1MO when you sign up as that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today’s show. 

Good morning everyone and welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. Welcome to today’s segment of Jerry on ICE. I’m Alex Germano. I’m a member of the older adult division and today what we’re going to do is discuss some of these effects of multiple sclerosis on the vestibular system, what we need to look out for as clinicians, how we can assess better and treat this population. First, let me tell you some of the offerings within the older adult division before jumping into these questions. We have two courses coming up this weekend, one in Watkinsville, Georgia and the other across the country in Boise, Idaho. We have some seats left for both courses. We also have a course coming up in Frederick, Maryland, August 5th and 6th. We have our MMOA Summit in Lexington, Kentucky on August 12th and 13th and we have courses in Minnesota, Texas and California to round out August. First, let’s talk about multiple sclerosis. This is a chronic, immune-immediated inflammatory disease. It causes neurodegenerative processes within the central nervous system. Now, typically onset of this condition is somewhere between 20 and 50. That’s when people are getting diagnosed. We’ve seen a shift, however, towards people getting diagnosed a bit later in life and then these people go on to become older adults. So that’s why we’re kind of, we’re having this discussion land within Jerry on ICE or this older adult discussion because we are out there treating a lot of people who have MS and have had it for a number of years. Now based on where these demyelinating plaques occur, people with MS can present in a wide variety of different ways, right, different patterns. And very often what happens with some of this demyelination is it occurs across the vestibular system, right? It impacts some of this vestibular information. Remember that vestibular system is vast. It touches many different points within our peripheral and central nervous system. We have parts of the vestibular system, not just in the inner ear, it’s part of the cranial nerves, part of our brain stem, parts of our cerebellum. And interestingly, the vestibular nuclei in that root entry zone of the eighth cranial nerve have been shown to be some of the most common neuroanatomic locations for sensory demyelination. Okay? And very commonly the vestibular nuclei in the entry zone of the eighth cranial nerve have some demyelination. And oftentimes people with multiple sclerosis have abnormal tests on vestibular function both centrally and peripherally. Centrally people with MS may struggle with the ability to sensory reweight with most of their reliance of balance coming from the visual and proprioceptive systems. So they’re not really integrating that vestibular sense. They’re maybe too visually reliant. Really our brain is just trying to balance out all this information to give us a sense of balance. Now researchers really think that this central integration of peripheral input is where the dysfunction lies within the disease process. Interestingly, this type of central integration problem could actually be causing one of the leading debilitating features of MS, which is fatigue. The hypothesized relationship between central vestibular integration and fatigue could be explained by this poor ability to gate sensory information. The person with MS is unable to process all the signals incoming. The cerebellum can’t do its job to override some other sensory noise such as like the vestibular ocular reflex as it normally does. That causes a poor perception of verticality. That contributes to increased sway. And imagine all this little sway that’s going on all day. That can contribute to fatigue. So this information can really help guide us on our journey in assessing people with MS and their vestibular system. Now most of the information I’ll talk about today regarding testing and the treatment of the vestibular system in people with MS comes from a group out of the University of Alabama at Birmingham led by Dr. Graham Cochran. And I’m going to link all these on Instagram for you. But this group really looks at the influence of the central vestibular system on function in people with MS. They concluded that we should be selecting measures that actually test central vestibular integration versus purely peripheral vestibular function. Because some people with MS don’t have that peripheral vestibular dysfunction. Really the problem is central. So what tests can we use to capture that central integration problem? Now these central integration tests are more significantly correlated with measures of fatigue and walking capacity. They do mention a limitation of the studies that they perform on people with MS are that they are using this more on ambulatory patients. They’re really testing the ambulatory community of people with MS. So it’s very much something to consider if you go to apply this to non-ambulatory populations or people kind of much further in their disease progression. Now the two tests that they think we should be performing are VOR cancellation and the subjective visual vertical. The VOR cancellation tasks, remember that’s our ability to kind of override our vestibular ocular reflex and remain fixated on a moving target. The VOR cancellation, it requires the integration between vestibular signals and visual system to produce an equal smooth pursuit eye movements, right? To keep vision stable on a moving target, moving at the same speed as our head. So VOR cancellation can really give us insight into this sensory integration. The subjective visual vertical, for example, is a task that requires integration of our otoliths, right? Our kind of gravity dependent inputs of our vestibular system and the visual system to help us orient to a true perceived vertical. So if you’ve ever seen people kind of presenting with maybe a tilt of the head or folks that are kind of leaning one direction or the other, they might have a sense of, they might have a mismatched sense of verticality and they’re aligning their head or their eyes a different way to line up with what they perceive as vertical. So the subjective visual vertical task, or sorry, the subjective visual vertical assessment can give us insight into the combination of otolith input and visual system input. So again, that sensory integration that we’re looking for. The subjective visual vertical test can be measured via a bucket test. There’s like research-based, lab-based ways to measure this that are more accurate, but we can do this clinically with what’s called a bucket test. Reactive therapy and wellness has a really good video on YouTube for that test and how to set one up with like a Home Depot bucket. Pretty simple. Vestibular rehab is a great addition to therapy protocols for people with multiple sclerosis. Vestibular rehabilitation programs have not only shown change in our folks’ balance and disability due to dizziness or disequilibrium, but has also been shown to impact fatigue, which is amazing. The protocols for vestibular rehab and the research look like a lot of sensory integration work. We want to work on visual, vestibular, and proprioceptive inputs over a variety of different conditions. What we’re really trying to do is beef up someone’s sensory fitness, so to speak. So you are going to see the themes of eyes closed, standing on foam, moving the head around in different planes, moving the body both forwards, backwards, and laterally. You’re going to see working in a variety of different positions, standing, kneeling, changing up that base of support, performing dynamic movement as well, such as walking. Then you’re going to see some ocular motor training added to the mix to enhance that visual system. We want to train up the visual system as well. So you are going to be seeing some ocular motor training. Now, they perform this in a progressive manner, just like we would do with resistance exercise. They’re consistently progressing the difficulty of set exercises, just like we would do. That is what makes the biggest difference for these patients. The missing piece to some of our treatments with people with MS might be that sensory integration component, or that central vestibular system work. To identify these problems, we need to use central vestibular system outcome measures, and we need to look at the VOR cancellation and subjective visual vertical. We need to include a variety of sensory challenges to our treatments. We need to select exercises that turn on the inner ear, that make the eyes work, that improve proprioception, and challenge the way our patients with MS integrate all of this information. We need to be masters of dosing and scaling, loading up people in a progressive, stepwise manner, while respecting the limitations of their fatigue in order to see the benefits from these interventions. I hope this gave you just a little bit of a different approach to folks with MS that you might be seeing that have balance or disequilibrium. Hopefully you can start to apply some of these concepts a bit earlier in the trajectory of their disease progression. So imagine starting to treat someone in their 20s and 30s with this sensory based approach. Maybe you can work to stave off some of these limitations later in the course of their disease process. I think that’s really exciting stuff. I hope that helps you out in your clinical practice. I hope you have a great rest of your Wednesday, and we really look forward to seeing you on the road with MMOA Live soon. Have a good one.

11:25 OUTRO
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