Insight to Assisting Patient with Multiple Sclerosis

This essay will look to explore, critique and interpret the existing literature relevant to Multiple Sclerosis within physiotherapy practice. The author will research pathophysiology, physiotherapy assessment, treatment and wider implications of living with a neurological disease.

The major cause of neurological disability in young and middle ages adults is Multiple Sclerosis (MS) (Stokes & Stack, 2014). The major types of MS based on clinical presentations are: Remitting Relapsing, Secondary Progressive, Primary Progressive and Progressive Relapsing (Perkin & Wolinsky, 2006). MS is prominent within a group of conditions known as ‘demyelinating diseases’ (Martin, 2010). These conditions have immune-mediated destruction of myelin as the main pathological finding (Stokes and Stack, 2014). The immune cells overwhelm the Central Nervous System (CNS) and cause neurodegeneration, but it’s noted by Golan, Staun-Ram and Miller, (2016) that the dynamic changes skimps other relative elements within the CNS tissue and affects certain elements.

Myelin Sheath’s are produced and surround nerve axons. Myelin acts as a nerve conductor (Shepherd, 1994). When actions are transmitted along nerves, myelin sheaths allow effective, rapid and efficient conduction, when this is damaged or lost, the conduction fails, and the impulse does not complete with usual function or speed (Stokes & Stack, 2014;Oberwahrenbrock et al., 2012).

MS is alternatively defined as the presence of distributed sclerosis (scars/plaques) in the CNS (Dutta & Trapp, 2007). The sclerosis that define the disease are remainders of the demyelinating process’ which remain in the white matter of the nerve tracks within a patient’s nervous system. Apart from demyelination, the cortex and deep grey matter within the brain can be affected. This can cause brain atrophy which is associated with disability, fatigue and cognitive impairments within MS, like Miss Shaw’s symptoms (Pirko et al., 2007). The plaques can vary in size and age and determine the damage induced on the myelin sheaths within the nervous system. When examining the brain and spinal cord, MS plaques are prominent throughout the brain stem, cerebellum, spinal cord and the anterior/posterior and lateral ventricles, close to the optic nerves (Stokes & Stack, 2014).

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Changes in pathophysiology within the CNS and brain generates the symptoms associated with poor mobility, weakness, balance, coordination and dizziness. This interruption can cause eyesight disturbances, tremors and speech difficulties (Martin, 2010). The damage to the CNS that MS causes is complex. The main physiological changes previously discussed, alter the nervous system’s ability to co-ordinate the body’s function, as nerve impulses cannot pass efficiently (Martin, 2010).

Sensory information is transmitted to the brain, muscles and organs through receptors (Stokes & Stack, 2014). The signal is stored and processed from the peripheral nervous system (PNS) and an action is completed, therefore, damage to these tissues, alongside plaque formation, can hinder the communication through the nervous system and cease typical function (Multiple Sclerosis Trust, 2019; Martin, 2010). Typically, symptoms expressed are dictated by areas affected within the CNS which alter the role of the associated nerve track, highlighting how MS symptoms vary throughout patients (Multiple Sclerosis Society, 2019). Further symptoms such as bladder and bowel complications, difficulty swallowing, or emotional inhibition can be noted (Perkin & Wollinsky, 2006). With regards to Miss Shaw, she may be experiencing walking difficulties due to plaque formation within the upper spinal cord, affecting nerve transmission downwards and sensory information from her legs to the brain, therefore causing weakness and altering her ability to co-ordinate efficiently (Multiple Sclerosis Society, 2019).

Physiotherapy assessment

According to Lennon and Stokes, (2011) physiotherapy assessments for individuals with MS are processes of collecting information about disordered movement patterns, underlying impairments, activity restrictions and societal participation, for the purpose of intervention planning and treatment. Furthermore, Refshauge et al., (2005) suggest that the sole purpose of an assessment is to determine the best intervention for the patient. This highlights the importance of assessments within clinical practice as it is critical for treatment planning.

Physiotherapy assessments focus on the patient’s ability and aspirations, not just limitations and impairments. Assessments are logical, systematic and linked directly to goal setting (Freeman, 2000). Assessments are accompanied with checklists and proformas that are utilised within clinical practice to give repeatable and integrated methods which enable a Multidisciplinary approach to care (NICE Guidelines, 2018). The assessment includes Subjective and Objective Information, Problem lists, Goal Setting and Treatment Planning (Lennon & Stokes, 2011). The subjective assessment includes general information and history taking of diagnosis, history of present condition, drug history, social history, past medical history, activity levels, personal care and other changes within vision, hearing, swallowing, fatigue and pain (Freeman, 2000). The subjective element gives physiotherapists time to build rapport and trust, whilst gaining an insight into the patient’s goals and concerns. It also gives time to notice patients posture, mental status, orientation and identify areas for immediate objective assessment (Lennon & Stokes, 2011).

The Objective assessment identifies impairments through observation and examination. Observational testing gives physiotherapists time to evaluate movement during functional tasks to determine ability. Observations on posture, standing, gait patterns, distances and velocity, whilst obtaining orientation, pain or weaknesses. It is good practice for therapists to refrain assistance and offer cues or demonstrations as it is important to determine the patient’s performance (Lennon & Stokes, 2011 ; Stokes & Stack, 2014). The physiotherapist will determine joint range of motion, muscle tone, speech, balance, dermatomes, myotomes, reflex’s, temperature, dizziness and coordination alongside visual disturbances (Freeman, 2000). For individuals with MS, specific functional assessments which consists of grip strength, hand and arm function, sit to stand, sitting balance and functional activities associated with personal care (e.g. Showering/Getting dressed) (Stokes & Stack, 2014). Patients movement patterns are characterised through body alignment and control; patient parameters should be compared to previous function or ‘adequate’ muscle strength (Edwards, 2002, Refshauge et al., 2005).

 From the examination, problem lists are generated linking activity restrictions and relevant impairments to help set goals (long-term/short-term) and create a personalised treatment plan with frames for achievement (Lennon & Stokes, 2011).

 Perkin and Wolinsky, (2006) recommend the above neurological assessment for each patient so they can be assessed and reassessed whilst enabling treatment to be modified accordingly based on progress. The National Multiple Sclerosis Society, (2018) suggest outcome measures should be applied periodically within the assessment, to establish and revise goals whilst measuring the benefit of an intervention. Stokes & Stack, (2014); Lambert, (2015) and NICE Guidelines, (2018) all state that standardised outcome measures should be an integral part of physiotherapy practice to decipher what requires measurement and its relationship to the patient. Outcome measures are key to clinical practice to enable practitioners to detect worsening symptoms and provide missing information. Gondek et al., (2016) conducted a review which reported that patient outcome measures have positive impacts on treatment and engagement whilst aiding clinical practice monitoring of services. It must be noted that the review examined widespread services including mental health and the clinical application of their findings were not specific to physiotherapy.

Physiotherapy Treatment:

 Individuals such as Miss Shaw are referred to physiotherapy due to a loss of movement, skill or the ability to perform functional activities (Stoke & Stack, 2014). Physiotherapy is documented as a crucial element of clinical care within the management of MS (NICE Guidelines, 2018). In 2016, Campbell et al., conducted a systematic review on 13 studies including gait, balance and exercise interventions within the MS patient population, they concluded that physiotherapy is an effective rehabilitation tool for individuals with MS by improving function and balance. This review included 13 studies with various intervention methods which may affect an individual outcome. Further research with coherent treatments may be appropriate to compare.

 Compston & Coles, (2008) and Heesen et al., (2006) insist that physiotherapists provide unique contributions to patients with MS as they improve and maintain functional abilities whilst forward planning to manage long- term symptoms. It is noted by MS Healthcare Standards cited by Freeman, (2000) and National Multiple Sclerosis Society, (2019) that early physiotherapy, alongside other medical interventions should be used to address mild impairments, balance, mobility, fatigue, pain, bladder/bowel dysfunction, decreased independence, alongside diminished quality of life and depression as interventions including behavioural and lifestyle changes may be easier to implement within early treatment.

 According to Khan et al., (2008) and NICE Guidelines, (2018), Physiotherapists look to develop comprehensive individualised treatment consisting of exercise programmes. These include variations of aerobic and resistance activity combined with cognitive behavioural techniques to help combat fatigue and mobility weakness. A trial by McCullagh et al., (2007) compared 12 individuals with MS undertaking exercise classes twice weekly with a control group. They found improvements in exercise capacity, quality of life and fatigue and the intervention continued for 12 weeks. It must be noted, within these studies no exercises were described making the study difficult to replicate. Doring et al., (2012) and Halabchi et al., (2017) researched the effects of aerobic and resistance training have within the MS population. Both researchers discovered when intensity was low to moderate, improvements in aerobic fitness and reductions in fatigue was found in patients with mild to moderate disability due to MS.
 Khan et al., (2008) present in their review that MS patients adapt positively to resistance training which may result in improved fatigue, quality of life and ambulation. It was acknowledged that balance exercises reduce falls risks within this population group. When critiquing the literature, studies included were chosen from independent researchers, reducing experimenter bias. Furthermore, all studies used varied outcome measures and presented limited evidence for short term effectiveness within home-based rehabilitation programmes. Also, specific ‘doses’ of treatment were not discussed in detail.

 NICE Guidelines, (2018) recommend stretches, yoga and vestibular rehabilitation to reduce fatigue whilst improving mobility, muscular strength and balance. O’Sullivan et al., (2014) and Cameron, (2010) recommend that functional balance exercises, gait assessment and energy conservation training within the MS population should be included within their rehabilitation, to assist with activities of daily living (ADL) and activity pacing whilst reducing the risk of falls. The CSP, (2019) explain that improvements within the above aspects promotes function whilst aiding standing balance and walking.

 When managing an MS patient , it’s important to determine how often the individual will need to be seen dependent upon their symptoms and their family requirements. The frequency of visits may continuously change due to their relapses and rehabilitation needs (NICE Guidelines, 2018). Halabchi et al., (2017) explain that each exercise should be safe, effective and patient appropriate to their goals. Goals should be reflective of patient’s strengths and weaknesses’ whilst being accessible from their home or a clinic, again, whilst implementing all benefits, focusing on education, safety and progress. The dynamics of patient centred care should be risk assessed and patient’s safety during treatment should be fundamental to each programme (Anderson, Gruise and Wiig, 2014).

 NICE Guidelines, (2018) explain therapists should help the individual with MS to continue exercising with scheme referrals. Regular communication between the individual, the healthcare provider and the physiotherapist is key to ensure high quality comprehensive care (National Multiple Sclerosis Society, 2019). The rehabilitation of the MS population is facilitated by education and self-management to allow patients to remain as independent as possible.

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 For those with MS, comprehensive annual reviews with a multidisciplinary team (MDT) and patient dependant reviews, look to examine and measure treatment plans whilst adjusting where required to maintain positive outlooks within physiotherapy (Khan et al., 2008; Nice Guidelines, 2018; Vukusica & Confavreux, 2007). The MDT has been found to be an effective and efficient way of treating those with MS (Forbes, 2007; Harris et al., 2003). It is the preferred method to ensure patients are receiving the right care for them, in the right place at the right time whilst improving the MS patient’s experience in terms of participation and activity levels (Multiple Sclerosis Academy, 2018; Khan et al., 2008). This approach exhibits constant re-assessment to measure the effectiveness of treatment. It is evidenced throughout The European Multiple Sclerosis Platform, (2012) within their guidelines and meta-analysis’ that a multidisciplined rehabilitation team with the correct supervisions, improves the patient’s life and implements key safety features to provide quality care. They MDT includes: Consultant Neurologists, MS nurses, Physiotherapists, Occupational Therapists (OT’s), Psychologists, Speech and Language Therapists, Dieticians, Social Workers and Continence Specialists (NICE Guidelines, 2018). All have key strategies to help manage MS patient’s symptoms and quality of life which are discussed later.

Psychosocial impacts of MS on the Individual, Family and Carers:

Martin, (2010) explains chronic illness’ such as MS are threatening to social networks. The stigma for individuals can be a burden as it alters future perspectives and lifestyle security (Halper, 2007). There are significant disturbances within a MS patient’s social, work, family and lifestyle. Large impacts derive from physical changes like limited mobility and incontinence. These symptoms may dictate individual’s participation within sports and social activities (Halper, 2007). Simple shared interests can become challenging for MS patients, it’s therefore vital for friends/family to adapt due to new circumstances, otherwise, social withdraw may occur (Martin, 2010). Krupp, (2008) stated two thirds of individuals with MS-fatigue report negative impacts on social and occupational activities as they are unable to participate as ‘normal’.

Benito-Leon et al., (2010) and Janssens et al., (2003) discuss that the diagnosis of MS is associated with poorer subjective well-being and quality of life, alongside social interactions and interpersonal relationships. Stokes and Stack, (2014) alternatively explain that MS ranges from a single deficit and disability can take months or years to develop key symptoms, enabling individuals to remain mobile and live a ‘normal’ life.

Research by O’Hara, De Souza and Ide, (2004) found that most day-to-day care for MS individuals is provided by family or friends, including mobility, household tasks, leisure and personal care. This directly impacts the independence of the individual and could add stress to close family members lives.

As MS is diagnosed between the ages of 25-40 years old, many patients have children to care for whilst combatting this disease (Multiple Sclerosis Trust, 2019). The impact of the condition can vary, but typical symptoms raise concerns that parents with MS may be unable to take care of their child as before, therefore causing emotional and financial stress (Halper, 2007). Bostrom & Nilsagard, (2016) studied 10 families on the impact of MS based on their experience. They found that for parents diagnosed with MS, the initial concerns were regarding the effects on their children. Single parents feel they are vulnerable and may struggle tackling their emotional well-being as well as their child’s. This study indicates an immediate impact on the family unit from diagnosis and throughout the progression of the condition. It has been noted by The National Multiple Sclerosis Society, (2019) that children can have difficulties understanding and coping with unseen symptoms of MS, such as mood and cognitive changes. They are misinterpreted as ‘not caring’ , therefore hindering a parent-child relationship. In contrast, Kalb, (2012) suggested that children can cope well with parent’s limitations, including those for mobility aids if they understand why it is happening and have substantial support.

In 2000, only 20-40% of individuals with MS were working (Halper, 2007). Individuals with MS may be unable to work due to their symptom decline, therefore affecting their financial state alongside the individuals sense of identify (Multiple Sclerosis Trust, 2019) For many people being employed includes elements of self-esteem as their role may be key within a community, for example Miss Shaw is a social worker; so her work is influences others’ lives (Rumrill, 2015). An investigation by Smith and Amett, (2005) found that fatigue was the primary symptom to reduce time at work, alongside mobility issues and cognitive impairments such as concentration loss which have a direct influence within problem solving jobs (Noyes, 2005)

 Soderburg et al., (1998) suggested that a diagnosis of MS will affect every aspect of life. This impact will extend to work, family, economic status and relationships within the larger community. Depression is the most common psychiatric disorder within the MS population with its prevalence being 50% compared to 15% in the general population (Schiffer, 2005; Muñoz San Jose et al., 2016). Multiple Sclerosis Trust, (2019) explain living with MS gives feelings of uncertainty, helplessness, chronic pain, poor sleep and overwhelming fatigue which all contribute to the development of depression. Within MS, depression can be due to lesions or general well-being and must be treated immediately (Multiple Sclerosis Society, 2019). Zorzon et al., (2001) reported an MRI study of 95 patients with MS. They found that 19% of these patients met the criteria for major depression whilst commenting that depression severity was correlated with right front lesion loading as well as subjective symptoms reported within a questionnaire.

Strategies to help:

 There are various strategies to assist with psychosocial limitations associated with MS. MDT’s look to create consistent services and continued care which includes patient involvement(NICE Guidelines, 2018; Multiple Sclerosis Academy, 2019). This allows empowerment for the patient as they are an active member of the team and can facilitate communication efficiently with all aspects of their care (Forbes, 2007). Perkin and Wolinsky, (2006) discuss patients’ ability to have an in/outpatient care approach which enables independence and personal decision making.

 Social workers must generate assessments and referrals when there are relapses or changes that affect work, family or lifestyle factors (NICE Guidelines, 2018). Social workers provide focus for ongoing care needs and support family units to integrate hospital and community services. They work alongside Occupational Therapists (OT’s) to manage housing needs or to obtain adaptive equipment/ mobility aids whilst developing care packages for children, extended family and the MS patient (Martin, 2010; Nice Guidelines, 2018). Care packages allow patients to be independent at home whilst recognising families require full support. For patients with children it is suggested by Bostrom & Nilsagard, (2016) that health professionals offer age-appropriate support and information where required. Giving patients’ children the opportunity to meet the MDT and understand their roles is crucial. DVD’s and books are available from the Multiple Sclerosis Society, (2019) to help children understand MS whilst bonding with their parent.

 Strategies to treat depression may include antidepressants, talking therapies such a psychotherapy or cognitive behavioural therapy alongside ‘coping skills’ workshops, which are supported by national support groups to give free access to individuals battling with depression and MS (National Multiple Sclerosis Trust, 2019). Some patients can be referred to psychologists who are integral members of the MDT team who look to manage emotional stress, memory, attention and cognitive impairments, as these are predictors of patient dependence (Multiple Sclerosis Academy, 2019). Alternatively, to treat depression, specialist MS nurses can provide knowledge on medication and converse with doctors on the best treatment approach. Also, Nurses can advise patients on what services are available, always encouraging self-education alongside their assistance. MS Canada, (2019) suggest self-directed management of care alongside the MDT which enables patients to be independent, accepting and empowered through their condition as social interactions, treatment choices and personal care is understood and well managed throughout the development of MS (NICE Guidelines, 2018).

 Individuals with MS whose condition is affecting their working life, are now protected by the Disability Discrimination Act, (1995) immediately from diagnosis whether they are symptomatic or not. Under the act, employers have the duty to consider reasonable adjustments to ensure there are no disadvantages to employment arrangements within the workplace. This act promotes independence and empowerment to enable those with MS to continue working without difficulty.

In conclusion, MS is a complex neurological disease with varying symptoms, implications and treatment options. It can affect an individual’s lifestyle drastically but there are key strategies, guidelines and charities which offer support to effectively enable the highest quality of life. Further research should be conducted into exact exercise intensity and prescription for the population group. This would enable standardised interventions which can be implemented nationwide.

Reference list:

• Anderson, J., Guise, V. and Wiig, S. (2014). Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature. BMC Health Services Research, 14(1).
• at: https://www.nice.org.uk/guidance/cg186 [Accessed 7 Aug. 2019].
• Benito-León, J., Rivera-Navarro, J., Oreja-Guevara, C., Pardo, J., Bowakim Dib, W., Orts, E. and Belló, M. (2010). Impact of Multiple Sclerosis on Health-Related Quality of Life. Multiple Sclerosis Journal, 15(11), pp.1347-1355.
• Boström, K. and Nilsagård, Y. (2016). A family matter – when a parent is diagnosed with multiple sclerosis. A qualitative study. Journal of Clinical Nursing, 25(7-8), pp.1053-1061.
• Campbell, E., Coulter, E., Mattison, P., Miller, L., McFadyen, A. and Paul, L. (2016). Physiotherapy Rehabilitation for People With Progressive Multiple Sclerosis: A Systematic Review. Archives of Physical Medicine and Rehabilitation, 97(1), pp.141-151.e3.
• Compston, A. and Coles, A. (2008). Multiple sclerosis. The Lancet, 372(9648), pp.1502-1517.
• Disability Discrimination Act. (1995). UK Legislation. United Kingdom: UK Government.
• Döring, A., Pfueller, C., Paul, F. and Dörr, J. (2012). Exercise in multiple sclerosis — an integral component of disease management. EPMA Journal, 3(1).
• Dutta, R. and Trapp, B. (2007). Pathogenesis of axonal and neuronal damage in multiple sclerosis. Neurology, 68(Issue 22, Supplement 3), pp.S22-S31.
• Edwards, S. (2002). Neurological physiotherapy. Edinburgh: Churchill Livingstone.
• European Multiple Sclerosis Platform (2012). Recommendations on Rehabilitation Services for Persons with Multiple Sclerosis in Europe. Diepenbeek, Belgium: European Multiple Sclerosis Platform.
• Forbes, A. (2007). What people with multiple sclerosis perceive to be important to meeting their needs. Journal of Advanced Nursing, 58(1), pp.11-22.
• Freeman, J. (2000). Clinical appropriateness: a key factor in outcome measure selection: the 36 item short form health survey in multiple sclerosis. Journal of Neurology, Neurosurgery & Psychiatry, 68(2), pp.150-156.
• Golan, D., Staun-Ram, E. and Miller, A. (2016). Shifting paradigms in multiple sclerosis. Current Opinion in Neurology, 29(3), pp.354-361.
• Gondek, D., Edbrooke-Childs, J., Fink, E., Deighton, J. and Wolpert, M. (2016). Feedback from Outcome Measures and Treatment Effectiveness, Treatment Efficiency, and Collaborative Practice: A Systematic Review. Administration and Policy in Mental Health and Mental Health Services Research, 43(3), pp.325-343.
• Halabchi, F., Alizadeh, Z., Sahraian, M. and Abolhasani, M. (2017). Exercise prescription for patients with multiple sclerosis; potential benefits and practical recommendations. BMC Neurology, 17(1).
• Halper, J. (2007). The psychosocial effect of multiple sclerosis: The impact of relapses. Journal of the Neurological Sciences, 256, pp.S34-S38.
• Harris, C., Costello, K., Halper, J., Hinrichs, J., Hutchinson, B., Naunton, A. and Yeung, M. (2003). Consortium of Multiple Sclerosis Centers Recommendations for Care of Those Affected by Multiple Sclerosis. International Journal of MS Care, 5(3), pp.67-78.
• Heesen, C., Romberg, A., Gold, S. and Schulz, K. (2006). Physical exercise in multiple sclerosis: supportive care or a putative disease- modifying treatment. Expert Review of Neurotherapeutics, 6(3), pp.347-355.
• Janssens, A., Doorn, P., Boer, J., Meche, F., Passchier, J. and Hintzen, R. (2003). Impact of recently diagnosed multiple sclerosis on quality of life, anxiety, depression and distress of patients and partners. Acta Neurologica Scandinavica, 108(6), pp.389-395.
• Kalb, R. (2012). Multiple sclerosis. New York: Demos Health.
• Khan, F., Turner-Stokes, L., Ng, L. and Kilpatrick, T. (2008). Multidisciplinary rehabilitation for adults with multiple sclerosis. Postgraduate Medical Journal, 84(993), pp.385-385.
• Krupp, L. (2008). Management of paediatric multiple sclerosis. Therapy, 5(5), pp.641-651.
• Lambert, M. (2015). Prevention of Treatment Failure. Washington: American Psychological Association.
• Lennon, S. and Stokes, M. (2011). Pocketbook of neurological physiotherapy. Edinburgh: Churchill Livingstone/Elsevier.
• Martin, L. (2010). Multiple sclerosis. Peterborough: Need2Know.
• McCullagh, R., Fitzgerald, A., Murphy, R. and Cooke, G. (2007). Long-term benefits of exercising on quality of life and fatigue in multiple sclerosis patients with mild disability: a pilot study. Clinical Rehabilitation, 22(3), pp.206-214.
• MS Canada (Multiple Sclerosis Society Canada). (2019). Improve your quality of life — MS Society of Canada. [online] Available at: https://mssociety.ca/managing-ms/living-with-ms/progressive-ms/improve-your-quality-of-life [Accessed 17 Aug. 2019].
• Multiple sclerosis academy (2019). MS Variance: The ‘co-ordinated multidisciplinary team meeting’ and what that term really means. [online] Available at: https://multiplesclerosisacademy.org/2018/12/14/the-coordinated-multidisciplinary-team-meeting/ [Accessed 12 Aug. 2019].
• Multiple Sclerosis Trust. (2019). Central nervous system (CNS). [online] Available at: https://www.mstrust.org.uk/a-z/central-nervous-system-cns [Accessed 5 Aug. 2019].
• Muñoz San José, A., Oreja-Guevara, C., Cebolla Lorenzo, S., Carrillo Notario, L., Rodríguez Vega, B. and Bayón Pérez, C. (2016). Psychotherapeutic and psychosocial interventions for managing stress in multiple sclerosis: The contribution of mindfulness-based interventions. Neurología (English Edition), 31(2), pp.113-120.
• National Multiple Sclerosis Society. (2019). Rehabilitation. [online] Available at: https://www.nationalmssociety.org/For-Professionals/Clinical-Care/Managing-MS/Rehabilitation [Accessed 5 Aug. 2019].
• National Multiple Sclerosis Society. (2019). Rehabilitation. [online] Available at: https://www.nationalmssociety.org/For-Professionals/Clinical-Care/Managing-MS/Rehabilitation [Accessed 10 Aug. 2019].
• NICE Guidelines. (2018). Multiple sclerosis: Management of multiple sclerosis in primary and secondary care | Guidance | NICE. [online] Available at: https://www.nice.org.uk/guidance/cg8 [Accessed 5 Aug. 2019].
• Noyes, B. (2005). Maximise your options. National Multiple Sclerosis Society. Multiple Sclerosis International, 2013, p.1.
• Oberwahrenbrock, T., Schippling, S., Ringelstein, M., Kaufhold, F., Zimmermann, H., Keser, N., Young, K., Harmel, J., Hartung, H., Martin, R., Paul, F., Aktas, O. and Brandt, A. (2012). Retinal Damage in Multiple Sclerosis Disease Subtypes Measured by High-Resolution Optical Coherence Tomography. Multiple Sclerosis International, 2012, pp.1-10.
• O’Hara, L., De Souza, L. and Ide, L. (2004). The nature of care giving in a community sample of people with multiple sclerosis. Disability and Rehabilitation, 26(24), pp.1401-1410.
• O’Sullivan, S., Schmitz, T. and Fulk, G. (2014). Physical Rehabilitation. 6th ed. Philadelphia: P.A F.A. Davis Company, pp.108-189.
• Perkin, G. and Wolinsky, J. (2006). Multiple Sclerosis. Abingdon: HEALTH Press.
• Pirko, I., Lucchinetti, C., Sriram, S. and Bakshi, R. (2007). Gray matter involvement in multiple sclerosis. Neurology, 68(9), pp.634-642.
• Refshauge, K., Ada, L. and Ellis, E. (2005). Science-based rehabilitation. Edinburgh: Butterworth Heinemann.
• Rietberg, M., Brooks, D., Uitdehaag, B. and Kwakkel, G. (2005). Exercise therapy for multiple sclerosis. Cochrane Database of Systematic Reviews.
• Rumrill, J. (2015). Employment and Community Living Issues for People with Multiple Sclerosis. Work, 52(4), pp.723-724.
• Schiffer, R. (2005). Review of Pseudobulbar Affect Including a Novel and Potential Therapy. Journal of Neuropsychiatry, 17(4), pp.447-454.
• Shepherd, G. (1994). Neurobiology. New York: Oxford University Press.
• Smith, M. and Arnett, P. (2005). Factors related to employment status changes in individuals with multiple sclerosis. Multiple Sclerosis Journal, 11(5), pp.602-609.
• Soderberg, J., Di Fabio, R., Choi, T., Hansen, C. and Schapiro, R. (1998). Extended outpatient rehabilitation: its influence on symptom frequency, fatigue, and functional status for persons with progressive multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 79(2), pp.141-146.
• Stokes, M. and Stack, E. (2014). Physical management for neurological conditions. Johanneshov: MTM.
• The CSP (Chartered Society of Physiotherapy). (2019). Multiple sclerosis. [online] Available at: https://www.csp.org.uk/conditions/multiple-sclerosis [Accessed 13 Aug. 2019].
• Vukusic, S. and Confavreux, C. (2007). Natural history of multiple sclerosis: risk factors and prognostic indicators. Current Opinion in Neurology, 20(3), pp.269-274.
• Zorzon, M., de Masi, R., Nasuelli, D., Ukmar, M., Pozzi Mucelli, R., Cazzato, G., Bratina, A. and Zivadinov, R. (2001). Depression and anxiety in multiple sclerosis. A clinical and MRI study in 95 subjects. Journal of Neurology, 248(5), pp.416-421.