Hi physio_girl

Also, the fact that she is falling more often and her legs are stiffer, would that suggest that she had spasticity? and hypertone?
Yes i would interpret either the feeling of stiffness or the increased resistance to passive movement as spasticity and maybe also contracture. However The subjective feeling of heaviness is often more to do with weakness - having to work hard to move against gravity and overcome momentum. Contrary to popular belief a spastic muscle is usually also weak (not too strong) and its antagonist is often even weaker. the trouble with spasticity is that you can't "switch off" the muscle when you want to. It seems to go hand in hand with dennervation of the coritico-spinal tract (although it is more complex then just the result of dennervation). Where you have spasticity you will have dennervation of the CS tract and therefore voluntary weakness.

If she is falling then that may have more to do with weakness, and loss of dexterity (for example she may be developing ataxia as well) rather than spasticity. Sensory deficits (particularly proprioception, vestibular and visual changes) can adversely affect her balance and increase the incidence of falling. Addressing falls may involve assessing the components of balance that are disturbed and working on those components of balance - whether it be weakness, anticipatory postural adjustments, limits of stability, sensory changes and so on.

Designing an exercise programme with both passive and active stretches.

And then maybe some hydro work, to relax and ease pain in the muscles.
And maybe some massage.

Is this along the right lines do you think?
What you are suggesting is not wrong - However it sounds a bit passive and short term. I would be more oriented towards improving her function in activity – also working on strengthening may be more important and do more for her than working on spasticity. If she is getting pain in her muscles slow gentle but sustained stretches may help. Unfortunately spasticity is not something that physiotherapy has been shown to do a huge amount for- particularly in the mid-to long term. Stretches may help prevent contracture but won't do much for it once it has occurred. Massage may offer some immediate relief and can be a great technique to improve psychological rapport but may not pay off in reducing spasticity other than for an immediate effect

MS patients have quite a lot of trouble with fatigue - have you thought about how to address this? Aerobic exercise that is slowly increased within what they can manage can be very helpful for fatigue. One strange phenomenon about MS is they often develop fatigue and feel dreadful with heat so keeping the exercise room cool with a fan can be helpful and think carefully about whether to put them in the hydro pool. I would not normally do this, unless they really got enjoyment out of it.


In summary I would think more about working on physical tasks that your patient is struggling with (eg walking or transfers or what is important to her), progressive resistance training for key weak muscles, building up aerobic capacity to improve fatigue. and addressing the reasons for falling. And all this has to be in the context of not overly fatiguing her. Working on aerobic activity and strengthening can also have positive effects on depression - which many people with MS suffer from at times.

Have you thought about looking at the evidence for interventions? this might help you construct a rational programme. There are a lot of systematic reviews out there that might point you in the right direction

All the best with you project.