Multiple sclerosis tertiary prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D., Julinka Auta Fernandes

Tertiary prevention in multiple sclerosis aims to limit the effects of established neurological impairment, preserve or restore independence and participation, and prevent avoidable secondary complications. Core interventions include individualized multidisciplinary rehabilitation, regular assessment of changing needs, adapted exercise and physical activity, fall prevention, assistive technology, complication surveillance, caregiver support, and needs-based palliative care.^[1][2]

Rehabilitation interventions are directed at function, activity, participation, and prevention of complications rather than the underlying inflammatory disease. Evidence supports physiotherapy, occupational therapy, exercise, and multidisciplinary rehabilitation for improving or maintaining functional outcomes and quality of life, although the appropriate combination and intensity vary between individuals.^[3]

All people with MS should receive a comprehensive review of their care at least annually. The review should be performed by healthcare professionals with expertise in MS and its complications and should occur sooner when function, independence, or care needs change.^[2]

The review should be individualized and include assessment of:

• Mobility, balance, falls, near-falls, and fear of falling
• Need for walking aids, seating, wheelchair assessment, or home adaptations
• Upper-limb function and activities of daily living
• Fatigue, pain, muscle stiffness, posture, and risk of contracture
• Cognition, communication, vision, speech, and swallowing
• Respiratory, bladder, and bowel function
• Nutrition, hydration, skin integrity, and bone health
• Emotional wellbeing, social participation, education, employment, and caregiver needs^[2]

Rehabilitation goals should be developed jointly with the person with MS, documented, functionally meaningful, and reviewed as circumstances change. Rehabilitation may involve rehabilitation medicine, MS nursing, physical therapy, occupational therapy, speech and language therapy, neuropsychology, dietetics, social work, orthotics, wheelchair services, and palliative-care professionals according to individual need.^[1]

Ambulatory or inpatient multidisciplinary rehabilitation should be considered when there is:

• Persistent functionally important impairment after a relapse
• Threatened loss of mobility, an important function, or independence
• Increasing difficulty with daily activities
• Threatened social, educational, or vocational participation
• Severe disability with defined rehabilitation goals requiring coordinated interdisciplinary care^[1]

Individualized exercise can improve or maintain physical fitness, muscle strength, mobility, balance, fatigue, participation, and quality of life. Exercise should be adapted to the person's disability, comorbidities, fatigue, heat sensitivity, pain, fall risk, preferences, and fluctuations in function.^[4]

Exercise programmes may combine:

• Aerobic conditioning
• Progressive resistance or strengthening exercise
• Balance and gait training
• Flexibility, positioning, and range-of-motion exercise
• Functional and task-specific training

The National Multiple Sclerosis Society consensus, endorsed by the Consortium of Multiple Sclerosis Centers, recommends that healthcare professionals promote exercise and lifestyle physical activity for people with MS throughout the disability spectrum. When feasible, people should progress gradually toward at least 150 minutes per week of exercise, lifestyle physical activity, or a combination of both. The programme should be adapted rather than discontinued when disability increases; people with very limited mobility may require seated, active-assisted, or caregiver-assisted exercise supervised by an appropriately trained professional.^[4]

People with impaired mobility should be asked about falls, near-falls, and fear of falling. Assessment should consider gait, balance, strength, vision, cognition, medication-related risk, footwear, transfers, and environmental hazards.^[1][2]

Fall and injury prevention may include:

• Individualized gait, strength, and balance training
• Transfer and wheelchair-skills training
• Appropriate walking aids or wheelchair provision
• Home and workplace safety assessment and modification
• Suitable footwear and management of visual or environmental hazards
• A personal plan for obtaining assistance after a fall, including an alarm or emergency-call system when appropriate^[1]

Orthoses, functional electrical stimulation, walking aids, wheelchairs, seating systems, and task-specific adaptive equipment should be selected following functional assessment. When foot-drop weakness predominates, the Deutsche Gesellschaft für Neurologie (DGN; German Neurological Society) guideline recommends assessing the benefit of functional electrical stimulation before providing a conventional foot-drop orthosis.^[1]

Orthoses and other assistive devices should not be described as treatments for the underlying ataxia or tremor. They may, however, improve positioning, safety, mobility, or performance of selected daily activities when prescribed for an individualized functional goal.

People with severely reduced mobility are at increased risk of pressure injury, contracture, deconditioning, pain related to posture, osteoporosis, and fracture.

Preventive measures include:

• Checking for areas at risk of pressure ulcers at every clinical contact when mobility is severely reduced
• Regular review of seating, wheelchair fit, pressure-relieving surfaces, positioning, skin care, and repositioning needs
• Regular assessment for contracture, with an individualized positioning, range-of-motion, stretching, splinting, or standing programme when appropriate
• Assessment and correction of unsafe transfer techniques
• Regular review of bone health and fracture risk in accordance with current osteoporosis guidance
• Safe weight-bearing, resistance exercise, and fall-reduction strategies when feasible^[2][1]

People with increasing disability should be asked actively about coughing or choking with food or fluids, a wet voice after swallowing, prolonged meals, recurrent chest infection, reduced intake, or unexplained weight loss. Suspected dysphagia should prompt specialist swallowing assessment and individualized swallowing therapy to reduce the risks of aspiration pneumonia, malnutrition, and dehydration.^[1]

Nutrition, hydration, body weight, respiratory function, cough effectiveness, and secretion clearance should be reviewed when disability is advanced. Positioning, texture modification, adaptive eating equipment, respiratory physiotherapy, or assisted airway-clearance strategies may be used following specialist assessment.^[1]

Bladder and bowel function should be reviewed regularly to identify complications such as recurrent urinary tract infection, urinary retention, renal risk, severe constipation, fecal impaction, incontinence-associated skin injury, or loss of independence. Persistent or complicated dysfunction should prompt appropriate specialist assessment.^[2]

Cognitive or communication changes that interfere with safety, daily activities, treatment adherence, employment, or independent decision-making should prompt individualized assessment. Occupational therapy, neuropsychology, speech and language therapy, compensatory strategies, environmental adaptations, and electronic communication aids may be considered according to the person's functional needs.^[1][2]

Tertiary prevention should also support:

• Continued participation in family, education, work, leisure, and community activities
• Workplace or educational adaptations and vocational rehabilitation
• Accessible housing, transport, and assistive technology
• Education in safe transfers, positioning, skin care, swallowing precautions, and emergency planning
• Assessment of caregiver knowledge, physical demands, emotional burden, respite needs, and access to support services^[2]

Palliative care should be considered according to symptom burden and unmet physical, psychological, social, practical, or spiritual needs; it is not restricted to the final days of life. It may be provided alongside rehabilitation and other active MS care.^[5]

People with severe or progressive MS and their caregivers should have access to needs-based general or specialist palliative care, including home-based care when appropriate. Care should address complex symptom burden, communication, psychosocial support, caregiver needs, and coordination between neurological, rehabilitation, primary-care, community, and palliative-care services.^[5][1]

The expected disease course, goals of care, preferred decision-makers, and advance care planning should be discussed sensitively and revisited as needs change, particularly when cognition, communication, swallowing, respiratory function, or independence is deteriorating.^[1]

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