Multiple Sclerosis (MS) is an autoimmune disease that affects the central nervous system (CNS) and it’s characterized mainly by demylination of the myelin sheath (CALABRESI, 2004). There are specific types of MS which are; relapsing-remitting type of MS (RRMS), secondary progressive MS (SPMS), primary progressive MS (PPMS), in addition to other types of MS but they are very rare such as progressive-relapsing MS (Norris, wells, 2007). There are many symptoms that specify MS. these symptoms can be categorized into the initial symptoms, the prodromal symptoms, and the symptoms that come along the course of MS (W.B Matthews, 1992). The recent methods of treatment for MS are mainly focusing at slowing the progression of the disease and keeping the symptoms under control, this can be achieved by using combinations of different medications (MCW Health link, 2007).
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Patients with MS usually have compromised balance (Fjeldstad, 2009). This can be caused by lesions located in the cerebellum that may lead to ataxia, or it could be as a secondary problem to diplopia, muscular weakness of the trunk or the limbs, vestibular problems, decreased sensory feedback and lower limbs spasticity (Fjeldstad, 2009). One of the new methods discovered to treat and help people with balance problems is the Wii-Fit. Many studies proved that the use of the Wii-Fit improves balance problems and helps people with diseases that may influence balance. Thus the research question of this paper is; is the Wii-Fit helpful in patients with MS who suffer from balance disorders.
MS was first discovered in 1849, although the first known description of a person with MS was from the fourteenth century in Holland (NINDS, 2007). MS is three times more common in women compared to men (NCEZID, DHQP, 2010). However, in patients who develop the MS symptoms later in life, the gender ratio is more equalized (NINDS, 2007). MS is not known as a childhood disorder because the statistics show that only 2 to 5% of the cases start before the age of 16. In addition, many of the MS symptoms are parallel to those of pediatric neurological disorders like metabolic disorders and leukodystrophies (NCEZID, DHQP, 2010). Finally, there is no universally acknowledged diagnostic criterion to diagnose MS in childhood (NCEZID, DHQP, 2010).
There are no recent statistics that show specifically how many people have MS in the world, but there are 250,000 to 350,000 patients with MS in the United States diagnosed directly by the physician (NINDS, 2007). This single statistic estimates that 200 new cases are diagnosed each week. The majority of patients with MS experience their initial symptoms between the ages of 20 and 40. Symptoms are rarely seen before the age of 15 or after the age of 60 (NINDS, 2007).
Caucasians are two times more susceptible to the disease than any other race (NINDS, 2007). Furthermore, MS is five times more common in temperate climates such as Canada, northern United States, and Europe than in hot and humid region (NINDS, 2007). Scientists have periodically received reports of MS epidemics, and the result was that the Faeroe Islands north of Scotland during World War II had the highest clusters of patients with MS ever. Yet there is no sufficient evidence that there is a direct relationship between the environmental factor and the increasing risk of MS. On the other hand, there is definitive evidence that the risk of developing or even worsening the condition of the disease is greater after acute viral infection (NINDS, 2007).
Pathophysiology of MS
MS is an autoimmune inflammatory disease that affects the central nervous system (CNS) (CALABRESI, 2004). It has no underlying cause and it’s characterized by axonal demyelination followed by degeneration (CALABRESI, 2004). The demylination specifically affects the myelin sheath, which is a shielding fatty rich protein insulator that covers the axons (Norris, wells, 2007). The myelin sheath aids in the rhythmic flow of the nerve impulses and the transmission of action potentials, which allows the communication between the brain and the different parts of the body (Norris, wells, 2007). However, in patients with MS the myelin sheath is destroyed by the body’s immune system. The immune system, which is the body’s defense system is malfunctioned in patients with MS, it fails to differentiate between the body’s own tissues and the foreign bodies, and starts to send diseased fighting cells to the CNS tissues to begin the destruction of the body’s own myelin sheath. When the body’s immune system starts to attack the body’s tissues this is called an autoimmune disease (Norris, wells, 2007).
Patients with MS usually experience their first symptoms as young adults (Norris, wells, 2007). Most of the patients are diagnosed with this condition at a young age, because very often at this age patients are going to school, driving a car, or starting a family. While performing the different activities of their life; patients eventually realize that they are not functioning well and there is something they need to be concerned about. Approximately 80 percent of patients with MS have their symptoms in a relapse and remit state; meaning that the symptoms come and go, making both the diagnosis and prognosis difficult (Norris, wells, 2007). MS is considered a non contagious disease and in most cases it does not shorten the patient’s life span (Norris, wells, 2007).
There are specific types of MS; 80 percent of patients begin with the relapsing-remitting type of MS (RRMS), which is characterized by the short-term flare ups or what is commonly called exacerbations or relapses, and it can last up to three months (Norris, wells, 2007). These relapses are followed by a partial or complete recovery or what is called remission. Women are diagnosed with RRMS more than men (Norris, wells, 2007). A significant number of patients go into a period of remission that lasts up to one year or even more, during this period of remission patients might experience mild symptoms that did not fully recover following the exacerbation or they may be symptoms free. However, even if patients do not get worse between the relapses or even if they don’t show any symptoms, there will be continuous changes in the CNS (Norris, wells, 2007).
More than 90 percent of patients with RRMS will eventually enter a second phase of RRMS if they were not treated suitably. This is called secondary progressive MS (SPMS) (Norris, wells, 2007). SPMS, occurs when the patient is experiencing worsening of the symptoms progressively. Nearly 80 percent of patients with MS are diagnosed with SPMS (Norris, wells, 2007). Most of the other 20 percent are diagnosed with primary progressive MS (PPMS). This type of MS doesn’t show a relapsing and remitting state, instead it is characterized by a progressive and steady worsening of the neurological status of the patient (Norris, wells, 2007). PPMS is fairly divided between the genders unlike the RRMS. Additionally, there are other types of MS but they are very rare such as; malignant or fulminant MS, benign MS, and progressive-relapsing MS (Appendix A) (Norris, wells, 2007).
There are many diagnostic tools used to evaluate the status of patients with MS. The most common diagnostic tool is magnetic resonance imaging (MRI) and lumbar puncture (Norris, wells, 2007). MRI, which views the lesions of the brain and spine, uses radiofrequency, computer stimulator, and a big electromagnet to contribute in providing a high quality picture of the brain (Norris, wells, 2007). MRI is used with patients with MS to assess the location and size of the lesions (Norris, wells, 2007). However, inflammation can be better assessed with the use of gadolinium-enhancement, which is a type of dye that is injected in the patient before doing the actual MRI (Norris, wells, 2007).
Moreover, the other tool that is commonly used with MS is lumbar puncture or spinal tap; where a thin needle is entered at the base of the spinal cord and a small sample of the cerebrospinal fluid (CSF) is collected (Norris, wells, 2007). CSF is the liquid that surrounds both the spinal cord and the brain (Norris, wells, 2007). After taking a small sample of the CSF, laboratory tests are initiated to evaluate the chemical and cellular abnormalities of the sample. The physicians mainly look for oligoclonal bands, which are atypical immune proteins called immunoglobulins. These proteins present in the CSF of nearly 90 percent of patients with MS, but these proteins can also occur with other neurological conditions other than MS (Norris, wells, 2007). When comparing the MRI and lumbar puncture, the MRI is more useful and conclusive tool for diagnosing MS. On the other hand, lumbar puncture can be useful in case the MRI results are normal or indecisive therefore it’s used less often. Other less common diagnostic tools for MS are; magnetic resonance spectroscopy and evoked potential tests (Norris, wells, 2007).
Symptoms of MS
Symptoms of MS can be divided into three categories, the initial symptoms, the prodromal symptoms, and the symptoms that come along the course of MS (W.B Matthews, 1992). The initial symptoms, which appear in the first episode of MS are often taken by the patient from the history. However, the longer the time between the relapse and the questioning, the more inaccurate the information taken from the patient. Recent review of published reports revealed the incidence of the initial symptoms as follows, weakness in one or more limbs 40%, optic neuritis 22%, paraesthesiae 21%, diplopia 12%, vertigo 5%, and disturbance of micturition 5% (W.B Matthews, 1992).
The prodromal symptoms are non specific symptoms that involve fatigue, irritability, limb pains, poor memory, and weight loss. These symptoms may be considered insignificant, because at this stage the abnormalities will not be detected in the cerebrospinal fluid (W.B Matthews, 1992). Furthermore, there are signs and symptoms that appear along the course of MS and in every advanced case of MS such as: weakness, spasticity, ataxia, tremors, sensory loss, visual disturbances and loss of bladder control (W.B Matthews, 1992; MCW health link, 2007). Then again, there are symptoms that are unusually seen with MS patients and it not proven to be associated with MS or any other medical condition that the patient suffers from such as: narcolepsy, spasmodic torticollis, and the restless legs syndrome (W.B Matthews, 1992).
One of the constant features of advanced MS is weakness of the limbs; the most common form of distribution is asymmetrical weakness of both lower limbs. The least common forms of distributions are weakness of one lower limb, one lower limb and one upper limb always on the same side, or weakness of one upper limb (W.B Matthews, 1992). Weakness may be attributed to a slowly progressive case of hemi paresis, which begins with one lower limb, and then progressively more to the upper limb of the ipsilateral side. In the cases of hemiplegia in MS; the face is spared and not influenced by the weakness. However, the weakness can reach the respiratory muscles, which may lead to serious complications and even death (W.B Matthews, 1992). Signs of sudden deterioration include restriction of respiratory movement and rapid shallow breathing; these signs are not to be taken for granted especially if the patient is having weakness in both upper limbs. Weakness in the respiratory muscles may lead to an increase in energy consumption during walking and during performing other types of activities; that is called chronic respiratory weakness (W.B Matthews, 1992).
Another feature of advanced MS is spasticity (W.B Matthews, 1992; MCW health link, 2007). Spasticity is a disorder of voluntary movement and increased resistance to passive movement (W.B Matthews, 1992). It usually affects the lower limbs more than the upper limbs. Nevertheless, this increase in tone is beneficial for some patients, because the increase in extensor tone can hold the weak knee extended during walking. However, if the tone increases beyond the reasonable limit, the patient will maintain the foot in planter flexion and that will make ambulation even harder and more difficult to the patient (W.B Matthews, 1992). Obtaining the desired tone to facilitate walking was proved impossible to attain. At the progressive stage of the disease there is an increase in the extensor tone, which is also called extensor spasm. This extensor spasm is considered inconvenient more than disabling e.g., it is extremely painful and occurs at night or when the patient gets out of bed in the morning. The patient needs several minutes for the spasm to subside (W.B Matthews, 1992). In advanced cases, flexor tone may take over and that will affect patient’s ability to walk (W.B Matthews, 1992). Patients may experience frequent falling, and it may be impossible to use a wheelchair. Eventually, patients may develop contractures mainly in the hamstrings and iliopsoas muscles (W.B Matthews, 1992).
One of the major symptoms that patients with MS complain of is fatigue (W.B Matthews, 1992; MCW health link, 2007). There are two main types of fatigue in patients with MS; the first type is physical fatigue and the other type is psychological fatigue (MCW Health link, 2007). However, in patients with MS it’s very difficult to distinguish the cause of the complain, is it from fatigue or weakness (W.B Matthews, 1992). The only factor that distinguishes the pathological fatigue of a patient with MS from an ordinary fatigue of a healthy person is the adverse effect of heat, thus it means when the patient gets lethargic and tired when facing the hot and humid weather (W.B Matthews, 1992).
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Sensory symptoms are also common to occur with this type of patients especially at the onset of the relapse (W.B Matthews, 1992). Usually the abnormal sensation begins in a single foot, then after few days it spread up to involve the whole bilateral lower limbs, perineum, buttock, and different levels of the trunk that vary with each patient. Patients usually describe the feeling as tingling sensation (W.B Matthews, 1992). There are many other signs and symptoms that may affect the MS patients such as urinary frequency, urgency, and incontinence (MCW Health link, 2007). In addition, some patients with MS may complain of pain, restless legs, lhermitte’s sign, and even mental changes such as dementia, affective disorder, and schizophrenia (W.B Matthews, 1992).
Finally, cerebellar dysfunction is a very common feature of advanced MS (W.B Matthews, 1992). This includes nystagmus, cerebellar ataxia, and dysarthria. Cerebellar ataxia can affect the gait. Truncal ataxia, the most common form of cerebellar dysfunction, is observed when the patient is sitting and it contribute to the increasing complaint of poor balance (W.B Matthews, 1992).
The current methods of treatment and medications aim at controlling the symptoms of MS, slowing the progression of the disease itself, and preventing undesirable side effects (MCW Health link, 2007). Significant numbers of people with MS suffer from spasticity (W.B Matthews, 1992; MCW Health link, 2007). Spasticity is often treated with tranquilizers and muscle relaxants such as Baclofen or lioresal, which can be taken orally and in serious cases they are injected into the spinal cord. They are considered the most commonly prescribed medication for spasticity. Other medications that are less commonly used for the treatment of spasticity are Tizanidine or zanaflex, Diazepam or Valium, and clonazepam or Klonopin (MCW Health link, 2007).
One of the common problems that patients with MS deal with is visual disturbances (MCW Health link, 2007). Which can recover with time even without any kind of medical intervention, the physician may prescribe a short course of therapy with methylprednisolone (Solu-Medrol) that may be introduced intravenously. In addition, oral steroids are occasionally used (MCW Health link, 2007).
Fatigue, which is the most common symptom of MS can be treated according to its type (MCW Health link, 2007). The physical fatigue can be avoided simply by instructing the patient to avoid heat and excessive physical activity. For psychological fatigue, the physician can prescribe anti-depressant medications for the patient. Other medications that can decrease fatigue are pemoline (Cylert), and amantadine (Symmetrel) (MCW Health link, 2007).
Many patients with MS may suffer from different kinds of pain (MCW Health link, 2007). Aspirin or acetaminophen can be very helpful in controlling back pain and muscle pain. Additionally, physical therapy is also advantageous in controlling the pain by correcting the improper posture, and strengthening and stretching the muscles (MCW Health link, 2007). Some patients may develop bladder dysfunction and that can lead to urinary infection as the disease progresses (MCW Health link, 2007). Antibiotics are often used in the treatment of urinary tract infections. In addition, the patient may take vitamin C supplements or drink cranberry juice to acidify the urine and thus to decrease the chance of further infections (MCW Health link, 2007). In patients with urinary incontinence bladder pace-maker can be implanted through surgery. It is controlled by a hand-held device that is carried by the patient, allowing the patient to control the muscles that surrounds the bladder, by contracting them when emptying the bladder and relaxing them in case of urine retention (MCW Health link, 2007).
Patients with MS may develop tremors, which can be often challenging during the therapy course because it often makes the therapy difficult and takes a long time. Tremors can be minimally controlled with drugs, or in severe cases it can be treated with surgical intervention, but the best treatment for the tremors associated with MS is by taking physical therapy (MCW Health link, 2007).
Finally, physical therapy rehabilitation is an integral part in the treatment of patients with MS (Patricia G, 2007). It’s very necessary that the physical therapy team posses the important knowledge, sensitivity, and experience when dealing with these kinds of patients. In addition, they have to appreciate the variety of symptoms that the patient may suffer from, and know how to deal with every emotional, social, vocational, and financial issues that their patients complain of. The physical therapist goals should be focused on the following: educating the patient about the disease and how to deal with it, providing home programs for dealing with symptoms, making the patient independent as much as possible, offering resources for community programs, providing equipments for the patients and their caregivers (Patricia G, 2007).
The Wii is a software and a hardware game package that belongs to the Nintendo wii, which is designed mainly to improve fitness and balance while in the same time providing entertainment for the users (Williams et al., 2010). It’s a video game that basically detects movement that is taking place on a balance board to allow the individual to play a variety of interactive games (Appendix B). The balance board is a flat board that the individual stands on, and it includes pressure sensors to detect any changes in weight shifting and the center of balance (Williams et al., 2010).
Recent studies have shown that the Wii-Fit can be used to treat or improve balance in a number of disorders that affect the balance. In 2010, Williams et al., conducted a study to determine if the Nintendo Wii-Fit is a reliable and useful intervention in community dwelling older adults. Older adults over the age of 70 and have high risk of falling were recruited for the study. They participated in computer-based exercises, and during their participation, fear of falling and balance were evaluated at weeks 0, 4, and 12. After the completion of the program, the participants were interviewed to know if the intervention was beneficial for them or not. Nearly 80% of the participants attended 75% or more of the training sessions, after week 12, the Berg Balance scores were obtained from all the participants and it was found that there’s a significant decrease in the risk of falling for the participants. The authors concluded that the Wii-Fit exercise program is beneficial and suitable for people with high risk of falling and thus, the Wii-Fit has the ability to improve balance (Williams et al., 2010).
Another study was conducted on children with Down syndrome (Abdel Rahman, 2010). It’s widely known that children with Down syndrome have lower scores on agility and balance tests compared to other children with other mental impairments. The main idea of this study was to examine if the Wii-Fit is helpful in improving balance in children with Down syndrome. Before starting the trial, balance was tested by using the Bruininks-Oseretsky Test of Motor Proficiency for thirty children aged 10 to 13 years with Down syndrome. The children were then equally and randomly divided into two groups; the study group received 6 weeks of Wii-Fit training and the control group received an ordinary physical therapy program. At the end of the program, the study group showed significant improvement in agility and balance compared to the control group. The author recommends that the Wii-Fit games can help in disorders that cause balance problems (Abdel Rahman, 2010).
Based on the literature review of this paper, the use of the Wii-Fit was proven beneficial for patients that have balance problems such as children with Down syndrome and community dwelling older adults that have high risk of falling. In addition, the presented information proved that MS can affect balance significantly. Thus since the Wii-Fit was useful in the cases of Down syndrome and community dwelling older adults, then it is possible that it would be useful in patients with MS that have balance problems.
Types of MS
The Wii-Fit package
The Balance Board
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