The coordination between doctors, physiotherapists, and neuropsychologists in multiple sclerosis: a comprehensive approach
Why MS requires coordinated multidisciplinary management — roles of each professional, challenges of inter-team communication, and resources for patients and caregivers
Multiple sclerosis (MS) is a chronic neurological disease that affects 120,000 people in France. Its uniqueness lies in its extraordinary clinical diversity: two patients with the same diagnosis can present completely different clinical pictures — one primarily affected by motor disorders, another by cognitive disorders, and a third by fatigue and visual disturbances. This heterogeneity makes the management of MS particularly complex and explains why a coordinated multidisciplinary approach is not a luxury but a medical necessity. This guide explores the coordination between the various professionals involved in the management of MS, with a particular focus on the respective contributions of the neurologist, physiotherapist, and neuropsychologist.
1. Multiple sclerosis: understanding the disease to better understand coordination needs
1.1 Mechanisms and clinical forms
Multiple sclerosis is an autoimmune disease in which the immune system attacks the myelin — the sheath that surrounds and protects the nerve fibers of the central nervous system. This demyelination slows down or interrupts the conduction of nerve impulses, generating symptoms that depend on the location of the plaques in the brain or spinal cord. The partial repair of myelin explains the characteristic remissions of the relapsing-remitting form, but each relapse can leave residual sequelae that accumulate over time.
There are primarily four forms of MS. The relapsing-remitting form (85% of cases at diagnosis) alternates between relapses lasting from a few days to several weeks with periods of stabilization or partial recovery. The secondary progressive form follows the relapsing-remitting form and is characterized by a continuous progression of disabilities without distinct relapses. The primary progressive form (10-15% of cases) manifests from the outset as a continuous progression without relapse, preferentially affecting the spinal cord. Finally, the progressive-relapsing form combines continuous progression with superimposed relapses. Each form has its own therapeutic and rehabilitation needs.
1.2 The different symptoms that justify a multidisciplinary approach
The diversity of symptoms in MS is precisely what makes monodisciplinary management insufficient. Motor disorders (spasticity, limb weakness, ataxia, balance disorders) fall under physiotherapy and functional rehabilitation. Cognitive disorders (slowed information processing, working memory difficulties, attention disorders, planning difficulties) fall under neuropsychology. Communication disorders (dysarthria, voice disorders) fall under speech therapy. Fatigue — one of the most disabling symptoms, present in over 80% of patients — requires a coordinated approach among all professionals who must adapt their interventions to this energy constraint. Psychological disorders (depression, anxiety) fall under psychology or psychiatry. Bladder and sphincter disorders require specialized management. The pharmacological management of all these symptoms falls to the neurologist.
2. The neurologist: conductor and prescriber
2.1 The role of the neurologist in coordination
The neurologist is the specialist physician responsible for MS. His role goes beyond mere medication management to encompass the overall coordination of care. He is the one who makes the diagnosis (according to McDonald criteria), initiates and adapts the baseline treatment (immunomodulators or immunosuppressants), manages relapses (IV corticosteroids), and monitors progression through regular MRIs. But he is also the one who prescribes rehabilitation, refers to various specialists, and coordinates the entire care pathway.
In France, the neurological follow-up of MS patients is often organized around MS resource and competence centers (CRCSEP) that offer coordinated multidisciplinary management in one location. These centers bring together neurologists, coordinating nurses, neuropsychologists, physiotherapists, occupational therapists, speech therapists, and social workers. Their existence illustrates the official recognition of the need for a multidisciplinary approach — but their geographical access is uneven across the territory.
2.2 The neurologist-rehabilitators communication: the stakes
The quality of communication between the neurologist and the rehabilitators (physiotherapists, neuropsychologists, occupational therapists) conditions the effectiveness of overall management. In practice, this communication is often insufficient: prescriptions are brief, rehabilitation reports do not always reach the neurologist, and the objectives of each professional are not always aligned. The patient often finds himself playing the role of a relay between professionals who work in silos.
Simple solutions can improve this communication. A standardized assessment report sent systematically to the neurologist after each neuropsychological or physiotherapeutic evaluation allows for shared follow-up. The participation of the physiotherapist or neuropsychologist in certain neurological consultations — particularly during annual assessments or important therapeutic decisions — allows for direct exchange. Digital tools for sharing files (DMP, secure health messaging) facilitate daily inter-professional communication. The DYNSEO session follow-up sheet is an example of a simple tool that formalizes the observations of rehabilitators in a transferable format.
3. The physiotherapist: maintaining motor function and managing fatigue
3.1 The specific objectives of physiotherapy in MS
Physiotherapy in MS pursues several objectives that evolve with the progression of the disease. In less advanced relapsing-remitting forms, the main objective is to maintain and optimize functional capacity — working on muscle strength, balance, coordination, and walking to compensate for the residual deficits from relapses and prevent physical deconditioning. In more advanced forms, the objective shifts to maintaining preserved capacities, preventing complications (stiffness, pain, pressure sores for wheelchair patients), and optimizing quality of life.
Spasticity — involuntary and permanent muscle contraction — is one of the main targets of physiotherapy in MS. If untreated, it generates pain, mobilization difficulties, sleep disturbances, and a progressive degradation of function. Physiotherapeutic techniques include passive and active stretching, joint mobilizations, local cryotherapy, and various neurofacilitation techniques. These interventions should be practiced regularly — ideally every day for severe forms — which raises the crucial question of the role of caregivers and the patient himself in performing exercises between sessions.
3.2 Managing fatigue: adapting intensity
Fatigue in MS is described as "central" — it is different from ordinary fatigue related to effort and results directly from brain lesions. It does not subside with rest alone, occurs unpredictably, and can be disabling even on days without significant effort. This central fatigue is one of the most misunderstood symptoms by those around the patient ("but you haven't done anything today") and represents one of the main causes of professional and social limitations.
The physiotherapist must adapt his intervention to this energy constraint. Sessions that are too intense or too long can cause a temporary worsening of symptoms (pseudo-relapse phenomenon or Uhthoff's phenomenon related to hyperthermia) and generate post-session fatigue that persists for several days. The rule is to dose the intensity based on the patient's condition on the day of the session — the same prescription may require significant adaptations depending on whether the patient arrives in a state of energy or exhaustion. The DYNSEO visual timer can be used to structure home exercise sessions in limited duration slots, with integrated breaks.
4. The neuropsychologist: evaluating and rehabilitating cognitive functions
4.1 Cognitive disorders in MS: an underestimated reality
Cognitive disorders affect 40 to 70% of MS patients at some point during their illness, but they often remain underdiagnosed and undertreated. Patients themselves sometimes attribute them to fatigue or psychological factors, and relatives may not perceive subtle difficulties in memory or attention. However, these disorders have a direct impact on quality of life, professional life, and autonomy.
The cognitive profile of MS is quite characteristic: slowed information processing (reduced processing speed) is the most universal symptom and one of the first to appear. Episodic memory disorders (memory of recent events) and working memory difficulties are common. Planning, organization, and flexibility difficulties (executive functions) occur later or in more severe forms. Verbal communication (verbal fluency, naming) can also be affected. In contrast, fundamental language, semantic memory (general knowledge), and visuo-constructive abilities are often preserved for a long time.
4.2 The role of the neuropsychologist in overall management
The neuropsychologist fulfills several functions in the multidisciplinary MS team. The first is the rigorous evaluation of the cognitive profile through standardized batteries (BICAMS, MACFIMS, BRB-N) that allow for objectifying deficits, situating them relative to norms, and tracking their evolution over time. These evaluations inform the neurologist about the progression of the disease, the effectiveness of baseline treatments on cognitive functions, and rehabilitation needs. The second function is cognitive rehabilitation — training programs targeting deficient functions, practiced in sessions and at home. The third is psychological support to help patients accept and adapt to cognitive changes and develop effective compensation strategies.
DYNSEO tools complement the neuropsychologist's work in home management. The application CLINT offers cognitive activities tailored for adults, with individualized progression that can be coordinated with the objectives of the neuropsychological rehabilitation program. The DYNSEO cognitive tests allow for regular follow-up between formal neuropsychological assessments. The memory test and the concentration test provide accessible indicators outside of consultations.
5. The patient at the center: their active participation in their own management
The most sophisticated multidisciplinary approach only produces its full effects if the patient is an active participant in their own management. In MS, where the disease often evolves over several decades, this posture of active engagement is particularly crucial. The patient who understands their disease, knows their aggravating factors, participates in therapeutic decisions, regularly practices their exercises between sessions, and develops compensation strategies for their daily difficulties achieves much better functional outcomes than the passive patient.
Specific training for MS patients — and for their caregivers — is available on the DYNSEO platform, including training on behavioral changes related to the disease and on supporting loved ones. This training provides the theoretical and practical foundations to understand the disease, adapt daily life, and maintain optimal quality of life despite the constraints imposed by MS. The DYNSEO AI Coach offers 24/7 access to personalized answers on daily questions — support available around the clock between medical consultations. The DYNSEO emotional regulation tools help manage the psychological dimensions of living with a progressive chronic illness.
Assess cognitive functions in MS
DYNSEO cognitive tests allow for accessible monitoring of memory and attention functions between formal neuropsychological assessments.
6. The occupational therapist in MS: autonomy and compensation in daily life
6.1 The occupational therapy assessment
The occupational therapist is the professional who evaluates and treats difficulties in performing daily living activities — dressing, cooking, using transportation, working. In MS, their role is twofold: to assess functional limitations in daily activities and to recommend technical, environmental, and behavioral adaptations that allow for the maintenance of autonomy despite deficits. The occupational therapy assessment should be conducted as soon as symptoms begin to impact daily functioning — not as a last resort when the situation is already very limiting.
This assessment includes an evaluation of the motor abilities of the upper and lower limbs, observation of daily living activities in a simulated or real context, an assessment of needs for technical aids, and an analysis of the home and workplace if necessary. It produces concrete recommendations: which kitchen utensils to adapt, how to arrange the bathroom to secure transfers, what technical aids for writing or using the computer, how to optimize work organization to manage fatigue.
6.2 Compensating for fatigue: occupational therapy strategies
Managing fatigue is probably the most important contribution of occupational therapy in MS. Central fatigue affects all functional activities — and its management requires a profound reorganization of how one plans their days, distributes efforts, and integrates breaks. The occupational therapist teaches energy management: identifying the most energy-consuming activities, planning them during the best windows of the day, simplifying movements (using aids that reduce effort), and planning breaks before feeling fatigued rather than after. This proactive approach, which may seem counterintuitive ("why rest if I'm not yet tired?"), is much more effective than reactive recovery.
The principle of the "3 Ps" — Plan, Prioritize, Position — is taught to patients as a framework for energy management. Planning means organizing activities in advance considering the energy load of each. Prioritizing means distinguishing essential activities from secondary activities and accepting that some things will not be done on difficult days. Positioning means adapting one's posture and environment to perform activities with minimal biomechanical effort — sitting for tasks that can be done seated, using work surfaces at the right height, using tools that reduce resistance.
7. The speech therapist in MS: communication, swallowing, and cognition
7.1 Communication disorders in MS
Communication disorders in MS are less known than motor disorders, but affect a significant proportion of patients at different stages. Dysarthria — difficulty articulating clearly, monotone voice, irregular speech rate — results from lesions affecting the motor control of speech. It can range from a slight impression of "slurred speech" to speech that is very difficult for non-familiar listeners to understand. Dysphonia (alteration of voice quality) and swallowing difficulties (dysphagia) may also appear, particularly in progressive forms.
The speech therapist evaluates these disorders and implements targeted rehabilitation programs. For dysarthria, exercises to strengthen and coordinate the oro-pharyngeal muscles, techniques to slow down speech rate, and training for intelligibility in different acoustic conditions are the main focuses. For dysphagia, adaptations of food textures, safe postures during meals, and compensatory swallowing techniques allow for safe eating for a longer time. The application MY DICTIONARY from DYNSEO can be a valuable augmentative communication tool for patients whose speech is heavily affected.
7.2 Speech therapy support for cognitive-linguistic functions
The speech therapist also contributes to the rehabilitation of cognitive-linguistic functions — verbal memory, verbal fluency, understanding complex texts — which may be affected in MS. This work complements that of the neuropsychologist and focuses on the linguistic dimensions of cognitive disorders: finding words, following a fast conversation, reading effectively. Compensatory strategies (note-taking, audio recording, reformulating important information) allow for maintaining effective communication despite these difficulties.
8. The psychological dimension of MS: depression, anxiety, and adjustment
8.1 Psychological disorders in MS
Depression affects 50 to 70% of MS patients during their lifetime — a rate much higher than that of the general population and even that of other comparable chronic diseases. This depression is both reactive (psychological response to the diagnosis announcement, successive losses, uncertainty of prognosis) and neurobiological (certain lesions in MS, particularly in the frontal regions, directly generate depressive symptoms). Its under-detection and under-treatment are real problems — depressive symptoms are often confused with fatigue or apathy related to the disease itself.
Anxiety is also very common, often related to the unpredictability of the disease progression ("will I have a relapse?", "will I be able to continue working?"), fear of relapses, and uncertainty of long-term prognosis. It can manifest as hypervigilance to symptoms (the slightest new sensation is interpreted as a sign of relapse), anxious anticipation of social or professional situations, or panic attacks. Regular psychological support — cognitive-behavioral therapy (CBT) or other validated approaches — is indicated in these situations.
8.2 Supporting quality of life beyond symptoms
Quality of life in MS is not limited to the absence of symptoms or the level of functional disability. Patients with significant neurological deficits can maintain a high quality of life if they benefit from robust social support, a sense of control over their lives, and the ability to find meaning and sources of pleasure despite limitations. Conversely, patients with relatively mild symptoms may suffer from a degraded quality of life if the disease has significantly impacted their professional identity or life plans.
The multidisciplinary team has a role to play in this often-neglected dimension. Group activities, adapted sports, patient associations, and therapeutic education initiatives allow patients to maintain a social network, share experiences and strategies, and not define themselves solely by their illness. DYNSEO emotional regulation tools — emotion thermometer, cognitive restructuring sheet — can support emotional regulation work in daily life, between follow-up sessions.
9. Work and MS: maintaining professional activity
Maintaining employment is one of the most important issues for MS patients, many of whom are diagnosed between the ages of 20 and 40 — in the midst of their active professional lives. Cognitive disorders, central fatigue, and symptom fluctuations are the most common obstacles to professional life — more than motor disabilities in less advanced relapsing-remitting forms. Adjustments to the workplace — partial telecommuting to avoid tiring commutes, flexible hours to account for energy windows, communication and organizational aid software — often allow for significantly longer professional activity.
The Recognition of Quality of Disabled Worker (RQTH) is a right that MS patients can assert as soon as the disease begins to impact their professional life. It opens access to funded workplace adjustments, enhanced protection against dismissal, and Cap Emploi services for maintaining employment or professional retraining. The occupational physician is the preferred contact to initiate these processes, in connection with the neurologist who can write the necessary medical certificates. Disclosing or not disclosing one's diagnosis to the employer is a personal decision that should be made with discernment — support from Cap Emploi or a social worker can help make the best decision based on the specific situation.
10. Practical coordination: tools and resources for the team and the patient
10.1 Networks and reference structures for MS in France
The management of MS in France relies on a structured network of centers of expertise and resources. The Resource and Competence Centers for Multiple Sclerosis (CRCSEP), of which there are about twenty across the territory, offer integrated multidisciplinary care with neurology, neuropsychology, physiotherapy, occupational therapy, speech therapy, and social work in one place. They also organize therapeutic education programs for patients (ETP) that teach patients and their families to better understand the disease, manage symptoms daily, and optimize coping strategies. Access to these centers is done through a referral from the neurologist.
The French Society of Neurology (SFN) and ARSEP (Association for Research on Multiple Sclerosis, www.arsep.org) publish validated medical information accessible to the general public. MS-Mag and MSconnaître are magazines and newsletters dedicated to MS patients and their families. These resources allow patients to be informed participants in their care journey — a stance that significantly improves long-term outcomes.
10.2 DYNSEO tools in the MS journey
The application CLINT from DYNSEO is particularly suited to the cognitive profile of MS patients. Its short activities (15-20 minutes), calibrated individual progression, and variety of exercises — memory, attention, processing speed, reasoning — precisely correspond to the cognitive functions most often affected in MS. It can be used as part of a home cognitive rehabilitation program in addition to sessions with the neuropsychologist. The memory test, the concentration test, and the executive functions test from DYNSEO provide accessible assessments between formal neuropsychological evaluations — with the possibility of comparing results over time to objectify progress.
The DYNSEO motivation board and the visual timer can support regular practice of home exercises by providing external structure and positive visual reinforcement — valuable during periods of intense fatigue or low motivation. The ultimate goal is not to replace the care team with digital tools — it is to offer a continuum of support accessible 24/7 that enhances the effectiveness of work done in sessions and maintains quality of life in the interstices between medical consultations.
Multidisciplinary coordination in MS is a permanent organizational and communicational challenge. It requires the active engagement of all actors — the patient, their family, and each professional on the team — and benefits from simple liaison and tracking tools. DYNSEO contributes to this ecosystem with resources tailored to the various dimensions of care: cognitive assessment, stimulation, emotional regulation, and support for caregivers. The common goal is always the same: to enable each person with MS to live the richest and most autonomous life possible, for as long as possible.
5. Physiotherapy in MS: specific techniques and adaptation to fatigue
5.1 Physiotherapy techniques specific to MS
Physiotherapy in MS uses particular techniques adapted to the neurological specificity of the disease. Proprioception — the perception of the body's position in space — is often impaired in MS, particularly in the lower limbs. Proprioceptive exercises on unstable surfaces, balance training, and foot sensitization techniques are specific components of neurological rehabilitation that do not appear in classical orthopedic rehabilitation.
The Uhthoff phenomenon — transient worsening of symptoms with an increase in body temperature — is an important clinical reality that the physiotherapist must integrate into their practice. Too intense sessions, conducted in overheated facilities or during summer months, can trigger pseudo-relapses that discourage patients and distance them from rehabilitation. The use of cooling garments, air conditioning in rehabilitation rooms, and reducing intensity during hot periods are practical adaptations that maintain access to physiotherapy throughout the year.
Spasticity, present in 60 to 80% of MS patients at some stage, requires a specific physiotherapeutic approach including passive and active stretching, proprioceptive neuromuscular facilitation (PNF) techniques, local cryotherapy, corrective postures, and prevention of contractures. These techniques must be practiced regularly — untreated spasticity generates progressive muscle-tendon contractures that become irreversible. For patients at home, learning daily self-stretching from the occupational therapist is an essential investment.
5.2 Integrating rehabilitation into daily life
One of the major challenges of physiotherapy in MS is integrating the benefits gained in sessions into daily living activities. A patient who walks correctly during the physiotherapy session but reverts to their old walking patterns as soon as they leave the office does not integrate the benefits of rehabilitation into their actual functioning. Neurology-specialized physiotherapists work on this transfer by using real functional tasks (walking to the mailbox, climbing the building stairs) rather than artificial exercises in the office.
The DYNSEO visual timer can be a useful tool for structuring home exercise sessions — by delineating defined-duration exercise slots, with integrated breaks that respect the constraint of central fatigue. The DYNSEO session tracking sheet allows for documenting exercises performed at home and patient observations, facilitating the physiotherapist's follow-up during subsequent consultations.
6. The cognitive challenges of MS: what the neuropsychologist brings
6.1 Assessment and cognitive profile in MS
The neuropsychological assessment in MS uses specific batteries developed for this population. The BICAMS (Brief International Cognitive Assessment for Multiple Sclerosis) is the internationally standardized battery recommended for cognitive follow-up in daily clinical practice. It includes three tests: the BVMT-R (visual memory), the CVLT-II (verbal memory), and the SDMT (Symbol Digit Modalities Test — processing speed and sustained attention). The SDMT is particularly sensitive to early cognitive impairments in MS and serves as an excellent marker for longitudinal follow-up. Studies have shown that the SDMT is more sensitive to cognitive decline in MS than brain MRI in certain configurations.
DYNSEO's online cognitive tests do not replace these standardized clinical assessments but can serve as a useful complement for follow-up between formal assessments. The concentration test and the executive functions test provide accessible indicators that the patient can perform at home and share with their medical team. The memory test evaluates verbal episodic memory, often affected in MS.
6.2 Cognitive rehabilitation in MS
Cognitive rehabilitation programs in MS primarily target processing speed, working memory, and executive functions. Recent meta-analyses show moderate positive effects of cognitive training programs on these functions, with limited but real transfers to daily functioning. The most effective programs combine specific training of the deficient function (memory, speed) with learning compensatory strategies (mnemonic techniques, externalized planning, reminder tools). The application CLINT from DYNSEO can be integrated into this home cognitive rehabilitation program — its memory, attention, and logic activities are progressive and calibrated for adults.
7. Living with MS: quality of life and psychosocial support
7.1 The impact on quality of life
MS affects quality of life in all its dimensions. Professional life — work stoppages related to relapses, job adjustments, risk of dismissal — is one of the major concerns for patients of working age. The RQTH (Recognition of Quality of Disabled Worker) opens rights to workplace adjustments and enhanced protection — it should be considered as soon as the disease impacts professional activity, even moderately. Family life — adjustments to parental roles, managing couple relationships in the face of the disease, impact on sexual life — are dimensions often neglected in medical care and that benefit from dedicated psychological and social support.
MS-L (French League Against Multiple Sclerosis) and its network of regional associations offer social and psychological support to patients and caregivers that complements medical care. Patient support groups, therapeutic education programs (ETP), and respite stays for caregivers are valuable resources that medical teams should systematically mention to their patients.
7.2 Research in MS: concrete hopes
Research in MS is among the most active in neurology. Highly effective disease-modifying treatments (natalizumab, ocrelizumab, cladribine, alemtuzumab) have transformed the prognosis of relapsing-remitting forms in the last fifteen years. Studies on neuroprotection — protecting non-demyelinated axons from progressive degeneration — and remyelination — repairing damaged myelin — open promising therapeutic perspectives for progressive forms, still insufficiently treated. Cell therapy and gene approaches are the subject of early trials.
These therapeutic advances do not diminish the importance of multidisciplinary care — they reinforce it. With patients living longer with a better-controlled disease, needs for rehabilitation, cognitive maintenance, and psychosocial support extend over decades. The partnership between the neurologist, physiotherapist, neuropsychologist, and social and psychological teams is more than ever the backbone of a care approach that allows MS patients to live fully, despite the constraints of their disease.
Frequently Asked Questions
Is physiotherapy reimbursed by Social Security for MS?
Yes. MS is a Long-Term Condition (LTC) that entitles you to 100% coverage by Health Insurance for all care directly related to the disease, including physiotherapy. The neurologist establishes the LTC care protocol that allows this coverage. Some forms of intensive rehabilitation (day hospitals, rehabilitation centers) may require hospitalization or MDPH coverage depending on their intensity.
Is a neuropsychologist necessary even if I do not feel any cognitive difficulties?
Cognitive disorders in MS can be objectified by standardized tests before being subjectively felt by the patient — this is particularly true for the slowing of processing speed, which develops gradually and for which patients develop compensation strategies without being aware of it. A reference neuropsychological assessment at the time of diagnosis allows for the establishment of a baseline profile to monitor evolution. It is recommended every two to three years or after each relapse potentially affecting cognitive spheres.
How to find a physiotherapist specialized in MS?
The French Society of Physiotherapy (SFK) and the French Association for Rehabilitation in Multiple Sclerosis (AFSEP) can direct you to physiotherapists trained in neurology and MS. The MS resource and competence centers (CRCSEP) often provide a list of partner private professionals in their region. The neurologist is also a valuable contact for recommendations of professionals they know and with whom they usually work.
Can the cognitive load of rehabilitation sessions worsen central fatigue?
Yes — and this is an important point that professionals well-trained in MS take into account. Central fatigue is exacerbated by cognitive effort as much as by physical effort. Sessions that are too cognitively or physically demanding can generate debilitating post-session fatigue. The rule is to adapt the intensity and duration to the patient's condition on the day of the session, and to schedule the most demanding sessions during periods of better energy — usually in the morning for most MS patients. Monitoring fatigue with a simple scale (MFIS or similar) helps to adjust the program.
Do disease-modifying treatments improve cognitive functions in MS?
Disease-modifying treatments reduce the number of relapses and slow the accumulation of lesions, which prevents the worsening of cognitive disorders in the long term. Some highly effective treatments (natalizumab, ocrelizumab, alemtuzumab) have shown positive effects on certain cognitive measures in clinical trials. However, they do not recover cognitive functions that have already been lost — neuropsychological rehabilitation is necessary for that. The therapeutic decision for disease-modifying treatment must integrate cognitive impact as a full objective, alongside the prevention of relapses and motor disabilities.
