Multiple
Sclerosis
SAADIA PERWAIZ, PT
BSPT, M. PHIL-MSK
AKHTAR SAEED MEDICAL AND DENTAL COLLEGE
Multiple Sclerosis
An auto Immune Disease characterized by inflammation,
selective demyelination, and gliosis.
It causes both acute and chronic symptoms and can result in
significant disability and impaired quality of life.
Etiology
Genetic
Genetic susceptibility, an exposure to viral agent can induce
an immune reaction causing myelin reactive lymphocytes to
attack myelin sheath.
Vitamin-d deficiency and smoking are
considered as risk factors
Pathophysiology:
Slow neural Oligodendrocytes
CD4, T-cells, B- Acute
Demyelination transmission, survive in early
cells, cross inflammation, phase , but with
blood brain autoantigens and disruption of nerve fatigue,
edema, progression anti-
myelin sheath conduction inflammatory
barriers infiltrates response weakens
block
GLIOSIS, BRAIN ATROPHY, LOSS OF AXONS AND MYELIN
THROUGHOUT THE BRAIN.
Four Major Clinical Subtypes
of MS
1. Relapsing-Remitting MS (RRMS)
Characterized by discrete attacks of neurological deficits
(relapse) with either full or partial recovery (remission) in
subsequent weeks to months.
The periods between relapses are characterized by lack of
disease progression.
85% of patients
2. Secondary-Progressive MS
(SPMS)
Characterized by an initial relapsing-remitting course,
followed by a change in clinical course with progression to
steady and irreversible decline with or without continued
acute attacks.
3. Primary-Progressive MS
(PPMS)
Characterized by disease progression and steady functional
decline from onset; patients may experience modest
fluctuations in neurological disability but discrete attacks do
not occur.
4. Progressive-Relapsing MS
(PRMS)
Characterized by a steady deterioration in disease from
onset (similar to PPMS) but with occasional acute attacks.
Intervals between attacks are characterized by continuing
disease progression.
Common Symptoms in
Multiple Sclerosis
Sensory Symptoms
• Hypoesthesia, numbness
• Paresthesias
Pain
• Paroxysmal limb pain,
• Headache
• Optic or trigeminal neuritis
• Lhermitte’s sign
• Hyperpathia
• Chronic neuropathic pain
Visual Symptoms
• Blurred or double vision (diplopia)
• Diminished acuity/loss of vision
• Scotoma
• Nystagmus
Cognitive Symptoms
• Short-term memory deficit
Bladder and Bowel Dysfunction
Motor Symptoms
• Paresis or paralysis
• Fatigue
• Spasticity, spasms
• Ataxia: Inco-ordination, intention tremor
• Postural tremor
• Impaired balance and gait
Depression and Anxiety
Sexual dysfunction
Speech and Swallowing
• Dysarthria
• Diminished verbal fluency
• Dysphonia
• Dysphagia
Patterns of symptoms
Varies greatly from person to person
Varies over time in each individual affected
First symptoms usually transient; typically sensory and
visual
Diagnosis involves evidence of damage occurring in at least
two separate areas of CNS and at two separate points in
time at least one month apart (dissemination of lesions in
space and time)
Stages
3 stages
Mild Moderate Severe
Diagnosis
MRI, demyelinating areas
Lesions on MRI do not always correlate with clinical
symptoms
Evoked potential, visual, auditory, somatosensory areas
showed evoked potentials
Lumbar puncture CSF fluid raised IgG antibodies
Management
Management
Medical Symptomatic
Corticosteroids, Physiotherapy, Speech And Language
DMARDS(Interferons) Therapists, Psychiatrist
Physical therapy Examination
Examination
Systems and Tests and
History
reviews measures
Physical therapy examination
• Mini mental status examination
Cognition • Minimum examination of cognitive function in MS
• Superficial and deep sensations
Sensation • Effects in relation with Quality of life scales
• Anxiety, stress, depression
Psychosocial function • Beck depression inventory
Pain • VAS, Mc-Gill pain questionnaire, neuropathic pain scale
•Gag reflex, dysphagia
Cranial Nerve Integrity
•Trigeminal neuritis
•Occulo-motor Dyscontrol, optic nerve, nerve 3, 4 and 6 examination
Musculoskeletal
Neural Control
Flexibility Motor function, Dexterity, Muscle performance, Strength,
coordination, gross and fine power, endurance, performance Tone and reflexes, Modified
Joint integrity, range of motion,
motor movements during functional activity Ashworth scale, Deep tendon
muscle strength
reflexes
Gait
Postural alignment,
6 Minute walk test, Respiratory function Integument
Control and balance
10- Meter walk tests
Functional status
Fatigue
Functional Environmental
factors Fatigue severity
independence
scale
measures
PHYSICAL THERAPY
INTERVENTIONS
1. Sensory and integumentary
deficit management:
Increase awareness of sensory deficits, compensate for
sensory loss, and promote safety
Visual compensation techniques
Tapping, verbal cueing, and/or biofeedback
Proprio-ceptive loading through exercise, light tracking
resistance, resistance bands or weights, and the use of a pool
Safety = adequate lighting, no obstacles, color contrast
Double vision = placing a patch over one eye
Pressure ulcers = Awareness, protection, and care of
desensitized parts
Regular pressure relief is essential… every 2 hours in bed
and every 15 to 30 minutes when sitting in a wheelchair.
Pressure-relieving devices (PRDs)
Prevention = good nutrition and drinking plenty of fluids
If nonblanchable skin redness develops (lasting longer than
30 minutes), patients should be instructed to stay off the
area until the redness disappears.
If the redness does not disappear within 24 hours, the
individual should seek medical attention.
2. Management of Pain
Relief of pain with regular stretching or exercise, massage, and ultrasound
Stabbing pain from Lhermitte’s sign may be
relieved with a soft cervical collar to limit neck flexion.
Hydrotherapy or pool therapy using lukewarm water
Pressure stockings or gloves can also be used to relieve pain, converting
the sensation of pain to one of pressure.
Neutral warmth
Multidisciplinary pain clinic
3. Exercise Training
Meaningful physiological and psychological changes,
improving function while lessening disability, and
enhancing quality of life.
Patients with RRMS who are experiencing an exacerbation
should not exercise until remission is evident.
3.1: Strength and
Conditioning
Exercise sessions should be scheduled on alternate days
Carefully balancing exercise with adequate rest periods.
Progression is generally slower than with healthy
individuals.
Exercising to the point of fatigue is contraindicated
3.2. Aerobic Conditioning
Sub-maximal aerobic exercise
3 to 5 days/week, on alternate days
Training intensity should be limited to 60% to
85% HR peak or 50% to 70% peak VO2.
Duration = 30 minutes per session or, for more involved
individuals, three 10-minute sessions per day.
3.3. Flexibility Exercises
Stretching and ROM exercises are necessary to ensure
adequate joint motion and to counteract the effects of
spasticity
Stretching and ROM exercises should be performed daily.
For adequate stretching, holding at end range should be a
minimum of 30 to 60 seconds repeated for a minimum of 2
repetitions.
Orthoses or dynamic splinting
4. Management of Fatigue
Energy Effectiveness Strategies (EES)
Adequate rest and the use of cooling and pre-cooling
treatments during exercise
Energy conservation = modifying the
task or modifying the environment
Activity pacing refers to the balancing of activity with rest
periods interspersed throughout the day.
5. Management of Spasticity
Mostly antigravity muscles
Including cryotherapy, hydrotherapy, therapeutic exercise,
stretching, positioning, or any combination thereof.
Fast, ballistic stretching movements are contraindicated,
because spasticity is velocity sensitive.
6. Cerebellar deficits (ataxia,
postural instability)
Postural control should first focus on static control (holding)
in weight-bearing, antigravity postures.
Progression through a series of postures to gradually
increase postural demands by varying the base of support
(BOS), raising the center of mass (COM), and increasing
the number of body segments moving.
Progress to dynamic postural control
The pool is an important therapeutic medium to practice static and
dynamic postural
Biofeedback training
Involve functional activities
Control of ataxic limb movements (tremor and dysmetria) can be achieved
through proprioceptive loading and light resistance.
PNF with light tracking resistance
Resistance bands or light weights to stabilize movements.
weight cuffs (wrist or ankle), weighted boots, or a weighted jacket or belt
can reduce tremors of the limbs or trunk.
Stress management techniques
7. Locomotion
8. Supportive role:
Orthosis and assistive devices
Functional training
Speech
Psychological issues
Education