Multiple Sclerosis

Dr. Iqra Shabbir

Orthopedic Manual Physical Therapist
Multiple sclerosis
• Multiple sclerosis (MS) is an autoimmune disease
characterized by inflammation, selective
demyelination, and gliosis.

• Gliosis occurs when your body creates more or larger glial cells (cells
that support nerve cells). These new glial cells can cause scars in
your brain that impact how your body works. Though they are not
brain tumors, necrosis and gliosis can cause symptoms similar to
brain tumors.
Cont…
• The cardinal symptoms are:
• intention tremor
• scanning speech
• Nystagmus
• Charcot’s triad.
Epidemiology

• the onset of MS typically occurs between ages 20 and 40

years. MS is rare in children, as is the onset of symptoms in
adults older than age 50 years.

• Women to men ratio is 2:1 to 3:1

• MS affects predominately white populations

Pathophysiology
• Mutations in the human leukocyte antigen major
histocompatibility complex (MHC) gene.

• The immune response triggers activation of immune cells .

• Phagocytic activity of macrophages may also contribute to
demyelination.
Cont..
• Brain atrophy, the loss of axons and myelin throughout the
brain, is evident even in early stages of the disease and is
progressive.
• There are certain areas of predilection, such as the optic
nerves, periventricular white matter, spinal cord (corticospinal
tracts, posterior white columns), and cerebellar peduncles
Inflammation

Active demyelination
Myelin is the layer that forms around nerves. Its
purpose is to speed the transmission of impulses
along nerve cells.
Disease Course
• There is benign MS, defined as disease in which the patient
remains fully functional in all neurological systems 15 years
after onset.

• Benign MS affects fewer than 20% of cases.

• At the other end of the continuum, there is malignant MS

(Marburg disease), a relatively rare disease course
characterized by rapid onset and almost continual progression
leading to significant disability or death within a relatively
short time after onset.
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.

• The stable patient may have local inflammatory activity that is

clinically silent.

• Affects approximately 85% of patients with MS at diagnosis.

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.

• May be the result of progressive axonal loss rather than new

lesions.

• Before newer treatments, the majority of patients with RRMS

progressed to SPMS.
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.

• PPMS is associated with later onset (mean age 40 years) and

more equal gender distribution.

• Affects approximately 10% of patients with MS.

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.

• Affects approximately 5% of patients with MS.

Exacerbating Factors
• MS relapses (exacerbations) are defined by new and recurrent
MS symptoms lasting more than 24 hours but generally of
longer duration that are unrelated to another etiology.

• Viral or bacterial infections

• Diseases of major organ systems

• Both major life stress events (divorce, death, losing a job,

trauma) and minor stresses (exhaustion, dehydration,
malnutrition, and sleep deprivation).
Pseudoexacerbation
• Temporary worsening of MS symptoms. The episode typically
comes and goes quickly, usually within 24 hours.
• The overwhelming majority of individuals with MS
demonstrate an adverse reaction to heat, known as Uthoff’s
symptom.
• Anything that raises the body temperature can bring on a
pseudoattack.
• External heat stressors
• Internal elevations in temperature
• Most pseudo-attacks resolve within 24 hours of cooling off
and/or the end of a fever.
Symptoms

• Sensory symptoms:
• Hypoesthesia, numbness
• Paresthesias
Pain

• Paroxysmal limb pain, dysesthesias

• Headache
• Optic or trigeminal neuritis
• Lhermitte’s sign
• Hyperpathia
• Chronic neuropathic pain
Visual Symptoms

• Blurred or double vision (diplopia)

• Diminished acuity/loss of vision
• Nystagmus
• Lateral gaze palsy
• Internuclear opthalmaplegia
Cognitive Symptoms

• Short-term memory deficits

• Diminished attention, concentration
• Diminished executive functions
• Diminished information processing
• Diminished visual– spatial abilities
• Depression
• Anxiety
• Pseudobulbar affect
Motor Symptoms
• Paresis or paralysis
• Fatigue
• Spasticity, spasms
• Ataxia: incoordination, intention tremor ,postural tremor
• Impaired balance and gait
Speech and Swallowing

• Dysarthria
• Diminished verbal fluency
• Dysphonia
• Dysphagia
Bladder Symptoms

• Spastic bladder
• Flaccid bladder
• Dyssynergic bladder
• Constipation
• Diarrhea and incontinence
Sexual Symptoms

• Impotence
• Decreased libido
• Impaired ability to achieve orgasm
Diagnosis
• The diagnosis of MS is made by a neurologist based on history,
clinical findings, and supportive clinical tests, including

• Magnetic resonance imaging (MRI); highly sensitive for detecting

MS plaques in the white matter of the brain and spinal cord,
bright spots and black holes
• In MRI perivenous demyelination known as Dawson’s finger are
usually seen

• CSF; elevated total immunoglobulin in spinal fluid

MRI of the brain and spinal cord in patient with MS
Medical Management
• Management of Acute Relapses; Corticosteroid therapy
(methylprednisolone), Plasmapheresis (plasma exchange)
• Disease modifying agents; immunomodulating agents
(interferon)
• Management of Symptoms
• Pain; Tricyclic antidepressants, gabapentin, Diazepam , NSAIDS,
carticosteroids
• Fatigue; Amantadine hydrochloride , modafinil
• Spasticity; Baclofen, Tizanidine, Diazepam, Phenol nerve blocks,
Botulinum toxin, surgery(tendonotomy, neurectomy, rhizotomy)
• Tremor ; hydroxyzine , clonazepam, propranolol, buspirone, Deep
brain stimulation (thalamus)
• Cognitive and emotional problems; antidepressants, psychologic
Bladder and bowel dysfunction
• Urinary tract infections and constipations
• Urodynamic work-up,
• Over- active, spastic bladder (storage dysfunction); Anticholiner­gic
medications ,
• Flaccid blad­der (emptying dysfunction); Crede maneuver
• Dyssynergic bladder (combined dys­function); alpha-adrenergic
blocking agents
• Continuous catheteriza­tion (indwelling or Foley catheter;
condom, or Texas catheter)
• Surgical urinary diversion (suprapubic catheter)
Rehabilitation Framework
• Restorative intervention
• Preventative intervention
• secondary prevention; early detection and early intervention
• tertiary prevention; minimizing the degree of disability
• Compensatory intervention
• Maintenance therapy
• A coordinated interdisciplinary team is necessary to oversee
the comprehensive examination and management needed to
address the patient’s complex and multifaceted problems.
Physical Therapy Examination &
Intervention

• Patient/Client History
Tests and measures
• Cognition • Aerobic capacity and
• Affective and psychological endurance
function • Skin integrity
• Sensation • Functional status
• Vision • Environment
• Cranial nerve integrity • General health
• ROM
• Fatigue
• Muscle performance
• Motor function
• Temperature sensitivity
• Posture
• Balance and coordination
Cognition
• Memory function, attention, concentration, conceptual
reasoning, problem solving, speed of information process­ing
should be examined as well as the effects of fatigue on cognitive
performance.
• Minimal Examination of Cognitive Function in MS (MACFIMS):
Comprehensive battery includes seven neuropsycho­logical tests
examining processing speed/working mem­ory, learning and
memory, executive function, visual- spatial processing, and word
retrieval.
• The MACFIMS takes approximately 90 minutes to administer.
• A brief screen of cognitive function can be achieved using the
Mini Mental Status Exam (MMSE).
Management of Sensory Deficits and
Skin Care
• Compensatory training strategies(visual, sensory)
• Tapping, verbal cueing, and/or biofeedback
• Proprioceptive loading through exercise,, resistance bands or
weights, and the use of a pool
•
• Adding contrast between items in the environment (e.g., stair
markings
• Double vision : Eye patch­ing
• Referral
• Awareness, protection, and care of desensitized parts.
• Regular pressure relief is essential.
• Pressure-relieving devices (PRDs)
• Prevention is the best strategy.
Management of Pain
• Regular stretching or exercise, massage, and ultrasound.
• Postural retraining and correction of faulty movement patterns
• orthotic and/or adaptive seating devices can reduce mal-alignment
and pain.
• Stabbing pain from Lhermitte’s sign may be relieved with a soft
collar to limit neck flexion.
• Hydrotherapy or pool therapy using lukewarm water for painful
dysesthesias
• Pressure stockings or gloves can also be used to relieve pain,
converting the sen­sation of pain to one of pressure.

• Stress management techniques, relaxation training, biofeedback,

meditation are often helpful in reducing both anxiety and pain.
• TENS; conflicting results, some MS patients experience
improvement and some a worsening of symptoms.
Exercise Training
• Strength and Conditioning
• Flexibility Exercises
• Aerobic exercise training
Management of Fatigue
• Fatigue is one of the most debilitating symptoms of MS and is
characterized by overwhelming sleepiness, exces­sive tiredness,
and sense of weakness that comes on sud­denly and severely.

• Therapists are faced with a balancing act, on one hand prescribing

exercise, while on the other hand avoiding overwork and the
development of fatigue.

• Aerobic exercise training (previously discussed) and energy

effectiveness strategies (ESS) are central to any intervention plan
to lessen fatigue.
Management of Spasticity
• Cryotherapy, hydrotherapy, therapeutic exercise, positioning, or any
combination thereof.
• Sustained stretching
• Splinting
• PNF
• It is important to reduce or eliminate all factors that can aggravate
spasticity (e.g., heat, humidity, stress).
Management of Coordination and
Balance Deficits
• Static postural control
• Dynamic pos­tural control
• Pool therapy and Water aerobics
• Movement transitions (e.g., sit- to-stand transfers)
• vestibular training exercises to reduce the effects of central
vestibular dysfunction.
• Frenkel’s exercises
• Stress man­agement
• Weights in control of ataxic movements
• Functional Training
Locomotor Training
• Early gait problem

• Standing and walking activities

• Walking in Pool
• Locomotor training using an overhead harness to sup­port body weight and a motorized
treadmill
• AFO, KAFOs, Rocker shoes
• Canes, forearm crutches, or a walker
• Wheeled mobility device (powered scooter or wheelchair) in more advanced stage

• s:
Management of Speech and
Swallowing
• Shallow respiratory patterns contribute to speech difficul­ties and
recurrent respiratory infections.
• Respiratory muscle training combined with activities to improve
trunk stability, head control, and sitting balance.
• Respiratory patterns facilitation through the use manual contacts,
resistance, and incentive spirometry.
• Diaphragmatic and segmental chest expansion, expiratory training,
and effective coughing.
• When dysphagia or difficulty in swallowing is present, physical
therapy efforts should be closely coordinated with those of the
speech—language pathologist and occupational therapist. The
physical therapist can assist in the management plan by improving
sitting position, head control, and oral-motor coordination.
• Upright pos­ture with a slightly forward head position and chin parallel
to table or slightly tucked is necessary to achieve good swal­lowing and
avoid aspiration.
• Oral-motor exercises can improve mouth function and include specific
exercises for lip closure, tongue movements, and jaw control.
• Stretch and resistance can be used to strengthen weak muscle actions.
• Swallowing reflexes can be stimulated by using icy bev­erages such as a
shake, sherbet, or fruit slush.
• Begin meals with something cold and to take single small sips, avoid
consecutive swallowing.
• Resistive sucking through a straw can also be helpful.
• Thicker liquids, which provide some resistance and there­fore some
facilitation of muscle action, are generally easier to swallow than thin
liquids such as water.
• Moist foods (with sauces, broth, water, or milk) are easier to
manage than dry ones. Semisolid and pureed foods are easier than
regular solids.
• Foods that irritate the throat (e.g., vinegar), stringy foods (e.g..
cake, cookies, potato chips, celery, cheeses) should be avoided.
• Chewing food thoroughly and not attempt to talk during eating.
• Fatigue can affect food intake.
• Modification in food stuff; consistency and size.
• The speech -language pathologist also teaches swallowing
techniques, including the power swallow: This involves having the
person first inhale and then hold his nr her breath, thereby closing
the airway. The person then swallows, exhales, and swallows again.
• Feeding tubes
• Heimlich maneuver
Patient and Family/Caregiver Education

• The disease process, clinical manifestations

• Prevention of secondary complications
• The rehabilitation process
• The home exercise program (HEP)
• Monitoring the effects and possible adverse reactions of
medications.
• Use of assistive devices and adaptive equipment.
• General health and stress management techniques.
• Community resources.
• Family support, care for care givers
Thanks!!