Multiple Sclerosis: An Overview

Multiple Sclerosis (MS) Overview

• MS involves demyelination of nerves, leading to scar tissue formation.
• This demyelination affects nerve transmissions in the brain and spinal cord.
• The process begins with inflammation, followed by myelin loss around nerve axons.
• Sclerotic plaques (scar tissue) develop at demyelination sites which slow down or block nerve transmissions.
• Increased plaque formation leads to more severe symptoms .

Who is Affected?

• MS typically affects individuals during their active years, with the average onset between 20 and 40, but can occur as early as 15 and as late as 45 years old.
• Women are slightly more prone to MS than men.

Etiology of MS

• There is a genetic component, but MS is not directly inherited.
• Monozygotic twins show a 25% to 30% occurrence.
• Risk increases if a first-degree relative (parents, siblings, or children) has it.
• Higher MS occurrence is linked to living farther from the equator, such as in Northern America and Europe.
• Viral infections like measles, canine distemper, herpesvirus-6, Epstein-Barr, Chlamydia, and pneumonia are factors.
• These infections can cause an overactive immune response, leading to axon demyelination.
• An abnormal immune response causes inflammation and damage to the central nervous system (CNS).
• T cells and B cells can trigger an autoimmune response, attacking myelin.

Diagnosis of MS

• Early diagnosis can be challenging.
• Diagnosis involves medical history, neurological examination, MRIs, Evoked Potentials (EP), and Lumbar puncture (LP).
• Doctors look for damage in at least two separate areas of the CNS (brain, spinal cord, and optic nerves).
• Evidence that damage occurred at different times is considered.
• Other possible diagnoses are ruled out.

Types of MS

• Four types of MS: Clinically Isolated Syndrome (CIS), Relapsing-Remitting MS (RRMS), Secondary Progressive MS (SPMS), and Primary Progressive MS (PPMS).

Clinically Isolated Syndrome (CIS)

• CIS is the earliest form of MS.
• It involves a single episode of neurological symptoms related to MS.
• MRI may show abnormalities in the brain or spinal cord.
• Individuals with CIS may or may not develop MS.
• Multiple attacks of symptoms lead to a diagnosis of Relapsing-Remitting MS.

Relapsing-Remitting MS (RRMS)

• RRMS is the most common form, marked by defined but unpredictable relapses.
• Relapses are also known as attacks, flair-ups, or exacerbations.
• During relapses, new symptoms appear or existing ones worsen.
• Between relapses, recovery can range from complete to nearly complete or remission to pre-relapse function.

Secondary Progressive MS (SPMS)

• RRMS eventually transitions into SPMS.
• SPMS involves progressive worsening with fewer relapses.
• SPMS may include occasional relapses and minor remissions or plateaus.

Primary Progressive MS (PPMS)

• PPMS is characterized by a slow accumulation of disability without defined relapses.
• It can stabilize for periods of time.
• Minor temporary improvements may occur.
• There are no classic periods of remission.
• Approximately 15% of MS patients are diagnosed with PPMS.

Signs and Symptoms

• Specific signs and symptoms depend on lesion location in the CNS and the extent of the lesions.
• White matter is frequently affected.
• Lesions are commonly found in the brain stem, cerebellum, and spinal cord.
• Optic and Trigeminal nerves can be affected.
• Optic nerve symptoms: visual acuity issues, colour blindness, visual field defects, diplopia, but total blindness is uncommon.
• Trigeminal nerve symptoms: trigeminal neuralgia.
• Other symptoms include fatigue, spasticity, weakness, impaired proprioception, intention tremors and circumducted gait.
• More symptoms are altered posture, vertigo, bladder dysfunction, bowel dysfunction, compensatory changes of unaffected or overused limbs, and paresthesia.
• Further symptoms include cold extremities or sweating abnormalities, edema, speech disturbances like dysarthria and slurring, mood swings, depression, euphoria, and cognitive problems like forgetfulness and inattentiveness.

Exacerbating Factors

• Vitamin/mineral and essential fatty acid deficiencies can exacerbate MS.
• Amalgam dental fillings affect MS.
• Food allergies, especially dairy products and increased intake of polyunsaturated fats, can affect MS.
• Stressful events, overexertion, heat, fever, injury, and emotional upset can worsen MS.

Contraindications for Massage Therapy

• Avoid techniques that can cause fatigue.
• Avoid frictions and vigorous work that increases SNS firing, as this can induce fatigue.
• Avoid heat applied over large areas.
• Avoid deep techniques in areas of altered sensation.
• Be cautious of decubitus ulcers.
• If you see red, inflamed areas over bony prominences, refer the patient to their MD.

History/Intake Questions

• Inquire about other present conditions like infection, cold, or flu, as these can increase susceptibility to fatigue.
• Ask about the last attack and remissions.
• Assess for diminished or loss of sensory perception and limb proprioception.

Assessment/Special Tests

• Conduct range of motion (ROM) assessments, sensory testing, and specific orthopedic tests.

Goals of Treatment

• Decrease SNS activity and prevent fatigue.
• Improve and maintain tissue health and decrease edema.
• Limit contractures and address postural changes and imbalances.
• Treat secondary conditions and temporarily decrease spasticity to maintain joint health and ROM.

Homecare/Therex Recommendations

• Encourage Activities of Daily Living (ADLs).
• Encourage movement rehab programs, especially for those with balance and weight shifting difficulties, for example, yoga.
• Suggest swimming or walking, but avoid over-fatigue.
• Recommend modified weight training in a cool environment, ensuring rest periods of up to 5 minutes.
• Advise submaximal resistance exercises.
• Educate patients on tissue health, self-lymphatic drainage, cool hydrotherapy, and signs of gangrene.