Multiple Sclerosis: Causes and Effects

Multiple Sclerosis

• A UMN condition that involves demyelination of nerves, leading to scar tissue (sclerotic plaques) and affecting nerve transmissions in the brain and spinal cord
• The inflammatory process results in myelin loss around nerve axons, followed by development of sclerotic plaques that slow down, disrupt, or block nerve transmissions
• Increased plaque formation causes more severe symptoms
• Average onset is between 20 and 40 years, possible between 15 and 45
• Women are slightly more affected than men

Etiology

• Genetic link but not inherited, found in 25% to 30% of monozygotic twins
• Increased risk for first-degree relatives (parents, siblings, children)
• Higher occurrence farther from the equator
• Overactivity of the immune response from measles, canine distemper, human herpesvirus-6, epstein-barr, chalmydia, pneumonia can result in demyelination of the axons

Immunological Factor

• Autoimmune response caused by T cells and B cells causes inflammation and damage to the CNS

Diagnosis

• Diagnosis can be difficult in early stages
• Medical history & neurological examination
• MRIs, Evoked Potentials (EP), Lumbar puncture (LP) are all means of diagnoses
• Diagnoses can be confirmed after evidence of damage can be found in at least 2 separate areas of the CNS
• Brain, spinal cord, & optic nerves are the areas damage will be looked for
• Evidence needed that damage occurred at different points in time
• All other possible diagnoses ruled out during diagnoses

Types of Multiple Sclerosis

• Clinically Isolated Syndrome (CIS)
• Relapsing-remitting MS (RRMS)
• Secondary progressive MS
• Primary progressive MS

Clinically Isolated Syndrome (CIS)

• Earliest form of MS
• Single episode of neurological symptoms related to MS
• MRI shows evidence of abnormality in brain or spinal cord
• Experience may or may not go on to develop MS
• Multiple attacks changes diagnosis to Relapsing-remitting MS

Relapsing-Remitting MS

• The most common form of MS
• Characterized by unpredictable but defined relapse, such as attacks or flair ups
• New symptoms appear or existing ones get worse
• Recovery between relapses can range from complete to nearly complete
• Pre-relapse function or remission can be signs between relapses

Secondary Progressive MS (SPMS)

• Transition from relapsing-remitting
• Progressive worsening but fewer relapses in this phase of MS

Primary Progressive MS (PPMS)

• Characterized by slow accumulation of disability without defined relapses
• Can stabilize for periods of time
• Can have minor temporary improvement
• No periods of remission
• Approximately 15% of MS patients are diagnosed with PPMS

Signs and Symptoms

• Specific signs and symptoms depend on the location and extent of lesions in the CNS, specifically in the white matter
• Lesions commonly found in the brain stem, cerebellum, and spinal cord
• Optic nerve signs & symptoms: visual acuity, colour blindness, visual field defects, diplopia
• Total blindness is uncommon
• Trigeminal nerve sign & symptoms: trigeminal neuralgia
• Trigeminal nerve can be affected
• Paresthesia is a common symptom
• Speech disturbances eg. Dysarthria and slurring are common
• Other Symptoms include:
  • Fatigue
  • Spasticity
  • Weakness
  • Impaired proprioception
  • Intention tremors
  • Circumducted gait
  • Altered posture
  • Vertigo
  • Bladder dysfunction, UTIs
  • Bowel dysfunction
  • Compensatory changes of unaffected or overused limbs
  • Cold extremities or sweating abnormalities
  • Edema
  • Mood swings, depression, euphoria, cognitive problem, forgetfulness and inattentiveness
  • Vitamin/mineral and essential fatty acid deficiencies
  • Amalgam dental fillings
  • Food allergies: dairy products, increased intake of polyunsaturated fats
  • Stressful events, over exertion, heat, fever, injury, emotional upset can exacerbate symptoms

History/Intake

• Techniques that can fatigue the patients
• Frictions, vigorous work that increases SNS firing - inducing fatigue
• Heat applied over large areas
• Deep techniques in areas of altered sensation
• Decubitus ulcers - local massage
• If you see red, inflamed areas over bony prominences the patient should be referred to their MD
• Are other conditions present? Infection, cold, flu - potentially increases susceptibility to fatigue
• Last attack? Remissions?
• Diminished or loss of sensory perception, limb proprioception?

Assessment/Special Test

• ROM will require assessment
• Sensory testing will be performed
• Specific orthopedic test

Goals

• Decrease SNS, prevent fatigue
• Improve/maintain tissue health, decreased edema
• Limit contractures, address postural changes/imbalances
• Address secondary conditions/temporarily decrease spasticity/maintain joint health, ROM
• Encourage ADLS

Homecare/Therex

• Encourage movement rehab programs if they have difficulties with balance & shifting weight
• Yoga, Tai Chi recommended
• Swimming or walking - as long as they don't over fatigue
• Modified weight training in a cool environment
• Ensure they are taking rest periods up to 5 minutes
• Submaximal resistance - resisting against gravity, gradually increasing to resistance bands
• Patient education - tissue health, self-lymphatic drainage, cool hydro, signs of gangrene