CNS: Multiple Sclerosis

• Termed "Multiple Sclerosis", the condition involves nerve demyelination, leading to scar tissue formation that disrupts nerve transmissions within the brain and spinal cord.

Development of Multiple Sclerosis

• It initiates with an inflammatory response, causing myelin loss around nerve axons.
• Scar tissue, or sclerotic plaques, forms at sites of demyelination.
• These plaques can slow, disrupt, or block nerve transmissions, exacerbating symptoms with increased plaque formation.

Who is Affected

• The disease typically strikes during active life stages, with average onset between 20 and 40 years, but can occur as early as 15 or as late as 45.
• Women are affected more than men.

Etiology Explained

• Genetic Factors: a genetic link has been found. This link has been seen in 25% to 30% of monozygotic twins, with increased risk if a first-degree relative has the condition.
• Environmental Factors: Higher occurrence of MS as distance from the equator increases, such as in North America and Northern Europe.
• Viral Factors: Infections like measles, canine distemper, human herpesvirus-6, Epstein-Barr, and Chlamydia pneumonia can cause overactivity of the immune response, leading to axon demyelination.
• Immunological Factors: Abnormal immune response results in inflammation and damage to the central nervous system; T cells and B cells can cause an autoimmune response that attacks myelin.

Diagnosis Explained

• Early diagnosis can be difficult.
• Diagnosis involves medical history, a neurological examination, MRIs, evoked potentials (EP), and lumbar puncture (LP).
• Doctors look for evidence of damage in at least two separate areas of the central nervous system (brain, spinal cord, and optic nerves).
• Evidence that the damage occurred at different points in time.
• To diagnose, other possible diagnoses are ruled out

Types of Multiple Sclerosis:

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

Clinically Isolated Syndrome (CIS) Details

• It is the earliest form of MS.
• It refers to a single episode of neurological symptoms related to MS.
• MRI scans show evidence of abnormality in the brain or spinal cord.
• Individuals experiencing CIS may or may not develop MS.
• Having multiple attacks of the symptoms changes the diagnosis to relapsing-remitting MS.

Relapsing-Remitting MS (RRMS) Details

• This is the most common type of MS.
• Characterized by relapse a.k.a. attacks, flair ups, exacerbations. These can be unpredictable but are defined
• The presence of new or worsened existing symptoms is a characteristic.
• Recovery between relapses can range from complete to nearly complete, or may return to pre-relapse function or remission.

Secondary Progressive MS (SPMS) Details

• It eventually transitions from the relapsing-remitting type.
• This phase involves progressive worsening with fewer relapses.
• Occasional relapses and minor remissions or plateaus may occur.

Primary Progressive MS (PPMS) Details

• Slow accumulation of disability without relapses.
• Can stabilize for periods of time
• May have temporary improvement
• Cases do not have periods of remission.
• Approximately 15% of MS patients are diagnosed with PPMS.

Signs & Symptoms

• Specific signs and symptoms depend on the location and extent of lesions in the central nervous system.
• It primarily affects the white matter.
• Lesions are commonly found in the brain stem, cerebellum, and spinal cord.
• Optic and trigeminal nerves can be affected.

Signs & Symptoms related to Optic and Trigeminal Nerves

• Optic nerve symptoms include visual acuity issues, color blindness, visual field defects and diplopia.
• Total blindness is uncommon.
• Trigeminal nerve symptoms include trigeminal neuralgia.
• Other signs and symptoms: fatigue, spasticity, weakness, impaired proprioception, intention tremors, circumducted gait, altered posture, vertigo, bladder dysfunction, UTIs, bowel dysfunction.
• Compensatory changes in unaffected or overused limbs can happen. Cold extremities or abnormal sweating, edema, and speech disturbances (i.e., dysarthria and slurring). Mood swings, depression, euphoria, and cognitive problems (i.e., forgetfulness and inattentiveness) can occur.

Exacerbating Factors

• Vitamin or mineral and essential fatty acid deficiencies.
• Amalgam in dental fillings.
• Food allergies, especially to dairy products, and increased intake of polyunsaturated fats.
• Stressful events, overexertion, heat, fever, injuries, and emotional upset.

Contraindications for MS Patients

• Techniques that can cause fatigue the patients.
• Frictions and vigorous work can increase SNS firing and induce fatigue.
• Heat applied over large areas.
• Deep techniques in areas of altered sensations.
• Local massage on decubitus ulcers.
• Red, inflamed areas over bony prominences require referral to their MD.

Massage Therapy: History & Intake

• Other present conditions such as infection, cold, or flu, can increase susceptibility to fatigue.
• It’s important to ask about the last attack and any remissions.
• Also, consider diminished or loss of sensory perception and limb proprioception.

Massage Therapy: Assessment & Special Tests

• Assessment involves:ROM, sensory testing, and specific orthopedic tests.

Goals of Massage Therapy

• Decrease SNS, prevent fatigue
• Improve/ maintain tissue health, decrease edema
• Limit contractures, address postural changes/imbalances
• Address secondary conditions and may temporarily decrease spasticity and/or maintain joint health and ROM.

Homecare & Therex

• Encourage activities of daily living withing the patients level of ability.
• encourage movement rehab programs, especially if they have issues with balance and shifting weight.
• Encourage activities like yoga, and tai chi.
• Encourage swimming or waking as long as they stay within their fatigue limitations.
• Modified weight training in a cool environment can be implemented, and ensure they are taking rest periods up to 5 mins.
• Submaximal resistance strategies: using only partial strength and resisting against gravity, and gradually increasing to resistance bands.
• Patient education about tissue health, self lymphatic drainage, cool hydro, signs of gangrene.

Case Study

• Emma is a 27-year-old Caucasian female diagnosed with Relapsing Remitting Multiple Sclerosis two years ago.
• She is a current smoker and has a history of depression.
• The patient self-referred herself to massage to help manage her weakness and fatigue. Additionally, the patient is looking to learn how to self manage her symptoms.

Multiple Sclerosis (MS) involves nerve demyelination and scar tissue formation, disrupting brain and spinal cord transmissions. It begins with inflammation, leading to myelin loss and sclerotic plaque formation. The disease typically manifests between 20 and 40 years, affecting more women than men.