Multiple Sclerosis: Etiology and Diagnosis

• Multiple Sclerosis (MS) involves the demyelination of nerves followed by the formation of scar tissue, disrupting nerve transmissions.

Etiology

• Average onset is between 20 and 40 years old, but can manifest between 15 and 45 years of age.
• Women are more prone to MS than men.
• MS has a genetic component, observed in 25-30% of monozygotic twins and increased risk with first-degree relatives affected, but it is not inherited.
• Higher occurrence is linked to living further from the equator, like in Northern America and Europe.
• Viral factors like measles or human herpesvirus-6 can cause an overactive immune response leading to demyelination.
• Abnormal function of the immune system causes inflammation/damage to the CNS.
• Autoimmune response from T and B cells can attack myelin.

Diagnosis

• Early stages are difficult to diagnose.
• Diagnosis is made via medical history & neurological examination, MRIs, Evoked Potentials (EP) and Lumbar puncture (LP).
• Doctors look for damage in two separate areas of the CNS: brain, spinal cord, & optic nerves.
• Damage must have occurred at different points in time
• Other potential diagnoses must be ruled out.

Types of Multiple Sclerosis

• Clinically Isolated Syndrome (CIS) represents the earliest form with one episode of neurological symptoms related to MS.
• MRI evidence of abnormality in the brain or spinal cord may or may not lead to MS.
• Multiple attacks of the symptoms changes the diagnosis to Relapsing-remitting MS
• Relapsing-remitting MS (RRMS) is characterized by unpredictable relapses where new symptoms emerge or existing ones worsen.
• Between relapses, recovery varies from complete to partial, or back to pre-relapse function/remission.
• Secondary Progressive MS (SPMS) evolves from RRMS, marked by progressive worsening with fewer relapses and occasional plateaus.
• Primary Progressive MS (PPMS) is characterized by slow accumulation of disability without defined relapses.
• 15% of MS patients are diagnosed with PPMS.
• There are no periods of remission with PPMS, but can have minor improvements over time

Signs & Symptoms

• These depend on lesion location & extent in the CNS.
• Lesions commonly occur in the brain stem, cerebellum, spinal cord, and can affect optic and trigeminal nerves.
• Optic nerve issues include visual acuity, colour blindness, visual field defects, diplopia; total blindness is rare.
• Trigeminal nerve issues include trigeminal neuralgia.
• Key issues can be weakness, impaired proprioception, intention tremors, and a circumducted gait.
• Patients may experience fatigue, spasticity, altered posture, vertigo, and bladder dysfunction.
• Other conditions connected include bowel dysfunction, paresthesia, speech disturbances like Dysarthria, and cognitive issues.

Contraindications & Intake

• Avoid techniques causing fatigue as well as frictions and vigorous work increasing SNS firing.
• Avoid heat application over large areas
• Decubitus ulcers mandate referral to their MD if red, inflamed areas over bony prominences are seen.
• It is important to identify other conditions such as infections, cold, or flu due to increased susceptibility to fatigue.
• Take note of the last attack date and remission status as well as sensory perception or limb proprioception deficits

Assessment/Special Tests

• Utilize ROM and Sensory testing, as well as specific orthopedic tests

Goals

• Decrease the SNS and prevent fatigue.
• Improve/maintain tissue health and decrease edema.
• Limit contractures and address postural changes/imbalances.
• Address secondary conditions and maintain joint health through ROM exercises while offering temporary spasticity relief.
• Encourage ADLs
• Encourage movement rehab programs

Homecare/Therex

• Yoga and tai chi for difficulties with balance and weight shifting
• Swimming or walking can be beneficial, provided it doesn't lead to over-fatigue.
• Perform modified weight training in a cool environment including rest periods.
• Submaximal resistance by resisting against gravity and using resistance bands.
• Patient education on tissue health, self-lymphatic drainage, and hydrotherapy.