Multiple Sclerosis (MS)

Multiple Sclerosis (MS)

• Demyelination leads to scar tissue, affecting nerve transmissions in the brain and spinal cord.
• An inflammatory process precedes myelin loss around nerve axons.
• Sclerotic plaques (scar tissue) develop at demyelination sites, disrupting nerve signals.
• Plaque formation worsens symptoms.

Target Demographic

• Onset typically in the most active years of life, between 20 and 40, but can range from 15–45.
• Women are slightly more prone to MS than men.

Etiology

• Genetics present a link, evidenced by 25-30% occurrence in monozygotic twins; risk increases with affected first-degree relatives.
• Environmental factors include higher incidence away from the equator in areas like Northern America and Europe.
• Viral infections such as measles, canine distemper, herpesvirus-6, Epstein-Barr or pneumonia can cause an overactive immune response, resulting in demyelination.
• Immunological factors involve abnormal immune response causing CNS inflammation and T & B cells attacking myelin in an autoimmune reaction.

Diagnosis of MS

• Early diagnosis is difficult.
• Diagnosis involves medical history, neurological examination, MRIs, evoked potentials (EP), and lumbar puncture (LP).
• Doctors seek evidence of damage in at least 2 separate areas of the CNS, such as the brain, spinal cord, and optic nerves.
• Evidence that damage occurred at different points in time helps diagnosis.
• Rule out other possible diagnoses

Types of MS

• Four recognized types of MS include clinically isolated syndrome (CIS), relapsing-remitting MS (RRMS), secondary progressive MS (SPMS), and primary progressive MS (PPMS).

Clinically Isolated Syndrome (CIS)

• CIS represents the earliest form of MS, marked by a single episode of neurological symptoms related to MS with MRI evidence of brain or spinal cord abnormalities.
• The course of CIS is variable; individuals may or may not develop MS later.
• Multiple attacks of the symptoms changes the diagnosis to Relapsing-remitting MS

Relapsing-Remitting MS (RRMS)

• RRMS is the most common form, characterized by unpredictable relapses (attacks, flare-ups, exacerbations).
• During relapses, new symptoms appear or existing ones worsen.
• Between relapses, recovery varies from complete to nearly complete, or there's a return to pre-relapse function or remission.

Secondary Progressive MS (SPMS)

• SPMS usually develops after relapsing-remitting MS, featuring progressive worsening with fewer relapses.
• Occasional relapses and minor remissions/plateaus may occur.

Primary Progressive MS (PPMS)

• PPMS involves slow accumulation of disability without defined relapses.
• It can stabilize temporarily with minor improvements, but lacks remission periods.
• Approximately 15% of MS patients are diagnosed with PPMS.

Signs and Symptoms

• Specific signs and symptoms depend on lesion location and extent in the CNS, affecting white matter.
• Lesions commonly occur in the brainstem, cerebellum, and spinal cord.
• Optic and trigeminal nerves can be affected, resulting in visual and facial issues.
• Optic nerve: visual acuity changes, color blindness, visual field defects, diplopia (double vision).
• Total blindness is uncommon.
• Trigeminal nerve: trigeminal neuralgia (facial pain).
• Common symptoms include fatigue, spasticity, weakness, impaired proprioception, intention tremors and circumducted gait.
• Additional indications can be altered posture, vertigo, bladder, bowel, compensatory changes, paresthesia, cold extremities or sweating abnormalities.
• Edema, speech disturbances, and emotional/cognitive issues may be present.

Exacerbating Factors

• Vitamin/mineral and essential fatty acid deficiencies should be addressed.
• Amalgam dental fillings, food allergies like dairy or high polyunsaturated fat intake should be avoided.
• Stressful events, overexertion, heat, fever, injury, and emotional upset can worsen symptoms.

Contraindications

• Avoid techniques that cause patient fatigue, such as frictions or vigorous work increasing SNS firing.
• Avoid heat applied over large areas and deep techniques in areas of altered sensation.
• Local massage is contraindicated over decubitus ulcers.
• Red, inflamed areas over bony prominences require MD referral.

History/Intake Questions

• Inquire about other present conditions, such as infection, cold, or flu, that increase fatigue susceptibility.
• Note the date of the last attack and periods of remission.
• Assess for diminished or loss of sensory perception and limb proprioception.

Assessment/Special Tests

• Conduct ROM and sensory testing.
• Implement specific orthopedic tests as applicable.

Goals of Treatment

• Treatment goals include decreasing SNS activity, preventing fatigue, and improving tissue health and decreasing edema.
• Treatment attempts to limit contractures, address postural issues/imbalances, manage secondary conditions and temporarily decrease spasticity, while improving joint health and ROM.

Homecare/Therex

• Encourage ADLs and movement rehab programs for balance and weight-shifting difficulties.
• Yoga and Tai Chi can be integrated.
• Swimming and walking are good as to not over-fatigue, as well as modified weight training in a cool environment, ensuring rest periods up to 5 minutes.
• Submaximal resistance exercises, using gravity and resistance bands, are beneficial.
• Patient education: including tissue health, self-lymphatic drainage, cool hydrotherapy, and signs of gangrene.