Multiple Sclerosis Overview Quiz

Multiple Sclerosis (MS)

• MS is an immune-mediated inflammatory disease
• It attacks the myelin sheaths of axons in the central nervous system (CNS)
• This leads to demyelination, which affects white matter
• The predominant age of onset is 20-40
• Worldwide incidence is approximately 0.1%
• The risk of developing MS in first-degree relatives is 1-3%
• MS prevalence is higher in Northern European descent and in temperate climates, but the geographical gradient is decreasing
• The disease course is highly variable and unpredictable
• The condition involves two primary pathogenic processes: an inflammatory demyelinating process and a neurodegenerative process
• This can lead to disability
• Multiple factors are implicated in the development of the disease, including environmental factors, genetic factors, and autoimmune processes.
• Symptoms are varied and can include sensory, motor, bladder, and cerebellar dysfunctions
• Visual changes, such as optic neuritis, and oculomotor nerve dysfunction can occur

Clinical Picture

• Any myelinated area of the central nervous system (CNS) can be affected
• Sensory manifestations are common
• Lhermitte's sign is a frequent symptom
• Optic neuritis is a common symptom
• Speech, motor disorders (paraplegia, quadriplegia), ataxia, bladder dysfunction, and precipitancy are other possible symptoms

Pathogenesis

• T cells are primed by antigen-presenting cells (APCs) in lymph nodes
• The blood-brain barrier (BBB) becomes permeable to leukocytes
• T cells interact with macrophages and microglia
• Cytokines are released
• Demyelination of neurons occurs

Course of Disease

• Relapsing-remitting MS (RRMS): Characterized by periods of relapse followed by recovery
• Secondary progressive MS (SPMS): RRMS progression to a continual disability increase
• Primary progressive MS (PPMS): Gradual decline in neurologic function from onset

Diagnosis

• MRI
• Evoked potentials (visual, auditory, somatosensory)
• CSF analysis

Treatment

• Treatment for attacks (relapses): Short course of corticosteroids
• Long-term therapy (disease-modifying therapy): Interferon
• Symptomatic management

Assessment of the patient

• Expanded Disability Status Scale (EDSS)

• Method to quantify disability in MS and monitor changes over time

• The EDSS assesses various functional systems including pyramidal, cerebellar, brainstem, sensory, bowel, bladder, visual function, mental status.

  Functional Systems for Scoring EDSS

  • Pyramidal functions: Relates to muscle strength
  • Cerebellar functions: Deals with coordination and balance
  • Brainstem functions: Implicates cranial nerves and bulbar function
  • Sensory function: Relates to perception
  • Bowel and bladder function: Assessment of bowel and bladder control
  • Visual function: Examines visual acuity, field, scotoma, and disc pallor
  • Mental functions: Includes fatigue and cognition.

Assessment of Fatigue

• Examining the threshold, frequency, and the length of required rest periods
• The Fatigue Severity Scale (FSS) assesses the severity of fatigue based on a 9-item scale measuring its effect on activities and lifestyles

Gait Assessment

• Observation
• Analysis (kinetics, kinematics)
• 6-minute walk test (6MWT)

ADL Assessment

• Functional Independence Measure (FIM)

Physical Activity

• More sedentary behavior
• Loss of aerobic capacity
• Impaired muscle strength in MS patients
• More comorbidities

Physiotherapy Interventions

• Every patient's needs vary
• AIMS (during attacks): Relaxation exercises, psychological reassurance, respiratory exercises, prevention of secondary complications
• AIMS (during remission): Varying needs depending on patient symptoms and condition

Sensory Treatment

• Sensory re-education: Strategies to increase awareness, compensate for loss, and promote safety (e.g., using rough materials for hypoesthesia)

Deep Sense Treatment

• Strategies for deep sense deficit: Targeting sensory deficits, promoting safety, using verbal cues, biofeedback, proprioceptive loading, and resistance bands

Pain Management

• Pain management strategies in MS: regular stretching, massage, ultrasound, hydrotherapy, postural retraining, stress management, biofeedback, and medication.

Motor Dysfunction Treatment

• Treatment varies based on specific symptoms (ataxia, spasticity, weakness)
• Strengthening exercises
• Functional exercises
• Aerobic exercise
• Coordination exercises

Postural Control and Gait Exercises

• Includes various exercises like standing, balance exercises
• Changing positions

Treatment of Vertigo

• Vestibular Rehabilitation Therapy (VRT): Promoting vestibular adaptation
• Habituation exercises: reducing magnitude of response
• Cawthorne Cooksey exercises:

Mental Function Assessment

• Impaired memory, concentration, attention, depression, anxiety, and emotional liability

Patient and Family/Caregiver Education

• avoiding fatigue and heat
• Importance of sufficient recovery period between exercises, tasks
• education on disease process, clinical manifestations

Bladder Rehabilitation

• Lifestyle modification
• Pelvic floor exercises
• Biofeedback
• Core stability exercises
• Tibial nerve stimulation

ADL and Hand Function Assessment

• Occupational therapy interventions
• Orthotics and assistive devices for stability and independence

Cranial Nerve Examination

• Optic nerve (visual field, acuity, reflexes)
• Oculomotor, trochlear, and abducent nerves (eye movements)
• Trigeminal nerve (sensory branches, mastication)
• Facial nerve (rare) (facial expressions)
• Vestibulocochlear nerve (vertigo)

Temperature Control and Cooling Therapy

• Pre-cooling or cooling during and after therapy to potentially decrease fatigue and improve physical training

Cognitive Behavioral Therapy (CBT)

• Reported as a reduction method
• using specific neurocognitive rehabilitation programs for improving motor planning and stress management