Understanding Multiple Sclerosis (MS)

What is Multiple Sclerosis (MS)?

• MS involves demyelination of nerves, leading to scar tissue formation that disrupts nerve transmissions in the brain and spinal cord.
• The process starts with inflammation, followed by myelin loss around nerve axons.
• Scar tissue, known as sclerotic plaques, forms at sites of demyelination.
• These plaques slow down, disrupt, or block nerve transmissions.
• Increased plaque formation worsens symptoms.

Multiple Sclerosis Demyelination

• MS involves damage to the myelin sheath, which is essential for nerve signal transmission
• In MS, the myelin sheath becomes damaged, exposing the nerve fiber

Who does MS affect?

• MS often affects people during active times of their lives.
• The typical age of onset is between 20 and 40 years, but it can occur as early as 15 or as late as 45.
• Women are slightly more affected by MS than men.

Etiology of MS

• There is a genetic component, but MS isn't strictly inherited; found in 25-30% of monozygotic twins. Risk is higher if a first-degree relative has it.
• Environmental factors include a higher incidence of MS further from the equator, like in North America and Northern Europe.
• Viral factors such as measles, canine distemper, human herpesvirus-6, Epstein-Barr, and Chlamydia pneumonia can trigger an overactive immune response, leading to axon demyelination.
• Immunologically, an abnormal immune response causes inflammation and damage to the CNS, with T and B cells attacking the myelin.

Diagnosis of MS

• Diagnosing MS can be difficult in the early stages.
• Diagnosis involves medical history and neurological examination.
• MRIs, Evoked Potentials (EP), and Lumbar puncture (LP) are used in diagnosis.
• Doctors look for evidence of damage in at least two separate areas of the CNS (brain, spinal cord, and optic nerves).
• Evidence of damage occurring at different points in time is considered.
• Other possible diagnoses must be ruled out.

Types of Multiple Sclerosis

• Clinically Isolated Syndrome
• Relapsing-remitting MS
• Secondary progressive MS
• Primary progressive MS

Clinically Isolated Syndrome (CIS)

• CIS is the earliest presentation of MS.
• It refers to a single episode of neurological symptoms related to MS.
• MRI scans may show abnormalities in the brain or spinal cord.
• People experiencing CIS may or may not develop MS.
• Multiple attacks of symptoms can lead to a diagnosis of relapsing-remitting MS (RRMS).

Relapsing-Remitting MS (RRMS)

• RRMS is the most common form of MS.
• It is characterized by unpredictable relapses (attacks, flare-ups, exacerbations)
• New symptoms may appear or existing ones may worsen.
• Recovery between relapses can range from complete to nearly complete, or remission.

Secondary Progressive MS (SPMS)

• SPMS often evolves from RRMS.
• It involves progressive worsening with fewer relapses.
• Occasional relapses and minor remissions/plateaus can occur.

Primary Progressive MS (PPMS)

• PPMS involves a slow accumulation of disability without defined relapses.
• There may be periods of stabilization.
• There can be minor temporary improvements.
• There are no periods of remission.
• Approximately 15% of MS patients are diagnosed with PPMS.

Signs and Symptoms of MS

• Specific signs and symptoms depend on the location and extent of lesions in the CNS.
• White matter is often affected.
• Lesions are commonly found in the brain stem, cerebellum, and spinal cord.
• The optic and trigeminal nerves can be affected.
• Optic nerve issues include changes in visual acuity, color blindness, visual field defects, and diplopia.
• Total blindness is uncommon.
• Trigeminal nerve issues can 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
  • Paresthesia
  • Cold extremities or sweating abnormalities
  • Edema may be present
  • Speech disturbances (dysarthria and slurring)
  • Mood swings, depression, euphoria, and cognitive problems like forgetfulness and inattentiveness

Factors Exacerbating MS Symptoms

• Vitamin and mineral deficiencies, particularly essential fatty acids.
• Amalgam dental fillings.
• Food allergies (e.g., dairy), and increased intake of polyunsaturated fats.
• Stressful events, overexertion, heat, fever, injury, and emotional upset.

Contraindications for Massage Therapy in MS Patients

• Techniques that cause fatigue. This includes frictions, vigorous work that increases SNS firing.
• Heat applied over large areas.
• Deep techniques in areas of altered sensation.
• Decubitus ulcers - local massage. If red, inflamed areas are seen over bony prominences, refer the patient to their MD.

History/Intake for MS Patients

• Check for other present conditions such as infection, cold, or flu which can increase susceptibility to fatigue.
• Inquire about last attack and remissions.
• Assess for diminished or loss of sensory perception, limb proprioception.

Assessment/Special Tests for MS Patients

• ROM
• Sensory testing
• Specific orthopedic tests

Goals for Massage Therapy in MS Patients

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

Homecare/Therex for MS Patients

• Encourage ADLs to the level of their ability.
• encourage movement rehab programs if they have difficulties with balance & shifting weight, such as yoga and tai chi.
• Swimming or walking, as long as they don't over fatigue.
• modified weight training in a cool environment
  • They should take rest periods up to 5 mins
  • Use sub-maximal resistance -- resisting against gravity, gradually increasing to resistance bands.
• Patient education on tissue health, self-lymphatic drainage, cool hydro, signs of gangrene.

Case Study: Emma

• Emma is a 27-year-old Caucasian female who was diagnosed with Relapsing Remitting Multiple Sclerosis (RRMS) two years prior.
• She smokes and has a history of depression.
• She is seeking massage to manage her weakness and fatigue.
• She wants to learn how to self-manage her symptoms.