Multiple Sclerosis (MS) Lecture Notes PDF

Contents  Introduction and selected stations about MS disease. Assessment of disability Neurological Examination of MS patients. Physical therapy interventions. MS Not a rare disease   Definition  Multiple sclerosis (M.S.) is an Immune mediated inflammatory disease...

Contents  Introduction and selected stations about MS disease. Assessment of disability Neurological Examination of MS patients. Physical therapy interventions. MS Not a rare disease   Definition  Multiple sclerosis (M.S.) is an Immune mediated inflammatory disease that attacks myelinated axons (white matter) in the central nervous system.  Chronic inflammatory demyelinating disease affecting mainly white matter of CNS.  Autoimmune Environmental and genetic factors play a key role in the development of the disease. Multiple sclerosis usually starts in individuals who are genetically susceptible (Dyment et al., 2004). Environmental Genetic  What is Myelin ?? 4- Increase conduction  Function of Myelin velocity Sheath 1. Protection 2. Insulation 3. nutrition  Pathogeneses  Multiple Sclerosis involves two primary pathogenic processes: 1- An inflammatory, demyelinating process is the first pathogenic process, manifested with a self-resolving and recurrently relapsing pattern of focal lesion formation in the CNS (Mallucci et al., 2015). The second pathogenic process is a neurodegenerative process that may include more longitudinal, high levels of inflammation and leads to a gradual accumulation of disability (Frischer et al., 2009).   Clinical picture  Any mylinated area in CNS can be affected  Sensory manifestations (most common).  Lerhmitte sign.  CN affection. Optic Neuritis (most common)  Speech disorders  Motor disorders Paraplegia Quadriplegia  Ataxia.  bladder disorders Precipitancy   Cranial Nerves Optic neurities  oculomotor nerves III,IV,VI  Fascial nerve (7th CN). UMN  Cochleovestibular (VIII) - Vetrigo (common) - Hearing impairment (rare)   Sensory affection Transient numbness and parathesia Any pattern +ve Lhermittes sign   Motor affection Monoplegia paraplegia Quadriplegia Cerebellar affection cerebellar ataxia, All sign and symptoms of ataxia   Autonomic disorders Blaader dysfunction - Prepitency Impotence , erectile dysfunction   Fatigue Subjective lack of physical or mental energy. Interfere with usual and desired activities.  prevalence of fatigue in PWMS 18 to 97 %.  Causes of Fatigue in MS Fatigue due to motor disability require more energy expenditure. Fatigue due to comorbidity ( anemia, thyroids,..). Fatigue due to depression. Fatigue due to sleep disorders. Fatigue as medication side effects. Primary Multiple sclerosis fatigue   Diagnosis  MRI.  Evoked potential (visual evoked potential , auditory evoked potential, somatosensory evoked potential ).  CSF analysis (Olgoclonal band, Igg index)   Course of disease RRMS  Relapsing _Remitting MS with full recovery between relapse  Relapsing_Remitting MS with residual deficit  Secondary progressive MS with initial remission and relapse followed by SPMS progressive disability PPMS  Primary Progressive MS from onset  Because the course of the disease may alter (RRMS to SPMS), clinicians need to be alert to changes in signs or symptoms in terms of severity, frequency, and impact on function.   Treatment Treatment for attacks (Relapse treatment). - Short course of cortisol. Long term therapy (disease modifying therapy) - Interferon Symptomatic managements  Importance of early treatment  Assessment of the patient  Expanded Disability Status Scale (EDSS): method to quantify disability in multiple sclerosis and monitoring change level of disability over time.  Functional systems for scoring EDSS 1-Pyramidal Functions. 5- Bowel and Bladder  Reflexes, Ms power Function. 2- Cerebellar Functions. Hesitancy, Retention, urgency ,  Head tremors, trunkle ataxia, limb incontinence, bowel dysfunction ataxia, tundum gait , gait ataxia, Romberg test, other cerebellar tests 6- Visual Function. 3- Brainstem Functions Examine Visual acuity, visual field,  Nystagmus, extraocular motility, other CN , Dysartheria, Bulber scotoma, disc pallor. 4- Sensory Function  Light touch , pain, vibration, position sense 7- Mental Functions  Fatigue, mentation  EDSS(0:4) score based on FS /pt able to walk male).  Present history: Onset of Disease: Course : ((RRMS), (SPMS), (PPMS), (PRMS))( Duration: Medications: (Prophylactic , Symptomatic ) -  Past history : other medical problems, History of Illness; previous attacks predisposing factors (stress, pregnancy..etc. )  Family history : Rare (but the disease has genetic susceptibility.  Chief Complain: Patient own words  B- Neurological Examination Mental function: Impaired memory (Short-term memory deficits), Concentration and attention. Depression , Anxiety , Emotional liability.  A brief screen of cognitive function can be achieved using the Mini-Mental Status Examination (MMSE).  Speech assessment:  Cranial Nerve Examination according to the Optic nerve affection and occurs Oculomotor nerves as a result of (3rd,4th,6th) spasticity, tremor, or ataxia Bulber Nerves (9th,10th,11th,12)  Optic nerve Patient may have optic neuritis, scotoma (dark spot may occur in the center of the visual field), and affected light reflexes. Test: visual accuracy and visual field examination. Oculomotor, trochlear and abducent nerves Patient may have diplopia, opthalmoplegia (weakness extraocular muscles) Test: All eye movements and nystagmus. Trigeminal nerve Test : Sensory branches supplying the face and muscles of mastication Facial N (rare) Test: muscles of facial expressions Vestibulocochlear nerve/vertigo assessment Vertigo is a sensation of spinning/self- motion, whether it feels like you are spinning or your surroundings are rotating. Assessment of vertigo The visual analogue scale (VAS).   Pain in MS Headache Trigeminal Neuralgia Musculoskeletal Lhermits pain pain   Sensory examination  Superficial sensation: Patient may have Parathesia or Diminution  Pain (pin break) or Lost at the  Crude touch (brush) distribution of glove and stock  Deep sensation Disturbances in - Test: position sense are also common, as are Joint sense lower extremity Vibration sense impairments of vibratory sense. ?   Motor assessment A. Observation Observe patient posture. Presence of postural abnormalities and postural tremor should be documented. The presence of cerebellar signs (ataxia, intention tremor, Nystagmus , dysarthria). The presence of vestibular dysfunction (dizziness, vertigo, nystagmus, blurred vision with head and body movements, and postural imbalance). Using any instruments, splints and assistive walking aids  B- Muscle tone assessment:  Spasticity is an Tone may be within extremely common normal, hypotonic or problem in patients spastic. with MS, occurring in 75% of all cases. Test of spasticity: Modified Ashworth Scale (MAS.) Test of clonus (clonus is a sign of spasticity).  C. Muscle strength assessment:  So no Wasting except long period of disease  Distal more than proximal LMN weakness UMN weakness  Test group or Functional strength using manual muscle testing (MMT). D.Deep and superficial reflexes examination Assess signs of UMNL as positive Babinski’s sign , loss of superficial abdominal reflexes and hyper reflexia. Test Deep tendon reflexes and superficial assessment. E- ROM and Muscle flexibility assessment   Respiratory assessment Patients with MS can also demonstrate respiratory muscle dysfunction (weakness, dyssynergia), contributing to reduced exercise tolerance. Examine :  Mobility of rip cage.  Respiratory rate and rhythm.   Balance and coordination assessment Due to affection of Vision , Deep sensation , 8th Cranial N. , muscles (ROM & weakness) , higher postural control ,cerebellum this can affect both of: 1- equilibrium (static & dynamic) 2 - Non equilibrium( dysmetria, dyssynergia, and dysdiadochokinesia)  Assessment of fatigue  Examine Threshold of fatigue  Frequency  How long rest period required   Assessment of fatigue  The Fatigue Severity Scale was used to assess patients fatigue within the past week.  FSS is a 9-item scale which measures the severity of fatigue and its effect on a person's activities and lifestyle.  This means the minimum score possible is nine and the highest is 63.  Gait assessment -observation -Analysis ( Kinetics , Kinematics ) Test 6 min. Walk test (6MWT). ADL assessment Test Functional Independence Measure (FIM) Physical Activity  More sedentary behavior  Loss aerobic capacity.  Impaired MS strength  More comorbidities. Effect of exercise  Physiotherapy interventions Every patient vary from another patient according to the stage, Type , severity & site of involvement. AIMs **During attack. 1- Relaxation exercise &psychological assurance 2- Respiratory exercise 3- Prevention of Secondary Complication. ** During remission ( between attacks)...   Sensory Treatment o Superficial Sensory Re-education like in - hypoesthesia..(rough material - rubbing) -hyperesthesia..(Soft material -maintain the pressure) Deep sense verbal cueing. Strategies should be instituted biofeedback can all to increase awareness of sensory deficits, compensate be effective forms of for sensory loss, and promote augmented feedback. safety. - Tapping. Proprioceptive loading through - Approximation. exercise - W.B exercises. Resistance bands or - joint sense. weights.  Pain treatment Regular stretching or exercise , Massage, and ultrasound, (TENS- according to every patient ). Hydrotherapy. Postural retraining and correction of faulty movement patterns , decrease pain Stress management techniques, relaxation training, biofeedback, and meditation are often helpful in reducing both anxiety and pain. Lhermitte’s sign may be relieved with a soft cervical collar to limit neck flexion  Motor dysfunction treatment According to the Case & manifestation if ataxic , spastic , weakness... By using - strengthening exercises - functional exercises - Tonic ex (core stability ex) - Aerobic exercise (60-75 % age predicted maximum heart rate (MHR))in form of cycling, walking, swimming, or water aerobics. - Coordination ex  Postural control and gait exercises include 1- Upright Postural Control in a body static position (standing on firm surface). 2- Balance exercises from stand on firm surface with wide then small BOS, with open eyes then closed.. 3- Balance exercises from stand on uneven surface with wide then small BOS, with eyes open then closed. 4- Changing body position from sitting to standing then return to sitting with eyes open then closed 5- From sitting to standing up then twisting to one side, then sitting to standing and twisting to the other side 6- Walking with sharp or wide turns to the right and left. Treatment of fatigue  Treat contributing factors to fatigue (depression, sleep disorders or pain).  Exercise therapy Endurance training. Hydrotherapy Resistance training. Inspiratory muscle training (IMT) improves inspiratory muscle strength, respiratory capacity and fatigue in patients with advanced MS. Aerobic exercises include bicycling and treadmill training are reported to reduce fatigue in patients with MS.  Relaxation  Temperature control and Cooling Therapy Pre-cooling or cooling during and after therapy may decrease fatigue and increase the effect of active physical training in thermo sensitive PWMS.  Cognitive Behavioral Therapy (CBT) It is reported that fatigue could be reduced by CBT using a specific neurocognitive rehabilitation program which improves motor planning using motor imagery (MI). Besides, stress management techniques such as meditation may be helpful in managing fatigue. Treatment of vertigo: I)-Vestibular Rehabilitation Therapy (VRT) is an exercises designed to promote vestibular adaptation and substitution. The goals of VRT are to enhance gaze stability, to provide postural stability, to improve vertigo. Habituation Exercises: is a reduction in the magnitude of the response to repetitive sensory stimulation, and it is induced by repetitive exposures to a provoking movement Cawthorne Cooksey exercises:  Gaze stability exercises VOR: Gaze stability and eye movement exercises visual fixation with head and trunk turn.  Bladder Rehabilitation intervention Life style modification Pelvic floor ex. Biofeedback Core stability ex. Tibial nerve stimulation ADL activities & Hand function  Occupational therapy  Orthotics and Assistive Devices may be used according to each patient to provide stability & independency   PATIENT AND FAMILY/ CAREGIVER EDUCATION  Avoid fatigue and heat for the patient.  Sufficient recovery period between exercises/tasks.  The disease process, clinical manifestations, and their significance in terms of management.  Prevention of secondary complications i, and activity limitations.  Monitoring the effects and possible adverse reactions of medications.  Use of assistive devices and adaptive equipment.  General health and stress management techniques.  ‫من نحن‬ ‫نحن مجموعة من المرضى بمرض التصلب العصبي المتعدد و المتأثرين بهذا المرض من أهل و أصدقاء للمرضى‪.‬قررنا أن نكون صوت‬ ‫المرضى في مصر ننقل معاناتهم و نتفاعل مع آمالهم و أحالمهم و نطالب بحقوقهم‪.‬‬ ‫و قد وضعنا نصب أعيننا هدفا ً أساسيا ً و هو تحسين نوعية حياة مرضى التصلب المتعدد في مصر و عائالتهم و دمجهم في المجتمع و‬ ‫جعلهم مواطنين مستقلين قادرين على اإلنتاج و تكوين أسر و االندماج في المجتمع‪.‬و من أهم أولوياتنا توفير العالج للمرضي و تغطية‬ ‫نفقات العالج من التأمين الصحي او نفقة الدولة و ادماج كل العالجات الحديثة تحت هذة المظلة و تنمية قدرات المرضي و تأهيلهم لسوق‬ ‫العمل و رعايتهم و أسرهم نفسيا ً و بدنيا و رفع وعي المجتمع بقضية هؤالء المرضى لتقبلهم في المجتمع كأفراد منتجين و لتفهم‬ ‫احتياجاتهم‪.‬و من أجل تحقيق هذة األهداف فنحن نقوم بهذة المهمة بالتعاون يدا بيد مع مجموعة من األطباء النابهين المتخصصين في‬ ‫مرض التصلب المتعدد و مراكز األشعة و المعامل و شركات األدوية و هم جميعا شركاؤنا الذين يعملون نفس الهدف و هو حياة أفضل‬ ‫لمرضى التصلب المتعدد‬