Multiple sclerosis

MULTIPLE SCLEROSIS
Dr Suraj B.Kanase
Associate Professor, Dept of Neurosciences
Krishna college of physiotherapy
KIMSDU University

• The word sclerosis comes from the Greek ‘skleros’
meaning hard.
• Hard areas called ‘plaques’ (also known as lesions or scars)
develop around the damaged nerves.
• ‘Multiple’ refers to the many different areas of
the central nervous system that may have
damaged myelin.

• Multiple sclerosis (MS) is a neurological disease that
involves the central nervous system (CNS), the
nerves that comprise the brain and spinal cord.
• It has two major features :
1. Destruction of myelin
2. Damage of axons.

• Multiple sclerosis (MS), also known as disseminated sclerosis
or encephalomyelitis disseminata, is an inflammatory disease in
which the insulating covers of nerve cells in
the brain and spinal cord are damaged.
• This damage disrupts the ability of parts of
the nervous system to communicate, resulting in
a wide range of signs and symptoms.

• MS takes several forms, with new symptoms
either occurring in isolated attacks (relapsing forms)
or building up over time (progressive forms).
• Between attacks, symptoms may disappear completely; however,
permanent neurological problems often occur, especially as
the disease advances.

• While the cause is not clear, the underlying
mechanism is thought to be either destruction
by the immune system or failure of
the myelin-producing cells.
• Proposed causes for this include genetics and
environmental factors such as infections.

DEFINATION :
• Dr. Jean Charcot defined the disease by its
clinical and pathological characteristics; paralysis and cardinal
symptoms of intention tremor, scanning, speech and
nystagmus, later termed Charcot’s traid.
• Using autopsy studies he identified areas of hardened plaques
and termed the disease sclerosis in plaques.

EPIDEMIOLOGY :
• MS is a disease of early adult life.
• The onset of MS typically occurs between the
ages of 15 and 50 years, with peak at age 30.
• The disease is more common in women
than in men by a ratio of 2:1.
• MS affects predominately white populations.
• Decreased sunlight exposure resulting in decreased vitamin D
production has also been put forward as an explanation.

AETIOLOGY :
Age
• Onset generally occurs between the ages of 20 and 50 years
in 70% of patients with the average age about 30.
It rarely develops before age 15 or after age 60.
Gender
• MS is about 2.5 times more common among women than men.
The gender gap is strongest among people who develop MS at a
younger age.

Race and Ethnicity
• Multiple sclerosis occurs worldwide but is most common
in Caucasian people of northern European origin,
especially those of Scottish descent.
Family History
• A family history of the disease may put some people at risk for MS,
although the risk for someone inheriting all the genetic factors
contributing to MS is only about 2 - 4%.

Genetic Factors
• Multiple sclerosis is not hereditary, but genetic factors appear to play
a role in making some people susceptible to the disease process
leading to the condition. The most significant genetic link to MS has
been identified in the major histocompatability complex (MHC), a
cluster of genes on chromosome 6 that are essential for immune
system function.

Environmental Factors
• Multiple sclerosis is more common in certain geographical areas of
the world, particularly areas that are farther from the equator.
Prevalence is generally highest in northern European and North
American countries.
Infectious agents
• Many microbes have been proposed as triggers of MS, but none have
been confirmed.

Early Symptoms :
Symptoms more likely to occur earlier in the disease include:
1. Vision Problems :
• Optic neuritis, inflammation of the nerves in the eye,
is a common early symptom in over half of patients.
• Patients may initially experience blurred or double vision,
usually because of problems with one eye.

• As the condition progresses, vision loss increases,
although total blindness is rare.
2. Tingling and Numbness Sensations-
• Tingling, crawling or burning sensations or loss of
sensation can occur.
• Patients may feel sensations of intense heat or cold.
• Symptoms often begin at the end of the legs
or arms and move up towards the beginning of the limb.

• L’Hermmitte’s sign : which is caused by lesions in
the cervical spine in the neck, is an
electrical buzzing sensation that runs down the back
and into the legs. It occurs when bending the neck forward.
3. Muscle Weakness and Spasms-
• Patients can feel weakness, clumsiness, or heaviness
in the limbs.

• They may have difficulty with finger dexterity.
• Muscle spasms and stiffness (spasticity), particularly in the
legs, occur in an initial attack of MS
in about 40% of patients.
4. Problems with Balance and Coordination-
• Patients have an unsteady gait and difficulty walking
normally and keeping their balance.

• They may have trouble grasping small objects.
• These problems can be compounded by other common
MS symptoms, such as dizziness and tremor.
• Ataxia (lack of muscle coordination) and tremors
(shaking or trembling of limb) affect up to half of patients.
5. Fatigue-
• Fatigue is the most common and debilitating
symptom of MS and often occurs early in the disease.

• Fatigue is typically worse in the late afternoon
and improves in the early evening, and
may be accompanied by an increase in
body temperature.
OTHER COMMON SYMPTOMS :
Other common symptoms that progress over time include:
1. Bladder and Bowel Problems-
• Some patients have problems emptying their bladder (urinary
retention) and bowels (constipation) or find they
cannot control their bladder and bowels (incontinence).

2. Pain :
• About two-thirds of patients have pain at
some point during the course of the disease,
and 40% are never pain free.
• Pain syndromes associated with MS include trigeminal (facial)
pain, powerful spasms and cramps, pressure pain,
stiffened joints, and a variety of sensations,
including feelings of itching, burning, and shooting pain.

TYPES OF MULTIPLE SCLEROSIS :
1. Relapsing-remitting multiple sclerosis :
• It is the most common form of multiple sclerosis.
• About 85% of patients are first diagnosed with this type of MS.
• It is characterized by relapses with either full recovery or some
remaining neurological signs/symptoms and residual deficit upon
recovery.

2. Primary progressive multiple sclerosis –
• It is characterized by disease progression from onset,
without plateaus or remission or with occasional plateaus
and temporary minor improvements.
3. Secondary progressive multiple sclerosis –
• It is characterized by initial relapsing-remitting course,
followed by progression at a variable rate that
may also include occasional relapses and minor remission.

4. Progressive-relapsing multiple sclerosis –
• It is characterized by progressive disease from onset
but without clear acute relapses that may or
may not have some recovery or remission;
commonly seen in people who develop the
disease after 40 years of age.

Management :
Medical management -
Corticosteroid therapy:
• Corticosteroid therapy (eg., prednisone, methylprednisone) is used
to treat to acute disease relapses, shortening the
duration of the episode.
• These drugs exert powerful anti- inflammatory and
immunosuppressive effects, diminishing swelling within the
CNS and temporarily repairing the blood brain barrier.

• Typically corticosteroids are given in high doses
(100 mg/day), administered intravenously for a brief course
(eg., 3-5 days) followed by tapered dosage of oral medications
over a period of 10 days to 5 to 6 weeks.
Muscle relaxants :
• Muscle relaxants are used for management of spasticity
and spasm.
• Oral baclofen is typically the first drug of intervention.
• Dosage is progressed gradually to obtain optimal effects.

Amantadine hydrochloride :
• Amantadine hydrochloride is the recommended first line therapy
in the clinical practice guidelines of the MS council.
• This is an antiviral and dopamine agonist shown to
have a significant impact on lessening fatigue.
Following are commonly used drugs in MS:
• Betarson Phenytoin
• Avonex Diazepam
• Amantadine hydrochloride
• Hydroxyzine
• Antidepressant medication
• Anticholinergic medications
• Copaxone
• Novantrone
• Rebif
• Corticosteroid therapy
• Muscle relaxants
• Carbamazepine

PHYSIOTHERAPY MANAGEMENT
1. Goals of treatment in relation to impairments:
• Cognitive function is to be improved
• Joint integrity and mobility must be improved
• Sensory awareness and skin integrity should be improved
• Pain is to be decreased
• Motor function should be increased
• Muscle performance should be improved
• Postural control and balance are to be improved
• Gait and locomotion is to be improved
• Management of fatigue
• Aerobic capacity must be increased

2. Goals in relation with physical actions, tasks and activities :
• Independence in activities of daily living must be increased
• Tolerance of positions and activities should be increased
• Activity pacing and energy conservation must be enhanced.
• Ability to assumeresume self care and home management is to be
improved

Means of management :
1. MANAGEMENT OF SENSORY DEFICITS AND SKIN CARE:
• Strategies should be instituted to increase awareness of
sensory deficits, compensate for sensory loss and promote safety.
• Tapping, verbal cueing and/ biofeedback can all be
effective forms of augmented feedback.
• Proprioceptive loading through exercise, light tracking resistance,
resistance bands or weights and use of a pool
may heighten residual proprioceptive function and improve
movement awareness.

The Patient is educated in the following principles of skin care :
• The skin should be kept clean and dry.
• Soiled skin should be cleansed and dried promptly.
• The skin should be inspected regularly and carefully.
• Particular attention to persistent areas of redness
and over bonny prominences.
• Clothing should be breathable and comfortable.
• Regular pressure relief is essential.
• Typically every 2 hours in bed and every 15 min when sitting in a
wheelchair.

2. MANAGEMENT OF PAIN :
• Patients may experience relief of pain with
regular stretching or exercise.
• Massage and ultrasound also helps in relief of pain.
• Postural training and correction of faulty movement patterns
along with orthotics and adaptive seating devices can
reduce malalignment and pain.

• Pressure stockings or gloves can also be used to relieve pain.
• Stress management techniques, relaxation training, biofeedback,
meditation and so forth are helpful in reducing
anxiety and pain.
3. EXERCISE TRAINING:
• The benefits of exercise have been shown meaningful
physiological and psychological changes, improving function while
lessening disability and enhancing quality of life.

Following exercises are given :
• Resistance training modes include weight machines, free
or pulley weights, elastic resistance bands or
isokinetic machines.
• Circuit training UE and LE in which improved work capacity is
developed through the use of various different stations that alternate
work between upper and lower extremities, distributes the load among
muscles and may prove best for reducing the likelihood of fatigue

• Functional training activities can be used to promote strength
and functional endurance. Individuals with balance problems
require the use of more stable posture.
• Group exercises classes can provide valuable motivation
and social support.
4. FLEXIBILITY EXERCISES:
• Flexibility and ROM exercises are necessary to ensure
adequate joint ROM and to counteract the effects of spasticity.

5. MANAGEMENT OF FATIGUE:
• It is characterized by overwhelming sleepiness, excessive
tiredness and sense of weakness that comes on
suddenly and severely.
• Aerobic exercises training and energy effectiveness strategies
are central to any intervention plan .
• These can include modifying the task or modifying
the environment to ensure successful completion of daily activities.

6. BALANCE TRAINING:
• It should emphasize practice of dynamic stability tasks
( eg., weight shifts, reaching, axial rotation of the head and neck,
axial rotation combined with reaching, so forth).
• Seated activities can include sitting on a compliant surface
(inflatable disk) or a therapy ball.
• Challenges to the balance can introduced by varying arm position ,
varying foot/leg position, or adding voluntary movements.

7. LOCOMOTOR TRAINING:
• Locomotor training focuses on primary gait impairments
which typically includes slowed peed, shuffling gait patterns,
diminished arm swing and trunk movements and an
overall attitude of flexion while walking.
• Training programs are designed to lengthen to stride,
broaden base of support, improve stepping, and improve heel-toe gait
pattern, increase contralateral trunk movement,
arm swing, increased speed and provide a program of
regular walking.

8. COGNITIVE TRAINING:
• Cognitive retraining involves the employment of repetitive drills
and mentally stimulating exercises designed to strengthen
areas of cognition that are weak.
9. COMPENSATORY STRATEGIES:
• Coping methods or organizational skills to help patients
use their strengths to compensate for areas of relative weakness.

Such strategies can include the following :
• Maintaining a consistent routine
• Making lists
• Keeping a daily planner
• Organizing the home or work environment

10. Range of Motion (ROM)
• Both passive and active functional ROM should be assessed in the
extremities and trunk, limiting detailed goniometric measurement to noted
problem areas for time and fatigue reasons.
• Sedentary or inactive persons with MS often present with significant
tightness in hip flexors, adductors, hamstrings and heel cords.
• Limited overhead reach is often noted in those with slumped posture due to
tightness in the pectoralis minor, major and latissimus dorsi.
• Poor head control due to postural and substitution patterns often leads to
tightness in the upper trapezius and posterolateral cervical muscles.
• ACTIVE EXERCISES, STRETCHING OF LIMBS, STRENTHENING
EXERCISES CAN BE EFFECTVE MEASURES TO IMPROVE ROM.

Multiple sclerosis

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