Multiple Sclerosis

DR.RINKAL PARMAR
 Multiple Sclerosis

- Chronic, inflammatory,
demyelinating disease OF CNS.
its not common.
- Affects the myelin sheath and axons
of the Central Nervous System (CNS).
- Progressive clinical course.
- Common cause of disability
in young adults.
 INTRODUCTION
• DEFINITION = IT IS A CHRONIC
INFLAMMATORY,
DEMYELINATING DISEASE OF
THE CENTRAL NERVOUS
SYSTEM.
• Clinically by neurological signs &
symptoms with remission &
exacerbation
- i.e. tremors, affected speech,
nystagmus,
• Ihe name is derived from
MULTIPLE SCARRED AREAS
termed as PLAQUES.
1. Research into the
Causes of MS

Genetic Environmental
factors factors
MS

Immunological
factors
What does the The Biology
of MS

central nervous
system do? Brain

The central nervous system

(CNS) consists of the:1 Spinal
cord
– Brain
– Spinal cord
The
• Also k/a DISSEMINATED
SCLEROSIS or
ENCEPHALOMYELITIS
DISSEMINATA
• Mainly affects the myelin sheath
and axons of the CNS
• Largely affects young adults
between the ages of 20 and 40.
 How does the CNS The Biology
of MS

work?
Messages travel to and from the CNS through nerve cells 3
Nerve Cell

Myelin surrounds the nerve fibers, protecting

them like the coating of a wire1

Myelin
Nerve fibers (or axon)
Cell body

Nerve fibers (or axon) Myelin

 How does MS affect the The Biology
of MS

CNS?
In MS, cells of the immune system attack myelin and can cause
permanent damage3

Areas where myelin has been Exposed nerve fibers are severed,
Nerve Cell damaged interrupt communication causing permanent damage
 EPIDEMIOLOGY
• Onset of MS typically occurs b/w
the ages of 15 and 50 years
• Peak at age of 30
• Rare in children
• Onset of symptoms in adults older
than the age of 50 years
• More common in women than in
man by a ratio of 2:1
ETIOLOGY
• The precise etiology of MS is
unknown.
• Mainly AUTO IMMUNE in nature.
• Viral infection triggers the
immunological response .
• Rubella and herpes are under
current investigation .
 ETIOLAGY / CAUSES
• Etiology / causes of MS is
unknown
• (1) ENVIORNMENTAL
FACTORS :
• (2) GENETIC FACTORS :

• If both parents are affected the

risk in their children is 10 times
that of the general population
• HLA region of Chromosome 6.
- changes in this area increase
the probability of getting MS
• MAJOR HISTO-COMPATIBILITY
COMPLEX (MHC) proteins,
encoded on chromosome 6 have
been linked to antibody production
(class 1 Ag) and MS
• (3) IMMUNOLOGICAL
FACTORS :
- It is an autoimmune disease
induced
by virus or other infectious agent
- mainly HERPES VIRUSES (1,2
and 6)
• Viral infections has been shown to
precipitate about 33% of relapse of
MS
4-Pathophysiology
 PATHOPHYSIOLOGY
• Immune response trigger the
production of T-lymphocytes,
macrophages, Immunoglobulin's

• Antigen activated producing

Autoimmune cytotoxic effects
within the CNS
• Blood brain barrier fails and Myelin
sensitized T-lymphocytes cells
enter and attack the the myelin
sheath that surrounds the nerve

• Myelin works as an insulator which

speed up the conduction from one
node of Ranvier to another
• Disruption of the Myelin sheath
produces active
DEMYELINATION, slowing neural
transmission and causing nerves
to fatigue rapidly

• With severe disruption , conduction

blocks with resulting disruption of
function
• Local inflammatiom, edema, and
infiltrates surround the acute lesion
and can cause a MASS EFFECT,
further interfering with the
conduction
mechanism
NORMAL CONDUCTION

ABNORMAL CONDUCTION
CLINICAL
MANIFESTATION
• Signs and Symptoms of MS vary
considerably
• It depends upon the location of the
specific lesion
• Early symptoms typically include
minor visual disturbances
i.e. Episode of double vision
• Paresthesias progressing to
numbness, weakness and fatigability
• More advanced stages, patients
demonstrate multiple symptoms
with varying involvement
• Onset of symptoms : minutes or
hours
• Less frequently , onset is insidious,
occurring over a period of weeks
or months
C/F- general
• Sensory Changes
• Pain
• Loss or diminished of sensation
• LOSS OF VISION
• CHARCOT TRIAL(SCANNING
SPEECH,NYSTAGMUS,INTENTIONAL
TREMOR)
• LHERMITTE S SIGN
• UTHOFF S PHENOMENON
LHERMITTE S SIGN
• Is called barber chair phenomenon
• Is an electrical sensation that runs down the
back and into the limbs
• In many pts, it is elicited by bending the head
foeward
• The sign suggest a lesion of the dorsal
columns of the cervical cord or of the caudal
medulla
• Seen in transverse myelitis, trauma, radiation
myelopathy,vitamin B12 deficiency and
compression of spinal cord in the neck
UTHOFF S
PHENOMENON
• ALSO CALLED UTHOFF’S SYNDROME
• Body gets overheated from hot weather,
exercise, fever and hot tubes
• It is possibly due to the effect of increased
temp on nerve conduction
• With an increased body temp, nerve impulses
are either blocked or slowed down in a
damaged nerve but once the body temp is
normalized, signs and symptoms may
disappear or improve
 COMMON CLINICAL
FEATURES
SENSORY SYMPTOMS
• Hypoesthesia
• Numbness of the face,body &
extrimity
• Paresthesias(pins & needle
sensation
• Disturbances in position sense
• Impairment of vibratory sense in
LE
 PAIN
• Trigeminal neuritis/nerralgia
• Lhermitte`s sign
• Chronic pain
• Dysesthesias – abnormal burning
or aching pain.
• Anxiety & fear can worsen the
symptoms
 VISUAL SYMPTOMS
•
found in 80% of patients .
• Blurred or double vision
• Loss of vision
• Nystagmus
• Optic neuritis is common – blurring
and gyaring of the vision ;
• Blindness is also common.
VISUAL SYMPTOMS
• A scotoma – dark spot may occur
in the center of the visual field .
• Diplopia , double vision can occur
when the muscles that control the
eyes are not well coordinated .
• Visual disturbances can be remit
and are the primary cause of
disability .
COGNITIVE SYMPTOMS

• Memory or Recall problem

• Decreased attention concentration
• Diminished problem solving and
judgment , planning and
sequencing.
• Diminished speed of information
processing
• Diminished visual abilities
• EMOTIONAL SYMPTOMS

• Depression – is very common .

• Anxiety , anger and dependency
increases .
• Emotional dysregulation symptom
( altering peroods of depression & mania
)
• Euphoria – exaggerated feeling of well
being .
• MOTOR SYMPTOMS

• Weakness or Paralysis
• Fatigue
• Spasticity
• Inco-ordination
• Intention Tremor
• Impaired balance
• Gait disturbances
• BLADDER SYMPTOMS

• Urinary urgency or frequency

• Incontinence
• dribbling
• BOWEL SYMPTOMS

• Constipation
• Diarrhea
• incontinence
• SEXUAL SYMPTOMS

• Sexual dysfunction
• SPEECH AND SWALLOING

• Dysarthria
• Diminished verbal fluency
• Dysphonia
• dysphasia
• CARDIOVASCULAR
DYSAUTONOMIA

• Caused by involvement of
AUTONOMIC nervous system
• Problem in cardio acceleration
• So decreased BP response during
exercise
• PATTERN OF SYMPTOMS

• Vary greatly from person-to-person

• Vary over time in each individual is
affected
• Early symptoms are typically
sensory or visual
• Involves more than one functional
component of the CNS
INVESTIGATION
• No Specific test
• CSF elevation of proteins
• MRI
 DIAGNOSIS
• MRI

• Most sensitive technique for imaging the

lesion in both BRAIN & SPINALCORD
• It detects both acute and chronic lesions
• Small and large lesions
• Help to distinguish new lesions with active
inflammation that occur during the
preceding 6 weeks or so
• Lesions are seen as a “BRIGHT SPOTS”
• T2 scans are used to detect more
long term disease activity in the
form of “BLACK HOLES”
 CLINICAL COURSE
• Highly variable from person-to-person
TYPES OF MS
• (1) BENIGN MS : defined as disease in
which the patient remains fully functional in
all neurological systems 15 years after
onset
- Affects < 20 % of cases
• (2) MALIGNANT MS :
- Relatively rare disease course
- Rapid onset
• (3) RELAPSING-REMITTING MS
(RRMS)
• Worsening of symptoms
• Relapses with either full recovery or
• Some remaining neurological signs &
symptoms
• Periods b/w relapses are
characterized by lack of disease
progression
• (4) PRIMARY PROGRESSIVE MS
(PPMS)

• Continuous worsening of
symptoms
• (5) SECONDARY PROGRESSIVE
MS
(SPMS)

• Progression with or without relapse

• (6) PROGRESSIVE-RELAPSING MS
(PRMS)
• Progressive disease from onset but
without clear acute relapse
• May or may not have some recovery
or remission
• Commonly seen in people who
develop the disease after 40 years of
age
prgnosis
• Good with medication
Treatment
1-Medical
Methypredniselon
Immunosuppressive
2- Spasticity
Baclofen, dantrolene,carbamazepine
3- pain
NASIDs
4-Fatigue
Amantadine,
• 5-Behavioural change
• anti depression
• b/b
• drinking water 8 glass
• dietary modification
• juices
PT RX
1)Mx of sensory deficits and skin
care
• Promote safety.
• Visual compensation techniques
are useful.
• Increase use of vision ,tapping,
verbal cueing, biofeedback.
• Light.........
Mx of sensory deficits
and skin care
• Proprioceptive loading through
exercise , light – tracking
activities , resistance bands or
weights are useful.
Skin care
• Skin break down...
• Keep clean n dry
• Inspection regularly
• Clothing loose n comfortable
• Change of position every 2 hourly
• (pressure relief)
• Pressure reliving devices
• Cushion(foam,fluid use)
Skin care
• Promote good nutrition and
drinking plenty of fluids – recovers
the skin .
2)Mx of pain
• Massage
• Stretching
• Postural training & correction
• Lhermitt’s sign relive – collar
• Pressure stocking gloves are also
useful to relieve pain
• Hydrotherapy
• Relaxation technique
• TENS
3)Exercise Training
• 1)Strength and conditioning
• 2)Cardiovascular training
• 3)Flexibilty
1)Strength and conditioning
Strength and conditioning
• Precautions to be taken with
memory & cognitive impairment –
individual may require written
instuctions, diagrams including
reminder of number of repetations
, correct use of equipement .
• Group exs.can improve valuable
motivation & social support.
• Aquatic ex
2)Cardiovascular
training

Termination criteria:DBP 115mm

SBP:200mm
3 session/week
Duration : 30 mins/ session
60-70 ./. Maximal HR
3)Flexibilty ex
• Stretching
• ROM ex
• Wheelchair bound /sedentary
patients may develop tightness in
hip flexors, adductors , hamstrings
and calf .
• Both PROM & AROM should be
performed daily for short periods .
Flexibilty ex
• More active patients may be
benefit from Tai – Chi which
provides relaxation & balance
training .
3)Mx of fatigue

• Excessive tiredness
• Activity diary
• Energy conservation technique
• Modification of task n environment
• Activity pacing: balancing of
activity with periods of rest
• Suggestion of planning
• Ergonomic equipment
• Home n work modification
• Sterss mx
5)Mx of spsticity

• It give 2 impairments
contracture
postural deformity

Pharmacological
Ice pack
Hydrotherapy
Stretching
• Prolonged positioning
• Serial cast
• ES
• Intermittent static stretching of
minimum 30 to 60 seconds / 5-6
repetations .
6)Mx of balance n
coordination

• Real life task

• Cerelellar deficits are common in
MS and be difficult to manage
• An important goal of therapy is to
promote safe and functional
balance.
• Reaching , turning and bending
can be pracised both im sitting &
standing .
• Weight cuff-------tremor
• Control of ataxic limb movement
can be achieved through
proprioceptive loading and light
resistance .
• A soft neck Collar-to stabilize head
& neck tremors.
• Frankle s ex------
7)Locomotor training
• Walking impaired
• Stretching n strengthing ex
• Cue
• Overhead harness
• BBs
• Orthrotics
• Wall walking
• Transfer
8)Functional training
• Bed mobility, transfer
• ADL training
• dressing,hyginge,bathing,toileting,
9)Mx of speech n
swallowing
• Chances of respiratory infection
• Breathing ex
• Aspiration
• Head control
• Oro motor exercises
• Moist food
10)Cognitive training
• Memory – cueing devices
e.g.alarms reminders
• Clear direction...way to toilet
• Under observation