Physical Therapy Haven

Population Characteristics:^1,2

• 400,000 people in the US and 2.5 million people worldwide are affected by MS
• Overall incidence is 3.6 per 100,000 for females and 2.0 per 100,000 for males 
• Begins in the ages of 20-40 years, symptoms rarely occur before 10 and after 60 years of age
• Women 2x as likely as men (except for primary-progressive form in which no gender difference exists) 
• Greater incidence in people living in higher latitudes 

Pathophysiology:^3,4,5

• The direct cause of MS is currently unclear; however inflammation, demylination, and chronic neurodegeneration are the primary physiological manifestations underlying MS
  • Symptoms often begin with an autoimmune response driven by T-cell mediated inflammation
    • Inflammation is initially temporary and remylination can reoccur to some extent
  • As diease course progresses, excessive glial cell activation occurs, leading to chronic neurodegeneration (myelin/oligondendrocyte loss and axonal damage)
    • This stage typically results in the cardinal signs and symptoms of MS 
  • Progressive cerebral atrophy is also seen and commonly used as a marker for disease progression 

Signs and Symptoms:^6,7,8,9 

MS is classically divided into four different types:

• Relapsing-remitting (RRMS): Acute neurological exacerbation followed by partial or complete recovery periods. Periods between exacerbations can last from several weeks through several years. 85% of MS cases are initially diagnosed as RRMS.
• Primary-Progressive (PPMS): Symptoms gradually worsen with no distinct relapsing/remitting episodes. Rate of progression is not necessarily linear, as symptoms can show various rates of decline with intermittent plateaus. 10% of MS cases are initially diagnosed as PPMS. 
• Secondary-Progressive (SPMS): Initial period of RRMS followed by a steady increase in symptoms that can include intermittent flare-ups and minor remissions. 50% of RRMS cases can develop SPMS if untreated within 10 years of diagnosis.
• Progressive-Relapsing (PRMS): Progressive worsening of symptoms upon initial onset with clear acute relapses, with or without full recovery. Symptoms continue to worsen between acute relapses. 5% of MS cases are initially diagnosed as PRMS.

Symptoms include:  

• Optical neuritis (causing blurred or double vision)
• Weakness, decreased flexibility/increased muscle tension, and muscle spasms 
• Numbness and tingling in limbs and face
• Gait and limb ataxia
• Lhermitte's sign (electrical shock running down the spine and back of the of legs after cervical flexion)
• Dizziness and vertigo
• Bladder dysfunction
• Excessive mental and/or physical fatigue
• Hypersensitivity to heat
• Depression and difficulty with dual tasking and concentration

Diagnosis:^7,9 

• There is currently no single diagnostic test for MS, as a cluster of findings is required including medical history, neurological examination, and exclusion of similar disorders/differential diagnosis 
• MRI scans are done of the brain and spinal cord to assess characteristic lesions of MS (presence of plaques and demyelination, cerebral atrophy)
• Samples of cerebrospinal fluid are taken to assess presence of inflammatory markers associated with MS

Prognosis:¹⁰

• In general, the prognosis of MS is variable and depends on the type of MS 
• Patient's with MS typically have normal life expectancies as the general population
• Roughly two-thirds of MS patients are ambulatory 20 years after diagnosis 
• 20% of MS patients are asymptomatic or show mild symptoms after initial onset of symptoms
• 20% have a rapid progression of symptoms after intial onset
• Prognosis is typically worse if patient is over 40, intial symptoms are widespread across the body, and a short time between initial first two attacks

Physical Therapy Interventions:¹¹

• There is currently a lack of literature on the most effective therapeutic program for MS patients. However, most studies include the following as beneficial:
  • Progressive resistance training of upper and lower extremities 
  • Endurance training (treadmill/aquatic/arm or arm-leg ergometry)
  • Gait training
• Flexibility and ROM maintenance is also important in reducing spasticity and muscle tone
• Education on fatigue management strategies
• Coordination and balance training 

1. Tullman MJ. Overview of the epidemiology, diagnosis, and disease  progression associated with multiple scleoris. Am J Manage Care. 2013;19(2 Suppl): S15-20.

2. Alonso A, Hernan MA. Temporal trends in the incidence of multiple sclerosis: a systematic review. Neurology. 2008;71(2): 129-135.

3. Compston A, Coles A. Multiple sclerosis. The Lancet Neurology. 2008;372(9648): 1502-1517.

4. Weiner HL. Multiple sclerosis is an inflammatory t-cell mediated autoimmune disease. Arch Neurol. 2004;61(10): 1613-1615.

5. Bermel RA, Badshi R. The measurement and clinical relevance of brain atrophy in multiple sclerosis. The Lancet Neurology. 2006;5(2): 158-170. 

6. Resolution of Lhermitte's sign in multiple sclerosis by treatment with weak electromagnetic fields. Int J Neurosci. 1995;81(3-4): 215-224. 

7. Multiple sclerosis: Hope through research. National Institute of Neurological Disorders and Stoke. Available at: http://www.ninds.nih.gov/disorders/multiple_sclerosis/detail_multiple_sclerosis.htm. Accessed February 26, 2014. 

8. MS the disease. National Multiple Sclerosis Society Web site. Available at: http://www.nationalmssociety.org/About-the-Society/Press-Room/MS-the-Disease#section-11. Accessed February 26, 2014. 

9. Gelfand JM. Multiple sclerosis: diagnosis, differential diagnosis, and clinical presentation. Handb Clin Neurol. 2014;122: 269-290.

10. Simon H. Multiple sclerosis. University of Maryland Medical Center Web site. Available at: http://umm.edu/health/medical/reports/articles/multiple-sclerosis. Accessed April 24, 2014. 

11. Doring A, Pfueller CF, Paul F, et al. Exercise in multiple scleorsis - an integral compnenet of disease management. The Empa Journal. 2012;3(2): 1-13.