Multiple Sclerosis
Dr. Ajit Kumar Gupta (PT)
Assistant Professor
Dept. Of physiotherapy
Galgotias University
Introduction
• Chronic, progressive, neurodegenerative
disease of CNS
• Immune-mediated
• Body attacks myelin→demyelination forms scar
tissue (sclerosis)
Image 1.
Image 2.
Epidemiology
• >400,000 in US
• >2.5 million in the world
• ~3:1 Female:Male
• Age at diagnosis: 20-50
• Most commonly mid-20’s to early 30’s
• Can occur in children and older adults; Occurs in most ethnic groups
• More common in Caucasians
• African-Americans more severe relapses, more aggressive disease course
• Hispanic Americans diagnosed at younger age
Epidemiology
• Unknown cause
• Environmental:
• Geographic:
Further from
equator
• Vitamin D
• Smoking
Image 3.
• Genetics
• First degree
relative: 2.5-
5% increase
in risk
• Identical
Twin: 25%
increase in
Symptoms of MS
Image 4.
Exacerbations
• Also known as a relapse, flare-up, attack
• Can last days to weeks or months
• Must last longer than 24 hours
• Shorter than 24 hours=Uhthoff’s Phenomenon
• Separated by >30 days from previous relapse
Image 5.
EDSS-Expanded Disability Status Scale
Image 6.
Image 7.
Relapsing-Remitting (RRMS)
85%
Time Image 7.
Secondary Progressive (SPMS)
50%
Time Image 7.
Primary Progressive (PPMS)
10%
Time Image 7.
Progressive Relapsing (PRMS)
5%
Time Image 7.
Pediatric MS
Image 8.
Medication
• Treating Relapses
• Corticosteroids
• Slowing Down MS
Disease Modifying Therapies
•
• Managing Symptoms
Pain, bowel & bladder, spasticity, etc
•
Treating Attacks
Image 9.
Disease Modifying Therapies (DMTS)
• Reduce frequency and severity of exacerbations
• Reduce MRI lesions
• Reduce progression of disability
• Recommendations
• Early & ongoing
• Manage side effects
• Assess responsiveness to treatment
Image 10.
*Do not make people feel better short term (side effects can be challenging)
Injection DMT Oral DMT
• Interferon • Aubagio
• Avonex • Gilenya
• Betaseron
• Extavia
• Tecfidera
• Rebif
• Plegridy
• Copazone
Infusion DMT
•Glatopa • Lemtrada
• Novantrone
• Tysabri
Images 11.
Image 12.
Image 13.
Complementary & Alternative Medicine
• Food and Diet • Massage
• Exercise • Marijuana (Cannibis)
• Stress Management • Dietary Supplements (Vit D)
• Acupuncture
Image 14.
Interdisciplinary Team
• Patient & Care Partners • Nutritionist/Dietitian
• Neurologist • Urologist
• MS Nurse • Primary care physician
• Rehabilitation specialist • Orthotist
• Physical Therapy , Occupational • Social Worker
Therapy, • Pharmacist
Speech/language pathologist
• Mental Health Specialist • PM&R
• Psychiatrist, Psychologist,
neuropsychologist
Image 15.
Meet Stacy
• 37 y.o. African-American Female
• Dec. 2007: dx with Relapsing-Remitting MS
Image 16.
• Sudden onset of severe vertigo and syncope
• April 2014: Exacerbation with R-sided weakness Image 17.
• Jan. 2015: MRI of brain consistent with MS
• >9 lesions, atrophy to both optic nerves
• No enhancing lesions
• March 2015: swallowing and balance difficulties
• Referred to PT to address balance
Initial Evaluation: Subjective
•Stopped work 1 yr ago due to difficulties with cognition and memory
•Lives alone in 2nd story apt, recently staying with mother
•Independent with ADLs / IADLs
•Intermittent 7/10 pain: pressure in shoulders and thighs
•Occasional dizziness with migraines
•LOB daily, last “fall” 3 months ago
Image 18.
Initial Evaluation: Objective
•ROM: Grossly WNL, pt “stiff” in shoulders
•MMT: 4/5 L triceps
•Alignment: B excessive pronation, pes planus, genu valgum
•Balance:
•↓ L single-limb stance, > 20s on R with cheating
•LOB when rising up from sitting, walking
•Gait:
•↓ B arm swing, trunk rotation, step length, gait speed
•Narrow BOS
Image 19.
Initial Evaluation: Objective
•Dynamic Gait Index (DGI): 18/24
•Difficulty walking with head turns, avoiding obstacles, etc.
•Vision: Convergence difficult within 6”, L eye > R eye
•Sensory Organization Testing (SOT):
•Somatosensory and Vestibular WNL
•Visual system deficits
•MS Impact Scale (MSIS-29):
•96 composite score (moderate) Image 20.
•86 on psych subscale (norm for adults with MS is 45.5)
Initial Evaluation: Assessment
• Safety with community ambulation / ADLs
• Visual system deficits
• Gait
• Alignment
• Sit↔Stand Strategy
• Strength?
• Education for fall prevention
• Psych concerns
Image 21.
Initial Evaluation
• Plan:
• HEP: LE stretching, 30-min cycling with intervals
• SPC until balance improves
• Standing balance with shifting gaze, 30 sec. BID
• Referral for eval for potential orthotics
• Contact referring PA regarding psych concerns
Image 22.
Visits #3-#5
• Possible signs of exacerbation
• Cramping in L calf, difficulty raising L UE, Numbness/tingling
in face
• Incident of forgetting where she was/why/how to call for
help
• Doesn’t want to tell her PA, is afraid of infusions
• Discussed importance of communicating with
neurologist
• Discussed psychological concerns and referral
to psychologist
Image 23.
Visits #3-#5
•Added calf stretching to address cramping
•Gait training (increase arm swing, etc.)
•Standing hip ABD exercises
•Progressed visual system exercises
• Standing balance/walking with visual/surface challenges
• Brock string exercises for convergence Image 24.
•Education: hydration, intervals, importance of referrals and HEP
Visits #6-#9
• Assistive device Training
• Ordered foldable SPC
• Available when needed
• Proper use to ↓ energy expenditure, avoid injury, ↓ risk of falls
• Multisensory balance training
• Obstacle course
• Various surfaces, various heights, carrying items of various weight
• Posture Training
• Core Strengthening
• AAROM Exercises
Image 25.
Progression Towards Discharge
• Transition to NC HOT summer
• Avoiding activities after morning hours
• Severe fatigue when outside
• Increase complaint of fatigue
• Trouble completing day to day activities
• Mental fogginess
• Lack of motivation to complete exercises
• Missed appointments Image 26.
Temperature Sensitivities
• Heat temporarily worsens symptoms.
• ¼ - ½ of a degree is all it takes!
• Heat slows the conduction of nerve signals.
• Uhthoff’s sign = pseudoexacerbation
Ideas on ways to help keep patient’s
cool?
Image 28.
Cool Products
Image 29. Image 31.
Image 30.
Image 32.
Image 34.
Image 33.
Cool Products
Figure 35.
Self-Efficacy
• Treatment plan challenging, yet attainable
•Celebrate successes!
Image 38.
• Joined new gym
•Encouraged in order to maintain progress made in PT
• Personal trainer unaware of the benefits of interval training
• Educating patient to educate herself
• Teach back method
• Identification of community resources
Discharge Visit #10
• DGI
• 23/24 (MDC=4.19)
• SOT
• Reached age predicted norms
• Improved composite score 69→ 81
• Continued use of ankle dominant correction strategy
•Others?
•ABC, Modified Fatigue Impact Scale
Reassessment
• Patient scheduled for 3-month f/u
• Cancelled via online scheduler with no reschedule
Any other information you would have
like to have seen?
Questions?
Image 39.
Resources
National MS Society
[Link].o
rg
Acknowledgements
•National Multiple Sclerosis Society-Greater Carolinas Chapter
•Diane Meyer
•Dr. Prue Plummer
•Past MS STEP UP Scholars
Heather Eustis, Joe
Miller
References
• What is MS? National MS Society website. [Link] Accessed January 4, 2016
• Who gets MS? National MS Society website. [Link] Accessed
January 4, 2016
• Khan O, Williams MJ, Amezcua L, Javed A, Larsen KE, Smrtka JM. Multiple sclerosis in US minority populations: clinical
practice insights. Neurol Clin Pract. 2015; 5(2): 132-142
• Managing Relapses National MS Society website. [Link]
Relapses. Accessed January 10, 2016
• Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS).
Neurology.
1983; 33(11): 1444-52
• Pediatric MS. National MS Society website. [Link]
MS. Accessed January 10, 2016.
• Medications. National MS society website. [Link] Access
January 20, 2016.
• Yadav V, Shinto L, Bourdette D. Complementary and alternative medicine for the treatment of multiple sclerosis.
Expert Rev Clin Immunol. 2010; 6(3):381-395
• Comprehensive Care. National MS Society Website. [Link]
Care/Managing-MS/Comprehensive-Care. Accessed January 24, 2016.
• Rigby SA, Domenech C, Thornton EW, Tedman S, Young CA. Development and validation of self-efficacy measure for
people with multiple sclerosis: the Multiple Sclerosis Self-efficacy Scale. Mult Scler. 2003; 9(1):73-81
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