Multiple Sclerosis


A presentation by:


Christopher McQueen

Michael Peak

Mark Pullen

Michael Sharp

Overview

Multiple Sclerosis is a disease that involves the loss of myelin sheath in the central nervous system. The symptoms vary from person to person, depending on what part of the nervous system is affected, including structures that control movement, sensation, and mental processes.


However, more than 91% of all persons with MS report difficulty walking, and difficulty with body movements.

Although MS is rarely fatal, its complications can be severe, including difficulty with breathing, injury due to falls, and a general lack of mobility.


With appropriate medical support and physical therapy, the disease process can be controlled, and movement can be improved and maintained.

Pathophysiology 

Multiple sclerosis is a chronic inflammatory demyelinating disease of the central nervous system. The body's immune cells attack the myelin sheath surrounding the central nervous system. The myelin sheath serves as an insulator and conductor around nerve cells. When the myelin sheath is damaged, the transmission of nerve impulses is slowed, stopped or can jump across into other demyelinated axons.

Epidemiology

Multiple Sclerosis is a chronic, usually progressive, disease that primarily affects young adults. More than 350,000 people in the United States and 2.5 million worldwide have been diagnosed with MS.


The disease affects women twice as much as men and is predominately seen in the white population.

Etiology

Unfortunately, the exact cause of MS is unknown. It is thought to be caused by a "perfect storm" of several contributing factors.

Multiple Sclerosis Sub-Types

Relapse Remitting Multiple Sclerosis


• 80% of MS patients.

• Patients have sudden onset of symptoms followed by a remission of symptoms.

• Duration of symptoms may vary

• Return to prior level of functioning varies.


Secondary Progressive Multiple Sclerosis


• 50% of RRMS patients progress to this phase.

• Gradual onset of symptoms without improvement of disease.

• Frequent exacerbations and plateaus of symptoms.


Primary Progressive Multiple Sclerosis


• 20% of patients.

• Gradual onset of symptoms without improvement of disease.

• Frequent exacerbations and plateaus of symptoms.


Other Types of MS


• Benign MS

• Malignant MS

• Progressive Relapsing

• MS that alternates between two or three different types.


Signs & Symptoms


• Visual changes

• Tingling in extremities

• Numbness

• Fatigue

• Bladder or bowel problems

• Sensitivity to heat




**It's important to note that signs and symptoms vary from patient to patient.



Diagnosis


• Most commonly diagnosed via MRI.


• Initially other diseases such as lyme disease 

are ruled out.


• A CSF test is done to  determine if remnants of myelin sheath are found within the spinal fluid.

Prognosis

• The earlier the diagnosis, the better the prognosis with the best results being diagnosed between

 the ages 20 and 40.


• Life expectancy is normal assuming conditions are medically managed.


• Functional prognosis can be determined 5 years after initial diagnosis.

Exacerbating Factors 

• Heat

• Stress

• Sickness

• Decline in health status.


• Uthoff’s symptoms – a pseudoexacerbation of symptoms that resolves in 24 hours.

Medical Management

Unfortunately there is no cure for Multiple Sclerosis... 

Yet! 


However there are medications that help manage some debilitating symptoms.

Common medications that are specifically used to treat Multiple Sclerosis:




• Rebif

• Copaxone

• Gilenya

• Tysabri

Rehab Management 

Manage the symptoms such as cognitive changes, pain reduction, motor dysfunction, sensation deficits, speech dysfunction, autonomic changes, etc...

Your goal as the therapist is to help the patient manage pain and treat their symptoms. Avoid maximal fatigue, overheating the patient, and take frequent rest breaks if necessary!

Physical Therapy Focus

• Strengthening

• Balance

• Pain management

• Massage

• Stretching

• Memory aids

• Sensory deficits

• Coordination training

• Aqua therapy

Case Study

Patient Background Information 

Kourtney Gallileo is a 26 year old female with RRMS. She is a dancer for the New York Broadway that recently participated in "Phantom of The Opera." She woke up one morning and couldn't feel her legs. Six months later, she got an electric feeling in her toes and then shortly after that her entire right side of her body went numb. She was then diagnosed with RRMS. Her biggest symptom is fatigue which causes other symptoms such as slurred speech, poor concentration, and sometimes difficulty with memory. She dances and considers it medicine. She advocates that a healthy diet, with physical activity and an appropriate amount of rest is paramount.

Past Medical History

Kourtney's past medical history is unremarkable prior to being diagnosed with RRMS. She maintains a low fat, high carb healthy diet with plenty of fresh fruits and green leafy vegetables. She avoids caffeine and alcohol and supplements with general multivitamins with a focus on vitamin B12. She gets roughly eight hours of sleep a night and takes naps frequently to combat her fatigue. She has occasionally gone to massage therapy complimented with chiropractic treatment. She is currently taking Tysabri to manage her MS.

Kourtney's MRI

Acute RRMS Physical Therapy

Therapeutic Exercises


• BOSU Squats

• BOSU Lunges

• Theraband Side-Steps

• Planks with Rotation 


Current Functional Status


• Slight bilateral LE weakness.

• ROM deficits in bilateral hip and knees.




Functional Applications


• Focus on maintaining LE, core, and UE strength, flexibility, endurance, and ability to dance.

• Elliptical for added endurance.

• Maintain flexibility for dance.

Subacute SPMS Physical Therapy

Therapeutic Exercises


• Wall Squats with Physio Ball

• Theraband Clocks

• Bird Dogs

• Clock Lunges


Current Functional Status


• Core instability.

• Bilateral shoulder strength and ROM deficits.

• Bilateral LE weakness.

• ROM deficits in bilateral hip and knees.


Functional Applications


• Exercise to maintain strength as ability decreases.

• Decrease intensity of exercise.

• Watch endurance - transition to seated recumbent bike or Nu-Step if necessary.

Chronic SPMS Physical Therapy

Therapeutic Exercises


• Single Leg Stance with Foam

• Theraband Diagonals

• Counter Squats

• Straight Leg Raises


Current Functional Status


• Balance deficits.

• Global strength deficits.

• Global ROM deficits.

• Core instability.

• Slurred speech.

Functional Applications


• Focus on maintaining whatever strength and function remains.

• Potential to be confined to seated exercises.

• Low tolerance to exercise possible.


Other Considerations

Invisible symptoms!

• Anxiety

• Stress

• Depression

• Social life effects

• Medication side effects

• Pain

• Cognitive changes

• Fatigue

For More Information

APTA, Move Forward PT

http://www.moveforwardpt.com/


National Multiple Sclerosis Society 

http://www.nationalmssociety.org/


Multiple Sclerosis Association of America

http://mymsaa.org/

References

Special Thanks to Professor Braddock for sharing her personal experience with Multiple Sclerosis.

Full Videos of Exercises

Top Right: Acute Stages

Bottom Left: Sub-Acute Stages

Bottom Right: Chronic Stages

Special Thanks

Video extras Joshua Wise and Hannah Coxwell.


Dr. D for casting the vision and inspiration.


Dr. Mac for set location.

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Public - 4/16/16, 2:09 PM