Multiple Sclerosis

(MS)
Mikhled Maayah PhD, PT
Definition of Multiple Sclerosis

• It is a chronic disease affecting the white matter

of the brain and spinal cord.
• It sometime spreading to the grey matter of the
cerebral cortex, cranial nerve and spinal nerve
roots.
• The course of the disease is most often
characterized by remissions and relapses,
eventually resulting in the patient becoming
seriously disabled
 Changes of the MS
• Small patches develop in which the myelin
of the nerve fibers is destroyed and the
axons become thinner than normal or
disappear.
• There is proliferation of the neuroglia and
the final state is a patch, irregular in shape,
sclerotic and grayish and shrunken in
appearance.
 Causes of the MS
• Destruction of the obligodendroglia (The neuroglial cells
responsible for the formation and maintenance of
myelin).
• Infection
• Auto-immune
• Disturbance in the circulation causing transient or
permanent ischemia of the areas involved.
• Trauma
• Influenza
• Sepsis
• Surgery
 Symptoms
• The optic nerve and optic chiasma are often
involved early in the course of the disease and
blurring of vision soon reduced to near blindness
• Retro-bulbar neuritis
• Diplopia, ptosis or strabismus
• Slight frequency in micturition
• Paraesthesia
• A feeling of heaviness in one leg which tends to
drag a little
• Exaggerated deep reflexes in upper and lower
limbs and loss of the superficial abdominal
reflexes
 Symptoms – CONT.
• Mental changes
• Hypotonus and ataxia
• Spasticity and exaggerated reflexes
• Sensory ataxia, diminished appreciation of vibration and
postural sense and sometimes impairment of cutaneous
sensibility.
• Weakness and spastic type of hypertonicity and a
cerebellar type of Hypotonia, affecting the head, neck,
arms and trunk.
• Jerky spastic patterns of movement in the legs and as
nystagmus, intention tremor, weakness and inco-ordination
of arm movements, and lack of postural stability of the
trunk and proximal limb joints .
 EPIDIMOLOGY
• The most common chronically disabling
disease in young adultd
• Affects women 2-3 times as often as men
• Onset generally from age 20 - 40
• Its onset is rare before 10 or after 60
years of age
• Annual cost estimate for US:$2.5 Billion
 MS Population

• Approximately one half million

people in the US with MS
• 40% being actively treated
• 40% have never been treated
• 20% have been on therapy but have
stopped for some reason
 Classifications of MS

• Benign
• Relapsing – Remitting
• Primary – Progressive
• Secondary-Progressive
• Progressive- Relapsing
There are patients with only rare relapses of their
disease and they are the Benign type.

The most common group of patients has relapses

that occur frequently, one to several times per
year, and they are the Relapsing/Remitting
type.
Secondary Progressive MS: Of these patients
(Relapsing/Remitting) a significant number will
eventually develop a slow decline

Primary Progressive: Occasionally patients start with

a progressive course and never have a relapse.

Progressive-Relapsing: Patients with both

progression and relapses
 MS Opportunities

• The major impact that doctors, nurses and

pharmaceutics can have on MS involves
educating the treatment patient about the
benefits of disease modifying therapy and
helping patients stay on therapy so that
do not become one of the 1 in 5 patients
who quit treatment
 Physiotherapy
• As the signs and symptoms which these patients present
vary greatly, careful and continual assessment must be
made of each patient, so that treatment is relevant to
the individual.
• Treatment and management of patients will differ
considerably according to the progress of the disease.
• The stages will therefore be considered separately.
• It must be remembered, however, that the stages merge
into each other, and are not clearly defined, and many
patients will never reach the stage of gross disablement.
 Stages of MS
• Grade I. Unrestricted: without restriction of activity for
normal employment and domestic life, but not necessarily
symptom-free.
• Grade II. Restricted: able to walk unaided for up to half
a mile, and able to use public transport.
• Grade III. Markedly restricted: capable of moving out of
doors with difficulty for up to a quarter of a mile, usually
with the aid of sticks, often unable to use public
transport.
• Grade IV. Mobile at home: able to move with difficulty
about the house with support from furniture, unable to
climb stairs.
• Grade V. Immobile at home: confined to a chair or
wheelchair.
• Grade VI. Bedridden: requires assistance for nearly all
activities.
 Treatment of the Early Stages
(Grade I merging to Grade II)

• At this stage, the patient is usually on a regime of active

exercises.
• The Rest Exercise Program
• The patient is advised to take short rest periods of 10-20
minutes 2 or 3 times a day, preceded by stressful mat
exercises.
• The exercises are usually performed by the upper limbs
to encourage a hyperemic response in the circulation to
the upper spinal cord and brainstem.
• Exercises may include:
– press-ups
– weight-lifting exercises while lying supine, or
the use of springs to exact maximal effort in a
short time.

• Any abnormal patterns must be corrected or the

exercise adapted; if continued, they will reinforce
the abnormal at the expense of the normal.
• Video-tape or cine-filming can be of use in
keeping an objective record of the patient's
progress.
• swimming, badminton, tennis
• Walking
• Regular out-patient physiotherapy should not be
necessary, nor encouraged.
Middle stage (Grades III-IV)
• The main object of the treatment was to help the patient
remain as independent as possible, while continuing to
live at home with his parents.
• In order to achieve this, treatment is used to inhibit
abnormal neuromuscular activity, to facilitate normal
movement patterns, to improve balance and equilibrium
reactions, and to gain better control of his arm
movements.
• Functional activities were constantly practiced as better
movement was obtained.
• ice-packs to the hypertonic muscle groups in his lower
limbs. These were applied in prone lying to avoid supine
lying, which increased the extensor hypertonia in his
legs.
• The patient should be treated on mats on the floor,
starting in side-lying with both legs slightly flexed
• Rhythmical passive trunk rotation to reduce Spasticity.
• Active trunk rotation was practiced to facilitate rolling and
turning in bed.
• Passive movements to the lower limbs, working from the
proximal to the distal joints.
• Shaking use to ease out any extra muscle tightness.
• Spastic muscles must never be forcibly stretched, they
should be carefully and gradually eased out to their full
length.
• From side-lying, the patient rolled into forearm support
prone lying, with the legs slightly flexed on pillows or a
wedge
• Rhythmical stabilizations can be given to the muscles of
the shoulder-girdle.
• Pressure through the long axis of the humerus to facilitate
co-contraction of the muscles around the shoulder and
elbow joints.
• The patient then practiced reaching forward to touch
objects placed in front of him
• This encouraged controlled, co-ordinated movement, after
facilitating the proximal fixation.
• The patient then moved to side-sitting to the right and left
• Balance and equilibrium reactions on a roll and balance
board.
• The patient astride the roll with the physiotherapist facing
him
• The physiotherapist could then gently rock the roll from
side to side, so stimulating the patient's natural balance
reactions.
• The patient could lie, sit or kneel on the balance board
• Gait training (training the patient in transference
of weight over the weight-bearing limb, while
moving forwards, backwards and sideways).
• Natural patterns of hip and knee flexion and heel-
toe gait were encouraged.
• Rhythmical stabilizations to the shoulder and
pelvis
• As the patient's movements improved, functional
tasks were continually added.
• Getting from sitting to standing, going up steps,
slopes and stairs, walking out of doors on rough
ground, and getting in and out of the passenger
seat of a car, were practiced.
Advanced stage (Grades V-VI)
• Passive movements to prevent flexion contractures, and
straightened legs to try and stimulate an extensor
response, and so prevent the patient going into further
primitive flexion.
• The use of sheepskins to prevent pressure sores and the
need for regular turning stressed.
• Wheel­chair was discussed with a deeper cushion with a
space
• Aids must be practical, and the patient and his helpers
shown how to use them correctly, preferably in the
patient's normal environment. No aid should be supplied
without careful instruction in its use.