MS

What is Multiple Sclerosis?

An autoimmune, demyelinating disorder of the CNS

Who first comprehensively described MS, and when?

Jean-Martin Charcot in 1868

What is Charcot’s Triad?

Intention tremor
Nystagmus
Scanning speech

What are the FSS and EDSS used for in MS?

Standardized measures of global neurological impairment/disability in MS

What does FSS stand for?

Functional Systems Score

What does EDSS stand for?

Expanded Disability Status Scale

What are the 7 functional system assessed by the FSS?

Pyramidal
Cerebellar
Brainstem
Sensory
Bowel/Bladder
Visual
Cerebral/Mental Functions

What does EDSS measure?

Overall neurological disability in MS, incorporating functional systems plus gait/assistive-device use

What is the EDSS range (0-10 in 0.5 increments)?

0 = Normal exam
1 = No disability
2 = Minimal disability
3 = Moderate disability
4 = Relatively severe disability
5 = Disability precludes full daily activities
6 = Assistance required to walk
7 = Restricted to a wheelchair
8 = Restricted to bed or chair
9 = Confined to bed
10 = Death

What are the 4 major MS clinical phenotypes?

Relapsing-Remitting (RRMS)
Secondary Progressive (SPMS)
Primary Progressive (PPMS)
Progressive Relapsing (Clinically Isolated Syndrome)

What characterizes Relapsing-Remitting MS (RRMS)?

Episodes of new/worsening symptoms (relapse) followed by periods of partial or complete recovery (remission)

What happens when recovery from an RRMS relapse is incomplete?

Disability can accumulate incrementally over time

What % of MS is initially diagnosed with RRMS?

85%

What is Secondary Progressive MS (SPMS)?

MS that begins with an RRMS course and then transitions to steadily worsening disability over time

Can SPMS have relapses or plateaus?

Yes. Progression can occur with or without notable relapses, remissions or plateaus

What % of people with RRMS develop SPMS within 10 years of diagnosis?

50%

What is Primary Progressive MS (PPMS)?

MS that gradually worsens from the beginning, without distinct relapses or remissions

What is key difference between PPMS and SPMS?

PPMS progresses from onset, while SPMS begins with RRMS and later becomes progressive

What % of individuals with MS have PPMS?

10%

True or False: PPMS can have occasional plateaus and temporary minor improvements

True, not distinct “remissions”

What characterizes Progressive-Relapsing MS?

Steady worsening from the beginning with superimposed relapses and little or no recovery

How does PRMS differ from RRMS?

In PRMS, disability continues to increase between relapses rather than remaining relatively stable

What % of individuals with MS have PRMS?

5%

What is Clinically Isolated Syndrome?

A first episode of inflammatory demyelination in one area of the CNS that could develop into MS if additional disease activity occurs

What makes a Clinically Isolated Syndrome “active”?

Relapses and/or evidence of new MRI activity, in which it will become RRMS

Why can MS produce so many different neurological symptoms?

Lesions can occur in different locations throughout the CNS (remember UMN lesion in brain/spinal cord)

What are common symptoms in MS?

Fatigue
Paresthesia
Muscle weakness
Pain/itching
Cognitive changes
Spasticity
Visual problems

What are some less common MS symptoms?

Dysphagia
Impaired speech
Tremors
Seizure
Hearing loss

What is common symptom at the initial onset of MS?

Blurred vision

What complications can result from bladder dysfunction in MS?

Recurrent UTI’s

What causes MS?

Exact cause is unknown; it likely results from an interaction between genetic and environmental factors

What are examples of genetic factors associated with MS?

Sex and ethnicity

What environmental factors are associated with MS?

Geography and vitamin D exposure

What happens to axons in MS?

CNS axons undergo demyelination, with lesions occurring in a random and unpredictable distribution

What cells dominate the inflammation of active MS lesions?

T-Cells and Macrophages

What does demyelination cause to neural conduction?

Conduction block and delayed synaptic transmission

What neurological problems can result from conduction block during an MS relapse?

Paralysis
Blindness
Numbness

What causes permanent sensorimotor deficits in MS?

Irreversible axonal damage

What are major risk factors for MS?

Female Sex
Family history
Anglo-Scandinavian ancestry
Prior Epstein-Barr Viral Infection
Low vitamin D
Smoking

What is one short-term benefit of PT for people with MS?

Improved health-related QoL

Why is individual prognosis difficult to predict in MS?

MS has an irregular/variable course

What factors are associated with poorer outcomes and faster progression?

Comorbid disease, particularly vascular disease, and smoking

What MRI finding is considered a poor prognostic indicator?

Greater number and distribution of plaques

What are the major principles used to diagnose MS?

CNS damage in at least 2 separate area and demonstrate the damage occurred at different points in time

What CNS areas can be involved when establishing MS lesions?

Brain, spinal cord, and optic nerves

What are two key MRI concepts used in MS diagnosis?

Dissemination in Space
Dissemination in Time

What is Dissemination in Space vs Time?

Space = lesions in different locations within the CNS
Time = lesions occurring at different points in time

What can therapeutic exercise significantly improve in MS?

Walking speed (10MWT)
Endurance (6MWT)

True or False: Therapeutic exercise reduces TUG and MS-Fatigue.

False; no change in TUG and might reduce MS-related fatigue

What can resistive exercise significantly improve in MS?

Muscle strength
Fatigue
Functional Capacity
QoL
Power

True or False: Aerobic exercise may improve VO2 max in MS

True

What may Functionl Training improve in MS?

Balance (but does not reduce fall risk)

What did the 8 Session “Free From Falls Program” improve?

8-Foot TUG, BBS, ABC with fewer falls reported 6 months post-training

Functional training is known to have significant improvements in?

Disability
Mobility
Fatigue

What did an 8-week aquatic therapy program improved in people with MS?

Functional Capacity
Balance
Perception of Fatigue

What did total body aquatic interventions lead to improvements in?

QoL and function
(some evidence of decreased fatigue)

What mechanical interventions are mentioned for MS?

Whole-body vibration (WBV)
Balance trainer systems

What can WBV/balance trainer systems have a significant improvement in?

Fatigue
Mood

What did WBV have a significant improvement in specifically?

Spatiotemporal Gait Parameters

How common is fatigue in MS?

Very; most common chief complaint at 75-95%

What are common contributors to fatigue in MS?

Deconditioning
Heat intolerance
Poor sleep
Infection
Pain
Polypharmacy
Mood
Bowel/Bladder
Physical exertion

How is fatigue defined?

Feelings of tiredness, lack of energy, low motivation and difficulty concentrating

What is state fatigue?

An instantaneous estimate of how fatigued a person feels right now

What is trait fatigue?

A characteristic of fatigue that can be quantified through objective or perceived fatigability measures

What is fatigability?

A measure of physical or cognitive work capacity

What is objective fatigability?

The magnitude of change in a performance measure after completing a prescribed task

What is perceived fatigability?

A person’s subjective estimate of past or future work capacity

What does the Modified Fatigue Impact Scale (MFIS) assess?

Physical, psychosocial and cognitive affects of fatigue on ADL’s

What is MFIS cuttoff score and MCID?

>/= to 38
4 points

How should subjective fatigue be documented?

Frequency
Duration
Severity
Precipitating Factors
Activity Levels
Effectiveness of rest attempts