Case Presentation on Multiple

Sclerosis

Presented by: Deepali Chandra

PG 1st Year (Neurological Disorders)
 MULTIPLE SCLEROSIS

Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central nervous system). In MS,
the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems
between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of
the nerve fibers.

Common symptoms include:

• Numbness or weakness in one or more limbs that typically occurs on one side of your body at a time
• Tingling
• Electric-shock sensations that occur with certain neck movements, especially bending the neck forward (Lhermitte
sign)
• Lack of coordination
• Unsteady gait or inability to walk
• Partial or complete loss of vision, usually in one eye at a time, often with pain during eye movement
• Prolonged double vision
• Blurry vision
• Vertigo
• Problems with sexual, bowel and bladder function
• Fatigue
• Slurred speech
• Cognitive problems
• Mood disturbances
Types of MS:

Relapsing-remitting • The most common type of MS

• Symptoms come and go
• When symptoms flare up, it is called
an attack or relapse which can lasts
days to weeks.
• Between attacks people may feel
normal.

Secondary progressive Symptoms come and go at first but

eventually worsen
Primary progressive Symptoms steadily worsen from the
onset
Progressive relapsing Symptoms steadily worsen, along with
attacks that come and go.
Stages of Multiple Sclerosis

MS Stage CHARACTERISTICS
Stage 1. Learning to live with the disease This stage follows the initial diagnosis,
where patients learn what to expect.

Stage 2. Moderate Disability Patients are still mostly independent, but

may need assistance such as a cane or
walker
Stage 3. Severe Disability About 25% of patients with MS will need
a wheelchair at this point and will need
to rely on others for assistance
Stage 4. End stage • This is the final stage of MS
• Patients have lost physical mobility
and independence
• Severe and life threatening
complications can occur.
The cause of multiple sclerosis (MS) is unknown, but it is thought to be a combination of factors, including:
• Genetics
• Environment
• Immune system dysfunction
• Infections
Fig: Pathophysiology of Multiple Sclerosis
Classic signs seen in Multiple Sclerosis

• Lhermitte's sign (also known as Lhermitte's phenomenon or the barber chair phenomenon) is the term used that
describes a transient sensation of an electric shock that extends down the spine and extremities upon flexion
and/or movement of the neck. Lhermitte described this phenomenon in patients with multiple sclerosis and other
spinal cord diseases. It was then further hypothesized that it resulted from irritation and inflammation of the spinal
cord, likely in the posterior and lateral columns.

• Uhthoff phenomenon, also known as Uhthoff sign or Uhthoff syndrome, is a transient worsening of neurological
function lasting less than 24 hours that can occur in multiple sclerosis patients due to increases in core body
temperature. Uhthoff’s phenomenon is most commonly observed in multiple sclerosis but may occur in other
optic neuropathies or disorders of afferent pathways for example neuromyelitis optica. In multiple sclerosis,
several factors including the blockade of ion channels, heat shock proteins, circulatory changes, effects of serum
calcium, and unidentified humoral substance have been hypothesized and investigated as a cause of Uhthoff’s
phenomenon.
 CASE PRESENTATION

Demographic Data:

Name : Pappu
Age/Sex : 41yr/Male
Occupation : Carpenter
Address : Haridwar
Handedness : Right

Subjective Assessment

• Chief Complaint:
Difficulty in walking, tingling sensation in lower limb, heaviness on face since 15 days.
 HISTORY OF PRESENT ILLNESS

Patient had an alleged history of tingling sensation and numbness in bilateral lower limbs since 5-6 years and had acute
loss of vision in left eye and weakness on the right side of the face 6 months back then the weakness gradually
increased in the left arm and lower limb. He was then brought to HIHT emergency and remained in the NMW for one
week and was discharged on regular medications. Patient again felt heaviness on the left face 15 days back and also
observed tingling sensation and weakness in both lower limbs and had difficulty in walking independently. He was then
brought to HIHT emergency on 16th Jan at around 4pm where further investigations were done and patient was kept in
HDU for a day, then was shifted to NMW on 17th Jan. Now patient is on regular medication and physiotherapy care.

Personal History: Patient was a smoker but has left smoking 2 years back
Family History : Not relevant
Drug History : DM type II on irregular medication (as DM occurred due to medicines)
OBJECTIVE EXAMINATION
a) On Observation:
Attitude of limbs: Anatomically positioned
Built: Mesomorphic
Posture: Supine
Mode of Ventilation: Room air
Type of respiration: Thoracoabdominal
External appliances: Foley’s catheter and IV cannula on left hand
No deformity, oedema, pressure sores, wounds, swelling, muscle wasting were present.

• GCS was normal – E4V5M6

• MMSE score was 30/30
• All cranial nerves were intact except left facial nerve and patient had blurring of vision on left side.
• Speech testing was normal
• Muscle girth was symmetrical
• Tone was normal but there was significant decrease in tone in the right lower limb as compared to the left one.
• Full active Range of Motion was present
 MMT:
 Reflexes
C5 5/5
Superficial & Deep Rt Lt
C6 5/5
Abdominal Present Present
C7 5/5
Plantar Present Present
T1 5/5
Biceps Present Present
L2 4/5
Brachioradialis Present Present
L3 4/5
Triceps Present Present
L4 4/5
Knee Present Present
L5 4/5
Ankle Present Present
S1 4/5
S2 4/5
Rhomberg’s test: positive as patient had sway posture while standing with open eyes.
Sensory system: intact

Balance:
Sitting balance - good
Standing balance - poor
Balance reactions - N/A.

Posture:
Lying – good
Sitting – at anatomical position, right ankle in more plantar flexion
Standing – N/A.

Gait: N/A
Hand functions: good

Assistive devices: wheelchair

 Functional Independence Measure

This indicated patient needed moderate assistance in performing his ADLs.

Investigation findings: Multiple nodular enhancing lesions are seen involving left frontal, bilateral basal
ganglia, posterior limb of both internal capsules, left medial temporal lobe and right anterior peripheral aspect of
upper medulla.
 Problem list according to ICF Model
MULTIPLE SCLEROSIS

BODY STRUCTURES PARTICIPATION

• Lower limb weakness • Difficulty in walking
• Facial weakness ACTIVITIES • Difficulty in maintaining balance
• Lt. eye blur vision • Difficulty in bed • Difficulty to go out and perform
• poor balance mobility ADL
• Inability to do ADL • Difficulty in performing
FUNCTION professional duties
• Poor balance • Difficulty in social interaction
• Poor concentration
• Poor vision
• Poor coordination
PERSONAL FACTOR
• Fear of fall
ENVIRONMENTAL FACTORS
• • Demotivation
Good family support
• • Lack of confidence
Long hospital stay
• • Agitated behaviour
improper home care
• Lack of available medical facilities nearby
Functional Diagnosis:
Multiple nodular enhancing lesions involving left frontal, bilateral basal ganglia resulting in tingling sensation,
blurring of vision in left eye and weakness in both lower limb.

Management Goals:

Short term Goals:

• Counselling of the patients and its care giver
• Prevention of secondary complications
• Improve bed mobility ,that is supine to side lying and then sitting
• Making ADL independent
• Improve overall muscular strength ,motor control and balance .

Long term goals

• Independent standing
• Gait training
• To improve functional activities independent
• To resume patients daily activities .
Day 1 Management
• High sitting with weight bearing
• Sit to stand training
• Standing with support
• Balance training
• Sensory perceptual training
• Pursed lip breathing

Day 2 Management
• Continued same treatment
• Static quadriceps and hamstring strengthening
• Core activation
• Deep breathing exercises
• Facial exercises

Day 3-5 Management

• CST
• Kegel exercises
Conclusion: Task-oriented circuit training is quiet
effective to improve balance and walking in
patients with Multiple Sclerosis. However,
further studies are needed to determine the
effect of TOCT on cognitive performance.
THANK YOU