Degenerative diseases

Multiple Sclerosis
Multiple sclerosis (MS) is an autoimmune disease
characterized by inflammation, selective
demyelination, and gliosis.
It causes both acute and chronic symptoms and can
result in significant disability and impaired quality of
life.
The onset of MS typically occurs between ages 20 and
40 years. MS is rare in children, as is the onset of
symptoms in adults older than age 50 years. he onset
of MS typically occurs between ages 20 and 40 years.
MS is rare in children, as is the onset of symptoms in
adults older than age 50 years
 Etiology
The risk of MS is increased in persons with an
affected family member.
Risk of MS may also be increased with vitamin D
deficiency and smoking.
It appears that although individuals do not
inherit the disease, they may inherit a genetic
susceptibility to immune system dysfunction.
 PATHOPHYSIOLOGY
• In patients with MS, the immune response triggers
activation of immune cells (e.g., T cells, CD4+ helper
T cells, B cells) that cross the blood–brain barrier. In
turn, these cells activate autoantigens, producing
autoimmune cytotoxic effects within the central
nervous system (CNS) (this process can be viewed as
a form of “friendly fire”). Phagocytic activity of
macrophages may also contribute to demyelination.
• Disruption of the myelin sheath and active
demyelination slows neural transmission and causes
nerves to fatigue rapidly. With severe disruption,
conduction block occurs with resulting disruption of
An acute inflammatory event emerges. Edema and infiltrates (e.g.,
monocytes, macrophages, and microglia) surround the acute
lesion and can cause a mass effect (abnormally high pressures),
further interfering with the conductivity of the nerve fiber
Inflammation gradually subsides, With repeat attacks, the anti-
inflammatory processes become less effective and are unable to
keep up. During the early stages of MS, oligodendrocytes survive
the initial insult and can produce re-myelination, Eventually the
oligodendrocytes become involved and myelin repair cannot
occur.
Demyelinated areas eventually become filled with fibrous
astrocytes and undergo a process called gliosis. Gliosis refers to
the proliferation of neuroglial tissue within the CNS and results in
glial scars (plaques).
At this stage, the axon itself becomes interrupted and undergoes
neurodegeneration. his is believed to be the main cause of
 Types of Multiple sclerosis
• benign MS, defined as disease in which the patient remains
fully functional in all neurological systems 15 years after
onset.
• malignant MS (Marburg disease), a relatively rare disease
course characterized by rapid onset and almost continual
progression leading to significant disability or death within a
relatively short time after onset
There are four major disease courses
• Relapsing-remitting MS (RRMS)
– It is characterized by discrete attacks or relapses, defined as
periods of acute worsening of neurological function. Relapses are
followed by remissions, defined as periods without disease
progression and partial or complete abatement of signs and
• secondary-progressive MS (SPMS).
– SPMS begins with a relapsing-remitting course followed
by progression to steady and irreversible decline with or
without occasional acute attacks.
• Primary-progressive MS (PPMS)
– It is a rare form occurring in about 10% of cases. It is
characterized by a nearly continuous worsening of the
disease from the onset without distinct attacks
• Progressive-relapsing MS (PRMS)
– begins with a progressive disease course from the onset
and steady deterioration (similar to PPMS), but with
occasional acute attacks.
 SYMPTOMS
• Symptoms of MS vary considerably, depending on
the location of specific lesions. The onset of
symptoms can develop rapidly over a course of
minutes or hours; less frequently, onset is insidious,
occurring over a period of weeks of months.
 diagnosis
The diagnosis of MS is made by the neurologist based
on a careful medical history, a complete neurological
examination, and supportive laboratory tests.
Laboratory tests used to help confirm the diagnosis
include magnetic resonance imaging (MRI), evoked
potentials (EP), and lumbar puncture (LP) with
cerebrospinal fluid (CSF) analysis.
MRI is highly sensitive for detecting MS plaques in the
white matter of the brain and spinal cord. New lesions
with active inflammation that occur during the
preceding 6 weeks or so are seen as areas of
increased signal intensity, “bright spots.”
 PHYSICAL THERAPY
EXAMINATION
Patient/Client History
• Age, sex, race/ethnicity, primary language, education
• Social history: cultural beliefs and behaviors, family and caregiver resources, social
support systems
• Occupation/employment/work
• Living environment: home/work barriers
• Hand dominance
• General health status: physical, psychological, social, and role function, health habits
• Family history
• Medical/surgical history
• Current conditions/chief complaints
• Medications
• Medical/laboratory test results
• Functional status and activity level: premorbid and current
Systems Review
– Neuromuscular
– Musculoskeletal
– Cardiovascular/pulmonary
– Integumentary
Tests and Measures/Impairments
• Cognition: mental status, memory
• Communication
• Anthropometric characteristics: body mass index, girth, length
• Circulation: response to position change/degree of orthostatic
hypotension
• Aerobic capacity and endurance: during functional activities and
standardized exercise protocols; cardiovascular signs
and symptoms in response to exercise and activity; pulmonary signs and
symptoms in response to exercise and activity
• Ventilation and gas exchange
• Integumentary integrity: skin condition, pressure sensitive areas;
• Sensory integrity and integration
• Pain: intensity and location
• Perceptual function: visuospatial skills
• Joint integrity, alignment, and mobility: range of motion (active and passive);
muscle length and soft tissue extensibility
• Posture: alignment and position, symmetry (static and dynamic, sitting and
standing); ergonomics, and body mechanics
• Muscle performance: strength, power, and endurance
• Motor function: motor control and motor learning
• Postural control and balance: degree of postural instability, balance strategies;
safety
• Gait and locomotion: gait pattern and speed, safety
• Functional status and activity level: performance-based examination of
functional skills (FIM level), basic and instrumental
ADL; functional mobility skills; home management skills
• Psychosocial function: motivation
• Assistive or adaptive devices: fit, alignment, function, use; safety
• Environment, home, and work barriers
• Work, community, and leisure activities: ability to participate in activities, safety
 PHYSICAL THERAPY
INTERVENTIONS
• Management of Sensory Deficits and Skin Care
• Management of Pain
• Exercise Training
– Strength and Conditioning
– Aerobic Conditioning
– Flexibility Exercises
• Management of Fatigue
• Management of Spasticity
• Management of Coordination and Balance Deficits
• Locomotor Training
• Orthotics and Assistive Devices
• Functional Training
• Management of Speech and Swallowing