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Multiple Sclerosis: Patient Assessment & Management

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1. Overview

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2. Clinical Phenotypes

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3. Pathophysiology

• Autoreactive T-cells (CD4+ Th1 and Th17) cross the blood-brain barrier, triggering inflammation
• B-cells and plasma cells contribute through antibody production and cytokine release
• Myelin destruction leads to slowed or blocked axonal conduction
• Chronic inflammation causes axonal transection and irreversible neurodegeneration
• Lesions occur preferentially in periventricular white matter, corpus callosum, optic nerves, brainstem, cerebellum, and spinal cord

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4. Clinical Presentation (Symptom Assessment)

Common Presenting Symptoms

Uhthoff's phenomenon — worsening of existing symptoms with elevated body temperature (fever, hot baths, exercise); distinguishes MS from new relapse; pathognomonic implication.

Lhermitte's sign — not specific to MS but highly suggestive of cervical cord involvement (also in B12 deficiency, cervical myelopathy).

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5. Neurological Examination

1. Mental status — cognition, affect, speech
2. Cranial nerves — visual acuity, visual fields, fundoscopy (optic disc pallor in past optic neuritis), eye movements (INO, nystagmus), facial sensation/strength
3. Motor — tone (spasticity), power (MRC grading), deep tendon reflexes (hyperreflexia), Babinski
4. Sensory — light touch, pinprick, vibration, proprioception (often dissociated involvement)
5. Cerebellar — finger-nose, heel-shin, Romberg, gait (tandem walking, stride length)
6. Bladder — post-void residual if retention suspected

Disability Assessment — EDSS (Expanded Disability Status Scale)

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6. Diagnostic Workup

MRI (Primary Diagnostic Tool)

• T2/FLAIR: hyperintense lesions (high sensitivity)
• T1 with gadolinium: enhancing lesions = active/acute inflammation (blood-brain barrier breakdown, <6 weeks old)
• T1 hypointense "black holes": chronic axonal loss
• Classic locations: periventricular, juxtacortical, infratentorial, spinal cord

McDonald Criteria 2017 (Diagnostic Standard)

• Dissemination in Space (DIS): lesions in ≥2 of 4 CNS regions (periventricular, juxtacortical/cortical, infratentorial, spinal cord)
• Dissemination in Time (DIT): simultaneous enhancing + non-enhancing lesions OR new T2/enhancing lesion on follow-up MRI OR second clinical attack

CSF Analysis

• Oligoclonal bands (OCBs): present in >95% MS patients (not in serum = intrathecal synthesis); IgG index elevated
• Mild lymphocytic pleocytosis (<50 cells/µL)
• Normal glucose
• Myelin basic protein may be elevated in active disease

Evoked Potentials

• Visual Evoked Potentials (VEPs): prolonged P100 latency in optic neuritis (subclinical demyelination useful for DIS)
• Somatosensory EPs, brainstem auditory EPs: detect subclinical lesions

Blood Tests (to exclude mimics)

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7. Management

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7.1 Acute Relapse Management

• IV methylprednisolone 1g/day × 3–5 days (or oral equivalent)
• Speeds recovery but does not alter long-term disability
• Plasmapheresis (PLEX): 5–7 exchanges over 2 weeks for severe steroid-refractory relapses

Note: Treat infections before steroids — Uhthoff's phenomenon mimics relapse.

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7.2 Disease-Modifying Therapy (DMT)

Platform/Moderate-Efficacy Agents

High-Efficacy Agents

DMT Selection Strategy

CIS / Active RRMS
├── Low disease activity → Moderate-efficacy (IFN-β, GA, DMF, teriflunomide)
├── Active/highly active disease → High-efficacy (natalizumab, ocrelizumab, ofatumumab)
└── Highly active despite platform therapy → Escalate to alemtuzumab/cladribine

PPMS → Ocrelizumab (only approved agent per Harrison's, p. 12550)

SPMS with active disease → Siponimod, ocrelizumab, ofatumumab, cladribine
SPMS without activity → No approved DMT proven; symptomatic management

Monitoring on DMTs

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7.3 Symptomatic Management

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7.4 Rehabilitation

• Physiotherapy: spasticity management, strength, balance, gait training
• Occupational therapy: adaptive equipment, home modifications, energy conservation
• Speech and language therapy: dysarthria, dysphagia
• Neuropsychology: cognitive rehabilitation, coping strategies
• Continence advisor: bladder/bowel programs
• Social work: disability benefits, driving assessment, employment support

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8. Monitoring & Follow-up

Routine Follow-up (every 6–12 months or sooner if active)

• Clinical review: relapses, new symptoms, EDSS progression
• MRI brain ± spine: typically annually; sooner if clinical change or high-efficacy DMT initiation
• Neuropsychological screening: SDMT annually
• Ophthalmology: OCT (optical coherence tomography) tracks retinal nerve fiber layer loss as biomarker of neurodegeneration
• Vitamin D: maintain levels >75 nmol/L (evidence for immunomodulatory benefit)
• Vaccination: annual flu vaccine; COVID-19 vaccines (avoid live vaccines on lymphocyte-depleting therapies)
• Bone health: DEXA scan (steroid use, reduced mobility risk)

Pregnancy Considerations

• Most DMTs contraindicated in pregnancy (IFN-β, glatiramer acetate are safest but should be stopped pre-conception or early pregnancy ideally)
• Disease activity often decreases in 3rd trimester, rebounds postpartum
• Breastfeeding incompatible with most DMTs
• Natalizumab may be continued through conception, discontinued by week 34 to avoid neonatal bone marrow suppression

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9. Prognosis

• Male sex
• Older age at onset
• Motor/cerebellar onset (vs. sensory/optic)
• High relapse rate in first 2 years
• Incomplete recovery from relapses
• High T2 lesion burden / T1 black holes at diagnosis
• Progressive course from onset (PPMS)

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10. Special Considerations

• Highly active MS ("aggressive MS"): Consider early high-efficacy therapy ("treat to target" strategy); NEDA (No Evidence of Disease Activity) goal: 0 relapses, 0 new MRI lesions, 0 disability progression
• Pediatric MS: >95% RRMS; similar DMT principles but limited trial data; natalizumab and ocrelizumab used off-label
• Older patients: Increased infection risk with high-efficacy immunosuppressive DMTs; consider de-escalation >55 years with stable disease
• Vaccinations before DMT initiation: Complete all live vaccines before starting lymphocyte-depleting therapy

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• Harrison's Principles of Internal Medicine, 21st Edition, pp. 12550, 12598 (McDonald Diagnostic Criteria, chronic myelopathy treatment including ocrelizumab for PPMS)
• McDonald 2017 Diagnostic Criteria (Lancet Neurology 2018)
• AAN/ECTRIMS Guidelines for MS DMT use

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Multiple Sclerosis: Physiotherapy Assessment & Management

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1. Role of Physiotherapy in MS

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2. Physiotherapy Assessment

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2.1 Subjective Assessment (History)

• Presenting concerns: main functional limitations, recent relapses, symptom fluctuation
• MS history: type (RRMS/PPMS/SPMS), duration, relapse frequency, current DMT
• Symptoms relevant to PT:
  • Fatigue (most common and disabling — distinguish MS fatigue from deconditioning fatigue)
  • Weakness, spasticity, tremor
  • Balance/dizziness
  • Falls history (frequency, circumstances, injuries)
  • Pain (neuropathic, musculoskeletal, spasticity-related)
  • Uhthoff's phenomenon (exercise-induced heat sensitivity)
  • Bladder/bowel (impacting exercise tolerance)
  • Cognitive deficits (affect compliance, motor learning)
  • Mood (depression/anxiety — extremely prevalent)
• Activity & participation: walking distance, ADLs, work status, leisure activities, driving
• Environment: home setup, stairs, aids used, support available
• Goals: patient's own rehabilitation priorities

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2.2 Objective Assessment

A. Posture & Body Structure

• Static posture (anterior, posterior, lateral views)
• Head-forward posture, kyphosis, pelvic tilt
• Limb alignment and foot posture

B. Range of Motion (ROM)

• Active and passive ROM at key joints (hip flexors, hamstrings, hip adductors, ankle plantar flexors — all commonly shortened in spastic MS)
• Prone hip extension test for hip flexor length
• Straight leg raise for hamstring length
• Ankle dorsiflexion — critical for gait

C. Muscle Tone Assessment

• Modified Ashworth Scale (MAS) — most widely used clinical spasticity scale:

• Penn Spasm Frequency Scale: self-report of spasm frequency
• Common patterns: spastic paraparesis (legs > arms), hip adductor and plantar flexor spasticity

D. Muscle Strength

• MRC Scale (0–5) for individual muscle groups
• Key muscles to assess: hip flexors/extensors/abductors, knee extensors/flexors, ankle dorsiflexors/plantarflexors, shoulder girdle, grip
• Handgrip dynamometry (objective, reproducible)
• Isokinetic dynamometry in research/advanced settings

E. Sensation

• Light touch (cotton wool), pinprick, vibration (128Hz tuning fork), proprioception
• Functional relevance: proprioceptive deficits drive balance problems and falls

F. Balance Assessment

G. Gait Analysis

• Observational gait analysis: watch for drop foot, circumduction, Trendelenburg, scissor gait (adductor spasticity), wide-based ataxic gait
• 10-Metre Walk Test (10MWT): comfortable and fast pace; measures walking speed (m/s); highly responsive to change
• 25-Foot Walk Test (T25FW): component of the MS Functional Composite (MSFC); most used in clinical trials
• 6-Minute Walk Test (6MWT): walking endurance; reflects functional capacity and fatigue
• Step/stride length, cadence: via walkway systems (GAITRite) or wearable IMUs where available
• Footwear and orthoses: assess current AFO fit, footwear appropriateness

H. Upper Limb Function

• 9-Hole Peg Test (9HPT): dexterity and fine motor coordination; part of MSFC
• Box and Block Test
• ARAT (Action Research Arm Test) for more severe deficits
• Assess intention tremor (finger-nose test), dysmetria

I. Fatigue Assessment

• Modified Fatigue Impact Scale (MFIS): 21-item; physical, cognitive, psychosocial subscales; gold standard in MS
• Fatigue Severity Scale (FSS): 9-item Likert; quick screen
• Visual Analogue Scale for Fatigue
• Distinguish: primary MS fatigue (lassitude — unprovoked, overwhelming) vs. secondary fatigue (from sleep disorders, depression, deconditioning, medication)

J. Respiratory Function

• Spirometry (FVC, FEV1) in advanced MS
• Peak cough flow (PCF) — if <270 L/min, assisted cough techniques indicated
• Respiratory muscle weakness occurs late but increases mortality risk

K. Pain Assessment

• Numerical Rating Scale (NRS) or VAS
• Pain DETECT or DN4 for neuropathic screening
• Characterize: location, quality, aggravating factors (distinguish neuropathic, spasticity-related, musculoskeletal overuse)

L. Functional Independence

• Barthel Index / FIM (Functional Independence Measure): ADL independence
• MS Walking Scale-12 (MSWS-12): patient-reported walking limitation; 12 items
• Multiple Sclerosis Impact Scale (MSIS-29): physical and psychological QoL

M. Falls Risk

• Falls history (number, circumstances, injuries in past 12 months)
• Fear of falling: Falls Efficacy Scale–International (FES-I)
• Environmental hazard assessment
• Medication review (sedating agents, antispasmodics worsening balance)

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2.3 Goal Setting

• Impairment level (e.g., reduce spasticity MAS from 2→1)
• Activity level (e.g., walk 200m independently)
• Participation level (e.g., return to work, community walking)

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3. Physiotherapy Management

3.1 Exercise Therapy

Aerobic Exercise

• Evidence: reduces fatigue, improves cardiovascular fitness, mood, cognitive function, and QoL (Cochrane reviews)
• Target: 150 min/week moderate intensity (RPE 12–14/20, 60–70% HRmax)
• Modes: cycling (stationary bike preferred initially), swimming, aquatic therapy, walking, arm ergometry
• Aquatic therapy: ideal — water thermoregulation mitigates Uhthoff's; buoyancy reduces fall risk; high patient acceptance
• Precautions: Uhthoff's phenomenon — use cooling strategies (cool water, ice vests, air conditioning), exercise in cooler parts of day, morning sessions

Resistance/Strengthening Exercise

• Evidence: improves muscle strength, walking speed, functional capacity
• Target: 2–3 sessions/week; 2–4 sets × 8–15 reps, 60–80% 1RM
• Focus: hip extensors, abductors, knee extensors, ankle dorsiflexors (anti-gravity and gait muscles)
• Progressive resistance training (PRT): safe even in moderate disability; begin at low loads and progress
• Functional electrical stimulation (FES): stimulates peroneal nerve in drop foot; activates dorsiflexors during swing phase → improved gait kinematics and strength

Combined Aerobic + Resistance

• Superior to either alone for fatigue, walking endurance, and QoL
• Recommended as first-line exercise prescription

Balance and Coordination Training

• Task-specific balance training: single-leg stance, tandem standing, reaching tasks, reactive stepping
• Vestibular rehabilitation: gaze stabilization exercises, habituation for dizziness from vestibular MS lesions
• Bobath/NDT approach: normalise tone, facilitate normal movement patterns
• Proprioceptive training: unstable surfaces (foam), eyes-closed tasks, perturbation training
• Tai Chi: evidence for improved balance, reduced falls, psychological benefit

Flexibility and Stretching

• Daily stretching of spastic muscle groups: hip adductors, hamstrings, heel cord (Achilles)
• Sustained (static) stretches ≥30 seconds; maintain throughout ROM
• Positional stretching (standing frame for plantar flexors/hip extensors)
• Serial casting: for fixed or dynamic ankle equinus

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3.2 Spasticity Management

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3.3 Gait Rehabilitation

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3.4 Fatigue Management

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3.5 Falls Prevention

• Multifactorial falls assessment and individualized program
• Exercise: balance training + strengthening most effective intervention
• Environmental modification: liaise with OT; remove trip hazards, install grab rails, stair rails
• Footwear assessment: supportive, flat, closed heel
• Orthoses: AFO improves foot clearance and reduces trip risk
• Walking aids: prescribe appropriate aid (stick, Lofstrand crutches, rollator/wheeled walker, wheelchair) at the right time
• Assistive technology: FES, wearable fall detectors
• Dual-task training: practice walking while performing cognitive tasks (fall risk often higher during dual-task in MS)

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3.6 Upper Limb and Tremor Rehabilitation

• Strengthening: proximal stabilizer strengthening (shoulder girdle, core) improves distal control
• Coordination retraining: repetitive task training, reaching/grasping tasks, fine motor exercises
• Weighted cuffs/utensils: dampen intention tremor during ADLs (evidence modest but patient-reported benefit)
• Constraint-induced movement therapy (CIMT): in unilateral weakness, forced use of weaker limb
• Mirror therapy: cortical remapping in unilateral impairment
• Splinting: wrist/hand supports to stabilize proximal joints during functional tasks

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3.7 Respiratory Physiotherapy

• Breathing exercises: diaphragmatic breathing, segmental expansion
• Assisted cough techniques: manual chest compression, mechanical insufflation-exsufflation (MIE/CoughAssist) when PCF <270 L/min
• Postural drainage / airway clearance: if aspiration/recurrent chest infections
• Inspiratory muscle training (IMT): threshold IMT devices; evidence for improved respiratory muscle strength and perception of breathlessness in MS

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3.8 Pain Management (PT Contribution)

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3.9 Wheelchair and Assistive Technology Prescription

• Walking aids: hierarchical progression — stick → Lofstrand crutches → rollator → wheelchair
• Manual wheelchair: lightweight, individually prescribed; upper limb assessment critical (shoulder overuse risk)
• Power wheelchair/scooter: for upper limb involvement or severe fatigue limiting self-propulsion
• Environmental control systems: voice-activated devices, ramps, hoists
• Liaise closely with OT and seating specialists

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3.10 Neuroplasticity-Based Approaches

• Task-specific repetitive practice: high repetitions of meaningful tasks drive cortical remapping
• Motor learning principles: blocked → random practice; external focus of attention; augmented feedback
• Constraint-induced movement therapy (CIMT)
• Virtual reality (VR) rehabilitation: evidence for balance, gait, and motivation in MS; Wii Fit balance games studied
• Transcranial magnetic stimulation (TMS) / tDCS: research stage; combined with PT may enhance motor learning

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4. Outcome Monitoring & Reassessment

Key Outcome Measures Summary

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5. Principles Guiding MS Physiotherapy

1. Treat to function, not diagnosis — individual goals, not disease labels
2. Exercise is medicine — prescribe it like a drug (type, dose, frequency, progression)
3. Fatigue-aware practice — avoid over-fatiguing; schedule PT at optimal times (not post-DMT infusion, not peak heat)
4. Promote self-management — home exercise programs, activity monitoring, education
5. Pacing and graded activity — boom-bust cycle is common; teach consistent moderate activity
6. Relapse awareness — suspend vigorous PT during active relapse; gentle ROM and positioning maintained
7. Psychological integration — screen for depression/anxiety; motivational interviewing; psychologically informed practice
8. Longitudinal relationship — MS is lifelong; PT involvement at key transitions (diagnosis, relapse, EDSS progression, loss of ambulation, pregnancy)

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• Geriatric Trauma Management (p. 82) — Tinetti Gait and Balance Test validation in MS and neurodegenerative disease
• NICE Guideline NG220: Multiple Sclerosis in Adults (2022)
• Cochrane Reviews: Exercise therapy for MS (Rietberg et al.; Learmonth et al.)
• MS Society UK / National MS Society Clinical Practice Guidelines
• Harrison's Principles of Internal Medicine, 21st Ed. (p. 12550, 12598) — MS overview informing PT context