Multiple Sclerosis

Multiple sclerosis is a disabling disease that affects the spinal cord and brain. In multiple sclerosis, the immune system attacks the myelin, (the protective sheath) that covers the nerve fibers and causes communication problems between the brain and the rest of the body. Slowly, the disease can cause deterioration of the nerves or permanent damage.

Symptoms of multiple sclerosis vary widely and depend on the amount of nerve damage and the type of nerves affected. Symptoms may differ from person to person and depending on the location of affected nerve fibers. Symptoms include:

• Numbness in the limb or limbs.
• Weakness.
• Tingling in parts of the body
• Electric-shock sensations during certain neck movements, especially bending the neck forward (Lhermitte sign is positive).
• Dizziness.
• Tremors.
• Lack of coordination.
• Unsteady gait.
• Slurred speech.
• Partial or complete loss of vision.
• Pain during eye movement.
• Prolonged double vision.
• Blurry vision.
• Prolonged double vision.
• Fatigue.
• Problems with bowel, and bladder function.
• Problems in sexual function.
• Lose the ability to walk independently.

The cause of multiple sclerosis is unknown. It is an autoimmune disease in which the body's immune system malfunction destroys the myelin sheath. When the protective myelin sheath is damaged and the nerve fiber is exposed, the messages that travel along that nerve fiber may be slowed or blocked. The exact cause is unknown:

• Occurs around 20 and 40 years of age.
• Genetically transferred.
• Infections.
• Environmental factors.
• Deficiency of vitamin D and low exposure to sunlight.
• Certain autoimmune diseases like pernicious anemia, thyroid disease, psoriasis, type 1 diabetes, or inflammatory bowel disease.
• Smoking, etc

Pathology:
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system, that gives rise to focal lesions in the grey and white matter and diffuses neurodegeneration in the entire brain. Focal inflammatory infiltrates in the meninges and the perivascular spaces and produce soluble factors, which induce demyelination or neurodegeneration, directly or indirectly through microglia activation. Demyelination and neurodegeneration occur by oxidative injury and mitochondrial damage leading to a state of virtual hypoxia.

Blood tests:
A blood test is done to rule out other diseases with symptoms similar to multiple sclerosis.

Spinal tap (lumbar puncture):
Lumbar puncture is done in which a small sample of cerebrospinal fluid is removed from the spinal canal to show abnormalities in antibodies that are associated with multiple sclerosis. Lumbar puncture also helps to rule out infections and other conditions with symptoms similar to multiple sclerosis.

Magnetic resonance imaging (MRI):
Magnetic resonance imaging (MRI) helps reveal areas of multiple sclerosis lesions in the brain and spinal cord.

Evoked potential tests:
This test records the electrical signals produced by the nervous system in response to stimuli. An evoked potential test may use visual stimuli or electrical stimuli and electrodes to measure how quickly the information travels down your nerve pathways.

Medication:  Cladribine, diroximel, teriflunomide, siponimod, etc.
Note: Medication should not be taken without the doctor's prescription.

Surgery:
There's no cure for multiple sclerosis.  A minor surgical procedure (rhizotomy) can be used to treat pain. The surgery is done by locating the nerves that communicate with the brain to signal pain and then the nerve fibers are burnt so they can no longer send pain signals.

Cryotherapy:
Cryotherapy or ice therapy is very effective and beneficial in patients suffering from multiple sclerosis. It is found that cold-water immersion offers relief from certain symptoms of multiple sclerosis.

TENS:
Transcutaneous electrical stimulation (TENS) stimulates endorphin production, our natural pain relief hormones. TENS is an affordable non-drug therapy used for treating pain in patients with MS.

Shockwave therapy:
Shockwave therapy is a series of high-intensity sound waves, delivered to an affected area. It increases the blood flow and stimulates repair. Shock wave therapy can be used for painful musculoskeletal disorders. This treatment could also work on spasticity in patients with neurological conditions such as multiple sclerosis.

Exercises:
Exercises are safe and effective and beneficial at multiple levels and have an important role in delaying negative symptoms of the disease. An appropriate exercise should be chosen according to the patient's strengths and weaknesses. The intensity, frequency, and duration of treatment in terms of activities and participation should be designed properly. Exercise is considered a safe effective means of rehabilitation, weight-bearing being one of the most beneficial exercises.

Strength training:
A strength training program is recommended for maintaining bone and muscle mass.  Strength training exercises for major muscle groups are recommended 2- 3 times, 3 sets of 8-15 repetition max (RM) per week, techniques such as Bobath, Vojtas, and Proprioceptive Neuromuscular Techniques (PNF) are carried out regularly and with sufficient intensity, show improvement in patients with multiple sclerosis. Strengthening exercises improve aerobic capacity, lower extremity muscle strength, fatigue, and depression. These exercises also have a positive effect on reduced activity limitations such as walking performance and balance and positively impact the quality of life.

Stretching:
Patients with MS have spasticity, especially in the lower extremities, causing the legs to stiffen.  Therefore, a regular stretching program should be incorporated into the daily routine of activities. Stretching exercises help to improve and maintain muscle length to allow greater flexibility.

Aerobic training:
Aerobic training is recommended for patients with mild to moderate disabilities for at least 30 minutes 2 times per week. These exercises reduce fatigue and improve mobility in patients with multiple sclerosis. Aerobic exercise training with low to moderate intensity can improve aerobic fitness and causes a reduction of fatigue in patients with mild or moderate disability.

Hydrotherapy:
Hydrotherapy has a positive effect on patients with progressive multiple sclerosis. It promotes energy levels, and mental and overall general health, and aids social interaction in the presence of a physical disability. Because of the reduced impact of gravity, hydrotherapy allows patients with mild to severe paresis of the lower extremities to perform standing and moving exercises.

Balance exercises:
Balance exercises can improve balance. As poor postural control increases the risk of falls. Multiple sclerosis patients have increased sway in stance, delayed postural perturbations, and reduced ability to move, limiting stability.

Hippotherapy:
Hippotherapy has a positive effect on the balance of patients with multiple sclerosis. The therapeutic effect of horseback riding intervention shows positive emotional and physical effects on neuromotor development and physical disabilities. Horseback riding improves balance, posture, and gait, and provides effective sensory stimulation and rhythmic anterior and posterior swinging motion in multiple sclerosis patients.

Motor Imagery:
Motor imagery is used in neuro-rehabilitation to facilitate motor performance. Motor imagery and rhythmic auditory stimulation can be used for walking rehabilitation, it improves walking speed, walking distance, and perception in multiple sclerosis patients.

Cognitive Behavioral Therapy (CBT):
Cognitive behavioral therapy has a positive effect on fatigue, and reduces moderate depression, over a short term, in multiple sclerosis patients.

Gait training:
Gait training forms a large part of neurorehabilitation for patients suffering from multiple sclerosis. As in multiple sclerosis patients, there is a decrease in speed and stride, and step length, an increase in the step width, a decrease in hip extension during the stance period, a reduction in knee flexion in the swing period, a decrease in ankle dorsiflexion in the initial contact and a decrease in ankle plantarflexion during the pre-swing phase. Thus, rehabilitation should focus on treating asymmetrical gait characteristics.

The patient should be advised to exercise daily as it can help retain flexibility and balance, promote cardiovascular fitness and a sense of well-being, and prevent complications from inactivity. Exercise also helps regulate appetite, bowel movements, and sleep patterns.