Neurorehabilitation Centre at CNA, Breda, Noord-Brabant, The Netherlands
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Similarly to ► Chap. 3, this chapter will also deviate from the classification used in ► Chaps. 1 and 2. The reason is that with multiple sclerosis (MS), no distinction can be made into primary impairments and secondary impairments. The symptoms are, namely, entirely dependent on where the sclerotic plaques arise. The localization of the sclerotic plaques defines the symptomatology that occurs as a result of MS. It is a syndrome with a great variety of symptoms. The occurrence of exacerbations is typical of MS. These can occur with variable frequency. It is important to introduce treatment interventions that have a positive influence on reducing these exacerbations. Medication and good harmonization of burden and resilience help to reduce the number of exacerbations.
If we look at the symptomatology, we see many commonalities with the other CNS disorders, such as spasticity, fatigue, slowed information processing, depression, etc. Of course this provides starting points for uniform treatment interventions in the case of CNS disorders, without losing sight of the uniqueness of the individual.
The chapter has been structured as follows: firstly the causes of MS are discussed and subsequently the prevalence and diagnosis. In ► Sect. 3 the different forms of MS are discussed and then the symptomatology of MS. Finally, in ► Sect. 5 the imbalance in the burden and resilience as a consequence of socio-emotional problems will be discussed.
4.2 Causes of MS
Multiple sclerosis (MS) is an autoimmune disease. The most important characteristic of an autoimmune disease is that the immune system attacks healthy cells. The myelin sheath becomes damaged as a result of inflammations. The myelin sheath ensures that information is conducted by the nerves without interference. It is comparable to receiving various stations on the television. The coax cable passes on the information, so that the images from the stations can be received in high resolution. When the insulating layer around the cable becomes damaged and the wires inside become damaged, the images you receive in your living room become hazy. This is what also takes place with MS. Initially the flow of information is problem-free, but demyelination causes interference in the nerve conduction, and the information is not passed on smoothly. Studies have shown that in MS patients, it is not only the myelin sheath that is damaged, but in the longer term, the actual nerves are also damaged. This is called axonal damage. Frequently that is the indicator that a relapsing-remitting MS is changing to the secondary progressive form (Teunissen and Vereijken 2007).
At the places where the inflammation has damaged the myelin, hard sclerotic plaques form (◘ Fig. 4.1 and 4.2). This results in a reduced nerve conductance.
Inflammation on the myelin sheath and the development of sclerotic plaques (Source: R. Hoof)
A substantial number of studies have been conducted worldwide into the causes of MS, but as yet only «pieces of the puzzle» have been found. Viruses and genetic disposition may play a role in the occurrence of this autoimmune disease. It is, however, becoming clearer that early treatment can limit the damage to the body.
4.3 Prevalence, Diagnosis, and Classification of MS
The diagnosis of MS is generally made in people aged between 20 and 40. Women have twice as likely to develop MS as men. There is no test with which MS can be diagnosed directly. The diagnosis is made on the basis of the anamnesis, the symptoms, and the presentation of the symptoms. Apart from these clinical data, an MRI scan, a liquor test, or visual evoked potentials (the response speed to a visual stimulus is measured and that provides information about the function of the eye nerve) can ultimately confirm the diagnosis of MS. The following aspects are of critical importance when making the diagnosis:
The symptoms and clinical signs must correspond with abnormalities in the white substance of the eye nerve, brain, or spinal cord.
The symptoms and abnormalities must point to multiple localizations in the central nervous system.
The symptoms and abnormalities must have occurred in at least two episodes (relapsing-remitting) or must have been progressive over at least a period of 6 months.
The complaints and abnormalities cannot be explained by another cause (for these additional investigations are frequently necessary).
A physiotherapist must be informed of this clinical diagnosis. In practice he regularly has patients reporting these symptoms. When these symptoms are recognized, which frequently occur in a certain chronology, the physiotherapist can decide to refer the patient to a specialist.
Patients with MS are classified according to the EDSS (Expanded Disability Status Score). The classification is as follows:
Normal neurological findings
No disability, minimal signs in one functional system
Minimal disability in one functional system
Moderate disability in one functional system; however, still able to walk without help (fully ambulatory)
Can walk 500 m without help but has serious disability in one functional system (gradual transition to the secondary progressive form)
Ambulatory without help or a rest pause at 200 m, but disability is too severe to be able to work full time
Needs a walking stick, crutch, or walking aid to walk 100 m, with or without rest pause
No longer able to walk more than 5 m, even with help; wheels self in wheelchair and can get in and out of wheelchair
Bedridden or chairbound, good use of arms, but needs help with transfer from/to chair/bed
Helpless bed patient, can communicate and eat
Dead as a result of MS (seldom)
The EDSS provide the opportunity to assess the course of the MS in the longer period.
4.4 Different Forms of MS
In spite of the variation in and the unpredictability of the symptoms, there is with MS a certain consistency in the way in which the disease behaves over the long term. MS is traditionally subdivided into three categories: relapsing-remitting, secondary progressive, and primary progressive MS.
4.4.1 Relapsing-Remitting MS (30–40% of Patients)
This form of MS is characterized by the frequent exacerbations that occur and by the ever-reducing level of functioning that the patient unfortunately experiences.
4.4.2 Secondary Progressive MS (Approx. 40% of Patients)
What is conspicuous about (◘ Fig. 4.3) is that it is identical to that of the relapsing-remitting form of MS but that in the end it takes a chronic progressive course. This is explained by the fact that axonal damage occurs over time (Teunissen and Vereijken 2007), and because of this the adaptation space decreases. That means that the axonal damage and the accompanying reduced adaptation space cause the MS to gradually become progressive (◘ Fig. 4.4).
Schematic illustration of the course of relapsing-remitting MS
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