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(Multiple Sclerosis cost drivers, 2014)

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Multiple Sclerosis (MS) is a degenerative disease (deterioration of special cells, tissue or organ systems no longer functioning normally ) of the Central Nervous System (CNS). 2.5 million people worldwide have been diagnosed with MS (Grant & Adams, 2009).

Primary lesions of MS are destruction of the myelin sheaths surrounding axons of neurons in the brain (refer to figure 1) . The areas where myelin is destroyed is known as Plaques. Although MS lesions can be found in any myelinated area of the CNS, the distribution of plaques is not altogether random. Regions preferentially damaged in MS include the white matter surrounding the ventricles, corpus callosum, optic nerves, brainstem, cerebellum, and spinal cord (Ge, 2006; Lucchinetti & Parisi, 2006; Noseworthy et al., 2000).

MS lesions predominantly affect white matter, but lesions also appear in the gray– white matter junctions and in the gray matter itself (Kidd et al., 1999). Preferential damage includes cortical sulci and the cingulate, temporal, insular, and cerebellar cortices. Cause of damage to myelin sheaths are still actively being investigated, some scientists believed that it was an autoimmune process in which the body’s own immune cells attack myelin sheaths, however others have disputed this claim (Grant & Adams, 2009).

Degeneration of myelin sheaths along with associated axonal damage, impedes and slows the saltatory conduction of action potentials down the axons. Nerves are therefore unable to send instructions to their target tissue, hence communication is implicated throughout the nervous system which lead to the various symptoms affecting MS patients (Iezzoni, 2010)

Symptoms of MS are varied and inconsistent from patient to patient, symptoms can be seen in figure 2.

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Neuropsychological deficits occur in about 50 % of individuals with MS. These symptoms often impair quality of life and social activities. Comprehensive clinical and population studies have shown that the most frequently impaired areas relate to memory, attention, information processing, abstract/conceptual reasoning, and visuospatial skills while primary language skills, immediate and implicit memory and verbal intelligence appear to be unaffected (Iezzoni, 2010) .

It appears that the core deficit refers to some relevant aspects of working-memory, the combination of clinical and experimental neuropsychological methods and brain-imaging techniques has brought unprecedented progress in understanding the nature and development of cognitive disturbances and the relation to structural brain-involvement (Iezzoni, 2010)

Refer to figure 3 for statistics.

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Figure 3

Cognitive Implications of MS- (Health Union, 2013)

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(Higuera & Pietrangelo, 2015)

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Figure 2

Common Symptoms of MS - (Heydon, n.d.)

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Figure 1

Demyelinization process- (Higuera & Pietrangelo, 2015)

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Treatment for patients with MS vary depending on their individual needs and therapeutic goals. There are various medications available to aid MS symptoms, mainly disease modification drugs. Medication is most frequently used to treat MS flares, to slow the disease progression and to treat signs and symptoms of disease. Patients also consider treatment outside of mainstream traditional western medicine such as acupuncture, chiropractic treatment, dietary supplements and certain herbs to name a few. Ongoing research means medications are constantly being improved and scientists are actively searching to improve current medication options (Grant & Adams, 2009)

Rehabilitation therapies aim to restore patients functional ability, if that is not possible therapy is aimed at maintaining current functional ability. The allied health professions including physical, occupational, recreational therapists and speech- language pathology specialists all work collectively in the rehabilitation process for MS patients (Iezzoni, 2010).

Physical therapist aim to restore patients functioning to its original state prior to an acute injury or illness, this includes muscle strength training, motion, balance, co-ordination, posture, fatigue and other functional impairments. Additionally Physical therapists also aid patients with strategies to minimize falls as well as evaluate patients for mobility aids, such as walkers and wheelchairs (Iezzoni, 2010).

Occupational therapists assists patients to adjust to their disability in their homes and social environments, their goal is to assist patients with everyday tasks as simple as bathing and dressing to cognitive tasks such as memory, reasoning and problem solving. Occupational therapists also aid patients to change their environments for safety and accessibility reasons (Iezzoni, 2010).

Physical medicine and rehabilitation is field also used in MS treatment and rehabilitation. Physicians within this field aim to maximize patients physical functioning, they specialize in the functioning of muscles, nerves, bones and rely heavily on clinical histories, physical examinations and non-invasive tests (i.e. MRI scans).After diagnosis these physicians work out individual treatment plans for patients often with combined consultation with physical and occupational therapists (Iezzoni, 2010)

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Extensive evaluations are carried out to determine diagnoses and treatment of patients. Neurologists, physical therapists and other clinicians have collaborated a range of measures/ scales aimed to examine the extent of MS symptoms and impairments. These scales measure muscle strength, co-ordination and cognitive processes.

Examples of measures:

The Expanded Disability Status Scale - Focuses on patients ability to walk, based on a 0 -10 scale where 0 is normal neurological examination and 10 is death caused by MS.

The MS Functional Composite – Comprised of a 25-foot long walking test.

Guys Neurological Disability Scale - Detailed scale considering the full range of body systems and functions affected by MS. Extensive testing means that domains that might otherwise be neglected, such as mood problems, fatigue, bladder and bowel problems, and sexual dysfunction are also examined in the scale.

The scale exams 12 functional domains: 0. Normal status; 1. symptoms causing no disability; 2. Mild disability; 3. Visual disability; 4. Speech and communication disability; 5. Swallowing disability; 6. Upper limb disability; 7. Lower limb disability; 8. Bladder disability; 9. Bowel disability; 10. Sexual disability; 11.Fatigue;12. Other disabilities.

-measured on a 6-point scale :

0 Normal status

1. Symptoms causing no disability

2. Mild disability—not requiring help from others

3. Moderate disability—requiring help from others

4. Severe disability—almost total loss of function

5. Total loss of function—maximum help required

Patient questionnaires have also been developed such as the Multiple Sclerosis Impact Scale, the Functional Assessment of Multiple Sclerosis scale, the Quality of Life Questionnaire for Multiple Sclerosis; the MS Self-Care Activities of Daily Living Scale and a version of the EDSS for patients to answer themselves (Iezzoni, 2010).

Having patients rate their own progress and symptoms allow insight for neurologists about their patient’s perception and the effects of MS on their daily functioning. Given the complexities of MS symptoms and disability evaluations, it is tempting to seek straightforward tests, such as MRI scans, to provide objective measures of overall MS disability or functional impairments. MRI scans of the brains and spinal cords of persons with MS show plaques or areas of myelin destruction caused by the disease process. However levels of impairment cannot be linked to scans as symptoms vary from patient to patient regardless of the size or location where destruction occurs (Polman, Thompson, & Murray , 2002)