Multiple Sclerosis and Amyotrophic Lateral Sclerosis

Question 1

What is Multiple Sclerosis (MS)?

Answer 1

MS is one of the most common non-traumatic neurological conditions affecting young and middle-aged adults, characterized by discrete areas of damage in the brain, spinal cord, and optic nerves.

Question 2

How common is MS in Canada?

Answer 2

Canada has one of the highest rates of MS per capita in the world. Most people are diagnosed between ages 20 and 49, with the average age being 43.

Question 3

Who is more likely to be diagnosed with MS?

Answer 3

75% of people in Canada living with MS are female, and females are three times more likely to be diagnosed than males.

Question 4

What body functions are most commonly affected by MS?

Answer 4

Vision, coordination, speech, strength, sensation, bladder control, and sexual function.

Question 5

Is MS a terminal disease?

Answer 5

No, MS is not terminal, and most people live normal lifespans. However, it can greatly affect quality of life, with an unemployment rate of 60-80% among those with MS.

Question 6

What is the primary contribution of massage therapy for people with MS?

Answer 6

Easing secondary effects of the disease in the body’s soft tissue, which can impair mobility and function and reduce quality of life.

Question 7

What is myelin?

Answer 7

Myelin is a proteolipid sheath covering most axons in the CNS, made by oligodendrocytes. It insulates neurons, prevents impulse mixing, and speeds up conduction of nerve signals.

Question 8

What is demyelination?

Answer 8

Demyelination is the process by which myelin sheaths are lost or destroyed. MS is the most common demyelinating condition in the CNS.

Question 9

What are plaques in MS?

Answer 9

Plaques are characteristic lesions of MS, appearing as greyish spots in white matter where myelin destruction occurs. They average 1-15 mm in size.

Question 10

What happens at an active plaque site?

Answer 10

Active plaques are edematous inflammatory lesions with infiltrating lymphocytes and macrophages. These immune cells consume myelin, attack oligodendrocytes, and rapidly kill them.

Question 11

What is the role of astrocytes in plaque formation?

Answer 11

Astrocytes synthesize fiber processes to form a living scar (gliosis) at the plaque site, making the tissue harder than the surrounding area.

Question 12

What characterizes old, inactive plaques in MS?

Answer 12

Old plaques are fields of permanently demyelinated axons filled with glial fibers in spaces where myelin bundles used to be.

Question 13

What is an exacerbation in MS?

Answer 13

Exacerbation, also called a relapse or flare-up, is a period of active demyelination with sudden onset of neurological symptoms, lasting 6-8 weeks and resolving over 2-3 months.

Question 14

What is remission in MS?

Answer 14

Remission is the period between exacerbations, which may return a person to normal or near-normal function, or leave considerable new disability depending on the disease stage.

Question 15

What is the average frequency of MS exacerbations?

Answer 15

The average rate of exacerbations is every eighteen months.

Question 16

What causes MS exacerbations?

Answer 16

MS exacerbations are caused by an autoimmune reaction where immune cells accumulate in CNS venules, breach the blood-brain barrier, and attack myelin, leaving behind plaques.

Question 17

Where are MS plaques typically found?

Answer 17

MS plaques are denser around blood vessels and the ventricles. They may be new or reactivations of old sites.

Question 18

How do immune cells attack in MS?

Answer 18

Immune cells release chemicals that cause inflammation and damage to myelin, neurons, and oligodendrocytes, perceiving myelin as an antigen and producing antibodies against it.

Question 19

What happens when myelin is stripped away?

Answer 19

Uncovered axon sections transmit poorly or erratically due to lost insulation, causing dysfunction in pathways dependent on those signals.

Question 20

What role do oligodendrocytes play during MS remission?

Answer 20

Oligodendrocytes remyelinate axons, often restoring normal or near-normal function in the early stages of MS.

Question 21

Why does remyelination become less effective over time in MS?

Answer 21

Repeated attacks and cumulative damage reduce oligodendrocyte effectiveness, eventually leading to their dysfunction or disappearance.

Question 22

What replaces oligodendrocytes in chronic MS plaques?

Answer 22

Glial scars (astrocytic fibrillary gliosis) fill the plaques, as astrocytes produce glial fibers after inflammation decreases and microglia disappear.

Question 23

What happens when nearby plaques join in MS?

Answer 23

Larger fields of tissue form where impulse conduction is disrupted, leading to more severe symptoms and deficits.

Question 24

What determines the severity of neurological deficits in MS?

Answer 24

Axonal damage/loss and the development of permanent inactive plaques are major determinants of profound neurological deficits.

Question 25

When are exacerbations in MS more likely to occur?

Answer 25

Exacerbations are more likely if the person's overall health is impaired, or during periods of illness.

Question 26

Do all individuals with MS experience a well-defined course of exacerbations and remissions?

Answer 26

No, some have an extreme form of the disease with little or no remission, while others may only have one or two exacerbations in their lifetimes or experience a low-grade chronic type.

Question 27

How does the progression of MS affect the distinction between flare-ups and remissions?

Answer 27

As the disease progresses, the distinction between states of flare-up and remission becomes less clear.

Question 28

What are the possible disability outcomes in MS?

Answer 28

Disability outcomes range from clinically insignificant to total physical disability, with a variety of acute, subacute, and inactive lesions scattered throughout the CNS.

Question 29

What is the suspected cause of MS?

Answer 29

MS is believed to result from a combination of immunological, environmental, infectious, and genetic factors.

Question 30

How is MS succinctly described in terms of its cause?

Answer 30

MS is an immune-mediated neurological disorder precipitated in a genetically susceptible individual by exposure to an environmental factor, likely a virus.

Question 31

Which genetic factor is strongly linked to MS development?

Answer 31

Changes in HLA genes, especially the HLA-DRB1*1501 variation, are strongly linked to increased MS risk.

Question 32

Which immune cells play a significant role in MS?

Answer 32

T cells and B cells are the key immune cells involved in the abnormal immune response in MS.

Question 33

What happens when T and B cells enter the CNS in MS?

Answer 33

Once in the CNS, T and B cells release chemicals that cause inflammation and damage.

Question 34

How many genes have been identified that contribute to MS risk?

Answer 34

About 200 genes contribute a small amount to the overall risk, including HLA-DRB1*1501, the most strongly associated variation.

Question 35

What is the risk of developing MS in the general population, and how does it compare for identical twins?

Answer 35

The risk in the general population is about 1 in 750–1,000. For identical twins, if one has MS, the other has about a 1 in 4 risk.

Question 36

Which ethnic group has the highest prevalence of MS?

Answer 36

White people of Northern European descent have the highest prevalence of MS.

Question 37

How does geography influence the risk of developing MS?

Answer 37

MS occurs more frequently in areas farther from the equator. People moving before age 15 assume the risk of their new area; those moving later retain the risk of their origin area.

Question 38

Why might vitamin D levels be linked to MS risk?

Answer 38

People living closer to the equator have higher vitamin D levels due to greater sun exposure, which may support immune function and protect against MS.

Question 39

How does obesity influence the risk of developing MS?

Answer 39

Obesity in childhood, adolescence, or early adulthood increases the risk of MS and may contribute to inflammation and MS activity.

Question 40

How does smoking affect MS risk and progression?

Answer 40

Smoking increases the risk of developing MS, speeds up disability progression, and worsens relapsing MS. Stopping smoking slows disability progression.

Question 41

Which virus significantly increases the risk of MS if contracted during adolescence?

Answer 41

Epstein-Barr Virus (EBV), the most common cause of infectious mononucleosis, more than doubles the risk of MS.

Question 42

What role does the gut microbiome play in MS risk?

Answer 42

Changes in gut bacteria have been linked to MS, with certain bacteria strains elevated in individuals with MS, contributing to immune system dysfunction.

Question 43

How do viral infections relate to MS exacerbations?

Answer 43

30–60% of MS exacerbations occur shortly after viral illnesses, such as colds or flu, suggesting that viruses can reactivate the disease.

Question 44

Does stress play a role in MS onset or relapses?

Answer 44

A relationship is considered possible but not strongly demonstrated. Stress can drain energy, making symptoms more noticeable during demanding times.

Question 45

Why is MS notoriously difficult to diagnose?

Answer 45

MS has non-specific symptoms that come and go, making diagnosis time variable from days to years. Often, it’s given as a probable diagnosis until clinical behavior over time confirms it.

Question 46

What role can massage therapists play in diagnosing MS?

Answer 46

They can observe patterns of symptom development and recurrence, suggesting neurological consultation when MS is suspected.

Question 47

What are the diagnostic criteria for MS?

Answer 47

1. Evidence of damage in at least two separate CNS areas. 2. Evidence that damage occurred at different times. 3. Rule out other possible diagnoses.

Question 48

What tools help speed the MS diagnostic process?

Answer 48

The Revised McDonald Criteria (2017), MRI, cerebrospinal fluid analysis, and evoked action potential (EP) testing.

Question 49

What is the clinical presentation of MS symptoms?

Answer 49

Symptoms vary widely between individuals and fluctuate over time. Onset and progression are unpredictable, often starting in lower limbs and progressing asymmetrically.

Question 50

Which visual symptom is most common in MS, and how does it present?

Answer 50

Optic neuritis, presenting as unilateral vision loss, light sensitivity, and pain behind the eye, often with a central blind spot (scotoma).

Question 51

What are other common visual symptoms in MS?

Answer 51

- Blurred vision - Double vision (diplopia) - Impaired color perception - Nystagmus (rapid, horizontal eye movement) - Oscillopsia (jumping images) - Internuclear ophthalmoplegia (failure of one eye to adduct while the other abducts)

Question 52

Is total blindness common in MS?

Answer 52

No, but many individuals with MS are legally blind.

Question 53

What are the first symptoms to appear in about half of MS cases?

Answer 53

Somatosensory symptoms, including sensory reduction (hypoesthesia, anesthesia), heightened sensitivity (hyperesthesia), and abnormal sensations (paresthesias and dysesthesias).

Question 54

What is the "MS Hug"?

Answer 54

A squeezing sensation around the torso, often described as feeling like a blood pressure cuff tightening. It is a common first symptom or sign of relapse in MS.

Question 55

What is Lhermitte's Sign in MS?

Answer 55

An electric shock or buzzing sensation down the back, sometimes into the extremities, when the head is flexed forward. It indicates dorsal column involvement.

Question 56

What are common motor symptoms of MS?

Answer 56

- Problems with walking (e.g., ataxia/dystaxia or drunken sailor’s gait) - Tremors, especially intention tremor - Tone disorders, ranging from hypotonia to spasticity - Painful cramps and spasms - Quadriplegic spastic paralysis in advanced stages - Hyperactive stretch reflexes, clonus, and Babinski’s Sign

Question 57

What are frequent motor-related subjective feelings in MS?

Answer 57

Clumsiness, stiffness, and "heaviness" in limbs, often accompanied by vertigo.

Question 58

What facial motor symptoms are common in MS?

Answer 58

- Facial myokymia (rapid flickering facial muscle movements) - Bell’s Palsy (facial paralysis due to cranial nerve VII dysfunction) - Dysphagia (difficulty swallowing)

Question 59

What are the primary speech problems in MS?

Answer 59

Dysarthria (difficulty controlling speech muscles) and scanning speech (monotonal, disconnected speech).

Question 60

What are the characteristics of MS-related fatigue?

Answer 60

- Occurs daily, often in the morning after restful sleep - Worsens throughout the day - Aggravated by heat and humidity - Comes on suddenly and is severe - Often unrelated to depression or physical impairment

Question 61

What are primary emotional symptoms in MS?

Answer 61

- Emotional lability (pathological laughing or weeping) - Depression during exacerbations - Euphoria in advanced stages, leading to indifference to health and loved ones

Question 62

What secondary emotional symptoms are common in MS?

Answer 62

Feelings of depression or anger related to the unpredictability of the disease and life adjustments.

Question 63

Which cognitive functions are often affected by MS?

Answer 63

- Information processing - Memory - Attention and concentration - Executive functions - Visuospatial abilities - Verbal fluency

Question 64

What urinary, digestive, and sexual symptoms are associated with MS?

Answer 64

- Constipation - Urinary frequency, urgency, and incontinence - Sexual dysfunction

Question 65

How can kidney damage occur in individuals with MS?

Answer 65

Kidney damage may result from abnormal reflexes impairing bladder emptying, leading to recurrent urinary tract infections.

Question 66

Why does sensitivity to heat affect people with MS?

Answer 66

Heat interferes with transmission along already impaired nerve fibers, worsening neurologic symptoms. This effect is temporary but can be intense.

Question 67

What types of pain are common in MS?

Answer 67

1. Ischemic muscle pain due to rigidity and spasticity 2. Pain from abnormal postures and altered gait 3. Trigeminal neuralgia 4. Dysesthesia, an abnormal burning pain from non-painful stimuli like touch

Question 68

What are seizures in MS caused by, and how common are they?

Answer 68

Seizures result from abnormal electrical discharges in injured or scarred brain areas. They occur in 2-5% of people with MS, slightly higher than the 3% incidence in the general population.

Question 69

What secondary symptoms of MS are particularly significant for massage therapists to address?

Answer 69

1. Fibrous contractures from low or poor usage of limbs 2. Poor circulation in bedridden patients, hypotonic/spastic muscles, or dependent edema 3. Back pain from altered gait or prolonged sitting 4. Degenerative joint changes from altered biomechanics 5. Compression and overuse syndromes (e.g., tendinitis from wheelchair or walker use)

Question 70

How can massage therapy benefit individuals with MS?

Answer 70

1. Minimize effects of fibrous contractures 2. Improve circulation in affected muscles 3. Alleviate back pain and address biomechanical stresses 4. Treat compression and overuse syndromes 5. Rehabilitate soft tissue injuries from frequent falls

Question 71

What is Clinically Isolated Syndrome (CIS)?

Answer 71

CIS is the first episode of neurologic symptoms caused by inflammation and demyelination in the CNS, lasting at least 24 hours. It is characteristic of MS but does not meet the criteria for diagnosis.

Question 72

What increases the likelihood of a second episode and MS diagnosis after CIS?

Answer 72

The presence of MS-like lesions on an MRI indicates a high likelihood of a second episode and diagnosis of relapsing-remitting MS (RRMS).

Question 73

What is relapsing-remitting MS (RRMS)?

Answer 73

RRMS is the most common MS type, with defined exacerbations followed by partial or complete remissions. Approximately 85% of people with MS are initially diagnosed with this type.

Question 74

What is secondary progressive MS (SPMS)?

Answer 74

SPMS follows RRMS and involves progressive worsening of neurologic function and accumulation of disability over time.

Question 75

What is primary progressive MS (PPMS)?

Answer 75

PPMS involves worsening neurologic function and disability from symptom onset without early relapses or remissions, accounting for approximately 15% of MS diagnoses.

Question 76

What is Amyotrophic Lateral Sclerosis (ALS)?

Answer 76

ALS, also known as Lou Gehrig's disease, is a degenerative motor neuron disease leading to muscle weakness, paralysis, and the inability to swallow, speak, and breathe.

Question 77

What is the prognosis for ALS?

Answer 77

There is no cure, and 80% of people with ALS die within two to five years of diagnosis.

Question 78

What factors contribute to the degeneration of motor neurons in ALS?

Answer 78

1. Faulty protein transport in nerve fibers 2. Faulty apoptosis 3. Mitochondrial dysfunction 4. Excitotoxicity from excess glutamate 5. Neuroinflammation

Question 79

What are the suspected causes of ALS?

Answer 79

ALS likely results from interactions between genetic and environmental factors, including smoking, exposure to neurotoxins, heavy metals, military jobs, and concussions.

Question 80

What is the difference between familial and sporadic ALS?

Answer 80

- Familial ALS: Accounts for less than 10% of cases, with a 50% chance of inheritance per child. - Sporadic ALS: Over 90% of cases, mostly with underlying genetic susceptibility, affecting twice as many males as females.

Question 81

How is ALS diagnosed?

Answer 81

ALS is diagnosed by eliminating other diseases using tests like blood/urine studies, EMG, NCV, MRI, muscle/nerve function tests, pulmonary function test (FVC), and genetic testing.

Question 82

What are some early symptoms of ALS?

Answer 82

Tripping, dropping things, difficulty with fine motor tasks, slurred or "thick" speech, muscle cramping, weakness, and twitching.

Question 83

What is spinal/limb onset ALS, and which areas are usually affected first?

Answer 83

It is the most common ALS type, where symptoms begin in either the arms or legs but not both.

Question 84

What are the lower limb symptoms of spinal/limb onset ALS?

Answer 84

Stumbling, tripping, difficulty running, and foot drop.

Question 85

What are the upper limb symptoms of spinal/limb onset ALS?

Answer 85

Decreased finger dexterity, cramping in the arm or hand, weaker hands, and arm/hand stiffness.

Question 86

What symptoms indicate lower motor neuron (LMN) degeneration in ALS?

Answer 86

Muscle weakness and atrophy, fasciculations, cramps, hyporeflexia, flaccidity, dysphagia, dysarthria, and dyspnea at rest.

Question 87

What symptoms indicate upper motor neuron (UMN) degeneration in ALS?

Answer 87

Muscle stiffness, hyperreflexia, and emotional lability.

Question 88

What is bulbar onset ALS, and what percentage of patients does it affect?

Answer 88

Bulbar onset ALS affects 20-25% of patients and begins with symptoms like dysarthria, dysphagia, hypernasal speech, laryngospasm, and sialorrhea.

Question 89

How does bulbar onset ALS progression differ from spinal/limb onset?

Answer 89

Bulbar ALS progresses faster and often involves limb weakness later in the disease.

Question 90

What cognitive changes occur in ALS?

Answer 90

30-50% of patients develop cognitive impairment, and 15-20% develop ALS-FTD, which affects rational thought, impulse control, and personality.

Question 91

What are common autonomic symptoms in ALS?

Answer 91

Rarely orthostatic hypotension or dizziness but advanced cases may have blood pressure fluctuations and tachycardia.

Question 92

What are the general symptoms of ALS progression?

Answer 92

Dyspnea/apnea, dysphagia/aphagia, dysarthria/anarthria, muscle fatigue, weight loss, insomnia, excessive saliva, or dry mouth.

Question 93

What assistive devices are typically needed as ALS progresses?

Answer 93

Mobility devices, feeding tubes, mechanical ventilation, and speech assistive devices.

Question 94

What are the most common causes of death in ALS patients?

Answer 94

Aspiration pneumonia and respiratory insufficiency.

Question 95

What emotional challenges are common in ALS patients?

Answer 95

Depression and anticipatory grief about losing independence, changing social roles, missing activities, and facing death.

Question 96

What are the primary goals of ALS treatment?

Answer 96

To slow disease progression, provide comfort, and promote independence as long as possible.

Question 97

What strategies are used to combat weakness and fatigue in ALS patients?

Answer 97

Fall prevention strategies, energy conservation techniques, orthoses, and adaptive equipment.

Question 98

What is the average survival time for ALS patients, and how can it be extended?

Answer 98

Average survival is 3-5 years post-diagnosis, but longer survival (up to 10 years) is possible with care from multidisciplinary ALS clinics.

Question 99

How can massage therapy help ALS patients?

Answer 99

By addressing the effects of the disease in the body's soft tissues and providing comfort, especially in palliative and hospice phases.

Question 100

What medications are available for ALS treatment in Canada?

Answer 100

Two medications slow progression and can extend survival by 3-6 months; other medications manage disease effects.

Question 101

What are the key differences between MS and ALS?

Answer 101

MS: - Myelin destruction in CNS affects sensory and motor neurons. - Majority is exacerbation-remission type. - Affects females more. - Not terminal (shortens life by ~7 years). ALS: - Motor neuron disease affecting voluntary NS. - Diagnosed later in life (ages 40-70). - Inheritable. - Less common (~4,000 Canadians affected).