Neurological Assessment

History: Patients with MS initially have a difficult time describing their symptoms, as the symptoms appear and subsequently resolve. The sine qua non of MS is that the symptoms are separated in time and space. These symptoms affect different parts of the body at different times. Patients may present with paresthesias of a hand that resolves, followed in a couple of months by weakness in a leg or visual disturbances (eg, diplopia). Patients frequently do not bring these complaints to their doctors because they resolve. Eventually, the resolution of the neurologic deficits is incomplete or their occurrence is too frequent, and the diagnostic dilemma begins.

Physical: Patients with MS may demonstrate various physical findings. These findings may change from examination to examination, depending on the pattern of disease and whether or not the patient is having an exacerbation or relapse.

  • A thorough physical examination, including neurologic assessment, is critical to determine deficits. All systems must be addressed, including motor, sensory, and musculoskeletal, as well as reflexes, tone, coordination, bulbar, vision, gait, and skin.
    • Some of the findings may include localized weakness, focal sensory disturbances (with persistent decrease of proprioception and vibration), hyperreactive reflexes with clonus in the ankles and upgoing toes, and increased tone or stiffness in the extremities with velocity-dependent passive range of motion (PROM).

       

    • Additional signs may include the following: nystagmus, internuclear ophthalmoplegia, visual disturbances, pallor of the optic disc, poor coordination of upper and lower extremity movements, and wide-based gait with inability to tandem walk.

       

    • Secondary problems may include skin breakdown and musculoskeletal complaints. Skin should be examined in all nonambulatory patients, and the musculoskeletal system must be addressed as appropriate.
  • Based on the findings, a patient may be rated according to several clinical scales. The most widely accepted clinical rating scale is the 10-point Kurtzke Expanded Disability Status Scale (EDSS), developed originally in 1955 as the Disability Status Scale (DSS). See Table 1.

Table 1. Expanded Disability Status Scale
Grade
Definition
0
Normal neurologic examination (all grade 0 in FS, cerebral grade 1 acceptable)
1.0
No disability, minimal signs in 1 FS (ie, grade 1 excluding cerebral grade 1)
1.5
No disability, minimal signs in more than 1 FS (more than 1 grade 1 excluding cerebral grade 1)
2.0
Minimal disability in 1 FS (1 FS grade 2, others 0 or 1)
2.5
Minimal disability in 2 FS (2 FS grade 2, others 0 or 1)
3.0
Moderate disability in 1 FS (1 FS grade 3, others 0 or 1) or mild disability in 3 or 4 FS (3/4 FS grade 2, others 0 or 1) though fully ambulatory
3.5
Fully ambulatory but withmoderate disability in 1 FS (1 grade 3) and 1 or 2 FS grade 2, or 2 FS grade 3, or 5 FS grade 2 (others 0 or 1)
4.0
Fully ambulatory without aid; self-sufficient; up and about some 12 h/d despite relatively severe disability, consisting of 1 FS grade 4 (others 0 or 1) or combinations of lesser grades exceeding limits of previous steps; able to walk without aid or rest approximately 500 m
4.5
Fully ambulatory without aid; up and about much of the day; able to work a full day; may otherwise have some limitation of full activity or require minimal assistance; characterized by relatively severe disability, usually consisting of 1 FS grade 4 (others 0 or 1) or combinations of lesser grades exceeding limits of previous steps; able to walk without aid or rest for approximately 300 m
5.0
Ambulatory without aid or rest for approximately 200 m; disability severe enough to impair full daily activities (eg, to work full day without special provisions; usual FS equivalents are 1 grade 5 alone, others 0 or 1; or combinations of lesser grades usually exceeding specifications for step 4.0)
5.5
Ambulatory without aid or rest for approximately 100 m; disability severe enough to preclude full daily activities (usual FS equivalents are 1 grade 5 alone; others 0 or 1; or combinations of lesser grades usually exceeding those for step 4.0)
6.0
Intermittent or unilateral constant assistance (cane, crutch, or brace) required to walk approximately 100 m with or without resting (usual FS equivalents are combinations with more than 2 FS grade 3+)
6.5
Constant bilateral assistance (canes, crutches, or braces) required to walk approximately 20 m without resting (usual FS equivalents are combinations with more than 2 FS grade 3+)
7.0
Unable to walk beyond approximately 5 m even with aid; essentially restricted to wheelchair; wheels self in standard wheelchair and transfers alone; up and about approximately 12 h/d (usual FS equivalents are combinations with more than 1 FS grade 4+; very rarely, pyramidal grade 5 alone)
7.5
Unable to take more than a few steps; restricted to wheelchair; may need aid in transfer; wheels self but cannot carry on in standard wheelchair a full day; may require motorized wheelchair (usual FS equivalents are combinations with more than 1 FS grade 4+)
8.0
Essentially restricted to bed or chair or perambulated in wheelchair but may be out of bed itself much of the day, retains many self-care functions; generally has effective use of arms (usual FS equivalents are combinations, generally grade 4+ in several systems)
8.5
Essentially restricted to bed much of the day; has some effective use of arms; retains some self-care functions (usual FS equivalents are combinations, generally 4+ in several systems)
9.0
Helpless bed patient; can communicate and eat (usual FS equivalents are combinations, mostly grade 4+)
9.5
Totally helpless bed patient; unable to communicate effectively or eat/swallow (usual FS equivalents are combinations, almost all grade 4+)
10.0
Death due to MS

 

  • These criteria have been revised over the years and remain the standard scale by which patients may be compared. The scale ranges from 0-10 in 0.5 increments. The scores from grades 0-4 are derived from Functional System (FS) scales that evaluate dysfunction in 8 neurologic systems, including pyramidal, cerebellar, brainstem, sensory, bladder and bowel, vision, cerebral, and "other."
    • Advantages of this scale are that it is widely used clinically, is easy to administer, and requires no special equipment.
    • Limitations of the EDSS are that it (1) is heavily dependent on mobility; (2) is somewhat subjective in certain areas (eg, bowel and bladder function); (3) is insensitive to small changes; and (4) does not present an accurate picture of the patientís cognitive abilities and functional abilities in performing activities of daily living (ADL).
  • Additional useful scales include the Ambulation Index, which is based solely on the ability to walk 25 feet, and the Scripps Neurologic Rating Scale, developed by Sipe in 1984. This scale has a finer incremental scale than the Kurtzke scale, but it is not widely accepted and does not consider cognitive involvement.

Causes: The cause of MS is not known. Both environmental factors and a genetic predisposition, which affect an individual's chance of acquiring the disease, appear to play a role.

  • Identical twin studies have shown up to a 60% risk of one twin's developing MS if the other is affected. The first-degree family members (children or siblings) of people affected with MS have a 3-5% risk of developing MS.
  • Geography is clearly an important factor in the equation. Persons from the equatorial regions of the world have a much lower incidence than those in the southernmost and northernmost regions. If an individual lives in an area with low incidence of MS until age 15 years, that person's risk is low; however, if an individual lives in an area with a high incidence until age 15 years, the risk of developing MS is high. The interesting point is that, if that person moves to an area of high incidence from an area of low incidence after age 15 years, the person does not have increased risk beyond the area from which he or she moved. It appears that whatever environmental factor is involved, it must exert its effect in early childhood. Certain ethnic groups (eg, Eskimos), despite living in areas of higher incidence, do not have high incidence of MS. Therefore, the exact role played by geography versus genetics in incidence of the disease is not clear.
 

 

                  

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Veronica Davidson/ mommyv : founder and owner of Friends With MS.com.   If your interested in information about MS please  Email me!  Or you can check out our yahoo newsgroup and read all of our previous postings.  All web links are on the Home page!