Multiple sclerosis physical examination: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
m (Bot: Removing from Primary care)
 
(31 intermediate revisions by 5 users not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
{{Template:Multiple sclerosis}}
{{Template:Multiple sclerosis}}
{{CMG}}; {{AE}} {{Fs}}


{{CMG}}
==Overview==
==Overview==
[[Physical examination]] of patients with multiple sclerosis is usually remarkable for [[lhermitte's sign]], [[spasticity]], increased [[reflexes]], [[internuclear ophthalmoplegia]], [[optic neuritis]], [[gait disturbance]], and [[urinary incontinence]].


==Physical examination==
==Physical Examination==


[[Image:Optokinetic nystagmus.gif|thumb|left|[[Pathologic nystagmus|Nystagmus]], characterised by involuntary eye movements, is one of many symptoms that can appear with MS]]
Physical examination of patients with multiple sclerosis is usually remarkable for:
Multiple sclerosis is difficult to [[diagnose]] in its early stages. In fact, a definite diagnosis cannot be made until other disease processes (differential diagnoses) have been ruled out and, in the case of relapsing-remitting MS, there is evidence of at least two [[anatomy|anatomically]] separate demyelinating events separated by at least thirty days. In the case of primary progressive, a slow progression of signs and symptoms over at least 6 months is required.


Historically, different criteria were used and the Schumacher and Poser criteria were both popular. Currently, the [[McDonald criteria]] represent international efforts to standardize the diagnosis of MS using clinical, laboratory and radiologic data.<ref>McDonald WI; Compston A; Edan G; Goodkin D; Hartung HP; Lublin FD; McFarland HF; Paty DW; Polman CH; Reingold SC; Sandberg-Wollheim M; Sibley W; Thompson A; van den Noort S; Weinshenker BY; Wolinsky JS. ''Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis.'' Ann Neurol 2001 Jul;50(1):121-7 PMID 11456302</ref>
===Appearance of the Patient===
*[[Gait abnormality|Gait]] and balance disturbance: Involvement of [[cerebellar]] tracts can cause [[Gait]] and balance problems in multiple sclerotic patients.<ref name="pmid25573524">{{cite journal |vauthors=Rinker JR, Salter AR, Walker H, Amara A, Meador W, Cutter GR |title=Prevalence and characteristics of tremor in the NARCOMS multiple sclerosis registry: a cross-sectional survey |journal=BMJ Open |volume=5 |issue=1 |pages=e006714 |date=January 2015 |pmid=25573524 |pmc=4289717 |doi=10.1136/bmjopen-2014-006714 |url=}}</ref>  


Clinical data alone may be sufficient for a diagnosis of MS.  If an individual has suffered two separate episodes of neurologic symptoms characteristic of MS, and the individual also has consistent abnormalities on [[physical examination]], a diagnosis of MS can be made with no further testing. Since some people with MS seek medical attention after only one attack, other testing may hasten the diagnosis and allow earlier initiation of therapy.
===Vital Signs===
* We may see positional change in [[blood pressure]] and [[heart rate]] due to [[autonomic dysfunction]].<ref name="AcevedoNava2000">{{cite journal|last1=Acevedo|first1=A. R.|last2=Nava|first2=C.|last3=Arriada|first3=N.|last4=Violante|first4=A.|last5=Corona|first5=T.|title=Cardiovascular dysfunction inmultiple sclerosis|journal=Acta Neurologica Scandinavica|volume=101|issue=2|year=2000|pages=85–88|issn=0001-6314|doi=10.1034/j.1600-0404.2000.101002085.x}}</ref>


===Skin===
* Skin examination of patients with multiple sclerosis is usually normal.
===HEENT===
* [[Internuclear ophthalmoplegia]]: [[Internuclear ophthalmoplegia]] ([[Internuclear ophthalmoplegia|INO]]) is defined as a [[Gaze palsy|gaze problem]]. Lesions in [[medial longitudinal fasciculus]] in [[brain stem]] are known to be the cause of [[Internuclear ophthalmoplegia|INO]]. The signs of [[Internuclear ophthalmoplegia|INO]] are difficulty with [[Adduction|adducting]] in lateral gaze.<ref name="pmid15136670">{{cite journal |vauthors=Kim JS |title=Internuclear ophthalmoplegia as an isolated or predominant symptom of brainstem infarction |journal=Neurology |volume=62 |issue=9 |pages=1491–6 |date=May 2004 |pmid=15136670 |doi= |url=}}</ref><ref name="pmid18678831">{{cite journal |vauthors=Mills DA, Frohman TC, Davis SL, Salter AR, McClure S, Beatty I, Shah A, Galetta S, Eggenberger E, Zee DS, Frohman EM |title=Break in binocular fusion during head turning in MS patients with INO |journal=Neurology |volume=71 |issue=6 |pages=458–60 |date=August 2008 |pmid=18678831 |doi=10.1212/01.wnl.0000324423.08538.dd |url=}}</ref><ref name="pmid11552000">{{cite journal |vauthors=Frohman EM, Zhang H, Kramer PD, Fleckenstein J, Hawker K, Racke MK, Frohman TC |title=MRI characteristics of the MLF in MS patients with chronic internuclear ophthalmoparesis |journal=Neurology |volume=57 |issue=5 |pages=762–8 |date=September 2001 |pmid=11552000 |doi= |url=}}</ref>


* [[Optic neuritis|Optic Neuritis]]: [[Optic neuritis]] can be the first [[Medical sign|sign]] of multiple sclerosis, especially when it’s accompanied by [[white matter]] [[MRI]] [[lesions]].<ref>{{cite journal |author=Beck RW, Trobe JD |title=What we have learned from the Optic Neuritis Treatment Trial|journal=Ophthalmology |volume=102 |issue=10 |pages=1504-8 |year=1995 |pmid=9097798}}</ref><ref>{{cite journal |author= |title=The 5-year risk of MS after optic neuritis: experience of the optic neuritis treatment trial. 1997 |journal=Neurology |volume=57|issue=12 Suppl 5 |pages=S36-45 |year=2001 |pmid=11902594}}</ref>
* [[Nystagmus]]
* [[Diplopia CT|Diplopia]]
* [[Ophthalmoplegia|Extra-ocular movements may be abnormal]]
* [[Facial pain]]
* [[Hearing loss]]


===Neck===
* [[Neck]] examination of patients with multiple sclerosis is usually normal.
===Lungs===
* [[Pulmonary]] examination of patients with multiple sclerosis is usually normal.
===Heart===
* [[Cardiovascular]] examination of patients with multiple sclerosis is usually normal.
===Abdomen===
* [[Abdomen|Abdominal]] examination of patients with multiple sclerosis is usually normal.
===Back===
* Back examination of patients with multiple sclerosis is usually normal.
===Genitourinary===
* [[Urinary incontinence]]


* [[Erectile dysfunction]]
* [[Vaginal dryness]]


Some signs are -
===Neuromuscular===
=== Internuclear ophthalmoplegia ===
* [[Lhermitte's sign]]: About 25-40% of MS patients experience [[Lhermitte's sign|lhermitte’s sign]] as an electrical shock sensation going downward from [[neck]] when the patients [[neck]] bends forward. [[Lhermitte's sign]] can correlate with [[MRI]] abnormalities of caudal [[medulla]] or [[Cervical spinal nerve|cervical]] [[dorsal columns]].<ref>{{cite journal |author=Gutrecht JA, Zamani AA, Slagado ED|title=Anatomic-radiologic basis of Lhermitte's sign in multiple sclerosis |journal=Arch. Neurol. |volume=50 |issue=8 |pages=849-51|year=1993 |pmid=8352672 |doi=}}</ref><ref>{{cite journal |author=Al-Araji AH, Oger J |title=Reappraisal of Lhermitte's sign in multiple sclerosis |journal=Mult. Scler.|volume=11 |issue=4 |pages=398-402 |year=2005 |pmid=16042221 |doi=}}</ref><ref>{{cite journal |author=Sandyk R, Dann LC|title=Resolution of Lhermitte's sign in multiple sclerosis by treatment with weak electromagnetic fields |journal=Int. J. Neurosci.|volume=81 |issue=3-4 |pages=215-24 |year=1995 |pmid=7628912 |doi=}}</ref><ref>{{cite journal |author=Kanchandani R, Howe JG|title=Lhermitte's sign in multiple sclerosis: a clinical survey and review of the literature |journal=J. Neurol. Neurosurg. Psychiatr. |volume=45 |issue=4 |pages=308-12 |year=1982 |pmid=7077340 |doi=}}</ref><ref name="pmid17868019">{{cite journal |vauthors=Boissy AR, Cohen JA |title=Multiple sclerosis symptom management |journal=Expert Rev Neurother |volume=7 |issue=9 |pages=1213–22 |date=September 2007 |pmid=17868019 |doi=10.1586/14737175.7.9.1213 |url=}}</ref>
* [[Spasticity]] (damage to the [[upper motor neurons]] and decrease inhibition of [[lower motor neurons]] in [[MS]] can increase [[muscle tone]] and [[Muscle rigidity|rigidity]] in 75% of [[MS]] patients).


[[Image:Internuclear ophthalmoplegia.jpg|thumb|right|180px|''Schematic demonstrating right internuclear ophthalmoplegia, caused by injury of the right [[medial longitudinal fasciculus]] ]]
*Patient is usually oriented to persons, place, and time
{{Main|Internuclear ophthalmoplegia}}
* [[Hyperreflexia]]
* Positive (abnormal) [[Babinski's Reflex|Babinski]]
* Proximal/distal [[muscle weakness]] unilaterally/bilaterally
*Unilateral or bilateral [[sensory loss]] in the [[Upper extremity|upper]]/[[lower extremity]]
*[[Gait abnormality|Abnormal gait]]
*Positive [[Trendelenburg's sign|Trendelenburg sign]]
*[[Tremor]]  
*[[Dysmetria]]


Internuclear ophthalmoplegia is a disorder of conjugate lateral gaze.  The affected eye shows impairment of [[adduction]].  The partner eye diverges from the affected eye during abduction, producing [[diplopia]]; during extreme abduction, compensatory[[nystagmus]] can be seen in the partner eye. Diplopia means double vision while nystagmus is involuntary [[eye movement]]characterized by alternating [[smooth pursuit]] in one direction and a [[saccadic movement]] in the other direction.
===Extremities===
*[[Tremor]]  
*[[Muscle spasm]]
*[[Weakness]]


Internuclear ophthalmoplegia occurs when MS affects a part of the [[brain stem]] called the [[medial longitudinal fasciculus]], which is responsible for communication between the two eyes by connecting the [[abducens nucleus]] of one side to the [[oculomotor nucleus]] of the opposite side. This results in the failure of the [[medial rectus muscle]] to contract appropriately, so that the eyes do not move equally (called disconjugate gaze).


===Optic neuritis===
Up to 50% of patients with MS will develop an episode of optic neuritis, and 20% of the time optic neuritis is the presenting  sign of MS. The presence of demyelinating white matter lesions on brain [[MRI]] at the time of presentation of optic neuritis is the strongest predictor for developing clinically definite MS. Almost half of the patients with optic neuritis have white matter lesions consistent with multiple sclerosis.
At five years follow-up, the overall risk of developing MS is 30%, with or without MRI lesions. Patients with a normal MRI still develop MS (16%), but at a lower rate compared to those patients with three or more MRI lesions (51%). From the other perspective, however, almost half (44%) of patients with any demyelinating lesions on MRI at presentation will not have developed MS ten years later. <ref>{{cite journal |author=Beck RW, Trobe JD |title=What we have learned from the Optic Neuritis Treatment Trial|journal=Ophthalmology |volume=102 |issue=10 |pages=1504-8 |year=1995 |pmid=9097798}}</ref><ref>{{cite journal |author= |title=The 5-year risk of MS after optic neuritis: experience of the optic neuritis treatment trial. 1997 |journal=Neurology |volume=57|issue=12 Suppl 5 |pages=S36-45 |year=2001 |pmid=11902594}}</ref>
==== Lhermitte's sign ====
[[Lhermitte's sign]] is an electrical sensation that runs down the back and into the limbs, and is produced by bending the [[neck]]forward. The sign suggests a lesion of the dorsal columns of the [[cervical]] cord or of the caudal [[Medulla oblongata|medulla]]; correlating significantly with cervical [[MRI]] abnormalities.<ref> {{cite journal |author=Gutrecht JA, Zamani AA, Slagado ED|title=Anatomic-radiologic basis of Lhermitte's sign in multiple sclerosis |journal=Arch. Neurol. |volume=50 |issue=8 |pages=849-51|year=1993 |pmid=8352672 |doi=}}</ref>
Between 25 and 40% of MS patients report having Lhermitte's sign during the course of their illness.
<ref>{{cite journal |author=Al-Araji AH, Oger J |title=Reappraisal of Lhermitte's sign in multiple sclerosis |journal=Mult. Scler.|volume=11 |issue=4 |pages=398-402 |year=2005 |pmid=16042221 |doi=}}</ref><ref>{{cite journal |author=Sandyk R, Dann LC|title=Resolution of Lhermitte's sign in multiple sclerosis by treatment with weak electromagnetic fields |journal=Int. J. Neurosci.|volume=81 |issue=3-4 |pages=215-24 |year=1995 |pmid=7628912 |doi=}}</ref><ref>{{cite journal |author=Kanchandani R, Howe JG|title=Lhermitte's sign in multiple sclerosis: a clinical survey and review of the literature |journal=J. Neurol. Neurosurg. Psychiatr. |volume=45 |issue=4 |pages=308-12 |year=1982 |pmid=7077340 |doi=}}</ref>  [[Lhermitte's sign]] is considered a classic MS finding, but it can be seen in several other conditions as well.


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Neurology]]
[[Category:Orthopedics]]
[[Category:Rheumatology]]

Latest revision as of 22:48, 29 July 2020

Multiple sclerosis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Multiple sclerosis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography or Ultrasound

CT Scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Alternative Therapies

Primary Prevention

Secondary Prevention

Tertiary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Multiple sclerosis physical examination On the Web

Most recent articles

cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Multiple sclerosis physical examination

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Multiple sclerosis physical examination

CDC on Multiple sclerosis physical examination

Multiple sclerosis physical examination in the news

Blogs on Multiple sclerosis physical examination

Directions to Hospitals Treating Multiple sclerosis

Risk calculators and risk factors for Multiple sclerosis physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D.

Overview

Physical examination of patients with multiple sclerosis is usually remarkable for lhermitte's sign, spasticity, increased reflexes, internuclear ophthalmoplegia, optic neuritis, gait disturbance, and urinary incontinence.

Physical Examination

Physical examination of patients with multiple sclerosis is usually remarkable for:

Appearance of the Patient

  • Gait and balance disturbance: Involvement of cerebellar tracts can cause Gait and balance problems in multiple sclerotic patients.[1]

Vital Signs

Skin

  • Skin examination of patients with multiple sclerosis is usually normal.

HEENT

Neck

  • Neck examination of patients with multiple sclerosis is usually normal.

Lungs

  • Pulmonary examination of patients with multiple sclerosis is usually normal.

Heart

  • Cardiovascular examination of patients with multiple sclerosis is usually normal.

Abdomen

  • Abdominal examination of patients with multiple sclerosis is usually normal.

Back

  • Back examination of patients with multiple sclerosis is usually normal.

Genitourinary

Neuromuscular

Extremities


References

  1. ↑ Rinker JR, Salter AR, Walker H, Amara A, Meador W, Cutter GR (January 2015). "Prevalence and characteristics of tremor in the NARCOMS multiple sclerosis registry: a cross-sectional survey". BMJ Open. 5 (1): e006714. doi:10.1136/bmjopen-2014-006714. PMC 4289717. PMID 25573524.
  2. ↑ Acevedo, A. R.; Nava, C.; Arriada, N.; Violante, A.; Corona, T. (2000). "Cardiovascular dysfunction inmultiple sclerosis". Acta Neurologica Scandinavica. 101 (2): 85–88. doi:10.1034/j.1600-0404.2000.101002085.x. ISSN 0001-6314.
  3. ↑ Kim JS (May 2004). "Internuclear ophthalmoplegia as an isolated or predominant symptom of brainstem infarction". Neurology. 62 (9): 1491–6. PMID 15136670.
  4. ↑ Mills DA, Frohman TC, Davis SL, Salter AR, McClure S, Beatty I, Shah A, Galetta S, Eggenberger E, Zee DS, Frohman EM (August 2008). "Break in binocular fusion during head turning in MS patients with INO". Neurology. 71 (6): 458–60. doi:10.1212/01.wnl.0000324423.08538.dd. PMID 18678831.
  5. ↑ Frohman EM, Zhang H, Kramer PD, Fleckenstein J, Hawker K, Racke MK, Frohman TC (September 2001). "MRI characteristics of the MLF in MS patients with chronic internuclear ophthalmoparesis". Neurology. 57 (5): 762–8. PMID 11552000.
  6. ↑ Beck RW, Trobe JD (1995). "What we have learned from the Optic Neuritis Treatment Trial". Ophthalmology. 102 (10): 1504–8. PMID 9097798.
  7. ↑ "The 5-year risk of MS after optic neuritis: experience of the optic neuritis treatment trial. 1997". Neurology. 57 (12 Suppl 5): S36–45. 2001. PMID 11902594.
  8. ↑ Gutrecht JA, Zamani AA, Slagado ED (1993). "Anatomic-radiologic basis of Lhermitte's sign in multiple sclerosis". Arch. Neurol. 50 (8): 849–51. PMID 8352672.
  9. ↑ Al-Araji AH, Oger J (2005). "Reappraisal of Lhermitte's sign in multiple sclerosis". Mult. Scler. 11 (4): 398–402. PMID 16042221.
  10. ↑ Sandyk R, Dann LC (1995). "Resolution of Lhermitte's sign in multiple sclerosis by treatment with weak electromagnetic fields". Int. J. Neurosci. 81 (3–4): 215–24. PMID 7628912.
  11. ↑ Kanchandani R, Howe JG (1982). "Lhermitte's sign in multiple sclerosis: a clinical survey and review of the literature". J. Neurol. Neurosurg. Psychiatr. 45 (4): 308–12. PMID 7077340.
  12. ↑ Boissy AR, Cohen JA (September 2007). "Multiple sclerosis symptom management". Expert Rev Neurother. 7 (9): 1213–22. doi:10.1586/14737175.7.9.1213. PMID 17868019.

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Multiple_sclerosis_physical_examination&oldid=1640876"