Multiple sclerosis physical examination

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

Overview

Physical examination of patients with multiple sclerosis (MS) may demonstrate objective abnormalities involving the visual, brainstem, pyramidal, cerebellar, sensory, gait, cognitive, and autonomic systems. Common findings include internuclear ophthalmoplegia, optic nerve involvement/optic neuritis, nystagmus, spasticity, hyperreflexia, pathological plantar responses, weakness, sensory deficits, tremor, dysmetria, Lhermitte's sign, and gait or balance impairment.

Physical Examination

Physical examination of patients with multiple sclerosis should be systematic and should document objective neurological abnormalities, functional impairment, and relevant non-neurological findings.

Appearance of the Patient

• Gait and balance disturbance: Observe gait initiation, base, stride, turning, foot clearance, arm swing, use of assistive devices, and ability to perform tandem gait. Gait impairment may result from pyramidal weakness or spasticity, cerebellar dysfunction, sensory impairment, vestibular dysfunction, or combinations of these abnormalities.
• Falls and postural instability should be assessed when clinically indicated.
• The Timed 25-Foot Walk Test (T25FW) may be used to quantify ambulatory performance and for longitudinal assessment of walking function in multiple sclerosis.

Vital Signs

• Routine vital signs are generally normal unless there is comorbidity or associated autonomic dysfunction.
• Blood pressure and heart rate should be assessed as clinically indicated. Symptoms suggestive of orthostatic intolerance may warrant assessment of orthostatic vital signs.

Skin

• Skin examination of patients with multiple sclerosis is usually normal.
• Assess for pressure injury, skin breakdown, or other complications in patients with significant immobility or impaired sensation.

HEENT

• Internuclear ophthalmoplegia (INO): INO results from involvement of the medial longitudinal fasciculus and is characterized by impaired adduction of the ipsilateral eye during lateral gaze, often accompanied by abducting nystagmus of the contralateral eye. Ocular alignment and extraocular movements should be examined systematically.

• Optic neuritis/optic nerve involvement:
  • Assess visual acuity in each eye separately.
  • Assess color vision when appropriate using a standardized color-vision test.
  • Assess the pupillary light reflex and look for a relative afferent pupillary defect (RAPD) when unilateral or asymmetric optic nerve dysfunction is suspected.
  • Assess visual fields when clinically indicated.
  • Perform fundoscopy to assess the optic disc and retina. A normal funduscopic examination does not exclude retrobulbar optic neuritis.
• Nystagmus
• Diplopia
• Extra-ocular movements may be abnormal

Neck

• Neck examination is often normal.
• Assess cervical range of motion and neurological signs when Lhermitte's sign or suspected cervical spinal cord involvement is present.

Lungs

• Pulmonary examination is usually normal.
• Assess respiratory function when there is advanced disability, severe weakness, bulbar dysfunction, or concern for respiratory compromise.

Heart

• Cardiovascular examination is usually normal.
• Evaluate for orthostatic symptoms or cardiovascular comorbidity when clinically indicated.

Abdomen

• Abdominal examination is usually normal.
• Abdominal examination may be relevant when evaluating bowel dysfunction, constipation, abdominal pain, or other abdominal symptoms.

Back

• Back examination is usually normal.
• Assess the cervical and thoracic spine when spinal cord symptoms, sensory levels, weakness, or Lhermitte's sign are present.

Neuromuscular

• Lhermitte's sign: An electric-shock-like sensation radiating down the spine or into the limbs may be reported or elicited with neck flexion. It is associated with cervical spinal cord or cervicomedullary involvement and is a supportive clinical finding rather than a specific diagnostic sign.

• Spasticity: Examine passive range of motion and velocity-dependent increase in muscle tone, particularly in the lower extremities. Standardized scales such as the Modified Ashworth Scale may be used when quantitative documentation of spasticity is required.

• Muscle strength should be assessed systematically and documented using a standardized grading system such as the Medical Research Council (MRC) scale.
• Hyperreflexia
• Clonus
• Positive (abnormal) Babinski response or other extensor plantar response
• Proximal and/or distal muscle weakness, unilateral or bilateral
• Sensory loss involving the face, trunk, or upper/lower extremities
• Assess superficial and deep sensation, including light touch, pinprick, vibration, and proprioception as clinically appropriate.
• Assess for a sensory level when spinal cord involvement is suspected.
• Abnormal gait
• Positive Trendelenburg sign when hip abductor weakness is present
• Tremor
• Dysmetria
• Dysdiadochokinesia or impaired rapid alternating movements
• Finger-to-nose and heel-to-shin testing should be performed when cerebellar dysfunction is suspected.
• Assess for intention tremor, truncal ataxia, and impaired coordination.

Cognitive and Behavioral Examination

• Cognitive impairment may occur in multiple sclerosis and may not be detected by routine orientation testing alone.
• Assess attention, processing speed, executive function, memory, language, and visuospatial function when clinically indicated.
• The Symbol Digit Modalities Test (SDMT) or another validated cognitive screening instrument may be used for baseline and longitudinal assessment in clinically stable patients with multiple sclerosis. The National Multiple Sclerosis Society recommendations were endorsed by the Consortium of Multiple Sclerosis Centers and the International Multiple Sclerosis Cognition Society.

Functional Assessment

• Timed 25-Foot Walk Test may be used to quantify walking performance and for longitudinal assessment.
• The Nine-Hole Peg Test may be used to assess upper-extremity manual dexterity when a standardized functional assessment is required.
• The Expanded Disability Status Scale (EDSS) may be used to quantify overall neurological disability. EDSS incorporates standardized assessment of neurological functional systems and ambulation and should complement, rather than replace, a detailed neurological examination.