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==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==


Physical examination of patients with multiple sclerosis is usually remarkable for:
Physical examination of patients with multiple sclerosis is usually remarkable for:
==== Lhermitte's Sign ====
About 25-40% of MS patients experience lhermitte’s sign as an electrical shock sensation going downward from neck when the patients neck bends forward. Lhermitte sign can correlate with MRI abnormalities of caudal medulla or 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>


==== Spasticity and increased reflexes ====
===Appearance of the Patient===
Damage to the upper motor neurons and decrease inhibition of lower motor neurons in [[MS]] can increase muscle tone and rigidity in 75% of [[MS]] patients.<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>
*[[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>  


==== Internuclear Ophthalmoplegia ====
===Vital Signs===
Internuclear ophtalmoplegia (INO) is defined as a gaze problem. Lesions in medial longitudinal fasciculus in brain stem are known to be the cause of INO.
* 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>


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.
===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]]
 
===Neuromuscular===
* [[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).
 
*Patient is usually oriented to persons, place, and time
* [[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]]
 
===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====
Optic neuritis can be the first sign of multiple sclerosis especially when it’s accompanied by white matter MRI lesions and is very common among these patients.<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>


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
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[[Category:Primary care]]
[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Orthopedics]]
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[[Category:Rheumatology]]
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Latest revision as of 22:48, 29 July 2020

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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.

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