4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation

ABPMR Physical Medicine and Rehabilitation Board Exam Study Guide Exam

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1 Chapter 1: Introduction & Exam Overview

1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown

2 Chapter 2: Musculoskeletal Medicine

2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns

3 Chapter 3: Spinal Cord Injury Rehabilitation

3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications

4 Chapter 4: Stroke & Neuromuscular Rehabilitation

4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder

5 Chapter 5: Electrodiagnostics (EMG/NCS)

5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies

6 Chapter 6: Traumatic Brain Injury

6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols

7 Chapter 7: Chronic Pain & Interventional Spine

7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy

8 Chapter 8: Amputee Rehabilitation & Prosthetics

8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain

9 Chapter 9: Pediatric Rehabilitation

9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders

10 Chapter 10: Prosthetics, Orthotics & Assistive Technology

10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping

11 Chapter 11: Medical Rehabilitation & Outcomes

11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation

12 Chapter 12: Cardiopulmonary Rehabilitation

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management

13 Chapter 13: Foundational Rehabilitation Concepts

13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation

Key Takeaways Explain This Topic AI

Multiple sclerosis is a demyelinating autoimmune disease of the CNS with relapsing-remitting (~85% at onset) and progressive phenotypes; MRI demonstrates periventricular, juxtacortical, infratentorial, and spinal cord plaques dissemination in time and space.

Disease-modifying therapies (interferons, glatiramer, natalizumab, anti-CD20 monoclonals like rituximab/ocrelizumab, sphingosine-1-phosphate modulators) reduce relapse rate and MRI lesion burden; rehab complements, but does not replace, disease modification.

High-yield disabling symptoms include fatigue, heat sensitivity (Uhthoff phenomenon), spasticity, impaired mobility, bladder/bowel dysfunction, cognitive impairment, and optic neuritis; interdisciplinary symptom management is central.

Exercise in MS is safe and beneficial—improving fatigue, mobility, quality of life, and cognition—delivered as moderate aerobic and resistance training with heat-management strategies.

Last updated: July 2026

Multiple Sclerosis & Demyelinating Disease Rehabilitation

Multiple sclerosis (MS) is a recurrent Domain C neurological condition. The physiatrist manages disability across relapsing and progressive phenotypes through interdisciplinary symptom control, exercise, and assistive technology while disease-modifying therapy is handled by neurology.

Diagnosis & Phenotypes

MS is diagnosed by dissemination of CNS demyelinating lesions in space and time , per McDonald criteria, using MRI (periventricular, juxtacortical, infratentorial, spinal cord plaques) and CSF (oligoclonal bands) or typical clinical attacks. Phenotypes:

Phenotype Proportion Course

Relapsing-remitting (RRMS) ~85% at onset Attacks (relapses) with partial/full recovery.

Secondary progressive (SPMS) Many RRMS evolve to SPMS Steady progression with or without relapses.

Primary progressive (PPMS) ~10-15% Progression from onset without relapses.

Clinically isolated syndrome (CIS) First attack May or may not progress to MS.

Disease-Modifying Therapy (Neurology-Led)

Injectables : interferon beta, glatiramer acetate.

Monoclonal antibodies : natalizumab (anti-alpha-4 integrin; PML risk with JC virus), ocrelizumab/rituximab (anti-CD20; used in RRMS and PPMS), alemtuzumab.

Orals : fingolimod, dimethyl fumarate, teriflunomide, siponimod.

Rehab does not substitute for DMT; the physiatrist reinforces adherence and monitors for complications (e.g., PML surveillance).

Symptom Management (Rehab Core)

Symptom Management
Fatigue Energy conservation, graded aerobic exercise, screen/treat depression, modafinil/amantadine off-label
Heat sensitivity (Uhthoff) Pre-cooling, hydration, timing activity, cooling garments
Spasticity Stretching, oral baclofen/tizanidine, focal chemodenervation, ITB
Mobility AFOs for foot drop (e.g., peroneal nerve stimulator/NESS), FES cycling, assistive devices
Bladder Anticholinergics for detrusor overactivity; intermittent catheterization for retention; screen for UTI
Bowel Bowel program, fiber, stimulant/osmotic laxatives
Cognition Neuropsych evaluation, cognitive remediation, compensatory strategies
Pain Neuropathic agents (gabapentin, SNRIs), PT for musculoskeletal contributors
Depression Screening, psychotherapy, pharmacotherapy
Exercise & Rehabilitation Fatigue + Deconditioning ──► ↓Activity ──► Further Deconditioning (Vicious Cycle)
│
└── Graded Moderate Aerobic + Resistance Exercise ──► ↑Mobility, ↓Fatigue, ↑QoL, ↑Cognition

Evidence supports moderate-intensity aerobic (e.g., 20-30 min, 3-5x/week) and resistance training in MS, improving fatigue, mobility, and quality of life without exacerbating disease. Heat intolerance (Uhthoff phenomenon) is managed with pre-cooling, indoor activity, and hydration. Resistive exercise is progressed gradually; relapse management temporarily reduces intensity. FES cycling and peroneal nerve stimulators address foot drop and disuse.

Disease Course, Prognosis & Red Flags

MS prognosis is variable; favorable factors include relapsing-remitting course, female sex, young onset, sensory presentation, and infrequent relapses. Poor prognosis correlates with male sex, primary progressive course, early cerebellar/pyramidal involvement, and high early lesion burden. The physiatrist should recognize red flags requiring urgent neurology: acute relapse vs pseudo-relapse (fever, infection—urinary tract infection is the most common trigger of pseudo-relapse—must be excluded before treating a relapse), progressive multifocal leukoencephalopathy on natalizumab (new neurologic deficits, JC virus positivity), and treatment-related CNS infections.

Cognition, Mood & Employment

Cognitive impairment affects 40-70% of MS patients, predominantly information processing speed, attention, and executive function, and is a leading cause of employment cessation independent of physical disability. Depression prevalence is high and bidirectional with fatigue and disability. Rehabilitation addresses cognition with compensatory strategies, occupational therapy for workplace accommodation, and screening/management of depression and anxiety—anxiety is often under-recognized and contributes to fatigue and reduced participation.

Interdisciplinary Team & Goal Setting Physiatrist (spasticity, mobility, symptom mgmt) ──┐
Neurology (DMT, relapse mgmt) ─────────────────────┤
PT (gait, balance, strength) ──────────────────────┤──► Patient-Centered Goals
OT (ADLs, upper-limb, cognition, work) ─────────────┤ (FIM, EDSS, MSIS-29)
Speech (dysarthria, dysphagia, cognition) ─────────┤
Urology / Nursing (bladder-bowel program) ──────────┤
Psychology / Neuropsych (cognition, mood) ──────────┘

Goal setting uses validated measures: the Expanded Disability Status Scale (EDSS, 0-10, weighted heavily on ambulation), MSIS-29, and FIM. Ambulation-based EDSS transitions drive assistive-device and DMT decisions.

Heat, Fatigue & Lifestyle

Beyond Uhthoff management, fatigue in MS is multifactorial (central, motor, deconditioning, depression, sleep disturbance, medication). Pre-cooling, pacing/energy conservation, treating reversible contributors (anemia, thyroid, sleep apnea, depression), and graded exercise all contribute. Smoking cessation and vitamin D adequacy are associated with better outcomes. The physiatrist coordinates these lifestyle and medical levers with the neurology-led DMT plan.

Demyelinating Differentials: NMOSD & MOGAD

Neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD) are distinct demyelinating entities the physiatrist must distinguish from MS because they preferentially attack the optic nerve and spinal cord, classically as longitudinally extensive transverse myelitis spanning three or more vertebral segments, and carry different prognostic and rehabilitation implications. AQP4-IgG-seropositive NMOSD is often more aggressive, with severe optic neuritis and myelitis and a higher relapse-related disability burden; MOGAD generally shows better recovery after individual attacks. Rehabilitation parallels MS—spasticity, neurogenic bladder and bowel, neuropathic pain, mobility loss, and assistive-technology needs—but the physiatrist should avoid attributing new deficits to MS progression without neurology review, since misphenotyping alters disease-modifying treatment. With cervical lesions, pressure-injury prevention and autonomic dysreflexia surveillance are essential.

EDSS Ambulation Milestones

The Expanded Disability Status Scale anchors rehab planning to ambulation, and knowing the milestones drives assistive-device prescription: EDSS 4.0 ambulates at least 500 m without aid or rest, 4.5 at least 300 m, 5.0 about 200 m without aid or rest, 5.5 about 100 m, 6.0 requires unilateral aid (cane or crutch) for 100 m, 6.5 requires bilateral aids for about 20 m, and 7.0 restricts the patient to a wheelchair. Crossing these thresholds objectively triggers cane, walker, or wheelchair prescription, home-exercise progression, and goal-of-care conversations.