From the Guidelines
A comprehensive physical exam for a patient with suspected multiple sclerosis (MS) should include a complete neurological assessment, incorporating mental status evaluation, cranial nerve testing, motor examination, deep tendon reflexes, sensory testing, coordination tests, gait assessment, and specific tests like Lhermitte sign and Uhthoff phenomenon, as these help identify lesions in different parts of the central nervous system 1.
Key Components of the Physical Exam
The physical exam should start with a mental status evaluation to assess cognitive function. Cranial nerve testing is crucial to detect abnormalities in vision, eye movements, facial sensation, and hearing. A thorough motor examination should assess strength in all extremities, looking for weakness or asymmetry. Deep tendon reflexes should be tested for hyperreflexia, and pathological reflexes like Babinski sign should be checked. Sensory testing should evaluate light touch, pinprick, vibration, and proprioception to identify areas of numbness or paresthesia.
Coordination and Gait Assessment
Coordination tests, including finger-to-nose, heel-to-shin, and rapid alternating movements, can reveal cerebellar dysfunction. Gait assessment should observe for ataxia, spasticity, or foot drop. The Romberg test evaluates balance with eyes closed, providing insight into proprioception and vestibular function. These tests are essential for identifying the dissemination of lesions in space and time, characteristic of MS.
Specific Tests for MS
Additional specific tests include the Lhermitte sign (electric sensation down the spine with neck flexion) and Uhthoff phenomenon (symptom worsening with heat). Visual acuity and visual fields testing may reveal optic neuritis, a common presentation of MS. These tests, in combination with the complete neurological assessment, help in making a diagnosis of MS, though correlation with MRI findings and sometimes cerebrospinal fluid analysis is ultimately required for a definitive diagnosis, as emphasized by the International Panel on the Diagnosis of MS 1.
Importance of Comprehensive Assessment
It's crucial to perform a comprehensive physical exam because no single clinical feature or diagnostic test is sufficient for the diagnosis of MS. The diagnosis depends on the objective demonstration of dissemination of lesions in both time and space, which can be suggested by clinical signs and supported by paraclinical diagnostic methods like MRI and analysis of cerebrospinal fluid 1. A thorough physical exam is the first step in identifying patients who may have MS and in guiding further diagnostic testing.
From the Research
Physical Exam Tests for Multiple Sclerosis
The diagnosis of multiple sclerosis (MS) is based on demonstrating evidence of inflammatory-demyelinating injury within the central nervous system that is disseminated in both time and space 2. A combination of the clinical history, neurologic examination, and other tests are used to make a diagnosis.
Neurologic Examination
The neurologic examination is a crucial part of the diagnostic process for MS. The examination should include:
- Assessment of cognitive function
- Evaluation of cranial nerves
- Assessment of motor function, including strength, tone, and reflexes
- Evaluation of sensory function, including pain, temperature, touch, and proprioathy
- Assessment of cerebellar function, including coordination and balance
- Evaluation of gait and mobility
Other Tests
In addition to the neurologic examination, other tests that may be performed to aid in the diagnosis of MS include:
- Magnetic resonance imaging (MRI) to evaluate the central nervous system for lesions
- Examination of the cerebrospinal fluid to evaluate for oligoclonal bands
- Evoked potentials to evaluate the function of the nervous system
- Urodynamic studies to evaluate bladder function
- Ocular coherence tomography to evaluate the optic nerve
Diagnostic Criteria
The diagnostic criteria for MS have evolved over the past several decades, with each revision impacting the apparent prevalence and prognosis of the disorder 2, 3. The current diagnostic criteria, known as the McDonald 2010 criteria, require evidence of inflammatory-demyelinating injury within the central nervous system that is disseminated in both time and space.
Differential Diagnosis
The differential diagnosis for MS is broad and includes other demyelinating diseases, inflammatory diseases, and infectious diseases 2, 3. A positive test for a putative MS "mimic" does not unto itself exclude the diagnosis of MS. The diagnosis of MS must be made through a combination of clinical history, neurologic examination, and other tests.
Note: The provided studies do not give a comprehensive list of physical exam tests that need to be performed on a patient presenting with possible multiple sclerosis. However, they do provide information on the diagnostic criteria and differential diagnosis for MS.