INTRODUCTION

Multiple sclerosis (MS) is a chronic neurological disease that affects the central nervous system and is characterized by demyelination of axons. MS has multiple etiologies and various types. The most common type of MS has a relapsing-remitting course.1 The other 3 types include clinically isolated syndrome, secondary progressive, and primary progressive MS.2 The disease is usually diagnosed in patients aged 20-45, and is diagnosed more often in females than males, with a ratio of 2:1.3 As of 2019, nearly 1 million people in the United States and 2.8 million worldwide have been diagnosed with MS.2 The etiology of MS is still unknown, but it is suspected that genetic and environmental factors may induce an immune response that attacks the myelin sheath surrounding nerves.3 Risk factors that may contribute include Epstein-Barr Virus exposure, living far from the equator, vitamin D insufficiency, smoking, and childhood obesity.2

Common symptoms of MS include diplopia, nystagmus, optic neuritis, muscle weakness, muscle stiffness, muscle spasm, clumsiness, bladder control issues, dizziness, numbness, and tingling.4 Psychiatric symptoms and mood disorders occur more frequently in patients with MS than with other chronic diseases.5 Each patient with MS may present with different patterns of disease progression and associated symptomatology.2 The location of demyelination and plaque development correlates with clinical symptoms observed in patients with MS. This provides some explanation for the variation in disease presentation.6 For example, gustatory alterations may be due to the presence of a demyelinating lesion in the area of the brain that regulates taste in 1 patient, whereas the absence of that particular lesion would lead to a lack of similar symptoms in another.7

The diagnosis of MS is primarily clinical and can be supported with magnetic resonance imaging (MRI).6 There is no cure for MS.2 Managing comorbid symptoms and acute exacerbations is critical, along with long-term disease-modifying therapy.6 Disease-modifying therapies approved for MS are broad-spectrum immunomodulatory drugs that reduce relapses but do not halt the disease progression or neuroaxonal damage.1 Additional treatments include functional promotion through rehabilitation to aid in the ability to perform activities of daily living.2 Improvements in disease-modifying treatments, especially for primary progressive MS remain an unmet need.8

Management of symptoms is essential in the treatment of MS patients. Impairments that may present in patients with MS include spasticity and muscle spasm, mobility and strength impairments, and altered balance.9 Management of these symptoms could be provided through conservative care in a chiropractic office. A study in the United Kingdom showed that 91% of 231 participants used complementary therapies to manage their MS.10 Of those, 42% utilized chiropractic care with 68% recommending it to others.10 Of those who did not receive chiropractic care, 78% reported lack of knowledge about chiropractic treatment as the reason.10

CASE REPORT

A 42-year-old female sought care for complaints of neck pain and left ankle pain. The neck pain intensity was rated at 3/10, with 0 being no pain and 10 being the worst pain imaginable. She had no history of injury or trauma. The pain started a week prior to the visit with a gradual onset. She described the quality of the pain as achy as well as burning. Pain from her neck radiated into her left hand, with associated numbness. The pain in her left ankle was rated at 8/10 on the same 11-point scale. Again, no history of trauma was reported. She stated a gradual onset, beginning approximately 2 months ago. The ankle pain was constant (100% of the day) and the quality was described as both throbbing and numbness. Both walking and standing were provocative, and nothing alleviated the symptoms.

Objective examinations for both the cervical spine and the left ankle were performed. Cervical examination revealed hypomobility and joint restriction from C4-C6 as well as increased pain with left lateral flexion. Muscle hypertonicity and myofascial trigger points were noted within the right cervical paraspinal musculature. Joint fixation was noted in the talocrural joint of the left ankle.

She was initially treated with gentle manipulation of the cervical spine as well as electric stimulation, ultrasound, and hot packs to her hypertonic musculature. Due to the recent onset of numbness in the left hand and unexplained etiology of numbness and severe pain in the left ankle, MRI of the cervical spine was ordered. During 3 visits over the next week, her neck pain improved and was reported as minor; however the numbness and tingling were unchanged.

MRI showed a lower cervical cord lesion that suggested acute demyelinating plaque. Referral to a neurologist was made, and further MRI of the cervical spine with contrast, as well as MRI of the brain with and without contrast was ordered. Brain MRI revealed 10-12 3-5mm T2 hyper-intensities in the brain. This finding, along with the previously revealed cervical cord lesion, led the neurologist to diagnose MS.

DISCUSSION

This case describes an example of how a patient seek care in a chiropractic office with early MS symptomatology. There are many different conditions that may present to a chiropractic office, and it is important to recognize those which require referral for proper diagnosis and treatment. Conditions causing radiating pain and numbness that are commonly managed conservatively include disc herniations, sciatica, cervical radiculopathy, and lumbar radiculopathy.11 The previously listed conditions may also require co-management, depending on severity. Other conditions that can cause neuropathic pain and require co-management or referral include but are not limited to alcoholism, diabetes, facial nerve problems, HIV/AIDS, stroke, Parkinson’s disease, complex regional pain syndrome, and shingles.12 Chemotherapy drugs, radiation therapy, and trauma or surgery with resulting nerve damage warrant consideration as well.12 Chiropractic care may have a role in co-managing musculoskeletal symptomatology associated with MS; however further research is needed to better understand the effects of specific treatments on patient outcomes.

In this case, the patient had an insidious onset radiating symptomatology in multiple regions. With no trauma, no alleviating factors, and an unknown cause, the potential of a red flag scenario must be considered. One of the earliest symptoms of MS tends to be numbness and tingling in the arms, legs, trunk, or face.4 Symptoms of MS have a propensity to develop abruptly within the span of a few days or hours.13 Both the onset and the location of symptoms in this patient were potential red flags that were correctly identified. It is important for clinicians to recognize atypical presentations so that early diagnosis of more serious conditions can be made. In this case, the radiating pain was neuropathic in nature and did not respond to conservative care. However the patient was grateful that an appropriate referral was made and she continued with chiropractic care for episodic management of mechanical neck and low back pain.

Early diagnosis of MS is essential for patient benefit. Symptoms of MS are apt to progress with time.13 Even in situations where there is regression, relapses tend to return with worsening symptomatology.14 With no cure available, management of symptoms becomes the primary treatment goal for patients with MS, and this includes aiding patients in their ability to complete activities of daily living. Progression of MS leads to balance impairment and decreases in strength and mobility.9 Active care exercises which can be performed within the conservative care setting can lead to improvements in MS patients’ mobility.15 Exercise can also lead to increases in muscle power, physical endurance, and mood.16 In the aforementioned British study, 78% of MS patients using alternative therapies who did not choose chiropractic care cited lack of knowledge as the reason. More research is needed on the role of chiropractic in symptom management for MS patients.

This is a single-patient case report, and the results may not be generalizable to other individuals presenting with similar conditions.

CONCLUSION

MS is a chronic neurological disease with characteristic demyelination of axons. The disease most commonly takes a relapsing-remitting course and, less frequently, a progressive accumulation of disability from disease onset. The etiology of MS is still unknown, but may involve genetic and environmental factors that may induce a response to central nervous system auto-antigens. The diagnosis of MS is mainly clinical and can be supported with MRI. Managing symptoms and acute exacerbations is critical along with long-term disease-modifying therapy. There is no cure for MS, and improvements in disease-modifying treatments remain an unmet need.

As a clinician it is important to understand the wide range of conditions that may lead to neuropathic pain, numbness, or tingling. Conditions related to neuropathic pain or radiculopathy require a thorough history and examination to ensure the patient receives the most appropriate treatment available. Chiropractic care may play a role in the management of MS musculoskeletal symptomatology, but timely diagnosis and appropriate referral are paramount.

Written consent for publication was obtained from the patient.

COMPETING INTERESTS

The authors declare no competing interests.