10/28 - Multiple Sclerosis - Physical Therapy and Rehabilitation Flashcards
What is the role/function of the microglia cells? T cells? B cells?
Microglia- are a type of CNS macrophages /white blood cell that ingest the antigen (foreign body/ bad guy) and present it to the T an B cells
T cells- responsible for cell destruction
B cells - responsible for antibody production
Both T an B cells have memory of the antigens and will mark them for destruction
What are cytokines and how do they play a role in immune defense?
Cytokines stimulate activity in B cells, macrophages and T cells and open the blood brain barrier -
What goes wrong in these processes and causes demyelination?
Myelin and myelin producing cells both get tagged as an antigen (bad guy) causing the microglia to identify the myelin as bad and present it to the T and B cells which create an antibody that marks the myelin as a foreign substance and causes it to be attacked by macrophages and T cells.
What process has a major role in the progressive nature of MS?
Direct Axonal Damage- when the autoimmune system attacks the axon instead of the myelin causing un-repairable degeneration
What is the take home point about all of these immune system processes?
It is a mutlifaceted inflammatory process of demyelination and progressive neurodegeneration. There is not just one cause!
What are the most common lesion locations for MS?
Supratentorial brain structures- periventricular, corpus callosum, optic nerve
Infratentorial brain structures- cerebellum, brainstem
Spinal Cord
What is a “lesion”?
Lesions are pro-inflammatory degeneration of the axons that clause plaque formations which “sclerose” the nerve
What area of the spinal cord is typically most affected in MS?
The cervical spinal cord. Typically don’t see it in the thoracic and lumbar spine
When the corpus callosum has a lesion, what deficits will be present?
Cognitive deficit
When the supratentorial region is sclerosed, what deficits will be present?
Both cognitive and physical disability
What is the LARGEST predictor of long term disability?
> 2 lesions
What specific deficits are seen when there is a lesion located in the inratentorial region?
Coordination and tremors
Upright postural control is affected
Eye movement and lack of visual stability
- Saccades
- VOR
- Smooth pursuitWhat is the most common eye movement disorder with MS? How do you diagnose the disorder?
Internucelar opathlmoplegia (INO) - decreased control of the ability to adduct the eye.
Use tracking to diagnose the issue - can be seen with convergence and divergence
What is the largest predictor of level of disability in MS?
Cervical lesion load (the number of lesions and their size)
What deficit does the presence of a lesion in the spinal cord cause ?
Significantly affects the ability to ambulate
If gray matter is involved in the lesion is prognosis better or worse?
It is worse because the cell body is affected and causes progressive/ chronic stages of MS
How does gray matter involvement affect seizure frequency? Cognition? Physical disability?
Seizure - 6x greater than the general population
Cognition -
White matter loss- causes issues in mental processing speed and memory
Gray matter loss- causes verbal memory, euphoria, disinhibition
Physical disability - as measures by the expanded disability status scale
Epidemiology - who gets MS? how old are they?
Women - mostly caucasian between 15-45 y/o
Alot in CO!
T/F genetic and congenital background is mostly attributed to how MS is contracted
False- no one knows- it could be genetic, it also could be after a viral infection ( have a 2/3rd higher risk of MS after having mono)
Could be due to Vitamin D deficiency….
NO ONE KNOWSS!
How does Vit D supplements affect the inflammation process?
With supplements there can be a reduction of activity of the T cells, B cells or cytokines
Vit D supplements are GREAT! It has a neuroprotective effect
2000-4000 IU/day of Vit 3
T/F - people that smoke have a 50% higher risk of MS
True!
T/F - people that live south of the equator have a higher risk of MS
False- north of the equator have a higher risk
Which test confirms the diagnosis of MS?
NONE. There is no specific test History Clinical exam Paraclinical exam- MRI/ spinal tap Rule out other plausible diagnoses
What defines an Ms “Attack”
Deterioration in function that follows typical symptoms of MS- loss of vision, loss of sensation, mobility issues that lasts > 24 hours and is greater than 30 days of separation from attack 1 to attack 2
What should the clinical exam include?
Cranial nerve screen
How do you screen for CN II?
CN II- Snellen chart Scotoma- visual blind spot Reduction of color distortion of color Anopsia- loss of visual field
How do you screen for CN II, IV, VI?
Tracking-smooth pursuit and convergence/ divergence
Saccades
VOR
How do you screen for VII?
Light touch/ sharp or dull
Facial muscle function
How do you screen for VIII
Hearing and Vestibular systems
Screen for VII IX X XII
Dysarthria
Screen for IX X
Dysphagia
CN XI
Trapezius motor function
CN XII
Tongue function and alignment
CN XII - you are testing the tongue - if you have the person stick out their tongue which way will the tongue deviate if the nerve is affected?
It will deviate TOWARDS the side of the lesion
What else do you want to examine in a patient with MS?
ALL neuro functions Reflexes- clonus/ babinski Tone / spasticity intentional movement - tremor, dysdiadochokinesia Sensation Proprioception/positioning/vibration Motor function Functional tests Self report measures
In the EDSS- steps 1.0-4.5 refer to people who have what function? Steps 5.0-9.5?
- 0-4.5 Fully ambulatory
5. 0- 9.5 defined by the impairment to ambulation
What is included in the paraclinical exam?
MRI
Spinal tap of the CSF
An MRi supports the identification of lesions in both time and space. How do you define time in regards to lesion? Space?
Time- new lesions that have developed and/or lesions that have progressed
Space- lesions in two or more locations - ie paraventricular, juxtacortical, infratentorial, spinal cord
When should someone have a spinal tap?
When their clinical presentation is atypical, when the MRI is unspecific, to rule other dx.
What constitutes a positive spinal tap?
Presence of oligoclonal bands- antibodies are in the CNS where they shouldnt be - because of cytokines
What are the 4 difference subtypes of MS?
Relapse Remitting - 85%
Secondary Progressive- 1/2 of relapse remitting will convert to secondary progressive
Primary progressive - 10-15%
Progressive - relapsing - rare subtype of ms
Clinically isolated syndrome - One episode of MS attack that does not stay
If someone has a CIS, what are the chances of a second attack?
It increases with time, if you have a 2nd attack there is a definite clinical diagnosis of MS
T/F in early stages re-myelination occurs more frequently than in later stages
True!
Who is more likely to have re-myelination?
Someone with an early diagnosis of MS, Women, subcortical and periventricular lesion areas
What is the prevalence of cognitive impairment in people with MS? what deficits are commonly present?
70%
Short term memory, attention/concentration, speed of processing, executive function
Dementia is rare - intelligence is usually intact
Worsens with grey matter involvement, lesion load, 3rd ventricle size and brain atrophy
How prevalent is fatigue in the MS population? What causes it?
86% sleep disturbance due to pain/spasticity/bowel or bladder metabolic issues/depression medications depression excessive exercise / activity
How prevalent are visual disturbances in the MS population? What deficits are typically present?
80% Optic neuritis Positional vertigo / nystagmus Eye movements - tracking and fixation Vestibular issues
How prevalent is depression in this population?
50%
What are common triggers for hypertonicity/ spasticity in people with MS?
Fatigue/ weakness
infection (UTI)
Heat
Medications
How prevalent is pain in people with MS?
86%
Correlated with increased age, disability, disease duration, progressive stages
What are some negative prognostic factors?
Older age at onset is worse male african american high relapse rate - in first 5 years Primary progressive type of MS Early motor/cerebellar disability high lesion load and brain atrophy early requirement of AD's
What are the 2 largest correlates to disability
Location - periventricular
Lesion load
How much is the life span impacted by MS?
decreases by 6-7 years
What are the types of medical management approaches?
Acute attack treatment
Drug therapies- proactive
symptom management
What are some of the side effects of corticosteroids?
increased agitation/anxiety driving restriction insomnia infection of IV site decreased bone mineral density
What is plasma exchange reserved for as treatment?
for severe attacks- if unresponsive to steroids
What are reasons for early treatment in MS?
therapies both medical and physical are less effective later in the disease state
try to improve symptoms and physical function ASAP
What are the ABC drug therapies and what is their purpose?
Interferon B 1a- Avonex/Rebif
Interferon B 1b- Betaseron
Glatiramer Acetate - Copaxone
Goals- ALL reduce attacks, stabilize progression of MRI changes,
Interferon B - slows progression of disability
T/F - Someone with a CIS who is treated early with an Interferon 1a has a higher likelihood (1:7) of not converting to MS
TRUE!!!!! Early treatment is good!
What is the name of the drug that is life threatening and can cause a brain disorder if taken?
Natalizumab - progressive multi-focal leukoencephalopathy
