10) Multiple Sclerosis Flashcards
MS
Immune-mediated inflammatory disease of the CNS characterized by relapses; Causes irreversible myelin & axonal damage
Explain the pathophysiology of MS
1) Abn immune response to a virus/environmental trigger in genetically susceptible individuals
2) T-cells get activated, cross the BBB, & release inflammatory mediators, which damage oligodendrocytes
What population is MS typically dx’ed in?
Women age 20-50
What is MS associated w/?
Brain & spinal cord lesions
When should MS tx start?
ASAP
Sx’s of MS
- Fatigue
- Pain
- Weakness
- Spasticity
- Tremor
- Impaired amb
- B&B dysfxn
- Visual disturbances
- Cognitive impairment
- Emotional changes
- Imbalance
- Incoordination
- Sensory changes
- Dysarthria
- Dysphagia
- Sexual dysfxn
What is the 1st sx of MS?
Fatigue w/no other indications that MS is occuring
Neuromyelitis Optica (Devic Disease)
Mimic’s MS bc of eye issues, but its really an optic nerve pathology
*MD realizes he was wrong bc MS tx doesn’t work for this
Relapsing Remitting MS (RRMS)
Acute attacks w/full recovery or partial residual deficit; Disease does not progress
Secondary Progressive MS (SPMS)
Starts w/RRMS followed by progression at a variable rate that may include occasional relapses & remissions
Primary Progressive MS (PPMS)
Disease progressively worsens w/out plateaus or remissions
What pt pop has the worst prognosis w/PPMS?
Males
Progressive Relapsing MS (PRMS)
Disease is progressive but w/clear acute relapses
Malignant MS
Very rare; Death usually occurs w/in 1yr from dx
Relapse
Sx’s lasting >1 or 2 days
Will an MRI show inflammation even if a pt has no sx’s?
Yes
What causes the axonal damage?
Continuous inflammation
When is there the most inflammatory activity?
Early
Why is MS one of the most difficult neuro pathologies to dx?
Bc there’s no standard set of clinical sx’s & there’s no single test that can always confirm the dx
What is clinical dx’s of MS based on?
MHx & sx’s
Expanded Disability Status Scale (EDSS)
Quantifies disability in 8 fxnl sx’s
EDSS Score of 1.0-4.5
Pt has MS, but they’re fully ambulatory
EDSS score of 5.0-9.5
Defined by the impairment to amb
EDSS score of 9.5
Pt is totally helpless & bedridden; Can’t communicate effectively, eat, or swallow
EDSS score of 10
Pt is dead
Prognosis of MS
1/3 has very mild course
1/3 have moderate course
1/3 become disabled
Factors for favorable prognosis
- Female
- Onset before age 35
- Monoregional vs polyregional lesions
- Sensory vs motor sx’s
- Complete recovery after exacerbation
What will an MS pt in rehab require?
Frequent reassessments
True or False: MS drugs don’t cure the disease, but they do alleviate sx’s.
True
What is used to tx relapses?
Steroids
True or false: Once the dx has been made, the damage has already started to occur.
True
When is tx most & least affective?
Most–>Early inflammatory phase
Least–>Later neurodegenerative phase
Sequelae of inactivity associated w/MS
- Impairment of neuromuscular fxn
- Psychosomatic disturbances
- URTI
- Thrombophlebitis
- Pressure ulcers
- Negative Ca2+ & N balance
- Other nutritional deficiencies
What should be done at regular intervals?
Rehab
PT implications
- PT’s w/MS have less muscle endurance & incr muscle fatigue
- 30% aerobic capacity deficit
- Pt’s don’t always recognized relapses
- PT’s need to be aware of everything that can be effecting the pt
- Respect the fatigue, but don’t give in to it
- Focus on improving & maintaining fxn
Why do MS pt’s have an aerobic capacity deficit?
As a result of marked deconditioning 2° to disuse, immobility, CV dysfxn. & sympathetic dysfxn
What worsens fatigue?
- Hot/humid weather
- Hot bath/shower
- Having another MS attack
- Stress
- Sleep problems
- Fever
- Incr in daily activities
- Exercise
- Age
- Gender
- Educational level
- Marital status
- # of kids
- Occupation
- Duration of illness
Primary Fatigue
Caused by factors related to the disease process such as demyelinization, inflammation, axonal loss, immune factors, pyramidal involvement, etc
Secondary Fatigue
Caused by pathological consequences of the disease such as meds, psychological effects, disuse, deconditioning, sleep disturbances, & heat sensitivity
Central Fatigue
Subjective sense of fatigue present in disorders of the NS
Peripheral fatigue
Disorders of the muscle & NMJ
Can central & peripheral fatigue co-exist?
Yes
Do women or men have more fatigue?
Women
What should be used to tx central fatigue?
Disease modifying drugs
What should be used to tx peripheral fatigue?
Exercise
Oxidative problems are the result of what?
Deconditioning
Why us improving oxidative capacity of muscle important?
Bc muscles want to produce energy anaerobicially
What causes autonomic dysfxn?
MS plaques
What will autonomic dysfxn do to exercise tol?
Decr it
Who is more significant AD found in?
Pt’s w/more severe disease
What systems does AD involve?
Sympathetic & parasympathetic
What pt pop has a very high incidence of AD?
MS w/CV pathologies
True or False: Pt’s w/autonomic dysfxn will have a blunt HR & BP response to aerobic exercise.
True
Benefits of exercise for pt’s w/MS
- Neuronal survival & plasticity
- Promotes neuronal health, survival, & resistance to injury
- Stims neurogenesis
- Preserves cognitive fxn
- Modulates dysregulation of immune fxn
- Disease-modifying anti-inflammatory effect–>Slows the disease process
Exercise Implications
- Educate
- Devo effective HEP
- Promote safe independence
- Provide resources for AD’s & community programs
- Tx for one problem can aggravate another
- Pt status should dictate intensity & frequency
- Don’t always need a mobility
- Goals should be adaptable & realistic
- Anticipate pt’s future
- Maintenance
- Don’t tx fatigue w/exercise
How often should pt’s w/MS amb for health?
Daily
Implications for aerobic exercise
- 2-3x/wk
- Start w/20 min including rest, then progress to 30-60min
- 65-75% of MHR; Progress THR by 5% monthly
Implications for anaerobic exercise
- 2-3x/wk
- 1-3 sets of 8-15reps for each major muscle group
- Alternate upper & lower body
- Based on pt’s status
- Progress by 2-5% when pt can consistently do 15 reps
Implications for flexibility training
- Do all major muscle groups
- 10-15min w/30sec holds
- Do after exercise sessions
How often should a pt do breathing exercises?
2x a day for 30min
What is the best exercise for machine for MS & why?
Air dune bc it distributes work over a greater muscle mass causing the VT to occur at a higher VO2 level
How long should it take for core temp to normalize after exercise?
30 min
Uhthoff’s Phenomenon
Reduction of visual acuity & incr fatigue associated w/hyperthermia
What happens to MS pt’s fx risk?
It increases 2x bc of sarcopenia & steroids
What positioning should weight training be done in?
Sitting
Yoga can be good for what?
Anxiety, pain, & spasticity
What drugs are used for acute relapses?
- Solumedrol
- Plsamapheresis
- Dexamethasone
What is tysbari for?
Relapsing MS or when injectables don’t work
Oral drugs
Gilenya & aubagio
Gilenya
1st oral drug for RRMS
Aubagio
Oral anti-inflammatory
Tecfidera
Anti-inflammatory that prevents T-cells from leaving the lymph nodes
Cytoxan & Mitoxantrone
For aggressive MS
What do disease-modifying drugs do?
- Decr frequency & severity of attacks
- Decr scaring
- Slow disease progression
