2.9 Neurological and Sensory MULTIPLE SCLEROSIS

Question 1

Multiple Sclerosis

Pathophysiology

Answer 1

Pathophysiology
Autoimmune = B cells invade/stimulate inflammation & scarring

What triggers immune response in unknown

Central Nervous System (brain, spinal cord, optic nerves)

Destruction of myelin sheath (insulation) surrounding axon, followed by inflammation & scarring = impaired conduction

-Motor and sensory nerves are impacted

Lesions happen in different areas so clinical S/S individualized

Different forms: Relapsing/remitting is most common

Severity varies, progresses in two stages

Risk factors: 20-40 yr old, women, climate

Question 2

Multiple Sclerosis

Normal neuron function

Answer 2

Normal neuron function – signal received by dendrites, message passed to soma through axon. Axon needs insulation of myelin sheath to function correctly. Then goes to terminal and synapse.

Question 3

Multiple Sclerosis

damage to myelin sheath

Answer 3

Scattered damage to myelin sheath is in patches (Plaques) Conduction is slow & distorted, even absent in severe damage. Can progress to scarring, demyelination, and deterioration of axon

Question 4

Multiple Sclerosis

Manifestations

Answer 4

Manifestations
Dependent on which neurons are damaged.

• Fatigue is very common.
• Visual impairments, nystagmus

Sensory: pain, *paresthesia, numbness, balance impairments (+Romberg’s)

Cognitive: memory loss, judgment/planning, concentration impaired

Mood: unstable emotions, depression, anxiety

Motor: stiff, slow, weakness, spastic paresis, *impaired gait

Bladder: urgency, retention, *incontinence

Bowel: constipation, incontinence

Sexual dysfunction
(*= common early sign)

Question 5

Multiple Sclerosis

Diagnosis

Answer 5

Diagnosis
Process – no specific test

Medical history- exacerbations of symptoms followed by remission

Neuro exam: Cranial nerves, coordination, strength, reflexes, sensation

MRI : lesions, atrophy

Lumbar Puncture: looking for elevate immune proteins

Evoked potential studies: apply stimuli & measure how long it takes to reach the brain

Can be visual, skin, or auditory impulses

Question 6

Multiple Sclerosis
Diagnosis
Evoked test

Answer 6

Evoked potential tests measure how long it takes for stimulation of different nerves to reach the brain and how big the response is. Impulses move more slowly along nerves that have been damaged, such as those impacted by the demyelination that occurs in MS.

Three evoked potential tests can be used in evaluating MS. For all them, electrodes are applied to the scalp with conducting gel, and placement depends on the test being performed.

Question 7

Multiple Sclerosis
Diagnosis
Evoked test
VISUAL

Answer 7

Visual evoked potentials (VEPs): Visual evoked potential testing looks at your brain’s response to light. It can be particularly helpful in confirming a diagnosis of MS because it can reveal nerve damage along your optic nerve pathways even if you’ve never had any associated symptoms. The test uses flashing lights, which don’t bother most people. Some, however, say it gives them symptoms similar to mild motion sickness.

Question 8

Multiple Sclerosis
Diagnosis
Evoked test
SOMATOSENSORY

Answer 8

Somatosensory evoked potentials (SSEP): SSEP measures the brain’s response to sensation through electrical pulses via electrodes stuck to your skin. Most people say it’s painless.

Question 9

Multiple Sclerosis
Diagnosis
Evoked test
Brainstem auditory

Answer 9

Brainstem auditory evoked potentials (BAEP): BAEP measures the brain’s response to sound by playing clicks, tones, or beeps into your ear through headphones.

Question 10

Multiple Sclerosis

Treatment

Answer 10

Treatment
Goal is to arrest progress early- remyelination can occur if damage isn’t too deep

MEDICATIONS:
Disease-modifying therapies:↓ lesions, ↓ frequency & severity of relapse, slow progression

corticosteroids decrease inflammation

immunosuppressants decrease immune response

interferon decreases immune response

glatiramer acetate (Copaxone) stimulates myelin proteins

fingolimod (Gilenya) traps immune cells in the lymph nodes

Question 11

Multiple Sclerosis
Treatment
Symptom management

Answer 11

Symptom management

fatigue –amantadine, modafinial

bladder – anticholinergics for OAB, cholinergic for retention

spasticity- muscle relaxants (baclofen), benzodiazepine

bowel – stool softeners, laxatives

tremors – beta blockers

Question 12

Multiple Sclerosis
Treatment
SURGERY:

Answer 12

SURGERY:
Tendon release
Placement of intrathecal infusion pump (pain pump) for baclofen (muscle relaxant)

Question 13

Multiple Sclerosis
Treatment
LIFESTYLE:

Answer 13

LIFESTYLE:

-DIET/NUTRITION various diets in the research supplements: vitamin D, probiotics safety concerns – problems with chewing & swallowing

SLEEP

ACTIVITY

IDENTIFY TRIGGERS : stress, fatigue, infection, smoking, med changes, heat (Uhthoss’s sign, heat intolerance)

Question 14

Multiple Sclerosis

Nursing Care

Answer 14

Nursing Care
Disease of young adults so the psychosocial, emotional, economic, financial effects significant

Fatigue management

Prevention of relapse: med, lifestyle, avoid triggers

Exercise: work with PT, paced activity

Safety: visual deficits, balance problems, impaired sensation

Speech and swallowing issues & aspiration prevention, work with SLP

Assistive devices: ambulation & ADLs

Care planning and resources

Bladder: teach cathing, risk for UTI, renal lithiasis, bladder spasm, incontinence, adequate fluids

Bowel: dietary fiber & fluids, constipation, meds, may need manual disimpaction

Prevent complications of immobility