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PassPMR - 05 Neurology > 4- Multiple Sclerosis > Flashcards

4- Multiple Sclerosis Flashcards

1
Q

Types of MS 🔑🔑

A

1. Primary progressive (PP MS)

10% of cases at disease onset & worst prognosis

2. Relapsing-remitting (RR MS)

85% to 90% begin with RR MS

Return to baseline or mild disability

3. Secondary progressive (SP MS)

50% of RRMS convert to SPMS after 10 years; 90% after 25 years

4. Progressive Relapsing (RP MS)

5. Clinically Isolated Syndrome

  • Attack/replase with evidence of inflammation and demyelination
  • Typically lasts a minimum of 24 hours
  • Does not yet meet criteria for MS

Cuccurollo 4th Edition Chapter 12 MS pg928-929

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2
Q

Good vs Poor Prognostic Indicators for MS 🔑🔑

A

GOOD PROGNOSIS

  1. Female sex
  2. Younger age at onset (less than 35 years)
  3. Sensory signs
  4. Optic neuritis
  5. Monosymptomatic
  6. Good recovery with long remission (RR type)
  7. Low disability
  8. Ambulatory

POOR PROGNOSIS

  1. Male sex
  2. Older at onset (age more than 35 years)
  3. Initial motor or cerebellar dysfunction
  4. Polysymptomatic
  5. Rapidly progressive
  6. High disability
  7. Non-ambulatory

Cuccurollo 4th Edition Chapter 12 MS pg929 TABLE 12-13

PMR Secrets 3rd Edition Chapter 57 MS pg479

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3
Q

30 years old lady visit you in the OPD with progressive weakness and visual disturbance. You are suspecting that she might have multiple sclerosis. Mention 6 diagnostic tests other than blood investigations that you would order. 6 marks 🔑🔑 MOCK 🟦

A

💡 Answer is the highlighted text only, others infos extra details.

  1. MRI of the brain and spinal cord
    • Most sensitive indicator of disease activity
    • Monitors disease activity and progression
    • Lesions
      1. Cortical
      2. Juxtacortical “Subcortical”
      3. Periventricular “Dawson’s fingers”
      4. Infratentorial
      5. Spinal cord
  2. CSF Analysis (Lumbar puncture)
    • Oligoclonal IgG bands (OCB)
  3. Visual evoked potentials (VEPs)
  4. Somatosensory evoked potentials (SSEPs)
  5. Brainstem auditory evoked potentials (BAEPs)
  6. NCS & EMG
    • Decreased amplitudes due to muscle atrophy
    • Abnormal activity (e.g., fibs, positive sharp waves [PSW])
    • Abnormal blink reflex tests

Cuccurollo 4th Edition Chapter 12 MS pg931-932

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4
Q

3 Most Prevalent Symptoms of MS 🔑🔑

3 Problems Affecting ADLs Reported by Patients (Remember the case in Ward 3)

A

Most Prevalent Symptoms of MS

  1. Fatigue (central in nature)
  2. Pain: Dysesthetic; painful spasms most common
  3. Bladder and bowel dysfunction

Problems Affecting ADLs Reported by Patients

  1. Fatigue (central in nature)
  2. Weakness
  3. Balance difficulties

Cuccurollo 4th Edition Chapter 12 MS pg929-930

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5
Q

MS patient with exacerbated symptoms. How do you approach the case? 🔑

A

MS Exacerbation

  1. Fever, heat, stress, fatigue
  2. Dehydration
  3. Pulmonary or urinary tract infection
  4. Medication side effects.

Cuccurollo 4th Edition Chapter 12 MS pg930

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6
Q

List 4 eye complications in MS and their treatment. 🔑🔑

A

💡 Again, think stroke in brain, eyes, brainstem, cerebellum.

Cuccurollo 4th Edition Chapter 12 MS pg936

DeLisa 5th Edition Chapter 25 MS pg627 & pg637

Ref: Ophthalmol Clin N Am 17 (2004) 265–273.

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7
Q

List 4 causes of central scotoma 🔑🔑 EXAM 2021

A
  1. Optic Neuritis (ON)
  2. Macular degeneration
  3. Diabetic macular edema
  4. Diabetic retinopathy
  5. Stroke
  6. Traumatic Brain Injuries

Dr. Maitham’s Note

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8
Q

Transverse myelitis (TS) 🔑🔑

List 4 Causes - Poor prognostic factors - Likely outcome - Rule of Rehabilitation

A

Mimicking Anterior Cord

  1. Pain and temperature are usually affected
  2. Proprioception and vibration are often spared.
  3. Weakness in the legs and trunk
  4. Reflexes are initially depressed and then hyperactive.
  5. Sphincter dysfunction is common.

Causes of “Spinal Cord to Myelin Infection”

  1. Multiple Sclerosis (MS)
  2. Neuromyelitis optica (NMO): Optic Nuritis + Transverse myelitis
  3. Infections
  4. Post infectious inflammation
  5. Autoimmune
  6. Idiopathic

Indicators for poor prognosis

  1. Rapid progression
  2. Back pain
  3. Spinal shock

Outcome

  • One-third of patients with TM recover completely
  • One-third improve but with significant residual neurological deficit
  • One-third do not improve at all

Treatment

  • IV solumedrol, IV immunoglobulins (IVIG), and plasmapheresis

Rehabilitation for Incomplete SCI

  • Mobility, spasticity
  • Bowel and bladder management
  • Avoiding decubitus ulceration and deep venous thrombosis

Cuccurollo 4th Edition Chapter 7 SCI pg544

Neurology Secrets 6th Edition Chapter 8 Myelopathy pg107

DeLisa 5th Edition Chapter 25 MS pg627

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9
Q

How is incoordination treated in MS? 🔑

A

Incoordination, Ataxia, Tremor, Dysmetria, Due to involvement of

  1. Spinocerebellar
  2. Cerebrum
  3. Dorsal columns

Management

  1. Balance training
  2. Frenkel’s exercises
  3. Weighted ankle cuffs and utensils
  4. Gait aids/mobility aids

Cuccurollo 4th Edition Chapter 12 MS pg935

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10
Q

Types of Tremor in MS & management 🔑🔑

A

Tremor in MS

  1. Resting tremor
  2. Postural tremor
  3. Intentional tremor

Non-Pharmacological

  1. Wrist weights → difficult to use if weakness and fatigability

Pharmacological

  1. Propranolol (Inderal)
  2. Levetiracetam (Keppra)
  3. Carbamazepine (Tegretol)
  4. Isoniazid

Surgical

  1. Deep brain stimulation
  2. Thalamotomy

DeLisa 5th Edition Chapter 25 MS pg636

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11
Q

List 4 Causes of decreased communication in MS.

A

ORGANIC OR MENTAL CAUSES

  1. Cognitive impairments
  2. Depression
  3. Fatigue
  4. Dysarthria
  5. Decreased voice intensity
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12
Q

OSCE: MS patient with fatigue. History and management.

List the major causes of slep disturnace in MS and their management. 🔑🔑

A

PRIOR TO SLEEP

  1. Poor sleep hygiene: Avoid foot late-night, Avoid TV, Incourage exercise, Supplement with melatonin or antihistamin

CAN’T SLEEP

  1. Pain: Exercise, TENS, Anticonvulsant, TCA
  2. Spasticity
  3. Restless legs syndrome (RLS): Iron supp, dopaminergic agents, benzodiazepine (clonazepam), and anticonvulsants.
  4. Depression, Anxiety: Exercise, CBT, SSRI Prozac or SNRI Cymbalta (duloxetine)
  5. Disease modifying treatment side effects

WAKE UP

  1. Neurogenic bladder leading to nocturia: Avoiding eating, drinking before bed
  2. Obstructive sleep apnea, central sleep apnea: CPAP, Weight loss

Braddom 6th Edition Chapter 46 MS pg996

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13
Q

Investigations & Treatment of Neurogenic bladder in Multiple sclerosis ? (5) 🔑🔑

A

INVESTIGATIONS

  1. Urinalysis
  2. Urine culture
  3. Post-voiding residual (PVR) volume measurement
  4. Renal ultrasound, specially in detrusor-sphincter dyssynergia (DSD) → reflux
  5. Urodynamic testing

SYMPTOMS of DSD

Failure to Store

  1. Incontinence
  2. Frequency, urgency
  3. Nocturia

Failure to Empty

  1. Double voiding
  2. Incomplete emptying
  3. Slow or intermittent stream

MANAGEMENT

Education/Behavioural

  1. Adequate fluid intake 2-3L per day
  2. Avoiding bladder stimulants past 6 pm to limit nocturia

Urine Collecting Devices

  1. Clean Intermitant Cathetrization (<500 mL per void)
  2. Indwelling Catheter
  3. Suprapubic catheter

Pharmacological

  1. Anticholinergic/Antimuscarinic: Oxybutynin (Ditropan), Vesicare
  2. Alpha Antagonist: Tamsulosin (Omnic, Flomax)
  3. Botulinum toxin A injections: Sphincter or Intradetrusor → temporary retention

Surgical

  1. Augmentation cystoplasty
  2. Sacral denervation
  3. Sphincterotomy
  4. Artifical sphincter
  5. Urethral stent
  6. Urinary diversion surgery

Cuccurollo 4th Edition Chapter 12 MS pg936

Braddom 4th Edition Chapter 20 Bladder pg441

DeLisa 5th Edition Chapter 25 MS pg635

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14
Q

Causes and Tx of Bowel Dysfunction in MS (or any other disease) 🔑🔑

A

Complians

  • Fecal urgency & incontinence

Risk Factors

  1. Immobility
  2. Abnormal colonic contractility (autonomic dysfunction)
  3. Inadequate diet and decreased fluid intake (avoid of nocturia and incontinence)
  4. Side effects of medications.

Treatment

  1. Education
    1. High fluid and high fiber diet
    2. Maximization of gastro-colic, colo-colic and recto-colic reflexes
  2. Devices
    1. Bowel Irrigation
  3. Medications
    1. Laxative (Bisacodyl) PO or Suppository night time
    2. Fiber/Bulk (Metamucil, Psyllium)
    3. Stool softeners (Docusate sodium)
    4. Bulk/Laxative (Normacol)
    5. Fleet Enema PRN

DeLisa 5th Edition Chapter 25 MS pg635-636

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15
Q

Sexual dysfunction in MS. Risk factors and management of ED 🔑🔑

A

Risk Factors

  1. Fatigue
  2. Decreased sensation
  3. Spasticity
  4. Depression
  5. Erectile dysfunction (ED)
  6. Decreased libido
  7. Ejaculatory dysfunction
  8. Impaired genital sensation (anorgasmia)
  9. Marital relationship problems

General Managment

  1. Education and counseling
  2. Fatigue and spasticity management
  3. Erection: Viagra, Vacuum Pump, PGE1 injections, Implanted penile prostheses
  4. Ejaculation: Vibratory stimulation
  5. Adequate sexual positioning
  6. Hormone replacement therapy if indicated

Treatment of Erectile Dysfunction

  1. Devices
  2. Vibratory stimulation
  3. Vacuum pumps
  4. Medications
  5. Phosphodiesterase-5 inhibitors (sildenafil [Viagra])
  6. Prostaglandin E1 injections
  7. Surgery
  8. Implanted penile prostheses.

DeLisa 5th Edition Chapter 25 MS pg636

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16
Q

How do spasticity present in MS? How do you manage it? 🔑🔑

A

PRESNETATION

  • Increasing difficulty bending the legs
  • Sensation of tightness with walking
  • Synergy patterns
  • Co-contraction of agonist and antagonist muscles
  • Posturedependent hypertonia
  • Clonus, spasms
  • Pain
  • Sleep disturbance
  • Impaired ADLs

MANAGEMENT

  1. Prevention
    • Remove noxious stimuli, optimize bowel, bladder, and skin management.
  2. Non-Pharma
    1. PT: Range of motion (ROM)
    2. OT: Positioning
    3. Modalities: Cryotherapy.
    4. Orthosis: casting and splinting
  3. Pharma
    1. Oral
      1. Baclofen (PO or ITB pump) 1st line of treatment for central spasticity.
      2. Tizanidine and clonidine (central alpha-2-adrenergic receptor agonist)
      3. Dantrolene (Ca+ channel blocker)
      4. levetiracetam (recently)
    2. Injection
      1. Botulinum toxin A → focal spasticity, target muscles, lower system effect
  4. Surgical
    1. Rhizotomies
    2. Tenotomies
    3. Intrathecal baclofen (ITB) → high risk of weakness, fits nonambulatory patient, improve from bedbound state to spending most of the day in a wheelchair

MEDICATION SIDE EFFECTS

  • Increased weakness
  • Functional deterioration
  • Sedation
  • Liver toxicity

Cuccurollo 4th Edition Chapter 12 MS pg935

Braddom 6th Edition Chapter 46 MS pg998

DeLisa 5th Edition Chapter 25 MS pg632

17
Q

Long-term positive prognostic indicators for disability and gait impairment include 🔑

Why MS patient have higher risk of falls? 🔑🔑 OSCE

Mention two tests for gait

What medication would you like to prescribe to improve gait in MS? 🔑🔑 OSCE

A

Positive Indicators for Gait

  1. Female gender
  2. Young age
  3. Complete recovery of initial exacerbation (specific tothe RRMS subtype)
  4. Reduced relapse rate in the first 5 years

High Risk of Falls

  1. Central → Apraxia
  2. Central → Fatigue
  3. Corticospinal → Spasticity, Weakness
  4. Cerebellar → Dysmetria & Cerebellar Ataxia
  5. Vestibulocochlear nerve → Imbalance & Dizzyness
  6. Dorsal Colum → Loss of Proprioception “Sensory Ataxia”
  7. Spinothalamic → Pain
  8. Cardiopulmonary → Immobility and deconditioning
  9. MSK → Decondition

Test for Gait

  1. Two- and Six-Minute Walk Tests
  2. The Timed 25 (T25) Foot Walk Test

Rehabilitation

  • HFAO: in case of hip flexion weakness
  • Functional electrical stimulation (FES): peroneal nerve stimulation
  • AFO: better clerance (ankle dorsiflexor weakness) and recude plantarflexor spasticity
  • Cane or lightweight walker

Medication

  • Dalfampridine (Ampyra) 10 mg orally twice a day : Contraindicated in seizure and moderate or severe renal impairment

Cuccurollo 4th Edition Chapter 12 MS pg935

Braddom 6th Edition Chapter 46 MS pg994

DeLisa 5th Edition Chapter 25 MS pg633-634

PMR Secrets 3rd Edition Chapter 57 MS pg483

18
Q

25 yo MS with ataxia, name 2 treatment modalities that could immediately improve gait. 🔑🔑

A
  1. Ankle weights or heavy footwear.
  2. Gait aid (eg 4 wheeled walker or cane).
  3. Flaired heal of shoe.

Ref: first principles.

19
Q

List types of Dysarthias in MS. 🔑🔑

A

Spastic (UMN), Ataxic (Cerebellar) & Mixed

20
Q

Speech & Swallowing Dysfunction in MS. Risk factors & Management 🔑🔑

A

Swallowing Dysfunction

  • Impairment of CNs (V, VII, IX, XII) may lead to swallowing abnormalities.
  • Delayed swallowing, dysphagia, or pooling may be seen
  • Treatment: exercise, positioning, and a change in food consistency or PEG tube

Speech disorders → decreased communication

  • Dysarthria
  • Dysphonia
  • Fatigue
  • Depression

Cuccurollo 4th Edition Chapter 12 MS pg936

21
Q

Treatment for acute flare up / attacks of MS and possible s/e 🔑

A

Methylprednisolone (1g for 3-7 days)

  • With or without an oral taper
  • Decrease length of exacerbation and return to pre-morbid function
  • Does not prevent further attacks or alter disease progression

Side Effects Short & Long Term

  • Gastrointestinal (GI) disturbance, fluid retention, mood swings, electrolyte imbalance, insomnia, acne, hyperglycemia, hypertension
  • Hypertension, osteoporosis, diabetes, weight gain, and cataracts

Cuccurollo 4th Edition Chapter 12 MS pg932

22
Q

Clinical Criteria for Definite Multiple Sclerosis (MS) 🔑

List 5 areas of MS lesion/plaques 🔑🔑

List 2 MRI findings other than typical MS lesions/plaques. 🔑🔑

A
  1. Dissemination in Space (DIC)
    • Two or more attacks with clinical evidence of two or more lesions in which the symptoms cannot be explained by a single lesion. Locations are:
      1. Cortical
      2. Juxtacortical/Subcortical
      3. Periventricular
      4. Infratentorial (cerebellum)
      5. Spinal Cord
    • Objective deficits seen on exam
  2. Dissemination in Time (DIT)
    • Neurologic deficits in two or more areas, reflecting white matter involvement, at two points in time for >24 hours separately by 1 month

Other MS Findings

  • Lesions of the corpus callosum extend in a fingerlike pattern “Dawson’s fingers”
  • With more chronic and severe disease, brain atrophy becomes apparent.

Neurology Secrets 6th Edition Chapter 14 MS pg186

Cuccurollo 4th Edition Chapter 12 MS pg931

Braddom 6th Edition Chapter 46 Box 46.3 pg988

DeLisa 5th Edition Chapter 25 MS pg628

23
Q

List 6 Differential Diagnosis of MS 🔑🔑

A
  1. Neuromyelitis optica (NMO)
  2. Transverse myelitis
  3. Systemic lupus erythematosus
  4. Rheumatoid arthritis
  5. Vasculitis
  6. Vitamin B 12 deficiency
  7. Neurosyphilis
  8. Sjögren syndrome
  9. Mixed connective tissue disease
  10. Carcinoma

Braddom 6th Edition Chapter 46 Box 46.2 pg986

24
Q

List 6 Factors Causing Secondary Fatigue in MS 🔑🔑 OSCE

A
  1. Thermosensitivity/heat dysregulation
  2. Mood disorder
  3. Anxiety
  4. Sleep disturbance
  5. Infection
  6. Thyroid dysfunction
  7. Anemia
  8. Medications
    1. Disease-modifying therapies (typically interferon)
    2. Antidepressants
    3. Antispasmodics
    4. Narcotics
    5. Sedatives

Braddom 6th Edition Chapter 46 MS pg996 Box 46.5

25
Q

List 4 disease-modifying agents for MS and their s/e 🔑🔑

List 4 disease-modifying agents used in MS.

A
  1. INTERFERON
    • Betaseron (Interferon beta-1b) S/C
    • Avonex (Interferon beta-1a) IM
  2. GLATIRAMER ACETATE
    • Copaxone
  3. MONOCLONAL ANTIBODY IV
    • Ocrevus (Ocrelizumab)
    • Tysabri (Natalizumab)
    • Lemtrada (Alemtuzumab)
  4. ORAL AGENTS
    • Gilenya (Fingolimod)
    • Aubagio (Teriflunomide)
    • Tecfidera (Dimethyl fumarate)

Weakened immune system

  1. Skin reactions
  2. Flu-like symptoms, myalgia, fever, chills
  3. Leukopenia
  4. Post-injection fatigue.

Cuccurollo 4th Edition Chapter 12 MS pg933-934

26
Q

List 3 Medications to treat fatigue in MS 🔑🔑 OSCE

A

💡 Amani went to the Prom for some Myth to fix her Mood

  1. Modafinil
  2. Amantadine
  3. Methylphenidate

Ref: Braddom pg 1244.

27
Q

At what EDSS score are patients with MS:

a. using a gait aid?
b. mostly wheelchair bound?
c. mostly bed bound?

A

a. gait aid: 6/10.
b. wheelchair: 7/10.
c. bedbound: 8/10.

[EK: I think 9/10 is confined to bed, while 8/10 is restricted to bed/chair)

Ref: EDSS scale.

28
Q

What are the Types of Fatigue?🔑🔑 Dr. Rawan

A
  1. Central fatigue
    • Dysfunction in arousal and attention.
    • Feeling of constant exhaustion, laziness, tiredness
    • Not alleviated with rest.
  2. Peripheral fatigue
    • Sense of exhaustion after a few minutes of physical activity
    • Alleviated with rest.
29
Q

List 6 Factors Causing Secondary Fatigue in MS 🔑🔑 OSCE

A
30
Q

List 6 Factors Causing Secondary Fatigue in MS 🔑🔑 OSCE

A
  1. Thermosensitivity/heat dysregulation
  2. Mood disorder
  3. Anxiety
  4. Sleep disturbance
  5. Infection
  6. Thyroid dysfunction
  7. Anemia
  8. Medications
    1. Disease-modifying therapies (typically interferon)
    2. Antidepressants
    3. Antispasmodics
    4. Narcotics
    5. Sedatives

Braddom 6th Edition Chapter 46 MS pg996 Box 46.5

31
Q

Outline a program for the management of excessive fatigue in a patient with MS

A

EDUCATION & RISK FACTORS

  1. Identify reversible causes

PHYSIOTHERAPY

  1. Resting days
  2. Exercise program
  3. Avoid heat and stress
  4. Use of assistive devices and gait aids like scooter

OCCUPATIONAL THERAPY

  1. Optimizing transfers
  2. Energy conservation: Pacing - Planning - Priorities - Positioning - Physical Fitness
  3. Energy conservation
  4. Environmental restructuring
  5. Work simplification

SOCIAL WORKER

  1. Social Supports
  2. Refer to Public Authority for Disability Affairs (PADA)

PSYCH

  1. CBT

MEDICATIONS

  1. Amantadine 100mg Twice Daily
  2. Modafinil 100 to 400 mg/day
  3. Methylphenidate

Cuccurollo 4th Edition Chapter 12 MS pg935-936

Braddom 6th Edition Chapter 46 MS pg995 Table 46.4 & pg996 Box 46.5

DeLisa 5th Edition Chapter 25 MS pg634-635

Ref: General principles.

32
Q

Describe an exercise prescription for MS 🔑🔑 Dr. Dia’a

What are contraindications to exercise in MS? 🔑🔑 Dr. Dia’a

A
  1. ENDURANCE
    • Aerobic training increases endurance
    • Arm cycling, walking, leg cycling, elliptical trainer
    • 30 minutes of moderate-intensity aerobic activity twice a week
    • Swimming at a cool temperature or aquatic exercise (<29 celsius)
    • Moderate-intensity physical activity is usually a 5 or 6 on a scale of 10
    • Talking but not singing a song during the activity.
    • Use cooling strategies; 50-70% VO2 max; 10-40 min duration.
  2. RESISTANCE
    • Light progressive resistive exercises prevent disuse atrophy
    • 10-15 Reps, 2 Sets, 2min Rest, Twice a week
    • Weight machines, Free weights, Cable pulleys, Elastic resistance bands
  3. FALL PREVENTION
    • Balance Exercises

CONTRAINDICATIONS

💡 MS worsens with heat, dehydration, and vigorous exercise.

  1. Acute exacerbation of MS
  2. Hot environment
  3. Exercises to point of fatigue (maximal and supramaximal exercise)

Cuccurollo 4th Edition Chapter 12 MS pg935-936

Braddom 6th Edition Chapter 46 MS pg995 Table 46.4 & pg996 Box 46.5

DeLisa 5th Edition Chapter 25 MS pg634-635

Ref: Multiple Sclerosis2008; 14: 35–53.

PassPMR - 05 Neurology (6 decks)

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