8 Multiple Sclerosis Flashcards
MS Etiology
2.3 million people worldwide
Women 2-3x more likely than men
Most commonly diagnosed 25-35 y/o
Strong correlation between MS prevalence and distance from equator- vit D may be a factor
Factors that may cause MS
Lower risk closer to equator
Smoking increases risk
Higher risk if parent or sibling has it
Human herpes virus-6, Epstein-Barr, chlamydia pneumoniae bacteria, canine distemper, measles
Pathology of MS
Acute demyelination of axons- recovery with axonal plasticity/re-myelination early on, but permanent axonal damage later on
McDonald criteria overview
Dissemination in time- 2 or more distinct attacks
Dissemination in space- 2 or more lesions in CNS
Exclusion of other diagnoses
McDonald criteria for diagnosis
2 attacks + 2 lesions = no additional info needed
2 attacks + 1 lesion = need diss in space
1 attack + 2 lesions = need diss in time
1 attack + 1 lesion = need both
Progressive course over 1 year- need diss in space by two of: MRI brain, MRI SC, CSF fluid oligoclonal bands
MRI types
T1- detects active inflammation
T2- detects old and new lesions
FLAIR (fluid attenuated inversion recovery)- subtle changes
Evoked potentials
Sensory- impulses to arm or leg
Brainstem auditory- listen for series of clicks in each ear
Visual- observe alternating checkerboard pattern, identifies pathologic transmission along optic nerve pathway, only type proven useful in MS diagnosis
CSF analysis
Obtained via lumbar puncture
Findings- IgG, oligoclonal bands, certain proteins common with myelin breakdown (immune-related markers)
Not specific to MS
Sensory and pain symptoms
Paresthesias (most commonly begin distally)
Loss of proprioception and vibratory sense
Dyesthetic pain (pain not provoked by stimulus)
Visual symptoms
Optic neuritis- blurred vision, change in color perception, visual field deficit = most common
Nystagmus
Oscillopsia
Intranuclear opthalmaplegia (disconjucate eye movements)
Optic disc pallor
Heat intolerance symptoms
Sensitivity to changes in core body temperature
Uhthoff phenomenon- increase in body temp causes increased in neurologic symptoms
Neuroblockade hypothesis- increased temp decreases nerve conduction in partially demyelinated fibers (greater demyelination –> greater conduction loss)
Primary MS fatigue
Central fatigue- demyelination leads to failure of motor pathways during rapid activity
Decreased efficiency of motor unit activation- dec oxidative capacity, slow muscle contractile properties, decrease number of slow-twitch fibers, lower tetanic and twitch tension in muscles
Cerebellar symptoms
Ataxia, incoordination, dizziness, imbalance
Urinary symptoms
Incontinence, incomplete emptying, increased frequency
Can get UTIs
Cognitive symptoms
Emotional lability, depression, anxiety, decreased executive functioning
Krutzke expanded disability status scale (EDSS)
0 (no disability) to 10 (death)
0-4.5 can walk independently
5.0-9.5 impairments in ambulation
Functional systems- pyramidal (motor function), cerebellar, brainstem, sensory, bowel and bladder, visual, cerebral or mental, other
FS scored 0 (low level of problems) to 5 (high level)
EDSS cutoffs
- 0- minimal disability in one FS (one S grade 2, others 0 or 1)
- 0- ambulates without aid or rest 200 m, disability severe enough to impair ADLs
- 0- essentially restricted to bed or chair but may be out of bed much of day. Retains many self-care functions
Relapsing-remitting
Most common 80%
Temp relapses lasting 1-3 months, complete or partial recovery between
Secondary-progressive
Second phase of RRMS if not treated
Progressive worsening, may or may not have relapses and remissions
Primary progressive
Steady worsening, no relapses or remissions
Progressive-relapsing
Steady worsening with intermittent acute flare-ups
Malignant MS
Rapid and progressive
Prognostic factors
Positive- RRMS, one symptom at onset
Negative- PPMS, older age at onset, male, African-American, early cerebellar or pyramidal signs, smoking, low vit D
Relapse/exacerbation management meds
Corticosteroids- IV or oral, high dose, short duration
Function of disease-modifying meds
Reduce number and severity of relapses
Reduce development of new areas of inflammation
Delay disability progression
Most act as immune-system modulators
Injectable disease-modifying meds
Avonex (interferon beta-1a)
Betaseron (interferon beta-1b)
Copaxone (glatiramer acetate)
Rebif (interferon beta-1a)
Oral disease-modifying meds
Aubagio (teriflunomide)
Gilenya (finfolimod)
Tecfidera (dimethyl fumarate)
Infused disease-modifying meds
Novantrone (mitoxantrone)
Tysabri (natalizumab)
Lemtrada (aletuzumab)
Exercise effects for MS
No decrease in pro-inflammatory or anti-inflammatory markers
No increase in neurotrophic factors
Correlation high aerobic capacity and structure preservation
No worsening, possible improvement in fatigue
Significant improvement in depressive symptoms and QOL
Trend to improved cognition
Improved muscle strength
Improvement in aerobic capacity
Gait speed and endurance improvements
Self-perceived ability to do ADLs trend for improvement
Gait training results
Increase in swing time, step length, stride length, foot angle
Decrease in time in stance and DL support and toe clearance
Improved isometric strength, disability score, 3-minute stepping
Treadmill training results
30 min 3x/week at 55-85% max HR
Significant increase in gait speed
Trend to improved endurance and fatigue levels
Faster rate of detraining
Results of aquatic therapy
Improved QOL/ decreased fatigue
Improved gait speed, BBS, TUG, grip strength
Decreased neuromuscular deficits
Fatigue impact
No significant difference in EDSS scores between low and high fatigue groups
Higher levels of fatigue reported = greater impairments in functional mobility, depression, physical and mental QOL
Disability not related to level of fatigue
Effects of exercise on fatigue
No significant change in fatigue after exercise
No significant change in functional ability after exercise
Increased symptoms may happen after exercise, but temporary and unlikely to have deleterious effects on fatigue and function
Exercise parameters to reduce fatigue
Endurance, resistance, and combined training
2-3 days/week, 60-80% max HR, 30 minutes/day
Acute care EDGE highly recommended measures
12-item MS walking scale 9-hole peg test BBS MS impact scale (MSIS-29) Timed 25-foot walk TUG cognitive and manual
12-item MS walking scale
Questionnaire to measure ability to ambulate
12-60 points (higher number = greater disability)
No cut-offs
9-hole peg test
Measures finger dexterity- time to place all pegs in holes and return to container
No cut-offs, but norms for different populations
MS impact scale (MSIS-29)
Questionnaire measuring physical and psychological impact of MS on daily life
1 (no impact)- to 5 (extreme impact)
No cut-offs
Timed 25-foot walk
Quantitative measure of mobility and leg strength
Average 2 timed trials
No cut-offs
TUG cognitive and manual
Cog- backwards by threes
Man- hold cup of water
Manual- 14.5 seconds or longer, difference of 4.5 seconds between manual and TUG
Cognitive- 15 seconds or longer
Inpatient and outpatient rehab EDGE highly recommended
12-item MS walking scale 6MWT 9-hole peg test BBS DHI MS functional composite MS impact scale MS quality of life Timed 25 foot walk TUG cognitive and manual
Dizziness handicap inventory
0-100 (higher score is greater handicap)
>59 risk for falls in MS
MS functional composite
Evaluates cognition, gait, and UE function in individuals with MS
Includes timed 25-foot walk, 9-hole peg test, paced auditory serial addition test
Convert to z-score, averaged
MS quality of life (MS QOL-54)
Focuses on physical health and mental health for MS
No overall score, but summary for physical and mental health weighted based on combo of scale scores
Each question is Likert scale
