chp 19 Flashcards
What is MS? and what is the Charcots triad?
MS is the chronic inflammatory disease of the CNS and usually is referred to as the crippler of the young adults usually affect ages 15-30. Charcot’s triad is intention tremor, scanning speech, and nystagmus and paralysis even though its not part of the “triad”
Is the disease more common in men or women? What population is it found in mostly. What is the equator theory
Whites get especially in North America and that people that live farther away from the equator are more likely to get the disease due to vitamin D insufficiency due to less sun exposure.
Etiology of MS couple of ways “believed” people get MS
One is through herpes (I, II, and VI) and chlamydial pneumonia are the suspected agents leading to the disease. Some believe that it can be genetic
Pathophysiology
In patients with MS the CNS triggers Lymphocytes, macrophage’s, and immunoglobulin antibodies to attack and then in turn trigger proteins release the antigen is activated producing an autoimmune response and this leads to friendly fire. The blood brain barrier doesn’t prevent the t-lymphocytes cells from coming and attacking the myelin and this leads to dymyelinization and then the swelling and edema occurs and then the myelin becomes hardened and then this blocks nerve conduction
Gliosis is what ? What are the stages of MS pg. 779 box 19.1
Relasping Remitting MS - characterized by relapses with either full recovery or some neurological signs and symptoms and residual deficit upon recovery. periods between relapses are characterized of lack of progression
Primary Progressive MS (PPMS) not PMS- Very little recovery continues to progress. Might see a little bit of plateaus here or there but, mainly its all goes downhill.
Secondary Progressive MS - Characterized by initial relapsing- remitting course- followed by a progression with some bouts of recovery and remission. This occurs after you have relapse - remitting MS. It comes back and its worse than before.
Pogressive plapsing- Characterized by a an initial progressive- followed by a minor relapse. Usually only seen in people over the age of 40
Benign MS- Characterized as a minor disease in which patients remain fully functional in all neurological systems 15 years after disease onset.
Malignant MS (Marburgs Variant) - Intial onset that is very progressive and leads to extreme disability very fast or even Death
Pseudo exacerbation and Uthoffs effect
Refers to the temporary worsening of symptoms for a 24 hour period this is the pseudo exacerbation. It is characterized when MS patients go into hot weather this can usually exacerbate there symptoms and lead to these pseudo attacks.
Common symptoms seen in MS tell me about each Pain, Visual changes (scotoma, optic neuritis, Marcus Gunn Pupil) Motor dysfunction, Balance and Coordination (dysmetria, dyssynergia, and dysdiadochokinesia), Do these patients experience Spascity and Bowel and Bladder issues?
Just think manly anything that is controlled by the CNS can be affected so essential your whole body. Visual changes - scotoma- blank spot appears in the central line of vision, optic neuritis inflammation of the optic nerve can lead to blindness but it’s rare, Marcus Gunn pupil-Shinning bright light into the affected eye pupil will expand opposite what it is suppose to do.
Yes the patient can experience bowel and bladder issues incontinence, nocturia, dribbling, urinary frequency, diaherra, along with sexual dysfunction
Motor issues dysmetria- over estimating a target ether over hypermetria or under hypometria. Dyssynergia - abbreant muscle patterns, dysdiadochokinesia- trouble with reciprocal movement. Ambulation issues due to motor weakness
Fatigue is very common
Speech issues- Dysarthia - slurred or poorly articulated speech, Dysphonia- decreased vocal quality harshness or hoarseness or hyper nasal sounds Dyshpagia - trouble swallowing.
Mental changes- Euphoria- I fucking rule the world, Pseduobublar affect- uncontorlable laughing or crying. Depression is very classic as well.
Cognitive impariments- loss of memory, planning, decreased attention and concentration, abstract thinking decreases in some cases.
Imaging - what shows up in the CSF is MS is suspected
immunoglobin and the prescene of oligoclonal IgB bands Patients with PPMS have higher levels than RRMS
Prognosis
Very few die form disease however, very few also don’t continue on to the workplace. At 15 years 50 percent of patients will use a cane or other AD.
Benin and RRMS are more favorable and less problem causing than PPMS.
Age: Young age is usually more favorable after age 40 as mentioned previously the PPMS becomes more of a factor.
Neurological findings: at 5 years are one of the prognostic factors is the involvement of the pyramidal tracts and cerebellar signs.
MRI findings: Favorable prognostic factors include low total lesion, low active lesion formation, and negligible myelin or axon loss
Medicines that help with MS
Betaseron and inetferon Berta 1-a Avonex and rebiff. They prevent the T-cells from crossing the blood brain barrier and causing demyleination. Others inlcude Copaxone and Novantrone
Managing Spascity, Fatique, and pain what are the main meds
Spascity - baclofen Zanaflex and Valium
Pain- dilantin, tegretol, valium, neurotonin Fatique- coffee or red bull jk. Symmetrel.
Cognitive- zoloft, prozac, Aricept for alzhemiers
Bladder issues- usually dealt with by anticholinergic medications
Things that PT should look at during examination
Congitive, Affective, Sensation ROM, Visual Acutiy more so eye doctor, Muscle performance, Fatique, posture, balance gait and locomotion, name some other things
Congitive- should look at memory, concentration, and higher mental capabilities,
Affective- Look for signs of depression and anxiety
Muscle and Joint - MMT and ROM Ashworth spascity scale, signs of cerebellar issues (ataxia, nystagumus, intention tremor)
Visual- Double vision, nystagumus, light reflex
Balance and Gait, Temp sensation, Skin integrity Functional status (things like ADL's) Home/ Work environment, Aerobic capacity (vitals HR. BP, RR) BORG Rate of perceived exertion, General Health via the SF -36 or other similar exams
BOX 19.3 gives a breakdown of an overall exam
Managment of Skin name some strategies to decrease skin issues
Skin should be clean and dry, Skin should be inspected regularly, Clothing should be breathable and comfortable not to tight or loose, Regular pressure relief is essential reposition every two hours in bed or W/C maneuvers should be used to teach the patient how to reposition themselves.
How to relieve pain?
Regular stretching, lukewarm water, postural training to maintain normal curves of the spine, pressure stockings and pressure relief. TENS units gate theory of control to stimulate the SG and decrease the pain by increasing nonoxious stimuli.
How to exercise with MS patients name of ideas
Exercise opposite days of non-endurance days
50 to 70 percent of MVC? so basically moderate intensities, resistance training via weight machines, elastic resistance bands, or isokinectic machines. Circuit training. Precautions should be taken to prevent fatigue, Written and posted exercises for people with memory loss, Group exercise classes are great especially with the social support, Cooling suits or spray bottles with mist are good so the patient doesn’t experience overheating which can worsen the symptoms.
How to perform cardio with MS patients and risks to avoid what are the values to look out for?
Recumbent bikes are preferred for patients with balance issues. Arm bikes are also awesome ways to increase cardiovascular support along with reciprocal motion and toe clips and heel straps great for foot placement Performance measures include HR, ratings of precieved exertion, VO2
Termination Criteria- SBP >200 DBP> 115mmHG
decrease in oxygen uptake
Manage core body temp, Monitor fatigue, Be careful for certain meds Baclofen can cause muscle weakness, HCL may reduce fatigue so blinds really how tried they are.
Follow the FITT principal
Traning intensity should be between 60-75 of peak HR and 50 - 65 percent of VO2 max and the list goes on pgs. 798-799
Management of fatigue-
Think of Energy Conservation techniques like power wheel chairs instead of a walker. However, be careful patients don’t become dependent on the W/C
Keeping a diary for the day - rank activites that seemed really tough and those that didn’t require that much energy.
Activity Pacing - Is balance between doing activites along with adequate rest periods to enure that the patient doesn’t over do it.
In - home inspection should be done to ensure proper environment to help reduce possiblity of fatique like moving bed and counch into same move. Get a stair lift if nessecary, proper level of chairs AC is available etc. Stress management techniques - like deep breathing exercises
Management of Spascity
ice packs and wraps to decrease nerve conduction velocity. Eliminate any conditions that have heat, humidity, and stress
ROM exercises-
PNF Patterns
Air splints
light weights
LE extesion seems to dominate for any kind of LE flexion and trunk rotation aka LE trunk rotations on ball Lumbar Rocks sometimes referred as.
baclofen
Management of Coordination and Balance
Lots of MS patients have cerebellar issues and should do the typical prone–> quadreped–> kneeling 1/2 kneeling –> platingrade–> standing
vary up the BOS
Joint Approximation (compression on joints primaryl hips and shoulders)
PNF
Aquatics are great to help increase balance due to the prinicples of buyoancy and other various water properties.
Stable to unstable surfaces etc..
Improving Locomotor issues
BWSS if available parallel bars if available Strengthening quads and hip abductors usually the muscles you want to focus on. Assitive device training and proper gait patterns. If the disease develops then might have go to a W/C.
Explain what PT do in terms of functional training and what OT does.
Bed mobility, transfers and locomotion done by PT. OT does the “shitty” work such as bathing, tolieting, and feeding. Speech with ST.
Who does the cognitive training
neuro-psychologist maybe determine the strengths and weaknesses of the patient
