CNS CLASS 10 - MS Flashcards
Multiple sclerosis is the one of the most common non-traumatic _______ _______ affecting young and middle-aged adults.
neurological conditions
T/F Canada has one of the LOWEST rates of multiple sclerosis (MS) in the world, with an estimated over 100K Canadians living with the disease.
FALSE HIGHEST
T/F As of 2013, Canada ranked fifth globally for number of cases.
TRUE
On average, _____ Canadians are diagnosed with MS everyday. Most people are diagnosed with MS between the ages of 20 and 49. In Canada, ___ is the average age of MS diagnosis. ___ % of people in Canada living with MS are female. Females are ___ times more likely to be diagnosed with MS than males.
12
43
75
3
T/F Overall incidence appears to be on the increase, although it is difficult to distinguish to what extent this finding reflects improvements in diagnostic technology. It is also presumed that many mild cases are never diagnosed.
TRUE
T/F One of the most compelling features of multiple sclerosis for health care practitioners is that no two cases are exactly alike.
TRUE
Discrete areas of damage develop in the ____, ____ ____ and _____ ______?
brain, spinal cord, and optic nerves.
They are random and unpredictable, both in location and in number. The symptoms each person exhibits are determined by the particular pathways disrupted in their brain. The body functions most commonly affected are (name 7)
vision, coordination, speech, strength, sensation, bladder control, and sexual function.
MS is not a terminal disease?
TRUE
T/F Conditions secondary to MS, like pneumonia, may cause death in severely affected individuals, but most live normal lifespans.
TRUE
T/F There is no cure, however, and MS is a disease which can greatly affect quality of life - the unemployment rate for people living with MS is a 60-80%.
TRUE
There appear to be several benefits that massage therapy can offer MS patients. The biggest contribution is in easing secondary effects of the disease in the body’s ____ ____. These ____ ____ changes, which impair mobility and function, can greatly reduce the quality of life of people with multiple sclerosis.
soft tissues (X2)
a proteolipid sheath which covers most of the axons which conduct nerve signals.
Myelin
In the central nervous system, myelin is made by ______ , whose myelin bundles are actually wrapped layers of cell membrane. Each ______ provides myelin to small regions of densely packed axons. Any given axon will have myelin bundles along its length supplied from a number of ______
oligodendrocytes (X3)
The myelin insulates the cell membranes of neighbour neurons to avoid mixing or confusing of ______ and improves the ability of the axon to carry ____ ____ , speeding up the ____ of impulses.
impulses
action potentials
conduction
Any process which results in myelin sheaths being lost or destroyed.
Demyelination
T/F MS is the most common demyelinating condition in the PNS.
FALSE IT’S IN THE CNS
the characteristic lesion of MS.
Plaque
When the disease is active, ____ destruction occurs in localized patches. The stripped sections appear as greyish-coloured spots in the white matter. ____ average 1-15 mm in size.
myelin
Plaques
An active plaque site is an ________________ _________________lesion with large numbers of infiltrating lymphocytes and macrophages
Edematous Inflammatory
These immune cells consume _____ and attack ______, rapidly killing them off. Chunks of _____ are transferred from the neurons to the large ______.
myelin
oligodendrocytes
myelin
macrophages
______, the major supporting and structural cells in CNS tissue, migrate to the site.
Astrocytes
______ role is to react to the injury by congregating together and synthesizing fibre processes to form a living scar_______
Astrocytes
GLIOSIS
These lesions are called plaques because the _____ fibres make them harder than the surrounding tissue. Old inactive _____ are fields of _____ demyelinated axons with gliosis filling the intervening spaces where the_____ bundles used to be.
glial
plaques
permanently
myelin
describes a period of active demyelination, often referred to as a relapse or ‘flare-up’.
Exacerbation and Remission
T/F The rate at which people with MS have exacerbations is very variable, but the average is every seven months.
FALSE IT’S EVERY EIGHTEEN MONTHS
_______ is the period between exacerbations and can signify complete disappearance of the disease.
Remission
When an ______ occurs, the most common presentation is sudden onset of neurological symptoms, usually over a period of several hours to a few days.
exacerbation
The symptoms last for 6-8 weeks, then gradually resolve over 2-3 months. Depending on the stage and severity of the disease, the remission may return the person to normal or near normal function, or there may be considerable new disability. Name these two periods of active demyelination?
Exacerbation and Remission
T/F MS is an inflammatory disease resulting from an autoimmune reaction.
TRUE
Immune system cells, responding to an unknown stimulus, accumulate in venules in the___ and exit the bloodstream into the ____. Once there, they attack____ , and in their wake leave a collection of ____ . The location of these plaques, while quite random, tends to be denser around blood_____ and the _____.
CNS
tissue
myelin
plaques
vessels
ventricles
It is believed that a component of myelin called myelin _____ _____ is the target of the attack. The theory is that the person’s ____ ____ ____ was breached, allowing immune cells which are normally excluded to enter the ____ tissue environment. These cells release chemicals that cause inflammation and damage to the _____, the _____ and the _____. The cells appear to make a determination that myelin is a potentially _____ substance (in other words they perceive it as an antigen). _____ against it are prepared for use at a future time.
basic protein
blood brain barrier
CNS
myelin, neurons and oligodendrocytes
threatening
Antibodies
When myelin is stripped away, the uncovered axon sections do not have sufficient ionic channels for _____ and the axon transmits poorly, if at all. _____ which does occur requires high energy expenditure by the neuron. Firing may be erratic or inappropriate due to loss of the insulation which prevents spontaneous or spill-over signals. A broader dysfunctional effect is produced because transmission in other parts of the____ is dependent on timely, stimulus-appropriate signals along the affected pathways.
depolarization
Conduction
CNS
When the disease goes into an _____ phase, attacks ensue at one or more locations. The _____ may be new or they may be _____ at old sites._____ takes 1-2 weeks. One type of microglia (the resident _____ of the CNS) promotes inflammation and _____ damage.
exacerbation
plaques
reactivations
Demyelination
macrophages
oligodendrocyte
The phagocytosis of myelin debris by a second subgroup of microglia plays an important role in the initiation of ______ Oligodendrocytes reappear at the site and begin remyelinating the axons. A small number may be survivors of the attack, but most have been formed by replication of nearby healthy cells. For most individuals in the early stages of the disease, the______ do excellent damage repair, restoring normal or near normal function. This is where the _______/_______ cycle comes from.
remyelination
oligodendrocytes
exacerbation/remission
After repeated attacks, especially at the same site, the_____ become less _____ . Their failure to maintain the cycle of repair is probably due to the cumulative effects of multiple _____. Eventually the oligodendrocytes disappear or become completely_____. As the plaque progresses from acute active to chronic inactive, its edema resolves, inflammation decreases, and microglia gradually disappear. Astrocytes produce _____ fibers, and ultimately a glial scar fills the demyelinated plaque (____ ____ ____). These characteristics prompted Charcot to name the disease “sclerose en plaque” and are also responsible for the distinctly demarcated, firm, retracted, and brownish discoloration of the long-standing chronic MS plaques on gross pathology images.
oligodendrocytes
effective
insults
dysfunctional
glial
astrocytic fibrillary gliosis
T/F In time there is often joining up of nearby plaques, creating larger fields of impulse conduction disruption.
TRUE
T/F Symptoms are most severe during an exacerbation and subside either partially or completely once it is over
TRUE
The axons are eventually damaged, and axonal damage/loss and the development of_____ inactive_____ are the major determinants of profound neurological deficit in MS sufferers.
permanent
plaques
T/F Exacerbations cannot occur at any time, but are more likely if the person’s overall health is impaired.
FALSE THEY CAN HAPPEN AT ANY TIME!
T/F Chronic symptoms can also worsen for short periods, for example if the person is ill.
TRUE
T/F Not everyone with MS has a well-defined course of exacerbations and remissions.
TRUE
T/F Some have an extreme form of the disease with little or no remission time, while others have only one or two exacerbations in their lifetimes.
TRUE
T/F Some people do not have exacerbations, but instead display a low-grade chronic type of disease.
TRUE
T/F As the disease progresses, in most individuals there is less distinction between states of flare-up and remission.
TRUE
Each person experiences a unique chronology of these events. As the disease progresses, there can be a variety of acute, subacute, and inactive _____ scattered throughout ____. The resulting disability pictures range from clinically insignificant to totally physically disabled.
lesions
CNS
T/F The cause of MS is not known
TRUE
Scientists believe ____ is triggered by a combination of factors: immunological, environmental, infectious, and genetic factors
MS
One gene that plays a key role in MS that has been best studied is the ___ ____ ___
HLA- DRB1 gene
HLA- DRB1 gene belongs to the ____ ____ _____ (aka)
human leukocyte antigen (HLA) complex family
The ____ complex allows the immune system to discriminate
between the body’s own proteins and proteins made by foreign
invaders (like viruses or bacteria). ____ genes come in different
variations, which makes the immune system apt to respond to foreign invaders.
HLA (X2)
Changes in many HLA genes have been linked to increased ___ risk, with the HLA-DRB1 1501 variation the strongest associated genetic change related to ___ development.
MS (X2)
_____ and _____ (lymphocytes) are two important immune cells that play a role in the abnormal immune response caused by MS.
T-cells and B-cells
T cells and B cells become activated in the ____ system and in MS, enter the CNS through ____ vessels. Once in the CNS, these cells release chemicals that cause inflammation and damage. This results in damage to _____ , _____ and _____. T cells call on other immune system cells to participate in the immune _____.
lymph
blood
myelin, nerve fibres and oligodendrocytes
attack
T _____ cells, a type of T cell, dampen or turn off inflammation. In MS, T _____ cells do not function correctly and do not effectively turn off inflammation.
regulatory (X2)
______ or “killer” T cells directly attack and destroy cells bearing certain characteristics.
Cytotoxic
B and T interact to lead the B cells to produce _____ and stimulate other proteins and in ____ , these cause damage in the____.
antibodies
MS
CNS
read MS pages 9 - 13
I said read them dammit!!!
T/F MS is notoriously not difficult to diagnose.
false it is notoriously difficult to diagnose
Explain why MS is notoriously difficult to diagnose?
This is because it has a non-specific group of symptoms which come and go. Diagnosis takes days to years, and frequently is given as probable rather than definite, with the final diagnosis depending on the clinical behaviour of the disorder over time and when other potential causes for symptoms have been ruled out.
T/F This reality is a difficult one for people with MS. They are frequently misdiagnosed, including psychiatrically. As well, attempts to address their early symptoms as individual problems do not usually produce results until the underlying MS cause is unmasked. Practitioners like massage therapists can play an important role in observing patterns of symptom development and recurrence, and in suggesting neurological consultation in cases where MS may be an explanation.
TRUE
T/F There is no specific diagnostic test for MS - the diagnosis is fundamentally clinical
TRUE
It helps if the person has characteristic symptoms when diagnosing, for example
(give 5 examples)
optic neuritis, paraesthesias or weakness in the limbs, vertigo, or urinary incontinence/urgency.
In order to make a diagnosis of MS, the physician must, find evidence of damage in at least two separate areas of the central nervous system (CNS), AND ________ ___ ________. Find evidence that the damage occurred at different points in time AND_____ __ _____ along with rule out all other possible diagnoses
dissemination in space
dissemination in time
_____ _____ _____ is sampled via a lumbar puncture (spinal tap) to detect the oligoclonal bands
presence of particular proteins (antibodies), called ______________________, which are known to be present with inflammation in the CNS. This helps narrow the diagnosis but does not specifically diagnose MS since there are other possible causes of the same findings.
Cerebral spinal fluid
oligoclonal bands
The ___ can be used to look for a second area of damage in a person who has experienced only one exacerbation of MS-like symptoms — referred to as clinically-isolated syndrome (CIS). The ___ can also be used to confirm that damage has occurred at two different points in time.
MRI (X2)
_____ _____ _____ testing measures the speed of nerve impulse conduction in the pathways of the central nervous system. In MS, nerve impulse conduction is slowed related to the myelin damage, and EP’s can record this slowing. There are three types of EP used for MS diagnosis: visual, auditory, and somatosensory.
Evoked Action Potential (EP)
T/F Perhaps the most exceptional thing about multiple sclerosis is that it has no unique symptoms or characteristic clinical presentation
TRUE
T/F Because MS can involve all parts of the central nervous system it manifests a large variety of symptoms in both the physical body and the personality
TRUE
T/F Symptoms won’t fluctuate over time in the same individual, and are never exactly the same in any two people with MS.
FASLE THEY WILL FLUCTUATE OVER TIME
T/F To work safely and effectively with patients with multiple sclerosis, the massage therapist needs an appreciation of the range of symptoms that can be encountered, as well a good understanding of the issues that can arise in treatment planning.
TRUE
T/F There is no characteristic pattern of onset. Some people suddenly develop acute deficits while others have years of seemingly unrelated mild transient symptoms.
TRUE
T/F The course of the disease is similarly unpredictable
TRUE
Some commonalities deserve comment: for example, symptoms usually appear sooner in the_____ limbs and remain more severe.
lower
Another commonality is that the limbs typically progress in assymetrical _____ patterns, so that each limb will likely present ______ on clinical observation.
unilateral
differently
T/F Almost every neurological symptom has been seen in MS
TRUE
_____ is a primarily grey matter disorder in MS
Aphasia
T/F Eyesight disabilities affect almost
everyone who has MS, and eyesight
problems often appear early in the
disease
TRUE
_____ _____ is the most common reason, but all
of the visual components of the brain
are susceptible
Optoc Neuritis
_____ _____ usually occurs unilaterally, causing
rapid onset of vision loss in the
affected eye, usually accompanied
by light sensitivity and pain behind
the eye which is increased by eye movement. The resulting impairment is usually a central blind spot in the visual field called _____ , but many presentations can occur.
Optoc Neuritis
Scotoma
Also common are blurred vision, double vision _____ , and impaired coloUr perception, as well as several disorders of ocular mobility including ________ (the eyes move rapidly back and forth, usually horizontally, when attempting to focus on an object)
diplopia
nystagmus
jumping images
oscillopsia
unilateral or bilateral, full or partial, failure of one eye to adduct while the other abducts
ophthalmoplegia
T/F Total blindness is not common, although many people with MS are legally blind.
TRUE
T/F Somatosensory symptoms are the first to appear in about half of MS cases
TRUE
Somatosensory symptoms are the first to appear in about half of MS cases. They range from sensory reduction and loss AKA ________ , ________ to extremes of sensitivity AKA _________
Many types of abnormal sensation, usually types of _________ like skin-crawling, are also customary. Painful paraesthesias (________) are also typical.
hypaesthesia, anaesthesia
hypereasthesia
paraesthesias
dysesthesias
T/F The zones of altered sensation are random and often patchy. (SS)
TRUE
T/F Symptom distribution corresponds to dermatome, peripheral nerve, or homuncular patterns. (SS)
FALSE Symptom distribution does not correspond to dermatome, peripheral nerve, or homuncular patterns.
The MS ____ is a first symptom of MS or a relapse and is a squeezing sensation around the torso that feels like a blood pressure cuff when it tightens._____ and _____ are common locations. (SS)
Hug
Abdomen and thigh
Although it can appear in other conditions, _______ Sign is fairly characteristic of MS (SS)
Lhermitte’s
Indicating dorsal column involvement, it is an electric shock or buzzing sensation down the back (and sometimes the extremities) when the head is flexed forward. (SS)
Lhermitte’s Sign
T/F Problems with proprioception are also fairly standard, as are impairments of vibratory sense. (SS)
TRUE
Taste abnormalities are rare and hearing deficits are uncommon, although episodes of transitory hearing loss and ________. (SS)
tinnitus
T/F Sensory disabilities tend not to accumulate, especially in more chronic progressive types of MS. Each person will have a highly individualized pattern of sensory abnormalities.
(SS)
FALSE Sensory disabilities tend to accumulate
MOTOR SYMPTOMS SHORTCUT
MOSY
Motor tracts in the brain, ______ , and spinal cord are all typically affected by multiple sclerosis. The result is a preponderance of_____ symptoms in most cases. (MOSY)
brainstem
motor
T/F Problems with walking and gait are considered a chief disabling aspect of MS. (MOSY)
TRUE
Problems with walking and gait are considered a chief disabling aspect of MS. One of the most common is _____/_____ (drunken sailor’s gait). The person has an uncoordinated lurching style of walking and often loses balance when turning
(MOSY)
dystaxia/ataxia
Tremors are also common, in particular _____ tremor, which involves increased shaking of the body part as the person tries to perform a focused action, such as reaching for a cup.
(MOSY)
intention
Disorders of tone are paramount, and range from_____ to severe _____. Particularly challenging to the bodywork professional is the fact that different body parts can experience different tone disorders simultaneously. In other words one lower limb may be spastic and the other rigid, while one arm may have low tone and intention tremor and the other may be quite normal.
(MOSY)
hypotonia
spasticity
Painful cramping and spasms are a frequent ordeal. In progressive forms of MS, the symptom picture will tend over time to standardize as _____ _____ _____ . This reflects a large scale loss of transmission of higher centre signals to the musculature.
(MOSY)
quadriplegic spastic paralysis
T/F Hyperactivity of the stretch reflexes is seen in a minority of individuals
(MOSY)
FASLE - Hyperactivity of the stretch reflexes is seen in a majority of individuals
Rapid intermittent tonic contractions, either discretely or as part of a spastic response) is common, especially at the ankle
(MOSY)
Clonus
People with MS often report subjective feelings in the limbs which correspond to motor dysfunction. The most recurrent are clumsiness, stiffness, and “heaviness” of body parts. ______ (movement hallucination) is a common experience and reflects abnormalities of cerebellar/brainstem pathways.
(MOSY)
Vertigo
an involuntary rapid flickering movement of the facial muscles, is fairly typical.
(MOSY)
Facial Myokymia
is facial muscle paralysis from loss of function in cranial nerve VII. When there is no obvious cause, _____ _____ in a young person should be investigated for MS.
(MOSY)
Bell’s Palsy
(difficulty swallowing) is another motor disability which can create numerous problems.
(MOSY)
Dysphagia
Speech impairment is very common in multiple sclerosis. There are two primary manifestations:
dysarthria and scanning speech
a problem with control (often because of spasticity) of the muscles involved in speaking
dysarthria
usually seen in advanced cases, in which each word or syllable receives equal emphasis, giving the speech a monotonal disconnected quality.
scanning speech
______ is one of the most common symptoms of MS, occurring in about ___ % of people and is one of the primary causes of early departure from the workforce. ______ may be the most prominent symptom in a person who otherwise has minimal activity limitations
Fatigue
80%
Fatigue
MS fatigue is different from other types of fatigue in that it can you name the 8 points?
- Generally occurs on a daily basis
- May occur early in the morning, even after a restful night’s sleep
- Tends to worsen as the day progresses
- Tends to be aggravated by heat and humidity
- Comes on easily and suddenly
- Is generally more severe than normal fatigue
- Is more likely to interfere with daily responsibilities
- Does not appear to be directly correlated with either depression or the degree of physical impairment.
results from the decline in conductivity of nerve fibre in the CNS.
nerve fibre fatigue
a related problem which stems from the need to consciously work on functions which are normally automatic
cognitive tiring
T/F There are also direct effects of the presence of plaques in brain centres influencing personality and emotional expression. These produce changes in mood, in the feeling of inhabiting one’s body, and in emotional expression.
TRUE
T/F There can also be problems with emotional control, such as pathological laughing or weeping.
TRUE
Depression is very common in multiple sclerosis, especially during an ________
exacerbation
a sustained state of cheerfulness, happiness, and ease not based in the person’s reality, is reasonably common in more advanced cases. It is a permanent change in personality and frame of mind, as though the person has become disassociated from objective knowledge.
Euphoria
Once considered a rather fortunate adaptation, euphoria is now viewed with more concern, since when questioned many euphoric subjects describe feeling depression and loneliness
Euphoria
Reduced cognitive function is reasonably common, although only in mild forms. More than half of all people with MS will develop problems with cognition. Certain functions are more likely to be affected than others: 6 POINTS
Information processing (dealing with information gathered by the five senses)
* Memory (acquiring, retaining and retrieving new information)
* Attention and concentration (particularly divided attention)
* Executive functions (planning and prioritizing)
* Visuospatial functions (visual perception and constructional abilities)
* Verbal fluency (word-finding)
________ is a frequent problem which may respond to massage therapy.
Constipation
A patient may also have problems with urinary frequency and urgency, perhaps proceeding to incontinence and the need for catheterization.
Kidney damage may occur from the effects of abnormal reflexes impairing bladder emptying and leading to recurrent urinary tract infections.
FYI
T/F Most people with MS are particularly intolerant of heat
TRUE
There is a common impression that pain is not a regular feature of MS, but this is often not true. Pain can result when plaques directly impair the________ pathways
spinothalamic
______ muscle pain is also a frequent consequence of rigidity and spasticity.
Ischemic
T/F Abnormal postures and imperfect limb usage can lead to painful syndromes.
TRUE
Neuralgias are common - _______ _________ is particularly frequent in MS
Trigeminal Neuralgia
Neuralgias are frequent in MS __________which is often an abnormal burning type of pain resulting from normally non-painful stimuli like touch and pressure.
dysesthesia
________ which are the result of abnormal electrical discharges in an injured or scarred area of the brain, are fairly uncommon in MS. Their incidence has been estimated at 2-5 percent, compared to the estimated 3 percent incidence of ________ in the general population.
Seizures (X2)
The Secondary Symptom Picture
READ PG 20/21
a first episode of neurologic symptoms caused by inflammation and demyelination in the central nervous system. The episode, which by definition must last for at least 24 hours, is characteristic of multiple sclerosis but does not yet meet the criteria for a diagnosis of MS because people who experience a___ may or may not go on to develop MS.
Clinically Isolated Syndrome (CIS)
CIS
T/F When CIS is accompanied by lesions on a brain MRI (magnetic resonance imaging) that are similar to those seen in MS, the person has a less likelihood of a second episode of neurologic symptoms and diagnosis of relapsing-remitting MS
FASLE When CIS is accompanied by lesions on a brain MRI (magnetic resonance imaging) that are similar to those seen in MS, the person has a high likelihood of a second episode of neurologic symptoms and diagnosis of relapsing-remitting MS
T/F When CIS is not accompanied by MS-like lesions on a brain MRI, the person has a much lower likelihood of developing MS.
TRUE
T/F Even with early treatment of CIS with disease-modifying therapy has been shown not to delay onset of MS.
FALSE - Early treatment of CIS with disease-modifying therapy has been shown to delay onset of MS.
the most common disease course
Relapsing-remitting MS (RRMS)
is characterized by clearly defined exacerbations of new or increasing neurologic symptoms. These exacerbations are followed by periods of partial or complete recovery (remissions). During remissions, all symptoms may disappear, or some symptoms may continue and become permanent. However, there is no apparent progression of the disease during the periods of remission.
Relapsing-remitting MS (RRMS)
_______can be further characterized as either active (with relapses and/or evidence of new MRI activity over a specified period of time) or not active, as well as worsening (a confirmed increase in disability following a relapse) or not worsening.
Relapsing-remitting MS (RRMS)
Approximately ___% of people with MS are initially diagnosed with ____.
85%
RRMS
follows an initial relapsing-remitting course. Some people who are diagnosed with RRMS will eventually transition to a_______ progressive course in which there is a progressive worsening of neurologic function (accumulation of disability) over time.
Secondary progressive MS (SPMS)
secondary
is characterized by worsening neurologic function (accumulation of disability) from the onset of symptoms, without early relapses or remissions.
Primary progressive MS (PPMS)
T/F Approximately 45% of people with MS are diagnosed with PPMS.
FALSE - 15%
