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PMR 05 - Neurology > Day 5 - Multiple Sclerosis > Flashcards

Day 5 - Multiple Sclerosis Flashcards

1
Q

Definition & Pathology of MS

A

Multiple sclerosis (MS) is the most common demyelinating disease of the central nervous system (CNS) due to immune-mediated inflammation & formation of hallmark white matter plaques → demyelination, relative axonal sparing, and brain atrophy.

Acute lesions: remyelination may occur, which results in a “remission.”

Chronic lesions: older plaques become sclerosed

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2
Q

Four main types of disease course in MS 🔑

A

Relapsing-remitting (RR MS)

The most common pattern: 85% to 90% begin with RR MS

Return to baseline or mild disability

Secondary progressive (SP MS)

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

Primary progressive (PP MS)

10% of cases at disease onset & worst prognosis

Progressive Relapsing (RP MS)

Clinically Isolated Syndrome

  • A first attack compatible with MS, with evidence of inflammation and demyelination
  • Typically lasts a minimum of 24 hours
  • Does not yet meet criteria for MS
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3
Q

MS commonly seen in

A
  1. Females > males 2:1
  2. Mean onset age 30
  3. Low vitamin D
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4
Q

Good vs Poor Prognostic Indicators 🔑

A

Ibn Sina “Good”: Female, ambulatory, young, optic, good recovery, RR..

  1. Female sex, Younger age at onset (less than 35 years of age)
  2. Monosymptomatic
  3. Sensory optic neuritis
  4. Sudden, good recovery with long remission (RR type)
  5. Low disability
  6. Ambulatory

Poor

  1. Male sex, Older at onset (age more than 35 years)
  2. Polysymptomatic
  3. Motor (first sign) ataxia and tremor
  4. Rapidly progressive
  5. High disability
  6. Non-ambulatory
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5
Q

List 6 Diagnostic Workup (Non-Blood) 🔑🔑

A
  1. MRI of the brain and spinal cord (Test of choice)
  2. CSF analysis (Lumbar puncture) → oligoclonal banding
  3. Visual evoked potentials (VEPs)
  4. Somatosensory evoked potentials (SSEPs)
  5. Brainstem auditory evoked potentials (BAEPs)
  6. NCS & EMG

Ref: Cucurollo

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6
Q

List 5 Hallmark location of demyelination 🔑

A

Dissemination in space, lesion in two out of five areas:

  1. Cortical
  2. Juxtacortical
  3. Periventricular
  4. Infratentorial (Cerebellar)
  5. Spinal Cord

Extra

  1. Brain stem
  2. Optic nerve
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7
Q

List 6 Differential Diagnosis of MS 🔑

A
  1. Systemic lupus erythematosus
  2. Rheumatoid arthritis
  3. Vasculitis
  4. Vitamin B 12 deficiency
  5. Transverse myelitis
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8
Q

3 Most Prevalent Symptoms of MS

3 Problems Affecting ADLs Reported by Patients

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
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9
Q

Five Domains of Motor Symptoms in MS, What to examine?

A
  1. Fatigue
  2. Spasticity
  3. Weakness
  4. Balance
    1. Cerebellum: DANISHP
    2. Dorsal columns: impairment of deep sensation, and proprioception
  5. Bulbar
    1. Dysarthira
    2. Dysphagia
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10
Q

Five Domains of Non-motor Symptoms in MS, What to ask?

A

Cognition: memory, attention, processing speed, learning

Cranial Nerves

  1. Optic n. Optic neuritis
  2. CN 3,4,6 : diplopia, internuclear ophthalmoplegia
  3. CN 5: Facial numbness
  4. CN 8: Deafness, tinnitus, vertigo, vomiting
  5. CN 9,10,11: Dysphagia

Sensory

  1. Pain: Dysesthetic; painful spasms
  2. Heat sensitivity (Uhthoff phenomenon)

Bladder, bowel dysfunction

Bed Questions

Sleep disorders, obstructive sleep apnea (OSA), restless legs syndrome

Mood: impaired emotional responses, depression

Sexual dysfunction

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11
Q

List 4 Common Signs in MS🔑

A
  1. Lhermitte’s sign

Passive neck flexion causing an electric, shock-like sensation radiating to the spine and
shoulders → Increased sensitivity of the myelin to stretch or traction.

  1. Uhtoff’s phenomenon

Exacerbation of fatigue, weakness and other symptoms when exposed to high temperatures or increased body temperature

  1. Tic douloureux

Painful trigeminal neuralgia

  1. Upper motor neuron signs

Spasticity, Hyperreflexia, Positive Hoffman and Babinski responses

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12
Q

Acute Attacks Tx for MS

A

Methylprednisolone (1g for 3-7 days)

Decrease length of exacerbation and return to pre-morbid function

Does not prevent further attacks or alter disease progression

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13
Q

Acute and chronic S/E of corticosteroid

A

Acute

  1. Gastrointestinal (GI) disturbance
  2. Fluid retention
  3. Electrolyte imbalance
  4. Mood swings
  5. Insomnia
  6. Acne
  7. Hyperglycemia
  8. Hypertension

Chronic

  1. Hypertension
  2. Osteoporosis
  3. Diabetes
  4. Weight gain
  5. Cataracts
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14
Q

List 4 disease modifying agents for MS

A

Oral

  1. FINGOLIMOD (GILENYA)
  2. DIMETHYL FUMARATE (TECFIDERA)
  3. TERIFLUNOMIDE (AUBAGIO)

IV for okra beef

  1. NATALIZUMAB (TYSABRI)
  2. OCRELIZUMAB (OCREVUS)
  3. ALEMTUZUMAB (LEMTRADA)

S/C for Seron

  1. INTERFERON BETA-1B (BETASERON)
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15
Q

List 3 common side effects for MS disease modifying agents? 🔑

A

Reduction of immune system:

  1. Flu-like symptoms
  2. Post-injection fatigue.
  3. Skin reactions
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16
Q

Medication for improving gait & cognition in MS 🔑🔑

A

Dalfampridine (Ampyra) 10 mg orally twice a day

Acetylcholinesterase inhibitors e.g., donepezil (Aricept) 5mg bedtime

17
Q

Expanded Disability Status Scale (EDSS)

A

The EDSS is a number that rates a patient’s degree of disability from MS on a scale of 0 to 10.

0 = Normal

4 = Ambulatory without aid

6 = Cane

7 = Wheelchair

8 = Bedbound

10 = Death

18
Q

How do you assess and manage fatigue in MS?

A

Fatigue Types

  1. Central fatigue
    • 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.
  3. Primary
    • Disease process (MS), Heat intolerance & vigorous exercise
  4. Secondary
    • Medical: Anemia, Hypothyroid
    • Psych: Anxiety, Sleep disorder, Depression, Stress
    • Spasticity
    • Disease-modifying therapies

Pharma

  1. Dopamin Agonists
    1. Amantadine 100mg Twice Daily
    2. Modafinil
    3. Methylphenidate
  2. SSRI Fluoxetine (Prozac)

Non-Pharma “Avoid triggers”

  1. Resting days
  2. Energy conservation
  3. Work simplification
  4. Pacing work
  5. Avoid heat and stress
19
Q

Tx Spasticity in MS.

A

1- Prevention: Remove noxious stimuli, optimize bowel, bladder, and skin management.

2- Modalities: Cryotherapy.

3- Orthosis: Positioning, casting and splinting,

4- PT & OT: range of motion (ROM),

5- Pharma:

Baclofen (PO or ITB pump) 1st line of treatment for central spasticity.

Diazepam and clonazepam (GABA A agonist)

Tizanidine and clonidine (central alpha-2-adrenergic receptor agonist)

Dantrolene (Ca+ channel blocker)

6- Surgical

Botox Injection

Rhizotomies, tenotomies

20
Q

Exercise prescription in MS.

A

In mild to moderate disability from MS, exercise improves aerobic capacity, strength, mobility, fatigue, quality of life, spasticity, cognition, depression, walking ability, and memory/hippocampal volume.

Strength

  • Light progressive resistive exercises prevent disuse atrophy
  • Major muscle group, 10-15 Reps, 2 Sets, 2min Rest, Twice a week
  • Do not exercise to the point of fatigue (submaximal exercise)

Conditioning “Aerobic”

  • Aerobic training increases endurance
  • 30 minutes of moderate intensity aerobic activity twice a week
  • Swimming in cool temperature or cycling

Strength

  • Light progressive resistive exercises prevent disuse atrophy
  • Major muscle group, 10-15 Reps, 2 Sets, 2min Rest, Twice a week

Conditioning “Aerobic”

  • Aerobic training increases endurance
  • 30 minutes of moderate intensity aerobic activity twice a week
  • Swimming in cool temperature or cycling

Contraindications

  1. Acute exacerbation of MS – start at beginning if present.
  2. Hot environment – maintain cool body temperature.
  3. Exercise not to point of exhaustion.
21
Q

List 4 ways to manage osteoporosis in general.

A

Prevention

  1. Encourage weight-bearing
  2. Ensure appropriate dietary calcium and vitamin D

Treatment

  1. Bisphosphonates (fosamax) 5-10mg daily
  2. Denosumab injection (Prolia) six-monthly injection.
22
Q

Causes & Tx Ataxia in MS.

A

Cause:

Lesion in spinocerebellar, cerebrum, and dorsal columns

Tx:

  1. Balance training
  2. Frenkel’s exercises
  3. Weighted ankle cuffs and utensils
  4. Gait aids/mobility aids
23
Q

List 4 Causes of decreased communication in MS.

A
  1. Fatigue
  2. Depression
  3. Dysarthria
  4. Decreased voice intensity
  5. Cognitive impairments
24
Q

List 2 Eye complications in MS and Tx.

A

Optic Neuritis:

Blurred vision - Residual decreased acuity - Central scotoma - Complete or partial loss of vision - Photophobia - Painful eye movement.

Tx: IV methylprednisolone, No treatment for the residual visual loss after ON.

Internuclear ophthalmoplegia (INO):

Demyelinating lesion of the medial longitudinal fasciculus (MLF)

Paresis of the medial rectus muscle → Inability to adduct the eye

  1. Nystagmus & Diplopia
  2. Blurred vision
25
Q

List 3 causes of pain in MS & Tx.

A
  1. Neuropathic Pain
    1. allodynia and hyperalgesia
    2. MS hug
    3. Headache & Trigeminal neuralgia (TN)
  2. Spasticity → Musculoskeletal Pain
  3. Disease modifying treatment (Injection site or side effect)

Neuropathic Pain

Nonpharma

  • PT/OT, therapeutic modalities (e.g., TENS)

Pharma

1- Tricyclic antidepressants (TCAs), amitriptyline

2- Anticonvulsant, Gabapentin (Neurontin), carbamazepine (Tegretol)

S/E Edema, sedation, weight gain, constipation

3- Local: Capsaicin, Lidocaine Patch (Versatis)

26
Q

Managment of Bladder Dysfunction in MS.

A

INVESTIGATIONS

  1. Urinalysis
  2. Urine culture
  3. Renal ultrasound
  4. Post-voiding residual (PVR) volume measurement
  5. Urodynamic testing

FAILURE TO STORE (MOST COMMON)

  • Hyperactive bladder with a small capacity
  • Hx Urinary frequency, urgency, Incontinence
  • Tx Detrusor muscle relaxant (Ditropan) or Vesicare

FAILURE TO EMPTY

  • Hypoactive bladder: Big boggy bladder with Closed sphincter
  • Hx Failure to void, overflow incontinence, incomplete emptying, slow or intermittent stream
  • Tx Self-intermittent Catheterization, Alpha antagonist (Minipres)

COMBINATION BLADDER (2ND MOST COMMON)

  • Bladder Sphincter Dyssynergia (DSD)
  • Bladder contracts → Sphincter closes → Backflow of urine to the kidney
  • Tx Pharma: Intermittent catheterization, Anticholinergics, Alpha-antagonists
  • Surgical: BT injections in the sphincter, Urethral stent/Sphincterotomy
27
Q

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

A

Risk Factors

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

Non-Pharmacological Tx

  1. High fluid and high fiber diet
  2. Maximization of gastro-colic, colo-colic and recto-colic reflexes
  3. Bowel program

Pharmacological Tx

  1. Stool softeners (Docusate sodium) PO
  2. Laxative (Bisacodyl) PO or Suppository
  3. Bulk/Laxative (e.g., psyllium or Normacol)
  4. Fiber supplements (e.g., Metamucil)
  5. Fleet Enema or Bowel Irrigation
28
Q

Sexual Dysfunction in MS. Risk factors, presentation, management.

A

Risk Factors

  1. Fatigue
  2. Decreased sensation
  3. Spasticity
  4. Depression
  5. Poor self-esteem

Male

  1. Fatigue
  2. Decreased libido
  3. Impaired genital sensation, paresthesias
  4. Erectile dysfunction (ED)
  5. Ejaculatory dysfunction, Anorgasmia

Female

  1. Fatigue
  2. Decreased vaginal sensation, paresthesias
  3. Anorgasmia
  4. Decreased libido
  5. Loss of lubrication

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
29
Q

List 4 causes of sleep disturbances in MS and Management.

A

1- Poor sleep hygiene

Lifestyle, Exercise, Melatonin, Antihistamin

2- Pain

Exercise, TENS, Anticonvulsant, TCA

3- Spasticity

4- Restless legs syndrome (RLS) and periodic limb movement disorder (PLMD).

Iron supp, dopaminergic agents, benzodiazepine (clonazepam), and anticonvulsants.

5- Mood disorder (depression, anxiety)

Exercise, CBT, SSRI Prozac or SNRI Cymbalta (duloxetine)

6- Neurogenic bladder leading to nocturia

Avoiding eating, drinking before bed

7- Sleep-disordered breathing, obstructive sleep apnea, and central sleep apnea.

CPAP, Weight loss

8- Disease modifying treatment side effects

30
Q

TCA in MS

A

Tricyclic antidepressants, should rather be avoided, due to issues with fatigue, orthostatic hypotension, balance, cognitive disturbances, and bladder problems.

31
Q

What is the role of electrodiagnostics in diagnosing MS?

A

Typical NCS/EMG: Generally none - PNS usually spared in MS.

Evoked potentials: SSEP somatosensory, VEP visual & BEAP brainstem auditory

32
Q

What are possible etiologies for pain in MS?

A

NEUROPATHIC:

  1. Trigeminal neuralgia (tic douloureux).
  2. Optic neuritis
  3. Chronic dysesthesia pain
  4. Lhermitte’s phenomenon
  5. Radicular pain
  6. Transverse myelitis

CENTRAL PAIN

Fibromyalgia (33% of MS Patients)

SPASTICITY

MSK (any msk problem can affect pts with MS):

  1. Facet syndrome
  2. Disc disease
  3. Osteoporosis
  4. Contractures

VISCERAL

33
Q

List types of Dysarthias in MS.

A

Spastic (UMN), Ataxic (Cerebellar) & Mixed

PMR 05 - Neurology (7 decks)

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