L22: Multiple Sclerosis

Question 1

What are 6 facts of multiple sclerosis?

Answer 1

1. 90-95% of normal life expectancy (6-7 years less)
2. MS have a lifelong need for physiotherapy
3. Disease progression is variable with unpredictable neurologically signs and symptoms that result in progressive disability, the rate of which varies from person to person
4. MS is most commonly diagnosed in women more than men in the age range of 20-50
   
   • Increasingly children being diagnosed MS
5. In the past, MS is advised to avoid physical activity as it potentially aggravated symptom.
   
   • Research shows the negative consequences of physical inactivity, including impact on muscle, connective tissues, CNS, PNS.
   • Research on the safety, efficacy and value of exercise interventions have dispelled the myth that physically activity is bad for MS.
6. Now, we do exercise using right pacing, diet, graduated exercise.

Question 2

What is multiple sclerosis?

Answer 2

an autoimmune system mediated, chronic inflammatory demyelinating disease of CNS.

Question 3

What is the cause of MS?

Answer 3

Immunopathology develops in a genetically susceptible individual exposed to an environmental trigger

• Not a strong genetic link

Question 4

What are 4 characteristics in the pathophysiology of Multiple Sclerosis?

Answer 4

1. Inflammationcause oedema, and the autoimmune response causes T cells to strip the axons of myelin
2. Partial or full demyelinationcauses nerve conduction to be partially or fully blocked.
3. A combination of both axonal loss and remyelinationmay be present within lesions
   
   • Can be remyelinated by nearby oligodendrocytes
   • When oligodendrocytes all died, there is no remyelination
4. Axonal lossis a main contributor to brain atrophy -linked to physical and cognitive disability
   
   • Axonal loss was more evident in severe longstanding lesions in long term MS
   • Substantial progressive and permanent disability in MS is caused by cumulative axonal loss that may occur in tracts with multiple lesions
   • Brain atrophy is a possible predictor of disease progression in RRMS
   • Losing white matter & grey matter affect cognition, fatigue

Question 5

What is impact of MS for nerve impulses?

Answer 5

Can reduce strength or completely stops nerve impulses

• Can be re-myelinated as long has oligodendrocytes
• If oligodendrocytes die off = no longer able to re-myelinate

Question 6

What are the 4 features of epidemiology of Multiple Sclerosis?

Answer 6

1. Gender:Women : men = 3:1
2. Latitude gradient
   
   • Sunlight & vitamin D minimise MS progression & symptoms
     
     • Live near the equator is good = more sun
     • Live away from the equator is bad = less sun
   • Birth month: People conceived in winter months have higher rate of MS
3. Genetics : Caucasian > others
   
   • Different countries have different prevalent types of MS
   • High incidence/risk –> links based on race
   • e.g. Asia has optic neuritis + spinal cord MS
4. Environmental:Pathogen, diet, sanitation
   
   • Closer to equator has less chance of MS
   • Opposite for Norway though -they have less chance to get MS because they eat whales

Question 7

What are 6 diagnosis of Multiple Sclerosis?

Answer 7

1. Clinical history
2. Exclude other diagnoses (McDonald Criteria)
3. MRI
4. Lumbar puncture: Rarely done now -unpleasant
5. Visual evoked response for additional info -not mandatory
6. Auditory evoked response for additional info -not mandatory

Question 8

What does MS look like on MRI?

Answer 8

• White dots are lesions
• Amount of lesions do not correlate with the amount of disability

Question 9

What are 5 types of MS (Clinical Progression of Multiples Sclerosis)?

Answer 9

1. Clinical isolated syndrome (CIS)
2. Benign MS
3. Relapsing remitting MS (RRMS)
4. Primary progressive MS (PPMS)
5. Secondary progressive MS (SPMS)

Question 10

What are 2 characteristics of the Clinical isolated syndrome (CIS)?

Answer 10

1. Pre-MS diagnosis is when a single episode of demyelination is clinically and MRI evident.
   
   • Need to recognise this because they need disease-modifying drugs to prevent or delay the second episode.
2. ~68% CIS will progress to a definite diagnosis of MS within 2 years.

Question 11

What are 3 characteristics of Benign MS?

Answer 11

1. 10% of MS has no disability 10 years after diagnosis
2. Classification can only be made retrospectively.
3. Return to normal between attacks

Question 12

What are 2 characteristics of Relapsing remitting MS (RRMS)?

Answer 12

1. 80% of MS has periodic attacks (neurological S&S) that evolve, stabilize and resolvepartially or completely over days or weeks.
2. No new disabilities between attacks.

Question 13

What is a characteristic of Primary progressive MS (PPMS)?

Answer 13

1. 10-20% of MS has steady progression of disability at a slow or fast rate, without attacks

Question 14

What are 3 characteristics of Secondary progressive MS (SPMS)?

Answer 14

1. 50% of RRMS
2. Residual dysfunction after relapse resolution
3. Accumulation of disability between relapses

Question 15

What is the disease progression and disability over time?

Answer 15

• MS can be present for >10 years before diagnosis depending on disease progression
• MS only becomes evident after passing clinical threshold.

Question 16

What are 7 symptoms of Multiple Sclerosis (any system)?

Answer 16

1. Primary impairments: Muscle weakness, motorataxia, spasticity and fatigueaffect the action system.
2. Mobility impairments are due to lesions in the pyramidal tracts supplying LLand thedorsal columns carrying LL sensory information.
3. Visual, auditory, somatosensory &vestibular impairments affectthe sensory and perceptual systems. Thisoccurs due to the impaired transmission andprocessing from these areas.
4. Balance impairments and incoordination are caused by the slowed/loss of proprioception.
5. Sensory ataxia is due to impaired transmission of somatosensory information to the cerebellum.
6. Brainstem and cerebellar lesions affect the connections between vestibular andother sensory systems, whichthen affects the motor outputs of the eyes and neck muscles. This contributesto balance problems and vertigo.
7. Trigeminal neuralgiaaffects motivation to be physically active.
   
   • Sharp shooting pain on the side of face-like allondynia -episodic
   • Patchy distribution, not following nerve distribution
8. Impairments of higher level processingaffectthe cognitive system, motor learningand skill acquisition.

Look out for symptoms out of physio scope -referral

Question 17

What are 6 less common symptoms of Multiple Sclerosis?

Answer 17

1. Speech: Dysarthria
2. Swallowing: Dysphagia,aspirationpneumonia
   
   • asiration pneumonia is a common cause of death
3. Headaches (trigeminal neuralgia)
4. Hearing loss: Tinnitus
5. Seizures
6. Breathingproblems
   
   • Respiratory muscle weaknessdue to loss of central drive.
   • MS hug “sensory”: Deel like cannot inhale enough

Question 18

What are 6 features of Dysautonomia as an MS symptom?

Answer 18

ANS dysfunction-CNS demyelination connection to ANSvia spinal cord, brainstem, hypothalamus

1. Heart rate
2. Temperature regulation (sweating response)
3. Blood pressure
4. Micturition
5. Respiratory rate
6. Sexual function

Question 19

What are 2 features of Thermoregulation (60-90%) as an MS symptom?

Answer 19

1. Lowered core body temperatureto35°C
2. Impaired thermoregulation: Increasedcore temperaturedecrease MS-related pain, but increases neurological symptoms

Question 20

What are 4 managements of Thermoregulation (60-90%) as an MS symptom?

Answer 20

1. Cooling during exercise
2. Resting after exercise
3. Lower hydrotherapypool temperature
4. Advice & education

Question 21

What are 3 features of Cardiovascular dysfunction (10-50%) as an MS symptom?

Answer 21

1. Midbrain lesions-safety of exercise
2. Reduced HR & BP response toexertion
3. Postural hypotension,dizziness,light headedness(balance)

Question 22

What are 3 managements of Cardiovascular dysfunction (10-50%) as an MS symptom?

Answer 22

1. Pre-screening for HR & BPresponses
2. RPE
3. Full cardiac testing undercardiologist

Question 23

What are 2 features of Sleep dysfunction (40-60%) as an MS symptom?

Answer 23

1. Causes: Breathing disturbance,immobility,leg spasms,pain, nocturia,medications
2. RSL, narcolepsy

Question 24

What is a management of Sleep dysfunction (40-60%) as an MS symptom?

Answer 24

Address individual factors by PT, OT, continence nurse, sleep clinics, neurologist, pain clinics,respiratory clinics

Question 25

What are 3 features of Bladder (30-50%) & Bowel (45-68%) dysfunction as an MS symptom?

Answer 25

1. Pontine and cervical spine lesions
2. Detrussor hyperreflexia (urge incontinence)
3. Dyssynergiaof detrussor &sphincter(urinary retention)

Question 26

What is a Bladder (30-50%) & Bowel (45-68%) dysfunction as an MS symptom?

Answer 26

Urodynamics by a urologis,continence nurse,PT,GP

Question 27

What are 2 features of Gastroparesis as an MS symptom?

Answer 27

1. Abnormal colonic motor activity
2. Anorectaldysfunction (constipation or incontinence)

Question 28

What is the management of Gastroparesis as an MS symptom?

Answer 28

Gastroenterologist, GP, continence nurse, dietician, PT

Question 29

Changeable, temporary symptoms may be a result of a symptom _____ or MS _____.

Answer 29

flare-up; exacerbation

Question 30

What are 4 characteristics of flare

Answer 30

1. Any worsening ofusual symptoms(sudden or gradual)
2. Presentation of new symptoms>24 hours
3. Can be physical or cognitive decline
   
   • See GP/neurologist
4. Both
5. Excludetemporary contributing factors
   
   • Anything that increases body temperature
   • Potential aggravating factors

Question 31

What is a major symptom of Temporary Flare-upsof Multiple Sclerosis?

Answer 31

Increase in body temperature

Question 32

What are 6 characteristics of “increase in body temperature” as a Temporary Flare-ups of Multiple Sclerosis?

Answer 32

1. UTI: Need antibiotics +/-bladder management
2. Other infections: e.g. Chest infection needs antibiotics +/-swallowing assessment
3. Other sickness
4. Physical exertion or exercise
5. Increases in ambient temperature: e.g. Heat of summer needs air-con or other cooling techniques
   
   1. A&E to avoid saunas, hot showers and baths
   2. A&E on cooling techniques
   3. Know your normal core body temperature (could be 35 C), so you know when your temperature is increased
6. Menstruation increases body temp, changes in cycle -bad day

Question 33

What are 4 characteristics of an MS “bad day”?

Answer 33

1. Medication changes “side effect of” or “need for”
2. Ineffective management strategies: e.g. Energy conservation
3. What were they attempting to do that day?
4. Could they structure “those” days better to avoid over-exertion?

Question 34

What are 3 exacerbations of Multiple Sclerosis?

Answer 34

1. Ongoing physical S&S that do not improve (>24 hours), despite management strategies
2. Deteriorating level of support in ADL
3. Emerging cognitive dysfunction without physical deterioration

Question 35

What are the 3 ways that neurological impairments and disability that can be restored by (Pathology of Acute Demyelinating Episodes)?

Answer 35

1. Resolution of oedema: Impaired nerve conduction of adjacent healthy nerves
2. Resolution of temporary cortical inactivation and early adaptive processes
   
   • Temporary cortical inactivation is when the healthy nerves above the affected area temporarily switch off because the affected area is not sending signals
   • Adaptation is brain rewiring
3. Spontaneous remyelination

Question 36

What are 3 post-exacerbations of Multiple Sclerosis (Pathology of Post-Exacerbation Recovery)?

Answer 36

1. Oedema resolution & remyelination both help spontaneous recovery (no time frame).
2. Remyelination’s contribution to functional recovery has not been identified as it is difficult to study this non-invasively.
3. Thus it is hard to distinguish between forced (therapy) and latent (remyelination) recovery.