L22: Multiple Sclerosis Flashcards
What are 6 facts of multiple sclerosis?
- 90-95% of normal life expectancy (6-7 years less)
- MS have a lifelong need for physiotherapy
- Disease progression is variable with unpredictable neurologically signs and symptoms that result in progressive disability, the rate of which varies from person to person
- MS is most commonly diagnosed in women more than men in the age range of 20-50
- Increasingly children being diagnosed MS
- 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.
- Now, we do exercise using right pacing, diet, graduated exercise.
What is multiple sclerosis?
an autoimmune system mediated, chronic inflammatory demyelinating disease of CNS.
What is the cause of MS?
Immunopathology develops in a genetically susceptible individual exposed to an environmental trigger
- Not a strong genetic link
What are 4 characteristics in the pathophysiology of Multiple Sclerosis?
- Inflammationcause oedema, and the autoimmune response causes T cells to strip the axons of myelin
- Partial or full demyelinationcauses nerve conduction to be partially or fully blocked.
- 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
- 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
What is impact of MS for nerve impulses?
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
What are the 4 features of epidemiology of Multiple Sclerosis?
- Gender:Women : men = 3:1
- 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
- Sunlight & vitamin D minimise MS progression & symptoms
- 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
- 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
What are 6 diagnosis of Multiple Sclerosis?
- Clinical history
- Exclude other diagnoses (McDonald Criteria)
- MRI
- Lumbar puncture: Rarely done now -unpleasant
- Visual evoked response for additional info -not mandatory
- Auditory evoked response for additional info -not mandatory
What does MS look like on MRI?
- White dots are lesions
- Amount of lesions do not correlate with the amount of disability
What are 5 types of MS (Clinical Progression of Multiples Sclerosis)?
- Clinical isolated syndrome (CIS)
- Benign MS
- Relapsing remitting MS (RRMS)
- Primary progressive MS (PPMS)
- Secondary progressive MS (SPMS)
What are 2 characteristics of the Clinical isolated syndrome (CIS)?
- 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.
- ~68% CIS will progress to a definite diagnosis of MS within 2 years.
What are 3 characteristics of Benign MS?
- 10% of MS has no disability 10 years after diagnosis
- Classification can only be made retrospectively.
- Return to normal between attacks
What are 2 characteristics of Relapsing remitting MS (RRMS)?
- 80% of MS has periodic attacks (neurological S&S) that evolve, stabilize and resolvepartially or completely over days or weeks.
- No new disabilities between attacks.
What is a characteristic of Primary progressive MS (PPMS)?
- 10-20% of MS has steady progression of disability at a slow or fast rate, without attacks
What are 3 characteristics of Secondary progressive MS (SPMS)?
- 50% of RRMS
- Residual dysfunction after relapse resolution
- Accumulation of disability between relapses
What is the disease progression and disability over time?
- MS can be present for >10 years before diagnosis depending on disease progression
- MS only becomes evident after passing clinical threshold.
What are 7 symptoms of Multiple Sclerosis (any system)?
- Primary impairments: Muscle weakness, motorataxia, spasticity and fatigueaffect the action system.
- Mobility impairments are due to lesions in the pyramidal tracts supplying LLand thedorsal columns carrying LL sensory information.
- Visual, auditory, somatosensory &vestibular impairments affectthe sensory and perceptual systems. Thisoccurs due to the impaired transmission andprocessing from these areas.
- Balance impairments and incoordination are caused by the slowed/loss of proprioception.
- Sensory ataxia is due to impaired transmission of somatosensory information to the cerebellum.
- 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.
- Trigeminal neuralgiaaffects motivation to be physically active.
- Sharp shooting pain on the side of face-like allondynia -episodic
- Patchy distribution, not following nerve distribution
- Impairments of higher level processingaffectthe cognitive system, motor learningand skill acquisition.
Look out for symptoms out of physio scope -referral
What are 6 less common symptoms of Multiple Sclerosis?
- Speech: Dysarthria
- Swallowing: Dysphagia,aspirationpneumonia
- asiration pneumonia is a common cause of death
- Headaches (trigeminal neuralgia)
- Hearing loss: Tinnitus
- Seizures
- Breathingproblems
- Respiratory muscle weaknessdue to loss of central drive.
- MS hug “sensory”: Deel like cannot inhale enough
What are 6 features of Dysautonomia as an MS symptom?
ANS dysfunction-CNS demyelination connection to ANSvia spinal cord, brainstem, hypothalamus
- Heart rate
- Temperature regulation (sweating response)
- Blood pressure
- Micturition
- Respiratory rate
- Sexual function
What are 2 features of Thermoregulation (60-90%) as an MS symptom?
- Lowered core body temperatureto35°C
- Impaired thermoregulation: Increasedcore temperaturedecrease MS-related pain, but increases neurological symptoms
What are 4 managements of Thermoregulation (60-90%) as an MS symptom?
- Cooling during exercise
- Resting after exercise
- Lower hydrotherapypool temperature
- Advice & education
What are 3 features of Cardiovascular dysfunction (10-50%) as an MS symptom?
- Midbrain lesions-safety of exercise
- Reduced HR & BP response toexertion
- Postural hypotension,dizziness,light headedness(balance)
What are 3 managements of Cardiovascular dysfunction (10-50%) as an MS symptom?
- Pre-screening for HR & BPresponses
- RPE
- Full cardiac testing undercardiologist
What are 2 features of Sleep dysfunction (40-60%) as an MS symptom?
- Causes: Breathing disturbance,immobility,leg spasms,pain, nocturia,medications
- RSL, narcolepsy
What is a management of Sleep dysfunction (40-60%) as an MS symptom?
Address individual factors by PT, OT, continence nurse, sleep clinics, neurologist, pain clinics,respiratory clinics
What are 3 features of Bladder (30-50%) & Bowel (45-68%) dysfunction as an MS symptom?
- Pontine and cervical spine lesions
- Detrussor hyperreflexia (urge incontinence)
- Dyssynergiaof detrussor &sphincter(urinary retention)
What is a Bladder (30-50%) & Bowel (45-68%) dysfunction as an MS symptom?
Urodynamics by a urologis,continence nurse,PT,GP
What are 2 features of Gastroparesis as an MS symptom?
- Abnormal colonic motor activity
- Anorectaldysfunction (constipation or incontinence)
What is the management of Gastroparesis as an MS symptom?
Gastroenterologist, GP, continence nurse, dietician, PT
Changeable, temporary symptoms may be a result of a symptom _____ or MS _____.
flare-up; exacerbation
What are 4 characteristics of flare
- Any worsening ofusual symptoms(sudden or gradual)
- Presentation of new symptoms>24 hours
- Can be physical or cognitive decline
- See GP/neurologist
- Both
- Excludetemporary contributing factors
- Anything that increases body temperature
- Potential aggravating factors
What is a major symptom of Temporary Flare-upsof Multiple Sclerosis?
Increase in body temperature
What are 6 characteristics of “increase in body temperature” as a Temporary Flare-ups of Multiple Sclerosis?
- UTI: Need antibiotics +/-bladder management
- Other infections: e.g. Chest infection needs antibiotics +/-swallowing assessment
- Other sickness
- Physical exertion or exercise
- Increases in ambient temperature: e.g. Heat of summer needs air-con or other cooling techniques
- A&E to avoid saunas, hot showers and baths
- A&E on cooling techniques
- Know your normal core body temperature (could be 35 C), so you know when your temperature is increased
- Menstruation increases body temp, changes in cycle -bad day
What are 4 characteristics of an MS “bad day”?
- Medication changes “side effect of” or “need for”
- Ineffective management strategies: e.g. Energy conservation
- What were they attempting to do that day?
- Could they structure “those” days better to avoid over-exertion?
What are 3 exacerbations of Multiple Sclerosis?
- Ongoing physical S&S that do not improve (>24 hours), despite management strategies
- Deteriorating level of support in ADL
- Emerging cognitive dysfunction without physical deterioration
What are the 3 ways that neurological impairments and disability that can be restored by (Pathology of Acute Demyelinating Episodes)?
- Resolution of oedema: Impaired nerve conduction of adjacent healthy nerves
- 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
- Spontaneous remyelination
What are 3 post-exacerbations of Multiple Sclerosis (Pathology of Post-Exacerbation Recovery)?
- Oedema resolution & remyelination both help spontaneous recovery (no time frame).
- Remyelination’s contribution to functional recovery has not been identified as it is difficult to study this non-invasively.
- Thus it is hard to distinguish between forced (therapy) and latent (remyelination) recovery.
