LEC 5: Multiple Sclerosis (MS) Flashcards
What is multiple sclerosis (MS)?
Chronic, progressive, degenerative, autoimmune disorder of the central nervous system. Body starts to attack itself, the myelin.
- Brain and spinal cord
- There is no cure for MS
Where is the highest rates of MS in the world?
Canada has one of the highest rates of MS in the world
- 100,000 Canadians currently
When are people usually diagnosed?
Most people are diagnosed between the age of 15 to 40 years old
What are the non-modifiable risk factors associated with MS?
- Gender: Affects women more then men (3:1)
- Race: Caucasians of northern European descent
- Family history: Small increased risk (3% increased risk)
- Environment: Cool climate, little sunshine
- Diet: Low in vitamin D levels
What are the three factors that play into MS (etiology and pathophysiology)?
- Immune system
- Genetics
- Environment
- Exposure triggers an abnormal immune response
*Don’t know what causes MS
CNS, MS, and the Role of the Immune System
a. Normally, we have nerve cells consisting of a nerve fiber, in the fiber there is myeline which helps transfer signals to the body
b. With MS, the body starts to attack itself, the body sees the myelin as a foreign invader
c. T-Lymphocytes determine that there is something foreign in the CNS system.
d. The T-lymphocytes migrate to the CNS and start to attack the myelin and stimulate other cells that help protect the body. Will eventually damage the nerve fiber and cause scar tissue to myelin
- Once the nerve fiber is damaged it cannot be repaired.
- The symptoms of MS will depend where the damage is happening in the CNS
e. Once the myelin is damaged the nerve impulses start to slow and if the nerve fiber is damaged then the nerve impulses cannot continue within the CNS part
- The immune system does not attack the brain and spinal cord all at once. It targets specific areas and is unpredictable. Will happen at different areas of the body at different times
When can myelin repair itself?
Can be regenerated if oligodendrocytes are intact, they make to myelin. But if the oligodendrocytes become damaged they cannot regenerate the myelin
What are the four types of MS?
- Relapsing remitting
- Primary progressive
- Secondary progressive
- Progressive relapsing
Relapsing Remitting
- Remission: Recovery nearly complete
- Relapsing: Flare up of the disease, when the symptoms re-occur
*Flare up are more common at the beginning of the diagnosis then towards the end
Primary Progressive
- Slow accumulation of disability
- Without defined relapses
- No distinct flare up or relapsing remitting
Secondary Progressive
- Follows relapsing remitting
- Distinct relapses and remissions less apparent
- Increasing levels of disability
Progressive Relapsing
- Symptoms steadily worsen
- Faster then the primary progressive
What do the medications for MS do?
Medications suppress the immune system therefore they are immunocompromised
What are the clinical manifestations (signs and symptoms) of MS?
- Signs and symptoms vary depending on the specific areas of the CNS affected
- Symptoms may be vary vague at first; hard to pinpoint because it attacks the body in different areas
- Fatigue (#1 symptom)
- Weakness
- Depression
- Shaking and loss of coodination
- Memory changes
- Numbness and tingling
- Pain
- Bladder and bowel dysfunction
- Visual loss
- Double vision
- Sexual dysfunction
- Unsteadiness and dizziness
What is the best way to diagnose MS?
MRIs are the best way to diagnose MS
What are the systemic effects of MS?
MS effects every body system
- Respiratory system
- Urinary system
- Gastrointestinal system
- Musculoskeletal system
- Neurological system
- Sensory system
- Reproductive system
MS Effects on the Respiratory System
- Diminished cough reflex
Potential Complication
- Respiratory infections
MS Effects on the Urinary System
- Hesitancy
- Frequency
- Retention
- Reflex bladder emptying
Potential Complication
- Recurring UTIs
- Incontinence
MS Effects on the Gastrointestinal System
Oral/ Esophageal
- Difficulty swallowing
- Dysphagia
Upper/ Lower GI
- Decreased or absent sphincter control
- Bowel incontinence
- Constipation
MS Effects on the Musculoskeletal System
- Fatigue
- Limb weakness
- Ataxic movement (shaky, irregular, uncoordinated)
- Intention tremors
- Spasticity
- Muscular atrophy
- Dragging of foot and foot drop
- Dysarthria with slurred speed
MS Effects on the Neurological System
- Emotional lability (euphoria or depression)
- Forgetfulness
- Apathy
- Scanning speech (breaking down words into their synonyms)
- Impaired judgment
- Irritability
Potential Complications
- Convulsive seizures
- Dementia
MS Effects on the Sensory System
Visual
- Blurred vision
- Diplopia
- Nystagmus
- Visual field defects (blind spots)
- Eye pain
Auditory
- Vertigo
- Nausea
Tactile (Especially in hands or legs)
- Numbness
- Parethesias (tingling, bruning sensation)
- Pain with spasms
- Loss of proprioception
Potential Complication
- Blindness
MS Effects on the Reproductive System
- Impotence (male)
- Loss of genital sensation
What are the diagnostic test for MS?
- Physical exam: Neuro exam
- Include subjective and objective assessment - Magnetic resonance imaging (MRI)
- Evoked potential (EPs)
- Test that measure the speed of the nerve impulses; sensation, light, and sounds - Lumbar Puncture (LP)
- Withdraw spinal fluid with a needle and look for proteins
- Proteins will tell you if there is inflammation but wont tell you why
Care of the Patient Who Has MS
- Are usually cared as out patients
- Are only hospitalized if flareup of symptoms are severe or injury
- Might need to go to assisted living facilities in the later part of their disease
Goals for Care: Maximize Neuromuscular Function
Want to maintain the strength of the muscle that are functioning well
- Recommend physiotherapy or exercise
Goals for Care: Maintain Independence in ADLs
May need assisted equipments
Goals for Care: Manage Fatigue
- Getting enough sleep
- Nutrition: vitamin D, vitamin B, high protein
- Rest when doing activities
Goals for Care: Optimize Psychosocial Well Being
- Suggesting support groups
- Family teachings: what to expect from MS, long term effects
- Getting active in things they enjoy to do
- Psychiatric support
Goals for Care: Adjust to Illness
- Education for family/ support and individual with MS
- Access to community services
Goals for Care: Reduce Factors that Precipitate Exacerbations (What Makes Symptoms Worst)
- Viral infections
- Stress
- Child birth
- Change in temperature
What are the three classes for medication management?
- Disease modifying therapies
- Relapse management medications
- Symptoms management medications
- Goal of drug therapy is to delay the progression and control the symptoms
- Individuals can be on each of these classes
What are disease modifying therapies?
Immunomodulators
- e.g Beta interferon
- Suppress the immune system, more at risk for infection
- Trying to stop the inflammatory system that is attacking the myelin
- To be used continuously; life long
- Hope that it will decrease flare-ups and the damage of myelin
What are relapse management medications?
Corticosteroids
- e.g prednisone
- Will decrease inflammation but are specifically used for the flare-ups
- Are not to be used long-term; only short term period of when they are having a flare-up
- Steroids suppress the immune system
What are the six symptom management medications?
- Pain
- Spasticity
- Fatigue
- Bowl dysfunction
- Bladder dysfunction
- Depression
Symptom Management Medication: Pain
- Neuropathic pain (gabapentin)
- Analgesics (acetaminophen)
Symptom Management Medication: Spasticity
- Muscle relaxant (diazepam, baclofen)
Symptom Management Medication: Fatigue
- CNS stimulant (modafinil)
Symptom Management Medication: Bowel Dysfunction
- Constipation (bisacodyl, sodium phosphate)
- Stool softener (docusate)
Symptom Management Medication: Bladder Dysfunction
- Antispasmodic (oxybutynin)
- Urine flow promotion (tamsulosin)
Symptom Management Medication: Depression
- Tricyclic antidepressant (amitriptyline)
- SSRI (paroxetine)
What is alternative therapy to MS?
- Chronic cerebrospinal venous insufficiency (CCSVI) treatment
- Not an effective treatment
Nutritional Therapies
- No standard prescribed diet
- High protein, high fiber (helps with constipation) with supplemental vitamins recommended
- Recommend 2000-4000 international units a day of vitamin D
Wellness Stratagies & Therapies
- Exercise
- Physiotherapy
- Massage
- Relaxation therapy
- Speech therapy
- Acupuncture
- Education
- Community and psychosocial support
Key Points for MS
- MS is an autoimmune disease of the nervous system in which there is damage to both the myelin and axons
- Numerous systemic effects on the body
- Goals for care include maximizing function and independence and precent and minimize exacerbations
- There are numerous wellness strategies to maintain quality of life while living with MS
