Masterclass: Multiple Sclerosis Flashcards
State facts and aetiology of Multiple Sclerosis
- MS is an autoimmune disease with no cure, it is more common in women and typically affects younger individuals.
- Progressive and affects several body systems
- Prevalence: 104 per 100,000
- High financial cost
- Quality of life is reduced
- Cause is unclear – but there are some risk factors
Outline the potential risk factors for MS
- Genetic predisposition (dysfunction in Human Leukocyte Antigen gene)
- Latitude (sunlight/vitamin D exposure plays a role)
- Viral exposure
- Smoking
- Obesity
Describe types of MS, as well as clinically isolated syndrome
Relapsing-Remitting MS (RRMS): episodes of relapse followed by periods of remission, where symptoms may partially or fully resolve (85% at diagnosis)
- Periods where immune cells attack the brain (relapse) immune cells stop attacking the brain and myelin repairs itself (remission) period of stability another relapse (can occur with days to years between)
Secondary Progressive MS (SPMS): Follows an initial RRMS course, then progressively worsens over time with fewer remissions.
- Progressive worsening of neurologic function over time
Primary Progressive MS (PPMS): Progressive from onset with relapses
- Worsening neurological function from onset of symptoms without early relapses or remission
Clinically Isolated Syndrome (CIS): Refers to a first episode of neurological symptoms caused by inflammation and demyelination but does not yet meet the criteria for MS. People may or may not go on to develop MS. Those with MRI changes are more likely to develop MS, and those with no MRI changes are less likely to get MS
Describe the pathophysiology of MS
The immune system attacks myelin (the protective sheath around nerve fibres) and oligodendrocytes, leading to demyelination. T-cells and B-cells play roles in this process, releasing cytokines and antibodies, respectively. This results in neuroinflammation and, over time, can lead to axonal loss, forming plaques in the CNS.
This leads to delayed transmission of information in the nervous system
Discuss the difficulties with defining prognosis in people with MS
Prognosis varies due to different MS types, unpredictable disease progression, and individual responses to treatment.
Lack of comprehensive data due to diagnostic challenges, delayed diagnoses and no central database
Outline and briefly describe 10 potential signs and symptoms of people with MS
Vision problems
Numbness or tingling
Fatigue
Muscle weakness or spasms
Mobility issues
Cognitive impairment
Balance difficulties
Bladder and bowel dysfunction
Pain
Depression
Understand the EDSS scale (the distinction between 1-4.5, 5-9.5)
*0 (no disability) to 5 or 6 (more severe disability).
*1.0 to 4.5: All patients can walk AND EDSS is primarily defined by the problems due to the functional systems
*5.0 to 9.5: Defined primarily by the problems of walking
Describe the management strategies for impairments in people with MS (note that the strategies are similar to patient with stroke)
Similar management to stroke
Management varies depending on type of MS, stage of MS and the location of plaques/lesions
a. Repetitive task specific training
Targets functional movements like transfers and gait
b. General exercise
Improves cardiovascular fitness, strength and endurance
c. Falls prevention
Essential due to balance and coordination issues
Discuss and describe fatigue in people with MS (as a primary and secondary impairment) and how these would influence/affect Physiotherapy.
- Fatigue in MS can be a primary impairment due to neurological dysfunction or secondary impairment from conditions like depression or deconditioning
- More common in patients with progressive disease
- Affects daily functioning
- This influences physiotherapy as sessions must be scheduled with consideration for energy levels, avoiding fatigue exacerbation.
Discuss how you could use a fatigue diary to structure a physiotherapy treatment program (think HEP and during the session)
A fatigue diary helps track fatigue patterns, aiding in planning home exercise programs (HEP) and physiotherapy sessions to optimise energy use and accommodate rest.
Can be used to guide treatment and monitor fatigue levels
Similarly, you could use the Fatigue Severity Scale
Discuss how non-motor impairments of MS could affect physiotherapy management
Fatigue can be often the most disabling symptom. *Can occur daily and often worse later in afternoon
*Aggravated by heat, pain depression + excessive exertion
*Affects daily functioning
Discuss management strategies for fatigue including the Cochrane evidence for using physiotherapy/exercise interventions.
- Monitor fatigue and explain to patients that symptoms may be exacerbated
- Medication: Amantadine (mild) and Madafinal (mod-severe) for fatigue
- Emotional support
- Energy conservation courses: courses to reduce impact of fatigue and increase self efficacy
- Address secondary causes of fatigue (depression/deconditioning, etc)
- Address heat sensitivity
- Appropriate exercise can reduce fatigue
- Support offered by MS society
Cochrane evidence supports exercise interventions for managing fatigue, with physiotherapy showing benefits in improving endurance and reducing fatigue severity
Define ataxia and outline the role of the cerebellum
Ataxia: loss of dexterity/coordination
- Reduced spatial and temporal movement accuracy
Deficits in movement
- Speed/timing
- Direction
- Amplitude
- Force
Cerebellum regulates movement coordination, balance and fine motor control
Outline adaptive motor behaviours that people with ataxia present with.
- Excessive preshaping
- Arms on tables (reduced degrees of freedom)
- Restriction of movement amplitude (to control degrees of freedom)
- Wide base of support
- Using arms excessively (with aids)
- Excessive stepping
- Walk faster (and difficulty slowing)
People with ataxia may use adaptive behaviours like wide based walking or arm bracing. Treatment strategies include balance and coordination exercises, use of assistive devices and proprioceptive cues. Cochrane evidence suggests physiotherapy can improve functional outcomes
Provide potential treatment strategies to manage and treat ataxia
- Use of external cues (visual, auditory and proprioceptive/tactile – taping)
- Balance training +/- ocular exercises, strengthening exercises
- Use of equipment (wheelchairs, parallel bars, standing frames, walkers, weights, special equipment)
- Use of constraints
- Timing tasks – closed tasks require rhythm and open tasks require prediction
- Whole task training: must challenge movement (PRE principles), people won’t improve coordination by moving a single joint – must be whole task). Fixing proximal joint
