MS Flashcards
1
Q
Multiple Sclerosis is a ______ disease
A
Demyelinating
2
Q
What do demyelinating dis’s do and what is the MOST COMMON form?
A
- DEC speed and quality of impulse conduction (saltatory conduction)
- MS is most common form
3
Q
Demyelination can occur due to:
A
- Systemic disease
- Malnutrition
- Toxic exposure
- Infection
- Anoxia→ deprivation of O2
- Ischemia→ local
4
Q
MS Defined:
A
Demyelinating dis. characterized by a course of demyelination relapses & remissions, superimposed upon gradual neurologic deterioration
5
Q
Keep in mind w/ MS:
A
ANY CNS white matter can be affected→ presentation will vary
*episodic AND chronic
6
Q
MS Prevalence
A
Female > Male; 2:1 ratio
7
Q
MS High Risk Areas
A
FURTHER AWAY FROM EQUATOR
- Northern US, Northern Europe, Southern Canada, New Zealand, Southern Australia
8
Q
MS Etiology:
A
Interaction b/w genetic predisposition & an inciting environmental antigen→ produces autoimmune demyelinating response in susceptible host
9
Q
Theory of autoimmune response in MS:
A
CNS myelin becomes infected by virus and is perceived as antigen
*immune system then targets the “antigen” aka destroys myelin
10
Q
Stress and MS
A
Stress does NOT HELP MS!
not proven*
11
Q
Pathophysiology of MS:
A
- Demyelinating lesions→ Plaques
- sharply delineated lesions viewed on MRI
- Inflammation may result in Mass Effect (obj in skull that pushes brain)
- acute exacerb’s tx’d w/ steroids
12
Q
More pathophys MS:
A
- IF oligodendrocytes survive→ remyelination may occur
- later stages→ if few remain, remyelination partial @ best
-
End Stage Patho:
- myelin replaced by fibrous scarring (gliosis)→ inhibits impulse transmission
13
Q
*Types of MS:
4:
A
- Relapsing-Remitting (most common)
- aka Exacerbating-Remitting
- Relapsing-Progressive
- aka Exacerbating-Progressive
- Primary-Progressive
- aka Chronic-Progressive
- Secondary-Progressive
- the one that begins as Relapse-Remitting then Chronic-progressive
14
Q
Types of MS:
Relapsing-Remitting
aka Exacerbating-Remitting
A
- Ep’s of rapid, abrupt deterioration w/ variable degrees of recovery over time
15
Q
Types of MS:
Relapsing-Progressive
aka Exacerbating-Progressive
A
- Relapses w/ lg degrees of residual impairs
16
Q
Types of MS:
Primary-Progressive
aka Chronic-Progressive
A
- Steady, progressive deterioration
- Pace of deterioration may be steady OR varied
17
Q
Types of MS:
Secondary-Progressive
aka the one that BEGINS as relapse-remitting THEN becomes chronic (primary)-progressive
A
one that BEGINS as relapse-remitting THEN becomes chronic (primary)-progressive
- Sometimes Full recovery
- Sometimes Partial recovery
18
Q
MS:
Definitive Dx requires WHAT?
A
- Requires clinical or para-clinical evidence of 2 or more spatially & temporally distinct lesions
- aka 2 diff areas @ 2 diff times***
19
Q
MS Dx and MRI Findings:
A
- Lesions may NOT correlate w/ s/s
- Lesions may BE PRESENT in absence of s/s
- CSF via Lumbar Puncture
- elevated IgG→ immune system elevation
- Oligoclonal bands→ destruction of oligodendrocytes
20
Q
Not Quite MS…
A
-
Clinically Isolated Syndrome (CIS)
- looks like exacerbation but happens 1 time
-
Radiologically Isolated Syndrome (RIS)
- Single time, has radiograph similar to MS, only one incident shown
21
Q
Primary S/S MS:
A
- Presents in # of ways→ depends on loc. of demyelination
- Need useful SC vs. Cerebral (where plaques are)
22
Q
Primary S/S MS:
Fatigue
A
- Single most common complaint in MS*
- Out of proportion to task causing it
- Present even if strength normal
- Fatigue→ Sx’s, HOW pt feels
- Fatigability→ Sign, change in motor perform
23
Q
PRIMARY Fatigue
A
Caused by actual MS
- Lassitude→ sx of severe fatigue
- DEC conductivity→ reduced impulse propagation
24
Q
SECONDARY Fatigue
A
Consequence
- infx
- spasticity
- ataxia
- weakness
- depression
- sleep deprivation
- polypharmacy (lots diff meds)
- decond.
25
Fatigue in PWMS and PT Implications
* **Ex. Type**
* Diminished ability to tolerate lg amts of ex
* DO: **Intermittent tx**
* **Ex. Scheduling**
* Schedule ex @ times of INC energy if they are willing to use that time to Ex.
26
**PRIMARY s/s MS:**
**Sensory Changes**
* Parasthesias→ partial sensation loss
* Dysesthesias→ abnorm sensation (burning)
MORE FREQ.
27
PRIMARY s/s MS:
Optic Neuritis
Optic neuritis
\*NOTE: **some have abrupt loss of vision 2-3d**
**COMMON**
28
PRIMARY S/S MS:
## Footnote
**Weakness**
* **PRIMARY→** from _plaques_ (demyelination)
* **SECONDARY→** disuse, deconditioning, disuse atrophy
29
PRIMARY S/S MS:
Weakness
**A note about Flexibility**
* MS does NOT directly cause prob w/ flex, but weakness and other sx cause probs
* W/out adequate flex→ person loses norm biomechanics for **gait & balance**
30
PRIMARY S/S MS:
## Footnote
**Spasticity**
**\*know the Mod Ashworth Scale!!**
* UMN Syndrome **common in PWMS**
* **worsens over time**
* **IF spinal origin→** Intrathecal Baclofen pump
* NOT USEFUL IF CORTICAL LVL MS
31
PRIMARY S/S MS:
## Footnote
**Heat Sensitivity**
* Common
* Worse fatigue and weakness w/ elevation in body temp
* transitory→ NOT permanent
* **Some benefit from cooling BEFORE ex.**
32
Primary S/S MS:
## Footnote
**Ataxia**
* Due to plaques in **cerebellum and DCML**
* **B/L**
* Dysmetria, dysdiadochokinesia, tremor, vertigo
* CNS vs. PNS vertigo
33
Primary S/S MS:
## Footnote
**Pain**
* Spasms from **hypERtonia**
* Burning dysesthesias from plaques in **thalamus or spinothalamic tract**
* **MSK pain** from inapp. mvmt patterns → weakness, disuse atrophy
34
**Primary S/S MS:**
**Psychiatric**
* Euphoria→ late stages
* Depression
* **Most common Cog. changes→** memory loss, impaired safety awareness\*\*\*
35
Secondary S/S MS:
**Weakness and Fatigue** that occur due to MS causes what?
Series of 2\* probs → VERY IMPORTANT TO PT's!!!
36
2\* S/S MS:
MSK issues
* Inapp mvmt patterns due to:
* **Weakness**
* **Fatigue**
* **Spasticity**
* Overuse syndromes/tendonitis 2\* to spasticity
37
2\* S/S MS:
## Footnote
**Weakness**
PRIMARY weakness cannot be affected by ex, 2\* CAN
38
2\* S/S MS:
Posture
* due to prolonged sitting
* Can benefit from pos'ing out of shortened pos.
* Poor posture leads to skin breakdown, contracture, resp. comps
39
2\* S/S MS:
**Balance Loss**
* Combo of 1\* and 2\* effects
* **1\***
* weakness, spasticity, ataxia, sensory loss, diminished motor control, visual loss, depression, fatigue
* **2\***
* 2\* weakness, contractures
40
Other 2\* S/S MS:
* Osteoporosis
* Infections
41
Medical Mgmt MS:
## Footnote
**One you should know**
Ocrevus→ **only FDA approved med to tx progressive types→** _Slows progression_
* **Steroids**
* Tx of choice for **acute exacerbation**
* **suppresses immune function**
42
MS and Spasticity
Keep in mind..
**Spasticity** can be **Useful!**
* Eradication of spasticity can _diminish underlying strength_
43
MS and 2\* Fatigue
* Improve fitness thru ex.
* **Energy Conservation tech's** combined w/ **meds**
* → Tx of choice for fatigue
44
Psychosocial Factors MS
Demanding dis. for both pt and caregiver→ **unpredictable and hard to see**
45
Rehab/PT Mgmt MS:
* No cure
* Tx focused on medically controlling **current exacerbation**
* Prevent 2\* deficits
* **EDUCATION→** teach pt and family as much as poss. about disease esp **self mgmt of comps**
46
MS and Evidence for Exercise
* Aerobic, MSK strength, Resp endurance
* Good therapeutic response to Ex.
* PTs should be **confident** in prescribing ex. in PWMS
47
NOTE: Great Quote
“PWMS respond to exercise the **same way** as those w/out MS: **they become _More Fit!!!”_**
48
MS more commonly dx'd b/w ___ and \_\_\_\_
30 and 35yo
49
Pathological features of MS:
Radiographs
“Plaques”
see pics
50
Primary s/s MS:
Where? Clinical Presentation?
* MS can affect **white matter anywhere t/o CNS**
* Clinical presentation depends on **loc of demyelination**
* may not correlate w/ imaging findings
* Wide variety s/s
51
Common s/s in PWMS
See pics
52
2 Ways to Classify MS:
1. Disease **subtype→ Phenotype**
2. Disease **severity**
53
Sub-Types of MS:
4
1. Relapsing-Remitting→ **most common**
2. Progressive-Relapsing
3. Primary (Chronic)-Progressive
4. 2\* Progressive
54
Subtypes MS:
## Footnote
**Relapsing-Remitting**
**\*most common**
* Rapid, abrupt deterioration w/ variable degs of recovery over time
* **aka exacerbating-remitting**
55
Subtypes MS:
## Footnote
**Progressive-Relapsing**
**aka Exacerbating-Progressive**
* Relapses w/ lg deg of residual impairment
56
Subtypes MS:
## Footnote
**Chronic-Progressive**
**aka Primary-Progressive**
* Steady progressive deterioration
* PACE of deterioration may be **steady or varied**
57
Subtypes MS:
## Footnote
**2\* Progressive**
* BEGINS as **relapsing-remitting** THEN becomes **chronic-progressive**
58
MS Education for pt.
## Footnote
**Exacerbation vs. Pseudo-Exacerbation**
**Talk about pseudo-exacerbation**
* Transient (temporary) worsening of sx's that can occur due to **stress, infection, overheating, overexertion**→ Full recovery occurs
* EX. Person w/ pseudo-exacerbation
* Temp. change in sensory sx's due to exercise but will **recover completely** w/in short pd of time
59
Remember…**for definitive dx for MS you NEED:**
* 2 clinical or para-clinical spatial and temporal distinct lesions @ 2 diff times
* **2 clinical findings OR**
* **2 radiological findings @ 2 diff times**
60
Not Quite MS:
* **CIS→** Exacerbation happens ONCE
* **RIS→** Radiographic evidence ONCE
w/ both→ **more likely to dev. MS in future**
61
MOST COMMON DISABILITY SCALE FOR MS
EDSS
Extended Disability Status Scale
\*Low reliability
\*see pics
62
WHERE DO WE SEE MOST PWMS?
Following EDSS
SEE PICS
63
MS:
## Footnote
**Disease Severity**
* Other measures
* Disease Steps (previous picture)
* Pt-Determined Disease Steps
* **NOTE:** plastic changes/compensations BEFORE sx's reach clinical threshold **aka become noticeable**
* **Relapse→** could be old recurring sx's OR new sx's
64
Med. Interventions for PWMS:
3:
1. **Mgmt of Acute Exacerbations**
2. **Long-term dis. mgmt**
3. **Sx mgmt**
65
Med. Interventions for PWMS:
## Footnote
**Mgmt of Acute Exacerbation**
* Goal: Halt inflamm process
* Tx:
* **high dose methylprednisolone: IV**
* **high dose prednisone: oral**
* **acthar (ACTH): subq/intramuscular**
**ALL= immunosuppress/anti-inflamm**
66
Disease Modifying Agents for MS:
## Footnote
**know this one**
\***Ocrevus→** only drug FDA approved to tx **progressive MS**
**\***Botoxin for **hypertonia**
67
MS:
## Footnote
**Med. Sx Mgmt**
* B&B dysf
* depression
* dizzy/vertigo
* emotional changes
* **Fatigue**
* itching
* pain
* sex. dysf
* spasticity
* tremors
* walking diff.
68
The Examination for MS pt.
* Some **MS-specific considerations**
* **Hx-taking**
* **Tests & Measures**
69
Examination for MS:
**MS-Specific Considerations**
* Systems review **should consider** BOTH **observed and occult** (not seen, pt not complaining about it)
* CV/Pulm
* autonomic→ monitor resp to ex.
* Integumentary
* Neuro/MSK
* PT Exam MUST ID Pt. problems that are **primary (**due to MS) **AND secondary (**consequence of another impair, act. limit., or participation restrict), or **combination**
***NOTE:** 2*\* problem IF **quick response** to intervention
70
MS Examination:
## Footnote
**Taking the Hx**
* verbal/non-verbal comm.
* **What do you see w/ simple observation?**
* facial express
* posture
* equip
* spont. mvmts
* **Things to Consider:**
* PMH
* Social Hx
* Current LOF
* Overall lvl of phys act.
* Any prev/current rehab/ex program
71
MS Examination:
## Footnote
**Other questions to consider**
**\*have gen. idea**
see pics
72
MS Pt. Exam:
## Footnote
**Fatigue**
* Special consideration for PWMS
* **_Participation-level_ measures→ “Trait”**
* what they exp **most of the time**
* MFIS- canvas
* FSS- canvas
* FSMC- canvas
* **_Immediate_ measures→** “**State”**
* how you feel **right now**
* VAS of Fatigue
73
MS Pt. Exam:
## Footnote
**Integumentary**
check skin
ask questions about skin safety-- esp lot of time in bed, w/c, sitting chair
74
What should be measured during the MS pt. Examination?
* **Vital signs→** vitals are vital!!!
* A/PROM
* Strength/motor control
* UMN signs
* Sensation
* Pain
* Posture
* Balance+Fall hx
* **Cerebellar function**
* tremor
* \*coordination
* nystagmus
* Bed mobility-**functional mobility**
* Transfers-**functional mobility**
* Walking + Gait-**functional mobility**
* Stair climbing-**functional mobility**
75
Vital Signs and PWMS
* IMPORTANT!!!
* CV **autonomic dysf** common in PWMS
* orthostatic dysreg, cardiac arrhythmias, blunted ex responses
76
A/PROM in PWMS
56.4% have contracture in @ least one major UE or LE jt
* Ankle=43.9%
* Shoulders=13.1%
* Hips=28.8%
* Knees=17%
77
Flexibility in PWMS
* w/ out adequate flex→ person loses norm biomechs necessary for walking, gait, balance
* **HIGHER prevalence in those w/ _progressive_ types of MS**
78
Strength and Motor Control in PWMS
70% have weakness (MMT = 3/5) in one mm group
* LE= ankle, knee, hips (50-53%)
* UE= shoulder, elbow, wrist (61-62%)
\***NOTE:** differentiate whether person has **normal motor control**, then test strength accordingly
79
\*Changes in flex and strength are **often present very EARLY in disease, even in absence of limits in function!**
see pics
80
Testing UMN Signs
* Spasticity
* **Mod Ashworth**
* DTRs
* biceps, tris, brachioradialis, quad, gastroc
* Clonus
* wrist, ankle
* Babinski
81
Examining Pain in PWMS:
* **Consider:**
* location(s)
* description
* intensity when **worst**
* worsened by..
* improved by..
* activities impaired
* **NOTE:** important to diff whether pain is **primary (neurogenic), secondary (jt pain due to compensatory mvmt patterns), or unrelated to MS (MSK source of pain)**
82
Bed Mobility and Transfers in PWMS
* GEN measured w/ **_observational analysis_**
* Consider **objective tests:**
* 5STS
* timed mobility tests
* **Observe carefully** to assist in **eval'ing critical contributors to limits.**
83
Posture in PWMS Exam
Sitting AND standing
\*if bed/chair bound→ **posture in these environments must be considered**
84
Balance in PWMS: Taking a Fall Hx
* Ask SPECIFIC QUESTIONS about falls
* people have poor recall of falls **unless catastrophic/injurious**
* dig deep!
* how/when/why falls happening?
* how many? frequent?
* SPLATT (another slide)
85
**SPLATT** Questions: **Related to Falls**
**SPLATT:**
* **S:** Symptoms @ time of fall
* **P:** Previous falls you've had
* **L:** Location of falls
* **A:** Activity you were doing
* **T:** Time of day
* **T:** Trauma→ injured @ all?
86
Balance Exam in PWMS:
REVIEW BALANCE!!!
* Consider test(s) to use
* Standing:
* Berg
* DGI
* MiniBEST
* 4-Square Step Test
* Functional Reach
* Sitting:
* Function in Sitting Test
* Trunk Impairment Scale
USE CLINICAL DECISION MAKING SKILLS!
87
Walking and Gait in PWMS
* 40-50% PWMS exp. **walking diff.**→ 70% report **one of their most _limiting problems_**
* 30-40% of care partners report walking limits causes **sig caregiver burden** and **neg. impacts their QOL**
88
Contributors to **Walking and Gait Dysf in Pts w/ MS**
see pics
89
Examining Walking and Gait in **PWMS**
* **Observational Analysis\*→** W/ and W/out AD
* Distance? Device? Assist needed?
* **_Repeatable_ measures of walking:**
* Timed 25'-Walk Test
* 2, 3, 6-Min Walk Test
* 12-item MS Walking Scale- **canvas**
90
Other Considerations for Examination of PWMS:
* **Vision**
* acuity
* oculomotor function
* **Vestib Function**
* Substantially HIGHER incidence of **peripheral vestib dysf** in PWMS vs age/sex matched peers
* **Mentation/cognition**
* **Resp strength/cough/breath support**
* use PFTs!
* common early in disease
91
3 places where **Fatigue** MUST be Considered:
1. Examination
2. Evaluation
3. Intervention
92
Fatigue…
* **Essential part** of **neuro. disability**
* Part of **mobility loss** in neuro patho may be due to **fatigue**
* **MUST BE CONSIDERED IN:**
* Exam
* Eval
* Intervents.
93
Fatigue vs. Fatigability vs. Pathologic fatigue/fatigability
* **Fatigue= Symptom**
* _Subjective_ state of being tired
* Feeling of not being able to perform a task or activity **effectively,** if at all
* **Fatigability= Sign (change in ability)**
* _Observational decline_ in performance during _sustained activity_
* Can be observed on ANY prolonged and/or intensive task
**NOTE: Pathologic fatigue or fatigability→** happens faster or more severely than expected in a non-disabled person\*
94
Recognizing **Fatigue vs. Fatigability**
**Fatigue (symptom):**
* NO ENERGY
* pt c/o fatigue
* pt avoids ex program or other activities
* caregiver report
* dec'd scores on self-report fatigue measures
* can also present as depression, anxiety
95
Recognizing **Fatigue vs. Fatigability**
## Footnote
**Fatigability (Sign):**
* **progressive** slowing of gait
* **progressive** weakness of rep'd contracts
* **worsening** of sensation/speech/vision during repetitive task
* **DECd performance** on a functional measure following exertion
* physio. measures→ temp, EMG, CV
* Pt caregiver complaint/ID
96
Interaction of **Primary** and **Secondary Fatigue/Fatigability**
Less mvmt is performed→ Deconditioning results→ tasks become “unlearned”
\**Where can we as clinicians intervene in this cycle?→***ALL LVLS!**
97
SPECIAL CONSIDERATION: **FATIGABILITY**
* **Decline in performance** w/ repetition OR during a prolonged work bout
* Need frequent breaks/rest!!!
98
Ex. Fatigability
6MWT
see pics…
99
Crux about **Fatigability**
* Evidence that there is a **declination in performance** after rep'd attempts and/or other fatiguing activity in PWMS
* Found in:
* Rxn time testing
* Postural control
* Functional balance tests
* Gait and walking
* Speech and communication function
100
Fatigue vs. Fatigability
\*Key thing to remember
**Always differentiate _symptom_ from _sign_!**
101
Fatigue is a \_\_\_\_\_\_
Symptom
102
Fatigability is a \_\_\_\_\_
Sign
103
Evaluation
aka…
Putting it all together!!!
104
What is the **Evaluation?**
* Time to consider **all of the findings** and develop **hypotheses** that may be confirmed or refuted by these findings
* **Add. testing/measuring/questioning** may be needed to confirm/refute equivocal findings
* **End Result→** Includes overall assessment of the pts condition, along w/ **specific prob list of what _needs to be addressed_**
105
Developing Intervention Plan
* HOW are you developing plan?
* What are “General” probs you might ID→ ones that may be amenable to trad. interventions?
* What are **MS-specific probs** that will req more individualized plan?
106
Remember in PWMS….
“Persons w/ MS respond to exercise the same way as those w/out MS: **they become more fit!”**
-Karpatkin, 2005
107
Developing Intervention Plan
What should it **focus on?**
* Focus on **maximizing function!**
* Consider components of the **motor relearning program**
* **task analysis**
* **practice whole task**
* **practice missing components**
* **transference of training**
* Address impairs of body structure/function as needed
108
**Considering Fatigue**
* MUST BE CONSIDERED when working w/ PWMS
* **One of the _main limiters_ of the effectiveness of PT interventions for PWMS**
* Must be balanced w/ the need to maximize therapy dosing
109
What can be done to combat fatigue during PT Interventions?
2 Leads:
1. **Intermittent Training**
1. work up until fatigability then break
2. **Maximal Strength Training**
1. Ex. 4 sets of 4 reps @ 90% 1RM
110
Intermittent Training
Work up until fatigability then break
111
Maximal Strength Training \*\*\*
Ex. 4 sets of 4 reps @ 90% 1RM
112
What about interventions for those who are **more disabled?**
* Maintain **max. flex and strength**
* Protect skin
* Address **person-specific goals**
* other ideas:
* mech. lifts
* chest PT
* incentive spirometer
* etc..
* **In the late to end stage:**
* you may fill role of hospice PT
* help do things THEY WANT TO DO
* participate where they want to participate
113
Bottom Line for PWMS:
* DON'T hesitate to work w/ PWMS
* Conduct **comprehensive exam** bc _no pre-defined clinical picture_**\***
* Treat as aggressively **as tolerated**→ **DO NOT UNDERDOSE!**
* Refer to other pro's as approp.
* Be in touch w/ more knowledgeable mentors to help when you're not sure what to do!
