MS Flashcards
What is multiple sclerosis?
Chronic demyelination disease of the CNS (only!) characterised by an inflammatory process and causing widespread degeneration of the CNS, gradually resulting in severe neurological deficit
Pathophysiology of disease:
Immune system attacks myelin - combo of genetic and environmental factors
Disruption of blood-brain barrier
Leakage of inflammatory cells - caused by the damage to the blood brain barrier. They can leak out of blood easily.
Destruction of oligodendrocytes and myelin sheath - by inflammatory cells
Disruption of nerve signals, rate of conduction of nerves is slowed down
Plaques can then form throughout the CNS
What does sclerosis mean? How does this contribute to the disease?
Sclerosis means scarring and multiple - which relates to the sites of the scarring, which can occur in different places throughout the brain and spinal cord
How are T cells involved?
T cells become misprogrammed to attack ‘itself’.
Once through the blood brain barrier, they signal macrophages
Cause of MS -
Environmental factors -
Not definite - suspect there are multiple triggers
Smoking
Low vid seen as risk factor - correlates as closer to equator = more sunlight
Obesity - and may contribute to inflammation
Environment - several believed geographical gradient.. MS occurs more frequently in areas further from equator
Causes of MS
Viral factors -
Genetic factors -
Viral - some viruses put people at more risk of developing MS
Genetic - not an inherited disease!
But there is a genetic risk that can be inherited
Risk of developing is higher if close relative has it
What are the four main areas being looked into to help identify the cause of MS?
1)immunology - looking at bodies immune system - B and T cells involved… research looking at potentially other cells
2) epidemiology - looking at disease patterns in large groups of people
3) genetics
4) infectious agents eg viruses
MS facts and figures-
1 in 50 people in Uk have MS
MS twice as common in females than males
Generally diagnosed between 20-40 years of age
Types of MS
Benign MS -
Really uncommon
Stable, and have a little blip… episodes potentially years apart
They will always return to their baseline!
Potentially will not need medical intervention
Types of MS
Relapsing remitting MS (RR) -
Patients will NEVER return to their true baseline
Disability level will slowly get worse after each relapse
85% diagnosed with this
Types of MS
Secondary progressive MS -
Patients will mov from RRMS to this
Progression of getting more and more scarring in CNS, therefore increasing disability level
RRMS will almost always lead to this
Types of MS
Primary progressive -
Very first symptoms are progressive
Always gradually getting worse - no period of stability or decrease
15% diagnosed with this
Signs and symptoms -
Bare in mind there are LOADS! Symptoms vary as areas of attack and scarring are non-specific, can happen all over!
Most common:
Fatigue, difficulty walking, vision problems (often from optic neuritis - optic nerve inflammation)
Problems controlling badger
Sensory deficits
Increased muscle tone
Reduced balance
Ataxia
Problems with thinking, learning and planning
Reasoning behind signs and symptoms
Vision deficits -
Weakness -
Spasticity and hyperreflexia -
Ataxia and poor coordination -
Sensory loss -
Vision - eg diplopia… occipital lobe, optic nerve, thalamus
Weakness - motor cortex, descending pathways
Spasticity/ hyper - motor cortex, descending pathways
Ataxia - cerebellum
Sensory loss - sensory cortex or ascending pathways
Reasoning behind signs and symptoms
Dizziness/ poor balance -
Sphincter disturbance -
Sexual dysfunction -
Mood problems -
Decreased intellectual function -
Fatigue -
Dizziness - vestibular system/cerebellum
Sphincter disturbance - spinal cord
Sexual dysfunction - spinal cord
Mood problems - limbic system, dopamine system and hypothalamus
Intellectual - frontal lobe
Fatigue - complex
How do we diagnose MS?
Takes several months or more
No single test can conclusively diagnose - more a case of ruling things out
Clinical history
Neurological examination by specialist
MRI scan
Evoked potential tests
Lumbar puncture - cerebral spinal fluid extraction - looking for inflammatory markers
Blood tests
What is MS relapse?
Need to be present to count as an MS relapse:
1) clinical event of the type usually seen in MS
2) event must last at least 24 hours
3)objective findings must be present (symptoms alone, no matter how characteristic do not count)
4) the event is not a temporary worsening entirely due to a fever or infection, make sure not due to this!
5) to count as distinct (new) attack, the onset of a clinical event must be at least 30 days after the onset of a prior attack
6) single paroxysmal episode does not constitute a relapse, but multiple paroxysmal events occurring over 24 hours or more can equal an attack
Medical treatment of relapse -
Involves either:
5 day course of steroid tablets taken at home - treatment choice because they reduce inflammation
Or
Injections of steroid medicine given in hospital for 3-5days
Disease modifying drugs(DMDs), benefits -
Fewer relapses
Less severe relapses
Reduce build up of disability which can occur if recovery isn’t complete from relapses
How do DMDs work?
They work with different parts of the immune system to reduce the inflammation caused by MS to nerve cells in the brain and spinal cord.
This helps reduce the number and severity of relapses
Each drug offers a different combination of benefits and risks
Medical treatment of symptoms! Examples:
Remember…. Manage by treating patients symptoms, symptoms vary!
Anti-spasticity agents and relaxants - baclofen, tizanadine, cannabis
Neuropathic pain - pregabalin, gabapentin
Anti-depressants
Analgesia
Catheterisation - patients with bladder problems
PEG feeding - if struggle with swallowing
Hyperbaric O2 - breathing o2 through mask in higher pressure chamber
Prognosis -
Factors associated with a better disease course -
SO variable
Better:
Being female (higher risk but better disease course)
Less than 40 when diagnosed
Having few relapses in first few years of diagnosis
Making complete recovery after each relapse
Long intervals between relapses
Symptoms that are mainly sensory in nature
Avg LE= 5-10 years lower than avg
People involved in the MDT -
MS specialist nurse
Community nurse
Neurologist
GP
Occupational therapist
Dietitian
Nutrition nurse
Orthotist
Optometrist
Wheelchair technician
Physio
Social worker
Speech and language therapist
Podiatrist
Carer
Psychologist
MS medications
Interferon beta, how it works and side effects -
May slow progression of RR MS
Induces production of neutralising antibodies and reduces inflammatory cells crossing blood brain barrier
Injected
Skin reactions and flu like symptoms
Medications
Glatiramer acetate, how it works and side effects -
May reduce number of relapses
Suppresses inflammatory response
RRMS only
Injected
Skin reactions and flu like symptoms
Medications
Teriflunomide, how it works and side effects -
Inhibits production of rapidly producing cells including T cells. RRMS only Injected
Oral
Headache, diarrhoea and nausea
Medications
Dimethyl dumarate, how it works and side effects -
RRMS only to reduce number of relapses not sure how it works
Oral
Headaches diarrhoea and nausea
Medications
Fingolimod, how does it work and side effects -
RRMS only
Reduce number of relapses
Has an effect on lymphocytes to stop them working and contributing to auto-immune reaction.
Oral
Colds, headaches and fatigue
Medications
Natalizumab, how it works and side effects -
RRMS only
Kills T cells
IV infusion
Headaches, shivers, stomach upset, joint pains
Sore throat, tiredness feeling sick
Medications
Alemtuzumab, how it works and side effects -
RRMS only
Stops T and B cells going into the brain
IV infusion
Headaches, rash, hives
Feeling or being sick
Fever itching going red on the face
Tiredness
