MS done Flashcards
A person can have MS for…
Long long time.
Age that MS starts?
Early forties
Ninety percent make use of this DME?
Power chair
Multiple Sclerosis =
multiple areas of scarring(sclerotic tissue) or plaques
As the name does say, that there are multiple areas that are sclerotic
MS is an _________ disease that has an _______ effect.
Autoimmune,
Inflammatory.
Does MS affect the periphery or also the CNS.
Also the CNS
There is also the Walking Pill, the Walking Drug, Ampera, or 4AP, it clogs up the holes that were
made.
.
Spasms are muscular
Seizures
Can you train them to send more action potentials?
Yes
Etiology
• Interaction between several factors:
• genetic predisposition, we did say that MS is an AI disease.
• an inciting environmental antigen, the enviornment can trigger this person who is predisposed
susceptibility of the host, ??? Isn’t this just genetics?
Difference between exacerbation and pseudoexacernbation
The real deal is for 48. Hours or more, the psuedo is for less than 48 hours.
What can trigger their exacebation?
Heat.
Risk of developing MS is greater if you have a
siblingwith MS, greater risk for ♀ sibling vs. ♂ sibling
- 3% for sibling
- 5% for fraternal co-twin
- 25% for identical co-twin
.
Implicated Viruses, yet to be proven
Epstein-Barr, Very strong correlation • Measles Canine Distemper A virus • Human Herpesvirus-6 • Chlamydia pneumoniae
The MECCH is this.
Measles Epstein barr Chlamydia pneumoniae Canine distemper A virus Human herpes virus 6
Favorable prognostic indicators:
Female, onset before age 35, monoregional vs polyregional attacks, and complete recovery afterattacks
So females are shielded againstt he brunt of this problem, as is their symbol.
If they are young, so they have the ability to recover
If they do recover sfter attacks it shows that they area type of person that can recover well.
Adm finaly if the attack was at one area and not at mulitple areas, this can show that this person has a strong reislience to this disease.
You g strong shielded female, that has it at one area, and did recoverf rom previous attacks.
This shows that they would most likely do well.
Unfavorable prognostic indicators:
• Male, brainstem symptoms (ataxia, nystagmus, tremor, dysarthria), poor recovery after exacerba-tions , &high frequency of attacks
So the men are apnot shielded,
If their attacks is on the brainstem, a major area, if they have had attacks and they did not recover well,and they are getting attacked over and over again.
Somwhy are they not recoveri well or getting attacked over and over again? They are very suceptinpble. They would most likely get attacked again.
And men do not have that shield that women have.
So these are not causes, but signs that these types of people are more likely to have a poor prognosis.
Vitamin D defieciency is bpvery prevalent forMS.
.
• Inc. prevalence in areas farther away from the equator (>400 latitude)
So who is more inclined towards being affected by the heat, someone who has not ebeen acclimated to the heat.
Those are the people who are in the cold areas, so they are not used to the heat, and when it does get hot they csn become exacerbated.
But really we are speaking about those who seem to have a predisposition.
But anything that will alpw me to remenpber this.
So colder climates they are more likely to have ms?
Or those who are more likely to get MS live in the cold climates?
Nope, its really a cause, interetingly enough.
Suvival Rate
From 1980-1989:
!
Survival rate from 15 to 40 yrs
Currently
Almost a normal lifespan
Secondary to Better Managment of Symptoms
The answer for fatigue is not
rest, but it isworking out.
The BBB is disrupted and triggers:
• Astrogliosis
• Production of a brain antigen called glial fibrillary
acid protein (GFAP)
• GFAP causes further disruption of BBB
• Mobilizes “activated” lymphocytes & macrophages to the scene.
• Macrophages initiate destruction of myelin sheaths & cell bodies of oligodendrocytes.
• Fibrous astrocytes fill the demyelinated areas & form the glial scar or plaque.
• Cytotoxic lymphocytes and macrophages are present in the plaques, leading to edema that can have a masseffect, simulating a tumor
The successful treatment of MS exacerbations with ster-oids is in part based on the drugs’ ability
to control theedema resulting from the inflammatory response
REMYELINATION AFTER EXACERBATION:
The survival of oligodendrocytes is the factor behind re-
myelination in early attacks
In later stages of the disease, no oligodendrocytes are
preserved, and remyelination occurs only at the bordersof the plaques, if at all.
If we can promote oglidendrocyte survival, even though the myelin will get destroyed they can get rebuild.
The issue with MS is not that the myelin gets destroyed, that nothing new, but the issue is that new ones do not get rebuilt.
Typical lesions are in the
periventricular region of thelateral ventricles and the optic nerves (often a 1st lesion)
Relapsing-Remitting (RR)
Episodes of rapid, abrupt & unpredictable deteriorationwith variable degrees of recovery over time & minimal
residual disability
• Periods btw relapses are characterized by lack of dis-
ease progression
• Most common (85-90%)
• After 10-15 years, will develop into progressive MS in
30-40% of individuals
• 50% need assistive devices 15 yr post onset
• 40% with attacks rendering them nonambulatory
never regain ability to ambulate
• Characterized by clearly defined acute attacks with full recovery (A) or with sequelae & residual deficit upon
recovery (B). Periods between disease relapses are
characterized by lack of disease progression.
Primary-Progressive (PP)
Characterized by a steady progression of continuous
worsening with minor fluctuations, but without distinct periods of relapses and remissions
• Plateaus rather than remissions
• Aka relapsing-progressive
• Tends to affect people who are older at disease onset• Approximately 10%
• Characterized by disease showing progression of dis-ability from onset, without plateaus or remissions (A)
or with occasional plateaus & temporary minor im-
provements (B).
Secondary Progressive (SP)
Begins as relapsing-remitting (80%), followed by pro-
gression with or w/o occasional relapse, minor remis-
sion, or plateau
• The decline may include new neurologic symptoms,
worsening cognitive function, or other deficits.
• Begins with an initial RR course, followed by progres-sion of variable rate (A) that may also include occa-
sional relapses & minor remissions (B).
Progressive-Relapsing (PR)
• Steady progressive deterioration from onset with clear, acute relapses that may or may not resolve
• Periods between relapses are characterized by contin-ued progression
• Pace of deterioration can vary
• The least common of all MS subtypes
• Shows progression from onset but with clear acute re-
lapses with (A) or without (B) full recovery
Diagnosis?
• MRI with gadolinium – picks up new lesions
• Evoked potentials – measures conduction velocityalong visual/auditory/sensory pathways to detect
demyelinization
• CSF – inc. gamma globulin & WBCs
MRIs,
CSF,
And
evoked potentials
Overfatiguing someone is…
Something that is transient.
Because the muscle is being used, but it is rooted in the CNS
The fatigue worried about MS is about..
Laccitude, an overwhelming of fatigue, like coming out of a sauna that you are groggy and the muscles are fatigued.
Like waking up in REM sleep. The evening after a marathon is this feeling.
Do you rest for MS?
Do not push into central fatigue. This will cause them to overheat.
But push a little bit, and cool the patient down, before it becomes long lasting, there is 99% no risk.
To make the room cool to about…
70 degrees, but the harder that they are working the cooler you need it to be.
The episodes of MS is usually with no _______ recovery.
Full
A _________ tells us that the person has MS.
Ogliodendrocytes.
Before ten years ago it was a rule out procedure.
What canresent like MS?
Glutten, diet is very important, but it could make it look like it is MS, because the episodes are able to be presented in different ways.
The way to know which type of MS after the spinal tap tells you that it is MS is just throughh…
Anecdotes, that you will see the history.
With medication episodes of relapsing and renitting can happen
Very very rare!
There are side effect of MS medications, but…
The benefits outweigh the costs.
EDSS stands for
Expanded Disability Status Scale
EDSS is from
0-10. 10 is death.
EDSS is a progression, that if it is 8 then everything prior to that is…
Also true.
The EDSS works usually for alot of people, it is very rare to have the symptoms that are true by what a higher number tells you without having what the lower numbers show.
Usually they will have all the symptoms that there are before that number. Its like they progress to that number.
.
Which imaging is for MS?
MRI.
Then a spinal tap, will tell you what it is.
.
Best to get a ______ every year.
MRI
Some MDs will do a _______ _________ every year.
Spinal tap
Immunomodulators are used for _______.
.
CRAB for MS medicstions.
Copaxone, Rebif, Avonex and Betaseron
CRAB causes what?
Lower the immune system, cause flu like symptoms, and they patients will need to self administer
If a patient is taking CRABS do you need to be more mindful and will you not work with them if you are a little bit sick?
Yes, because they are extemely prone to getting sick.
Tysabri can cause…
PML, Progressive multifocal leukoencephalopathy,
People with exacerbation are on…
Corticosteroids. Hi doses for not mpre than 7 days.
During their corticoid steroid sessions is it a very good time to perform rehab?
Yes, because they are very uninflammed.
4AP((4EAminopyridine) is used for what?
MS for fatigue.
4AP((4EAminopyridine) what does it do?
Fills in the gaps.
Aderol is very common?
Yes, these medications give you a ton of energy, a lot of mental alertness.
Why is it important to know that they are on aderal or other medications that are not directly for MS?
Aderal will cause an effect on HR, it can cause a herpart attack.
When someone is on a ADERAL type of drug for energy provision, will we work with the patient?
Yes, but take vitals more often.
Medical(Management(of(Symptoms Fatigue
Amantadine((Symmetrel)
Modafinil((Provigil)
Moderate benefit in managing MS5related fatigue in some pa5tients
4AP((4EAminopyridine) for diminished conductivity poor endurance
In0patients0receiving0disease6modifying0agents
glatiramer0acetate0is0associated0with0less0fatigue0than0
interferon0beta61b
Gabapentin+(Neurontin) is really the only treatment for neurological pain?
Yes
Baclofen and tezanidine are used for …
Spasticity of the muscles, which that can cause pain.
Seondary fatigue is true by MS?
No, it can happen to anyone.
What is the age that MS starts usually at?
40
What assistive device do many many people with MS make use of?
A power chair.
Multiple Sclerosis =
multiple areas of scarring(sclerotic tissue) or plaques
How do we take a look at these scars?
We use MRI
How often should a MRI be done for the MS population?
Once a year
Why would we want an MRI for the ms population?
To see the progression of these sclerosis.
What kind of disease is MS?
It is an autoimmune disease.
What kind of attacks does ms have?
Inflammatory
What do these attacks do to the person?
They demyelinate the nerves.
What happens when there is demylenation of the nerves?
It will slow down the saltatory conduction.
attacks, aka?
relapses, or exacerbations
Episodes of CNS inflammation called attacks, relapses, or exacerbations, resulting in:
Destruction of myelin
• Astrogliosis – glial scarring
• Destruction of oligodendrocytes
• Irreversible axonal damage
Besides lowering the production of the myelinwhat happens to the nerves?
They die
Do these older dead nerve get removed wuickly enough?
No
What happens if there is an abundance of dead nerve cells?
It impedes the conduction, like a traffic jam.
What is the walking drug?
Ampera, it amps you up, Walking Pill, the Walking Drug, Ampera, or 4AP
How does ampera help the person who has MS.
It fills in the gaps of the areas that there has been a breakdown of myelin.
Is MS a progressive disease?
Yes
Is MS progressing all the time?
Yes
So MS is a general progressive autoimmune disease but it is not always getting worse?
Yes
Can we train the nerves to send more signals?
Yes
What is one thing that we can do to have the person with MS to better be able to conduct himself?
To get more signals sent out from their nerves.
What is a first neural sign that people can notice in those who have MS?
This is optic neurosis.
What three things happen tot he eyes with MS?
Nystagmus, optic neuritis, and diplopia.
What happens to someone who has MS?
Dysarthria, if there nerves in their mouth is not good, then one would think to say that these people are not able to speak well.
What central nervous system issues will MS arise?
Fatigue, depression, cognitive Impairment, unstable mood.
Is at their mouth MS will not allow them to speak properly what will happen at the throat?
They will have a hard time to slow.
Now if there is neural damage by the musculoskeletal system, then what will we be able to see?
Spasms, weakness, ataxia.
If at the muscles there can be weakness and ataxia and spasms, then what will we be able to see at the sensations?
Diminished sensation(hypoesthesia), different sensations(paraesthesia), and pain.
What is a very unwelcomed paraesthesia?
Pain
What would happen when there is a lack neural innervation to the bowel and bladder?
There would be bowel and bladder incontinence, the muscle will not be able to keep their contents in place.
Name me a few areas that a we can see affected by MS?
Eyes, tongue, throat, muscles, sensations, central, bowel, and bladder.
Primary Progression is?
They steadily gets worse, but they do not have bouts of exacerbation.
Relapsing and remitting is?
It is like what the classic stock market charts are. The person gets worse, and then gets better, but does not get as good as they were, and then when they relapse they actually now get worse than what they were.
Should really be called remitting and relapsing, or maybe because the person gets worse, they relapse, and then they calm down, they remit. This is why it is called relapsing remitting.
Secondary remitting is what?
We see the name remitting, so we are to think of relapsing remitting, but a much worse type.
That when they have exacerbation they will actually get worse than the relapsing of the relapsing remitting.
What is an exacerbation?
When they loose function.
What is a pseudoexacerbation?
When a person looses function.
What is the difference between an exacerbation and a pseudo-exacerbation?
Exacerbation are more than 48 hours and a psuedo is less than 48 hours.
Are people with MS sensative to heat?
Yes
What type of temperature increase will bring about exacerbation?
Increase in core temperature.
Core MS.
Etiology
• Interaction between several factors:
- genetic predisposition, they have a predisposition.
- an inciting environmental antigen, the environment causes them to become activated
- susceptibility of the host, are they susceptible?
Males or females are more likey to get MS?
MS is for the Ms. This is for females.
What are the percentages of the sibling increase for MS?
3% for sibling
• 5% for fraternal co-twin
• 25% for identical co-twin
Implicated Viruses, yet to be proven
Epstein-Barr, Very strong correlation • Measles • Canine Distemper A virus • Human Herpesvirus-6 • Chlamydia pneumoniae
A very high correlational viral component to MS.
Epstein-Barr
Favorable prognostic indicators:
Female, because this is not something crazy, it is usual.
onset before age 35, they are young, strong.
monoregional vs polyregional attacks, it is not wide spread.
and complete recovery after attacks, not primary progressive, or relapsing and remitting, nor secondary remitting.
Unfavorable prognostic indicators:
Cerebellar based
• Male, it is strange so we do not think that it will fair well for the person.
brainstem symptoms (ataxia, nystagmus, tremor, dysarthria), it is central, bad sign, and this can be senses as a polyregional of some sorts, because it is at the root of all issues, even though in the body it is monoregional, but the brain is so so important that it can be mpconsidered multiregional.
poor recovery after exacerbations, & high frequency of attacks, if they are not recovering well then it is bad.
Men or women have a better prognosis?
Women
Poly or mono regional has a better prognosis?
Monoregional
If they recover well or if they do not recover well will there be a better prognosis?
A fuller recovery is a better prognosis.
Is the brain to be considered as mono or poly regional?
Poly regional
Why is the brain to be considered as poly regional?
Because the brain is like a team all put together.
Which vitamin deficiency is very prevalent ispn those with MS?
Vitamin D
Where are those who have MS more likely to have come from?
Inc. prevalence in areas farther away from the equator (>400 latitude)
Those who are further away from the equator are they to have more or less vitamin D?
Less
So those who are farther from the equator are more likey to have MS and ms have been correlated with a Vit D deficiency?
Yes
More prominent in ________, less so in ________& _________.
Caucasians, Africans and Asian
What age is the cut off to determine the local’s influence on the person’s chance to contract MS?
15
What is the survival rate for those with MS?
15-40 almost a full lifespan.
Why is 15-40 years of living with MS almost a lofespans?
If they get it at age 40 and have it for another 40 years then the personw ill have lived for 40 years.
For those who fatigue is it better to rest or is it to work out?
To work out,
If work out is okay for the person, is there any issue that we show be concerned about?
Their core temperature increasing.
Why would steroids be able to help the exacerbations of MS?
Because they lower the edema and this will not allow the mass effect to be present, and then the local damage will not be had.
Can there be remyelination after exacerbations?
Yes
What cells do we need to make the nerves remyelinated?
Ogliodendrocytes
Why is there no remyelination after some exacerbations?
Because the ogliodendrocytes are gone.
The BBB is disrupted and triggers:
• Astrogliosis
• Production of a brain antigen called glial fibrillary
acid protein (GFAP)
• GFAP causes further disruption of BBB
• Mobilizes “activated” lymphocytes & macrophages to the scene.
• Macrophages initiate destruction of myelin sheaths & cell bodies of oligodendrocytes.
• Fibrous astrocytes fill the demyelinated areas & form the glial scar or plaque.
• Cytotoxic lymphocytes and macrophages are present in the plaques, leading to edema that can have a masseffect, simulating a tumor
.
Typical lesions are in the…
periventricular region of thelateral ventricles and the optic nerves (often a 1st lesion)
Just gets worse without getting better?
Primary progressive.
Gets worse with plateaus?
Primary progressive
Gets worse with slight remissions, with very slight improvements, but basically it just keeps on getting worse?
Primary progressive
Most common thep of MS.
Relapsing-Remitting
The classic stock market chart?
RR
It gets worse, then better, not as well as beofre, and then it gets worse?
RR
When it gets better, it does not get worse progressively on that interim between the exacerbations?
Relapsing-Remiting
It looks like a stock market chart it is progression but it is not progressive?
Once you hear that it is not progressive, you know that it is not Primary progressive or secondary progressive or progressive relapsing, it can only be relapsing-remitting.
Secondary Progressive (SP)
Begins as relapsing-remitting (80%), followed by progression with or w/o occasional relapse, minor remission, or plateau
• The decline may include new neurologic symptoms, worsening cognitive function, or other deficits.
• Begins with an initial RR course, followed by progression of variable rate (A) that may also include occasional relapses & minor remissions (B).
Why is it called secondary progrssive?
Because it turns into a primary progressive type, but it does not start off as primary progressive.
SP, secondary progressive, it starts off as?
Relapsing and remitting
After the relapsing remitting what can it turn into?
Secondary progressive
How does secondary progress advance?
After it stops acting like a relapsing remitting it would act like primary progression.
What is progressive relapsing?
Look at the name, does it progress? Yes, and does it relapse to become worse? Yes.
So progressive relapsing.
Can relapsing remitting turn into a progressive form of MS, what?
Yes, secondary primary.
What is the percentage of the those who develop secondary progressive from RR?
10-15%
Tends to affect people who are older at disease onset type of MS
The elderly will have it worse than the young, sp this is PP.
The least common of all MS subtypes?
Progressive-Relapsing, this one has the two types put together, so is it uncommon, to progress and to get worse all of a sudden, may we never have to see this, it is getting worse and then it jumps in the worsening, progressive relapsing.
EDSS – Expanded Disability Status Scale
Range from 0 (normal) to 10 (death from MS) in 0.5 increments
The EDSS is similar to the?
VAS for pain, that 0 is nothing and 10 is the worse amount of pain possible.
0-10 for the progression of MS’s disability is to use which scale?
The EDSS, the Expanded Disability Status Scale
What imaging will we make use for in MS?
MRI
Why would we make use of MRI in the MS population?
To see if any new areas have become more demyelinated, new legions, new scars formed by the body on the. New areas that have become demyelinated.
What are evoked potentials?
It measures the speed of the electrical conduction, this will allow us to see if there are any areas that have become demyelinated and then scarred.
Allows us to see the speed of the electrical conduction.
Evoked potentials.
What do we take out and measure to test for MS?
CSF
What do we look for in the CSF to jpknow that there is MS present?
gamma globulin & WBCs
Why an increase of WBC in the CSF to see if there is MS?
Because it tells us that the body has launched its autoimmune attack.
Most common oral muscle relaxant is?
Oral baclofen
Name me four oral muscle relaxants.
Baclofen, Tizanidine,Dantrolene sodium,Diazepam
To relax the muscle DAN, TIZ, and DIAZ Came Bac.
Who is DAN?
Dantrolene sodium
Who is DIAZ?
Diazepam
Who is TIZ?
Tizanidine
Who is BAC?
Baclofen
Side effects of oral muscle relaxants, like diaz, tiz, dan, and bac?
Sedation+(drowsiness)
Weakness
Fatigue
If the muscles are relaxed so then the person is also relaxed, this is what? This is sedation, the body follows the brain and the brain may also follow the body.
Carbamazepine((Tegretol)(
Paroxysmal+(sudden,+sharp+onset)+spasms
What does one do if oral medications for spasms are not enough?
Intrathecal baclofen, Botulinum)toxin)(BT))injections, Phenol(injections, Surgical(intervention
Why is there spasms?
This is one of the muscular reactions that we said was to be with those who have MS.
Botux is short term or long term?
Short term
How long would botux last for?
3 months
For how long must the pt do what after the BOTUX injection?
4 weeks of stretching
4 weeks of stretching is done after what?
After botux
Why must there be 4 weeks of stretching after botux?
To maintain the new ROM and to lessen the spams.
Phenol(injections
Unpredictable+in+degree+and+duration+of+response+and+are+associated+with+sensory+side+effects
• Tendons+ ( tendonotomy)
• Nerves+(neurectomy)
• Nerve+roots+(rhizotomy)
These would be done when?
When there is years of spasticity, it is like a last resort.
What is a last resort?
Surgery is usually a last resort.
What are some surgical interventions for spasticity?
Cutting the tendon, cutting the full nerve, cutting the nerve root.
What were the three sensory issues that we said can arise from MS?
Pain, paraesthia, and hypoesthesia.
What can be prescribed pharmapseuticaly for the pain that can arose from the senosry influence of the MS?
Burning,(central(neuropathic(pain:+ Tricyclic+antidepressants+(TCAs)Paroxysmal(pain(responds(to( • Carbamazepine+(Tegretol) • Amitriptyline+(Elavil) • Phenytoin+(Dilantin) • Diazepam+(Valium) • Gabapentin+(Neurontin) Pain(from(Spasticity(and(Spasms Anti5inflammatory+drugs Mild+painkillers+ Strong+opiods+–+limited+effectiveness+and+are+not+typically+pre5scribed+ • Oxycodone • Methadone • Morphine
When would you make use of tricyclic antidepressants, TCA?
Tri as you might there is a deep central bother here, so we shall make use of tricyclic antidepressants for burning central neuropathic pain.
For depression, this has to be a neuropathic pain.
For sudden onset pain?
- Carbamazepine+(Tegretol), a car can move sudddenly
- Amitriptyline+(Elavil), AMI
- Phenytoin+(Dilantin)
- Diazepam+(Valium)
- Gabapentin+(Neurontin)
What are two things that DIAZEPAM can be used for?
For spasticity, along with BAC, TIA, DAN, and DIAZEPAM, can also be used for sudden onset of pain.
Can anti inflammatories be used for pain?
Yes
What is a classic anti inflammatory med that is consistently take for pain?
NSAIDs
Hat other medications are taken that are much harder?
Strong+opiods+–+limited+effectiveness+and+are+not+typically+pre5scribed+
• Oxycodone
• Methadone
• Morphine
Do strong opioids work well for MS mediated pain?
No
What types of pain meds does not work too well for MS mediated pain?
Strong opioids.
Name me a few fatigue medications.
Amantadine, Modafininil, 4AP.
What is amatadine?
I’m a to dine, and it is boring
An antifatigue medication
What is modafinil?
Ma and da they are boring, antifatigue medication.
What is 4AP?
To allow for better conductivity to enhance endurance.
Name me a few anti-tremor medication.
- Hydroxyzine+(Atarax,+Vistaril)
- Clonazepam+(Klonopin])
- Propranolol+(Inderal)
- Buspirone+(Buspar)
- Ondansetron+(Zofran)
- Primidone+(Mysoline)
Is there cognitive deficits for the person with MS?
Perhaps
What medication has been shown to have modest help with cognitive deficits of MS?
Articept, this is a alzheimer’s medication, this is a medication that helps to make sure that there isn’t much more plaques formation, so with plaque formations in the brain of the MS, then this Articept can help.
Is there dpression as one of the central brain issues?
Yes
What medications can be applied to assist with depression?
Depression+can+be+managed+effectively+with+antidepres5sant+medications:
• Fluoxetine+[Prozac]
• Paxil
• Sertraline+[Zoloft]
Some+antidepressants+can+also+decrease+fatigue
What about the bladder, what happens there?
there is incontinence.
A person who has bladder issue what are the two main very general dysfunctions that can happen?
They can have a problem with holding the product and they can have difficult with emptying.
How would one determine which of these two, difficulty to hold back or difficulty in emptying, issues is the problem of the MS bladder control?
A complete urodynamic work needs to be done.
What is the class of medications that will allow the person to keep his urine back?
Anti-Cholinergic,
What ares some anti-cholinergic medications that help to keep the urine back?
- Propantheline [Pro-Banthine]
- oxybutynin [Ditropan]
- imipramine [Tofranil]
What are some behavioral advise that can be given to someone who has a hard time holding back their urine?
Drink 8 glasses of water per day,
but avoid caffeine and alcohol
If a person has a hard time in emptying what are they supposed to do?
The crede maneuver, they place pressure on the lower abdomen,
They can catherize themselves,
What are some medications that people who have a hard time in emptying their urine supposed to take?
- Cholinergic stimulation, anti-cholinergic medication, these will keep a person from going, but if the medication is a cholinergic stimulator then they will go.
- Urecholine, again we see choline, it means to go.
+A+dyssynergic+bladder+(combined+dys5function)+
Managed+with • Alpha5adrenergic+blocking+agents • Terazosin+[Hytrin] • Prazosin+[Minipress] • Tamsulosin+[Flow+Max])+ • Antispasticity agents • Baclofen [Lioresal], anti spasmoc meds • Tizanidine hydrochloride+[Zanaflex] anti spasmoc meds,
Bac and tia, and dan, and diaz, they all are our friends who make it that it is anti-spasmic.
If the bladder is tight will they spill or hold back?
They will spill
If the bladder is flaccid, will they spill or will they hold back?
They will hold back
When the bladder is flaccid is it closed or is it opened?
Flaccid bladder is closed.
What is a person who has MS and ise xperiencing constipation supposed to do?
The same thing that most people would do if they have constipation. Drink plenty of water. Fiber Bulk5forming supplements Metamucil FiberCon Citrucel Benefiber
+Incontinence+
Dietary+changes
Avoidance+of+irritants+(caffeine,+alcohol)
Adjustment(of(medications(used(to(reduce(spasticityCan(contribute(to(the(problem
Addition+of+medications+to+control+bowel+spasms+
• tolterodine+[Detrol]
• Popantheline+[Pro5Banthine]
.
We dealt with bladder hold up and spills and bowel back ups and incontinence, what else with the genitals is there for one to consider?
Sexual Symtpoms
Impotence
inc. genital sensation
inc. genital lubrication
Whats two tests that we give for fatigue?
• MFIS (Modified Fatigue Impact Scale), how much does the fatigue impact you.
• FSS (Fatigue Severity Scale), how severe is the fatigue.
How severe is the fatigue and how much does the fatigue impact the person’s life.
What can decreased electrical conductivity cause?
I would think that this can cause many many different things, but one thing that it does for sure is fatigue, because it would make it that the person would need to exert too much energy in carrying out their activities.
Is the fatigue of the person with MS correlated to the amount of work they do?
No, it is more than what they are used to.
What can increase the Ms’s fatigue?
Heat
When does the person with MS have more fatigue?
Late afternoon and evening, this is similar to the non-MS person. That as the day goes on they will get more fatigued.
What dompeople with MS think about exercise?
That it would cause further fatigue
Why are people with MS more prone to forgoe exercising?
Because they think that it would promote their fatigue.
If done how would exercise help to alleviate fatigue for someone who has MS?
Properly and correctly.
People with MS when they start exercising they may develop faulty…
Movement patterns.
tingling, pricking, numbness, pins &needles, “falling asleep”
Paraesthesia:
abnormal sensations such as burning, itching, electric shock, wetness, tight banding
Dysesthesia:
L’Hermitte’s Sign
• A shock like sensation in the spine or LEs pro-
duced by rapid neck flexion, as in coughing, and is
indicative of dorsal column demyelinating damage
• Not limited to MS only; can be caused by other con-ditions
They bend their neck and it causes a tingling going down their spine. This is?
Le’rmotte’s sign
Is lermittes sign limited to those with MS?
No
For those with MS what is L’Hermitte’s Sign indicative of?
Dorsal column demylenation. Dorsal, posterior, because that is where sensories are at, and demyelination, because this is what happens with MS.
What is one cranial nerve that can cause alot of pain?
Trigeminnal pain, CN V.
tic douloureux is?
Trigeminal pain CN V
Where in the brain is there demyelination of it would result in muscular weakness?
One can say that the periphery are affected, surely, but in the brain the area that is affected to cause muscular weakness for someone who has MS is…motor cortexor pyramidal tracts, the motor cortex of course, this is where the motor activities are planned out, so even though the muscles fibers are strong but their innervations is lacking,
Is there decreased visual acuity?
Yes
The person has a disruption of their vision for 2-3 days,what is this?
Optic neuritis
Which one of these is not had by some one who has MS? Decrease visual acuity, visual field deficitis, blurred vi-sion, diplopia, transient or permanent blindness, loss of central vision, tracking problems, optic neuritis.
They can have any of these.
Why is there spasticity in MS.
Because it is an UMN condition.
When would we not see spasticity in MS.
When they have just taken their medications and are at the peak of their medications.
Besides for spasticity what else will we see that is part of e UMN issue?
We see spasticity, hyper-reflexivity, and relexes that are not proper, like synergies maybe.
What kind of heat issues do we need to worry about in those with MS?
Their core temperature raising
Can exercise raise their core temperature?
Yes
Uhthoff’s symptom:
a condition where small ’s in bodytemp cause worsening of sx (esp. of optic neuritis)
What type of modalities is usually contraindicated for those with MS?
Heat
If cerebellum is affected then what will likely result?
Ataxia
Ataxia is usually caused by legions where?
In the cerebellum
Besides for the cerebellum, where else can legions lead to ataxia?
Dorsal column
Why would dorsal column cause ataxia?
Because they will have a lack of sensation and this would cause them to not be able to not feel and then they cannot know how to adjust themselves.
What are two types of tremors?
Intentional and postural.
What is intentional tremors?
A shaking when someone attempt tongo and grab something.
What is postural tremors?
Emerges when pt attempts to maintain a pos-ture & may persist or worsen w/ goal-directed mvt of the limb(s)
Which body parts does postural tremors affect more?
Affects more proximal ms, head/trunk may be involved
In addition to pain from sensory disturbances (Dyses-thesia, L’Hermitte’s sign, trigeminal neuralgia), people with MS may have pain of other origins, for example…
Spasms from spasticity
- In addition to pain from sensory disturbances (Dyses-thesia, L’Hermitte’s sign, trigeminal neuralgia), people with MS may have pain of other origins
- Spasms from spasticity, for example…
• Musculoskeletal pain from inappropriate & ineffi-
cient movement patterns due to weakness, disuseatrophy, & contractures
Respiratory involvement commonly affects…
20% of patients with MS
What are some reasons why people get respiratory issues?
Primary- loss of motor control to respiratory muscles
• Secondary- deconditioning, postural changes, aspiration pneumonia, medication S/E
Can aerobic wxercise help those with MS.
Yes
What gains will those MS have when they make use of aerobic exercise?
Significant improvements in • VO2 max, • upper and lower extremity strength,they used resistive machines to get to the aerobic • decreases in skinfolds, • triglycerides, • depression, anger, fatigue
Can strengthening help those with MS?
Yes
Would respiratory exercise help those with MS.
It did improve the expiratory pressure but Functional impact was not assessed.
So if you work out the respiratory muscles it should help your respiratory muscles, but if thisnwould impact the functionality of the person, this is harder to gauge.
When is the body temperature the coolest?
In the morning.
What are somethings that we can do to help the person with MS to remain cool?
A/C, cool clothing, cool immersion, ice packs, ice drinks, fans, all of these are aimed at lowering the body’s core temperature.
Doesre-cooling last?
One study said no, and one study said upto an hour.
Aquatic Therapy
- Buoyancy decreases the amount of work, which may limit fatigue
- Coolness may reduce thermosensitivity
- Water may provide a resistive element for dysmetria and ataxia
- Widely used and advocated, little research has examined its efficacy
- 11 subjects with moderate disease
- Effects of aquatic therapy on gait parameters
- 10 week program of freestyle swimming and shallow water calisthenics
- Results:
- No changes in gait parameters
- Decreases in subjective reports of fatigue
- Improvements in muscular strength & endurance
What is at the core of aquatic therapy?
It is less weights since the person is floating, they are cooler, and they are moving still so it does allow them to get stronger aerobically and strength wise.
According+to+the+National+MS+Society’s+Medical+Advisory+Board
Rehabilitation+referral+should+be+initiated+
whenever+there+is+an:
“abrupt+or+gradual+worsening+of+function+or+
an+increase+in+impairment+that+has+a+signifi5
cant+impact+on+the+individual’s+mobility,+
safety,+independence,+and/or+quality+of+life.”
When they get worse to the point that they cannot function.
What thpe of impairment from MS cannot be fixed?
Direct CNS impairment.
What type of damage incured from MS can be fixed?
Indirect)impairments:
Caused)by)evolving)multisystem)dysfunction)))
from)inactivity)and)disuse)
What is the three geenral idea of rehab?
You need to fix the problems that they have locally, then you need to fix the action that they cannot do, and then address the area of their life that they cannot participate in.
What else is there for a PT to do for a person with MS besides improving the impairment, resolving the functional limitation, and allowing the person to return to their participations?
- Assisting+the+patient+in+effective+coping+skills
- Promoting+acceptance
- Adjustment+to+limitations+and+disabilities+and+en5hancing+quality+of+life
After the idea of restoring their abilities,mwhat must we do?
Make sure that they maintain their abilities, with preventative PT?
What are some things that we do with preventative PT for those with MS?
Secondary!prevention
• Decreasing+duration+and+severity+of+symp5
toms
• Delaying+the+emergence+of+disease+sequelae+through+early+detection+and+intervention,+
termed
Preventative is decreasing the symptoms?
Yes it is, because if the symptoms are decreased then that is a prevention of worse symptoms.
Preventative is delaying the progression?
Yes it is, because if you prevent you are trying to not allow it to come about, so you prevent it from coming on now, even if it could come on later.
So after restorative PT what is done?
Preventative PT.
What is a focus of preventative PT?
To go and make sure that they have their symptoms less often, and when they have it to last less time, and when it is there to be less severe.
Documentation+must+be+clear:Preventative+intervention+focus+on
- Promotion+of+health
- Promotion+of+wellness
- Promotion+of+fitness
- Preservation+of+optimal+function
So we have restored and prevented what we can, but there are just somethings that they cannot do, what do we do then?
!Compensatory!intervention(
What is compensatory that it is different than restorative?
Restorative is fixing, this is altering the person, but compensatory is fixing the environment, “nothing is wrong with the person its the world that is mistaken”
!Compensatory!intervention(Modifying+the+
Task
+ Activity
+ Environment
For compensatory Documentation+must+be+clear:
- Reflective+of+compensatory+intervention+focus+on
- Regaining+function
- Maintaining+function
But not the most optimal way.
What do we do for those who are have sensory deficits?
• Increase+awareness+of+sensory+deficits,make them aware that they have a lack of sensation, which ties in with promoting their safety, and then additionally we would want to have them compensate for their sensory loss.
Ex: someone who is hard of hearing must admit that they cannot hear well, and then they will be careful with crossing the streets and their overall surroundings, additionally it can be suggested that they get hearing aids to assist them with their hearing.
Compensate+for+sensory+loss
• Promote+safety
If someone has proprioception loss what can they use to make up for it?
Visual
If a person with MS has trouble seeing, who should they be referred to?
A low vision specialist
Why would sensory loss lead to pressure ulcer?
They just do not feel that there is undo pressure on them, or that they are wet, or that their posture is bad, they may not feel like they need more nutrients, all of these things add up to make it that they will be able to get pressure ulcers.
Every how many minutes is one supposed to reposition in bed?
Every 2 hours
Every how many minutes is one supposed to reposition in the wheelchair?
Q15M
Where can pain come from from someone who has MS?
The MS itself can give the pain, due to the damaged sensory nerve covering, then there is the pain that comes from the damages that results due to MS, back posture, pressure ulcers, walking badly,
So we have discussed more directly that which is with MS, the next one is slightly less to MS but it is still with MS, it is the pain that the medications of MS would cause, maybe the constipation, maybe just pain,
Additionally maybe there is pain just because of something unrelated to MS entirely.
Can spasms cause pain?
Yes
How to relief pain of the person who has MS?
Of course we MUST go and see which of our four categories is it that causes the pain.
Patients+may+experience+relief+of+pain+with:
Regular+stretching
Exercise
Massage
Lhermitte’s+sign
Stabbing+pain+with+trunk/cervical+flexion)
May+be+relieved+with+a
soft+cervical+collar+to+limit neck+flexion, since it would prevent neck flexion.
Management(of(Chronic(Pain
Stress+management+techniques
Relaxation training
+ Biofeedback
+ Meditation
These are all things that someone would think is not really PT, but it is just what we can advise them to do.
Does TENS work for chronic pain for people with MS?
Some it gets them better and some worse.
When there is an exacerbation what donwe do to our exercise schedule?
We pause it.
Strength(and(Conditioning(E(
FITT
Prescription+is+based+on+four+inter5related+elements:+
++Frequency+of+exercise
Intensity+of+exercise
++Type+of+exercise
++Time+or+duration, early day could be more possible, since they have not fatigued or have not heated up and that has not have them fatigue.
What is an advantage of circuit training?
It splits the work between the UE and LE to lower the incidence if fatigue and increasing the time exercising.
Cardiovascular(dysautonomia
HR(and(BP(responses(may(be(blunted
That the increase does not happen in line with the level of the workout.
What tondo for spasticity?
Stretch
How to stretch for spasticity?
Holding at end range: Minimum of 30-60 seconds
Repeated for a minimum of 2 repetitions
Does cold therapy reduce spasticity?
Yes
If a patient has spasticity, what can we prescribe for them?
Cold, seeking a physician to prescribe antispastic medications, stretching, PNF patterns.
When is cryotherapy contraindicated?
Autonomic response increased
HR, RR, or nausea
In terms of ESTIM what can we do to lower spasticity?
We can use it on the antagonists to the spastic muscles.
When cryotherapy a contraindication?
When they have Autonomic+responseincreased+HR,+RR,+or+nausea
What thpe of stretching is contraindicated?
Fast ballistic stretches
Why are fast ballistic stretches contraindicated?
Because spasticity is velocity based.
What type neurological treatments should be avoided for those with MS?
Brunstrum, because we do not want them to develop improper movements.
Can relaxation exercises help those with MS?
Yes
Which tone seems to dominate?
Extensor tone
If extension is predominate, then how would you decrease it?
Have them do work when they are in flexion.
Give an example of an exercise that would help extensor tone?
That they are hook-lying and a ball is between their legs and they are now in hip flexion and knee flexion, and then they are to be able to move their trunk.
