Multiple Sclerosis Flashcards
Objectives
- Define Multiple Sclerosis (MS) and describe the associated pathology
- Describe the general goals and treatment appropriate for a patient with MS
fyi
- Demyelinating disease of CNS
- Usually affects people between ages 20 and 40
- Unpredictable course
- Charcot’s triad: paralysis, intention tremor, scanning speech, nystagmus
Multiple Sclerosis
Epidemiology-Multiple Sclerosis
- Onset usually between 15 and 50 years of age
- Very rare in children or over age 50
- More common in women (2:1)
- 400,000 people in US
- Mostly seen in white population
- 2 epidemics have been reported ? A slow virus perhaps?
Etiology of MS
- Unknown
- Theories: autoimmune mediated pathogen or possibly induced by virus
- 15% positive family history
- May inherit genetic susceptibility: see increase incidence in twins
- May have and environmental trigger that occurs in genetically susceptible people
Mortality of MS
- Most patients survive 22 - 25 yrs
- Death caused by infection (respiratory, UTI)
Pathophysiology of MS
- Immune response-> produce T-lymphocytes, macrophages, immunoglubulins antigen is activated produces autoimmune cytotoxic effects
- T-lymphocytes attack myelin: slows neural transmission: nerves fatigue or can disrupt function if severe
*
Diagnosis of MS
- No reliable, specific test (increased immunoglobulin & oligoclonal bands in CSF in 65-95% of cases)
- Plaques observed on MRI
- Acute lesion with inflammation
- Older lesions: lack myelin
- Clinical criteria: evidence of:
- Multiple CNS lesions
- Discrete episodes of neurological disturbance or progression over time
- No better neurological explanation
What are the 6 types of MS…??? P779, Box 19.1
- Relapsing-remitting MS
- Primary-progressive MS
- Secondary-progressive MS
- Progressive-relapsing MS
- Benign MS
- Malignant MS (Marburg’s)
what is the pathophysiology of MS Over time:
- Over time: neuroglial tissue proliferates and creates plaques: then the axons undergo retrograde degeneration
- Lesions occur in cerebrum, brainstem, cerebellum, dorsal spinal cord
- Affects white matter more than gray matter
this type of MS
- will have periods without acute worsening, will have periods with partial or complete abatement of symptoms
- 80% of time will develop secondary progressive course
- The course of the disease may change over time
Relapsing remitting
see the most
- New and recurrent MS symptoms that last > 24hours
- Health deterioration
- Viral or bacterial infections
- Diseases of major organ systems
- Stress can lead to acute attack
- Adverse reaction to heat (Udoff’s symptom)
- Psuedoexacerbation : temporary worsening of symptoms, lasts <24 hrs
Exacerbations of MS
Clinical Symptoms of MS
Can vary
- Visual disturbances
- Parasthesias: can lead to numbness, weakness, fatigability
- Onset can be rapid (m0re common)or insidious
common Motor Symptoms of MS
- Spasticity and reflex spasms
- Weakness
- Gait disturbance
- Fatigue
- Cerebellar and bulbar symptoms
- Swallowing/Respiratory difficulties
- Nystagmus
- Intention tremor
- Dysphagia
common Sensory symptoms of MS
- Numbness
- Pain (usually of musculoskeletal origin)
- Paresthesia
- Dysesthesia
- Distortion of superficial sensation
common Visual symptoms of MS
- Diminished acuity
- Double vision
- Scotoma- dark spot in center of field of vision
- Ocular pain
common Bowl and bladder symptoms of MS
- Urgency
- Frequency
- Incontinence
- Urinary retention
- Constipation
common Sexual symptoms of MS
- Impotence
- Diminished genital sensation
- Diminished genital lubrication
common Cognitive and emotional symptoms (50-70%) of MS
- Depression
- Lability
- Disorders of judgment
- Agnosia-
- Memory disturbance
- Diminished conceptual thinking
- Decreased attention and concentration
Precipitating Factors (things that can bring on MS) of Changes in health status with MS
- Viral or bacterial infections (cold, flu, bladder infection)
- Physical injury (lumbar puncture)
- Pregnancy
Transient deterioration of MS
- Adverse reaction to heat: modalities, prolonged exercise, fever
- Hyperventilation
- Stress: physiological or psychological
- Exhaustion
- Dehydration
- Malnutrition
- Sleep deprivation
Predictors of Good Outcome of MS
Female
Onset with only one symptom (strong indicator)
Complete recovery after attacks
Onset < 40 y/o
Predictors of Bad Outcome of MS
- Progressive course is ominous
- Male
- Onset > 40 y/o
- Significant cerebellar signs at 5 yrs (nystagmus, tremor, ataxia, dysarthria)
- High frequency of attacks with incomplete recovery
Adverse affects of treatment medications of MS
- Injection site reactions
- Flu-like symptoms
- Depression, allergic reaction, liver reaction
- Flushing, anxiety, pain, palpitations, SOB: Copazone
- Support pts hope for positive outcome
Overly aggressive PT Rx can cause exacerbation ***
Treatment is intended to ?
- provide symptomatic relief, prevent secondary complications, and maintain optimal functioning as long as possible.
- Rx does not alter the underlying pathology or course of the disease
provide the least that they need to be functional, we are not chaning the course of disease. We can educate them. To not overdo
LTGs of MS
- Maximize functional status and independence
- Prevent/ retard development of secondary impairments
- Promote emotional and social adjustment of patient and family
- Maintain employment as long as possible
- Educate patient/ family to maximize retention of rehab gains
Global things for MS
- Maximize functional independence
- Minimize complications secondary to decreased mobility
- Compensation for loss of function
- Education: psychosocial adjustment, vocational training, family issues
Assistive Devices/Equipment for someone with MS
what is the Guiding philosophy ? and what are some examples of devices.
- assistive devices/equipment is selected to provide maximum stress relief so patients can make the best use of the limited energy stores
- AFO: rigid/hinged polypropylene, double upright
- Gait assistive device: cane, crutch, walker, w/c
- IADL equipment: bathing, dressing, utensils
- Safety: mobile phone
Sensory changes with MS
- Very common
- Usually parasthesias or numbness of face, body, extremities
- Problems with position sense or vibratory sense
Pain with MS
- 80% have pain,, in 55% of cases it is clinically significant
- Pain can be acute and paroxysmal: sudden, spontaneous
- Intense, sharp, shooting, electric shock, burning
- Trigeminal neuralgia, headache, paroxysmal limb pain
- Paroxysmal limb pain: usually worse at night and with exercise
- Aggravated by change; high temperature
- Hyperpathia: hypersensitive to minor stimuli
- Headaches are common
- Neuropathic pain: burning sensation (comparable to pain of disc herniation)
- Musculoskeletal pain: due to many factors. Can have spasticity and tonic spasms
definition
hypersensitive to minor stimuli
Hyperpathia
what kind of pain is a burning sensation (comparable to pain of disc herniation)
Neuropathic pain
common, feels like ice pick pain behind eye, accompanied by blurring or graying of vision or blindness in one eye
Optic neuritis
Visual changes with MS
- Nystagmus is common
- Internuclear opthalmoplegia:
- Impaired conjugate gaze,
Motor dysfunction with MS
- Weakness: corticospinal lesion:
- Movement can be slow, stiff, weak
- Decreased strength, power, endurance
- Poor synergistic movements
- Cerebellar lesion: asthenia, generalized muscle weakness and ataxia
- As disease progresses can have total paralysis
Fatigue with MS
- 75-95% of individuals
- More than half: most troubling symptom
- 79%: interferes with physical functioning
- 67% overall performance
- Can come on abruptly
Fatigue Precipitating factors (what brings it on?)
- physical exertion, exposure to heat and humidity, depression, , sleep disorders, mood disorders, low self esteem, medical conditions, secondary complications from MS, medication side effects
- If person feels in control of his environment, less likely to have fatigue