multiple sclerosis Flashcards
what is multiple sclerosis?
- chronic, inflammatory demyelinating and neurodegenerative disease of the central nervous system
what are the 3 types of disease that MS is described?
- heterogenous
- multifactorial
- immune mediated
what is multiple sclerosis caused by?
- caused by complex gene- environment interaction
what is the pathological hallmark of MS?
- accumulation of demyelinating lesions that occur in the brain and spinal cord’s white and gray matter
what does multiple sclerosis not affect?
- doesn’t affect the PNS
what is the estimated prevalence of MS in Europe for the past three decades?
- 83 per 100,000
what gender are more likely to develop multiple sclerosis?
- females
- female: male ratio is around 2:0
what countries have higher rates of multiple sclerosis?
- Northern countries
how many people live with MS in Europe?
- more than 1,000
what is the percentage increase of people living with MS over the last 3 years?
- more than 35% increase
what is the estimation of the number of MS individuals in the UK?
- over 130,000 people
how many people are newly diagnosed with MS each year in the UK?
- nearly 7,000 people are newly diagnosed each year
what percentage of MS individuals are women?
- 73%
what are the 4 primary disease courses of multiple sclerosis?
- clinically isolated syndrome
- relapsing- remitting MS
- secondary progressive MS
- radiologically isolated syndrome
what does clinically isolated syndrome refer to?
- refers to the first episode of neurological symptoms
what is clinically isolated syndrome caused by?
- caused by inflammation and demyelination in the CNS
how long must the episode last in clinically isolated syndrome?
- must last at least 24 hours
what is the relation of CIS to MS?
- CIS can be a precursor to MS
- but not all individuals with CIS go onto developing MS
how does an MRI show an increased likelihood of person progressing from CIS to MS?
- MRI showing brain lesions similar to those in MS increases the likelihood of progression to MS
what are the common symptoms of clinically isolated syndrome? (3)
- headaches
- gait problems
- verbal disturbances
what is the most common disease course?
- relapsing remitting MS
what is relapsing- remitting multiple sclerosis characterised by?
- characterised by clearly defined attacks of new or increasing neurological symptoms (relapses) followed by periods of partial or complete recovery (remissions)
what percent of MS patients are initially diagnosed with RRMS?
- 85% are initially diagnosed with RRMS
does the disease progress in the remission phase?
- disease does not appear to progress during the remission phase
how is relapsing- remitting multiple sclerosis modulated?
- modulated through medication
what is secondary progressive multiple sclerosis?
- neurological function worsens
- disability accumulates from the onset of symptoms without early relapses or remissions
how many people with MS are diagnosed with SPMS?
- about 15%
what is the hardly recognised course of MS?
- radiologically isolated syndrome
what is RIS used for?
- used to classify individuals with MRI- detected brain or spinal cord lesions consistent with MS but without past or current neurological symptoms
what does a graph showing progressive relapsing MS show?
- shows steady decline since onset with super- imposed attacks
what does a graph of secondary progressive MS show?
- initial relapsing remitting multiple sclerosis that suddenly begins to decline without periods of remissions
what does a graph of primary progressive MS show?
- steady increase in disability without attacks
what does a graph of relapsing- remitting multiple sclerosis show?
- unpredictable attacks which may or may not leave permanent deficits followed by periods of remission
what are the three prominent pathological features of progressive multiple sclerosis?
- global brain atrophy
- slowly expanding lesions
- predominantly microglia/ macrophage- mediated inflammatory response
what is neurodegeneration in MS driven by?
- driven by complex interplay between compartmentalised neuroinflammation, oxidative stress, iron toxicity and mitochondrial dysfunction
when does neurodegeneration in MS occur?
- occurs as early as the radiologically and clinically isolated syndrome starts
what do CNS injuries have the potential to do?
- potential to affect everything
what does MS specifically affect? (2)
- optic nerve
- any tissue within the brain and spinal cord
what are the symptoms like in people with MS ?
- widespread
- heterogenous (different across multiple individuals)
what are the 11 common symptoms of multiple sclerosis?
- fatigue
- weakness
- spasticity
- sensory impairments
- pain
- bladder dysfunction
- disorders of emotions
- tremors
- incoordination or ataxia
- dysarthria
- dysphasia
what does a clinical assessment for MS involve? (2)
- neurological examination
- medical history
what is signs of neurological impairment and history of symptoms suggestive of?
- suggestive of CNS involvement
what is the most sensitive non- invasive test for detecting MS- related brain and spinal cord changes?
- magnetic resonance imaging
what does MRI help with?
- helps to identify lesions/ scars (sclerosis) typical of MS
what does CSF stand for?
- cerebrospinal fluid
what dos CSF analysis involve?
- lumbar puncture (spinal tap)
what do you analyse from the lumbar puncture?
- presence of oligoclonal bands (unique proteins) in the CSF, which are not found in the blood supports the diagnosis of MS
what is an evoked potential test?
- test that measures the brain’s electrical activity in response to stimuli
what can evoked potential tests detect?
- can detect demyelinated lesions along nerve pathways that are too small or in locations not detected by MRI
what is the point in blood tests when diagnosing MS?
- important to rule out other diseases with similar symptoms e.g., lyme disease or certain autoimmune disorders
what does the McDonald Criteria integrate?
- clinical presentation with MRI findings
what did the 2017 revision of the McDonald Criteria allow for?
- earlier and more accurate diagnosis by incorporating specific MRI criteria that can substitute for a clinical relapse in determining disease dissemination in time
what are the two main things that the McDonald criteria involves?
- dissemination in space and time
what does dissemination in space refer to?
- how the lesions evolve across structures
what does dissemination in time refer to?
- how the lesions progress in time
what are the two outcome measures used to measure disease severity?
- functional systems score (FSS)
- expanded disability status scale (EDSS)
what are the three main medical management of multiple sclerosis?
- disease modifying therapies
- management of acute relapses
- symptomatic treatment
what do disease modifying therapies reduce?
- reduce relapsing frequency and severity
- slow disability progression
- limit new disease activity
what are some examples of drugs used in disease modifying therapies?
- interferon beta preparations
- glatiramer acetate
- natalizumab
- figolimod
- ocrelizumab
- cladribine
what does the choice of DMT depend on? (4)
- disease course
- drug effectiveness
- side effects
- patient preferences
how do you manage acute relapses?
- anti- inflammatory medications
- high dose corticosteroids
- plasmapheresis
what are exacerbations of MS usually treated with?
- usually treated with high- dose corticosteroids such as intravenous methylprednisolone
what does symptomatic treatment involve?
- pharmacological and non- pharmacological treatments including medication and therapy
what impairments are assessed in multiple sclerosis? (5)
- fatigue
- cognition
- balance
- gait
- upper extremity
how do you assess fatigue?
- modified fatigue impact scale (MFIS)
- fatigue scale for motor and cognitive function
what are the common cognitive deficits? (7)
- learning
- memory
- information processing speed
- executive function
- planning
- organisation
- initiation
how do you assess cognition?
- paced auditory serial addition test (PASAT)
how do you assess balance?
- anticipatory response challenges and reactive balance strategies
- perturbation response
- BESTest
- miniBESTest
- TUG
- BBS
how do you assess gait?
- speed
- distance
- quality (observation gait)
- gait cycle
- step length
- step width
- cadence
- single- leg support
- double- leg support
- 6MWT
- TUG
how do you assess upper extremity?
- box and blest test (BBT)
- nine hole peg test (NHPT)
how do you manage fatigue?
- energy conservation programs show strong evidence for managing MS- related fatigue
what rehabilitation interventions manages fatigue in neurological conditions? (3)
- physical activity
- cognitive education programs
- energy conservation strategies
what are sensory interventions to manage fatigue? (3)
- vestibular rehabilitation
- exercise - based sensory integration interventions
- vibration
what shows the most promising intervention for treating fatigue?
- balance exercises
- cognitive behavioural therapies
what medical management is used for spasticity?
- antispasticity medications
- baclofen
- tizanidine
- gasapentin
- dantrolene
- tolperisone
- benzodiazepines
- sativex oromucosal spray
what may be required in selected cases for the medical management of spasticity?
- botulinum toxin
- intrathecal baclofen
what interventions can be used for spasticity?
- ROM
- stretching
- orthotics (braces and splints)
how do you manage pain? (6)
- pharmacological management
- posture
- movement
- sitting
- orthotics
- supportive equipment/ adaptive equipment
what do balance exercises prevent and enhance?
- prevents falls and enhance walking stability and posture control
what are the benefits of coordination exercises?
- reduces energy requirements
- increases continuity of movement
what are Frenkel exercises improve? what does it involve?
- improve movement coordination
- involves slow repetitions of each movement stage, gradually increasing in complexity
what are the three phases of sitting up?
- withdrawing feet
- bending trunk forwards
- straightening legs while getting
what are some balance exercises?
- balance based torso weighting
- balance and eye- movement exercises in persons with MS
what should you consider balance in?
- consider balance in different postural settings
- sitting, wheelchair use, walking aid
what is the main management of balance?
- core stability exercises
- task oriented training
- conventional balance training
- effectively improve balance in ataxic MS patients
what are the 6 interventions for balance?
- mobility
- aerobic and strength training
- task specific training
- torso weighting
- mobility assistive devices
- orthotics
