Multiple Sclerosis Flashcards
Pathophysiology of MS
. White matter demyelination with lymphocytic infiltration
. Axonal damage and brain atrophy
Epidemiology
. Common in female
. Symptoms 20-50 yrs
. Peak 30 yrs
Patterns of MS
1. Relapsing Remitting: Most common (85%) - One attack/yr - Disability accumulates over time - 50% end up secondary progressive 2. Secondary progressive: steady deterioration w/o acute relapse 3. Primary progressive: 10-15% - gradual & continuous deterioration w/o relapse 4. Progressive relapsing: 5% - high mortality
Symptoms of MS divide into
Motor
Sensory
Cognitive
Lhermitte’s Sign
Sudden sensation of electric shock passes down from neck into the back, arms and legs.
- Increased by neck flexion.
- Result of the increased sensitivity of
the myelin to stretch or traction
Prognostic Signs of MS
Good: Female, <35yo, sensory / optic, relapsing remitting.
Bad: Male, >35yo, motor / cerebellar, progressive relapsing.
Outcome Measures of MS
1) Expanded Disability Status.
2) Multiple Sclerosis Impact Scale
3) Hamburg Quality of Life Questions in MS.
Things to be considered before putting exercise plan in MS
- May worsen symptoms, increase core temp
- Avoid overload
- Passive and active ROM
- Aerobic Training
Consideration before starting rehabilitation in MS patients
1) Fatigue
2) Spasticity
3) Ataxia
4) Incoordination
5) Neurological deficit
Target: range limitation and strength deficit.
Fatigue in MS A. Define. B. Access. C. Treat. D. Risk Factors.
Definition: subjective lack of physical or mental capacity to preform usual activities.
1) Fatigue descriptive 2) Fatigue severity 3) Fatigue Impact.
Tx: Amatadine – Modafinil “after” Rule out: poor sleep hygiene and medical diseases.
Risks: Heavy meal – Exercise – Heat – Hot Shower.
Uhthoff’s Phenomenon
Visual problems with MS patient reporting back spots BL when they are exposed to heat (exercise, weather, shower, sauna, fever).
- Myelin dysfunction when surrounded fluid heats up.
Complication of spasticity in MS?
Risk Factors?
Exercises?
Pharmacological and Non-Pharmacological Tx?
1) ADL: touch, proprioception, hand skills, strength.
2) Movement: increased tone – overflow pattern – unintentional agonist-antagonist contraction.
Risks: UTI, pressure sore, constipation “bed bound”.
- An increase in spasticity may be an indication of a coexisting condition including infection & trauma.
Non-Pharmacological Tx
1) Stretch: day & night (spasm)
2) Active ROM
3) Assistant Exercises
Pharmacological Tx:
1) Baclofen (y-aminobutyric) ½ life 1.5-4hrs
2) Benzo: Valium (Diazepam), Colanzepam
Combination of:
- 3 agents
- local Injection (neurolysis or botulium toxin)
- Drosal Root Rhinozotomy.
Lines of Tx for spasticity in MS?
1st Line: Daily positioning – Stretch – Splinting
2nd Line: Oral Agent (Baclofen 5-10mg)
Local Spasticity: Local Botulium Toxin
The autoimmune response in MS causes.
“What would you see in CT image”
1) demyelination
2) axonal damage
3) brain atrophy.
Pregnancy in MS
Decreases relapses, then increases after delivery. No change long term
Common symptoms in MS (List 10)
Frontal – Temporo-Parital – Corticospinal – Occipital/eye – Cerebellar – Brain stem – Dorsal Column – Body & Bladder.
1) Bladder and Bowel dysfunction
2) Fatigue (Central in nature)
3) Pain
4) Visual disturbances: Optic neuritis, diplopia, nystagmus
5) Cerebellum and basal ganglia: ataxia, intention tremor
6) Doral column: Sensory abnormalities (paresthesias),
impairment of deep sensation, proprioception
7) Corticospinal tract: Weakness and spasticity
8) Frontal lobe dysfunction: Cognitive, memory,
learning, and impaired emotional responses,
depression
9) Speech abnormalities: Dysarthria
10) Brainstem abnormalities: Myokymia, deafness,
tinnitus, vertigo, vomiting, transient facial
anesthesia, dysphagia
Top 3 problems affecting ADLs reported by patients
- Fatigue
- Weakness
- Balance difficulties
All new symptoms result from new MS lesion. (Yes/No)
Aggravation of symptoms in old and previously silent lesions may be caused by fever, heat, stress, fatigue, or other medical problems, especially pulmonary or urinary tract infection, dehydration or medication
side-effects.
MS
Dissemination in time?
Dissemination in space?
DIT: lesion at any time, follow up T2, clinical attack
DIS: 1 lesion in 2 areas in typical regions.
A) 2 Attacks + 2 Clinical Lesions “OR” 2 Attacks + 1 Clinical Lesion + Prior attack of another lesion not yet found B) 2 Attacks + 1 Clinical Lesion “AND” DIS 1 Attack of another lesion “OR” DIS 1+ Lesions in 2+ Areas C) 1 Attack + 2 Clinical Lesions “AND” DIT another attack DIT new or enhancing MS-typical MRI lesions compared to baseline CSF +ve Oligoclonal bands
Cerebral Spinal Fluid (CSF) Examination in MS
1) Increased in Protein (myelin basic, 25%)
2) Oligoclonal IgG bands (greatest sensitivity)
3) WBCs
Describe the changes seen in MS patient
1) VEP (Visual Evoked Potentials)
2) BAER (Brainstem Auditory Evoked Response)
3) SEP (Sensory Evoked Potentials)
4) EMG/NCS
1) P100 latency is abnormal (slowing secondary to plaques) in 75%
2) Testing the pontine area displaying an absence or delay of wave formation secondary to the demyelinating process.
3) Prolongation of absolute peak or interpeak latency
4) Fibs, Positive Sharp Waves (PSW), Facial myokymia and a decrease Motor Unit Action Potentials (MUAP)
Medical Treatment of MS
- Corticosteroids (Methylprednisolone)
- Immunomodulator agents: Disease-modifying
- Immunosuppression agents
1st Line:
Interferon – Gtalimramer Acetate – Tecfidera – Gilynea
2nd Line:
Gilynea - Tysabri – Lemtrada - Ocrevus
Corticosteroids (Methylprednisolone) in MS
- Used in acute attacks = “exacerbation”
- Most responsive symptoms: Optic neuritis, brainstem, motor, acute pain, bowel and bladder.
- Least responsive: Cerebellar, sensory.
- Pulse therapy: ~1000mg/day Intravenous IV for 4–7days with a 2 week taper, switch to PO
- Increase risk of HTN, osteoporosis, diabetes, and cataracts
- Does not prevent further attacks or alter disease progression
Exercise in MS
- Exercise improves conditioning not weakness.
- Aerobic training increases endurance. Light progressive resistive exercises prevent disuse atrophy.
- Do not exercise to the point of fatigue.
- Fatigue worsens with increased temperature, stress, and activity
- Swimming should be done at a cool temperature.
- Heat worsens the condition, secondary to delaying impulse conduction.
