Multiple Sclerosis

Question 1

Typical onset of an inflammatory cause of weakness

Answer 1

Monosymptomatic (20% of patients present with unilateral optic neuritis)
Symptoms may worsen with heat
Slow, but progressive muscle weakness
Fatigue after walking or standing
Frequent episodes of tripping or falling
Difficulty in swallowing or breathing
Some people develop muscle pain - tender to touch

Question 2

Aetiology of inflammatory-induced weakness

Answer 2

MS
Polymyositis
Dermatomyositis 
Inclusion body myositis 
Necrotising autoimmune myopathy

Question 3

What is MS?

Answer 3

Inflammatory plaques of demyelination in the CNS, disseminated in space and time
- i.e. occurring at multiple sites with more than 30 days between attacks
Demyelination heals poorly, causing axonal loss
Incidence increases with latitude (risk is fixed at the place you went through puberty)

Question 4

Clinical presentations of MS

Answer 4

Monosymptomatic
Optic nerve
- optic neuritis
- optic disc swelling
- RAPD
Spinal cord
- UMN lesions
- numbness, paraesthesia and decreased vibration sense
- incontinence/constipation and sexual dysfunction
Brainstem
- opthalmaplegia
- neuralgia, hearing loss, vertigo, dysphagia and dysphonia
Cerebellum - rare
- epilepsy, trigeminal neuralgia and tonic spasms
Others
- cognitive and visuospatial decline, depression and decreased executive functioning

Question 5

How is MS diagnosed? - McDonalds criteria

Answer 5

2 or more attacks with 2 or more objective clinical lesions
- no additional tests required
2 or more attacks with 1 objective clinical lesion
- MRI: spatially disseminated lesions or
- positive CSF and 2 MRI lesions or
- second attack at a new site
1 attack with 2 or more objective clinical lesions
- dissemination in time by a new lesion on repeat MRI after 3 months, or a second attack
1 attack with 1 objective clinical lesion
- dissemination in space (MRI, or positive CSF + 2 lesions consistent with MS) - dissemination in time (MRI or second attack)
Insidious neurological progression suggestive of primary progressive MS
- positive CSF AND dissemination in space on MRI OR
- continued progression for one year

Question 6

Investigations in ?MS

Answer 6

If presentation with 2 or more attacks and 2 or more objective clinical lesions, then no further imaging is required
MRI - can detect lesions disseminated in space and time (2 at different times and different sites required)
CSF
- oligoclonal bands of IgG on electrophoresis that are not present in the serum
- suggests CNS inflammation
Visual evoked potentials (VERS)
- if there has been demyelination at any time along the optic nerve (symptomatic or asymptomatic), the conduction of visual images to the occipital cortex will be delayed
- >100ms

Question 7

What are the clinical subtypes of MS

Answer 7

Relapsing remitting - most common
Secondary progressive MS
Primary progressive MS
Progressive remitting MS

Question 8

Describe relapsing remitting MS

Answer 8

Unpredictable attacks that may or may not leave permanent deficits
Followed by periods of remission

Question 9

Describe secondary progressive MS

Answer 9

Initially relapsing remitting illness that suddenly begins to decline, without periods of remission

Question 10

Describe primary progressive MS

Answer 10

Steady increase in disability without relapses, from onset

Question 11

Describe progressive remitting MS

Answer 11

Steady decline since onset, with super-imposed attacks

Question 12

Define relapse and remission

Answer 12

Relapse - focal inflammation, damage to myelin and oligodendrocites and conduction block
Remission - inflammation subsides and there is remyelination of damaged area
- some can return to normal function

Question 13

Acute management of MS relapse

Answer 13

IV methyprednisolone for 3-5 days (and PPI) shortens acute relapses
- no change in prognosis
- give no more than twice a year
Physiotherapy and occupational therapy

Question 14

Long-term management of MS

Answer 14

Lifestyle advice - regular exercise, smoking cessation and avoidance of stress
Disease modifying drugs
Symptom management

Question 15

Describe the role of disease modifying drugs in MS

Answer 15

Dimethyl fumerate - mild/moderate relapsing remitting MS
Monoclonal antibodies
- alemtuzimab (acts against T-cells)
- netalizumab (acts against VLA-4 receptors that allow immune cells to cross the BBB)
1st line
- beta-interferon and glatiramer (reduce relapse frequency)
- dimethyl fumerate
- teriflunomide suppresses immune system
2nd line
- fingolimol
- natalizumab
3rd line
- alemtuzumab (resets immune system and can eliminate relapses)

Question 16

Medications for symptom management in MS

Answer 16

Spasticity 
- baclofen/gabapentin
- lizanidine or dantrolone
- diazepam 
Tremor
- botulism toxin A injection
Urgency and frequency
- self-catheterisation 
- tolterodine
Fatigue 
- CBT, exercise and amantadine

Question 17

Who is involved in the MDT for a patient with MS

Answer 17

Nurse/ANP
Neurologist 
Psychiatrist
Psychologist/neuropsychologist 
Social worker 
Urologist 
Speech pathologist
Pharmacist
Occupational therapist
GP
Physiotherapist

Question 18

Describe the role of the MS nurse in the MDT

Answer 18

Specialist training in MS
- source of information and advice
Acts as a link between hospital and community services
Often first point of contact for concerns about MS

Question 19

Describe the role of the physiotherapist in the MDT

Answer 19

Exercises and body movements help reduce fatigue, pain, muscle stiffness, spasms and problems with balance
At home or outpatient appointments
Help manage day-to-day tasks after a relapse

Question 20

Describe the role of the occupational therapist in the MDT

Answer 20

Help activities of daily living that are negatively affected by MS
- going to work, doing hobby’s, eating, getting dressed, etc
Make changes to home and workplace +/- special equipment to achieve this
Help with balance, tremor and fatigue
Relearn, or change the way you do a task to make it easier

Question 21

Describe the role of the psychologist in the MDT

Answer 21

MS can affect memory and thinking
They will help to identify the specific problem and the personal strengths of the patient that will help them overcome it
Mood disorders (common in MS) can also be managed