Multiple Sclerosis

Question 1

What is MS

Answer 1

Inflammatory plaques of demyelination in the CNS deissmeniated in space and time - occurring at multiple sites with >30 days between attacks.

Cell-mediated autoimmune disorder that causes CNS demyelination.

Demyelination heals poorly causing axonal loss.

Patients develop progressive disability.

Question 2

How does MS typically present?

Answer 2

30 years old, 3:1 female:male
More common at higher latitudes

Usually mono symptomatic presentation with:
Unilateral optic neuritis - pain on eye movement and loss of central vision
Corticospinal tract and bladder involvement
Symptoms may worsen with head (bath or exercise)

Question 3

What are subtypes of MS?

Answer 3

Relapsing-remiting disease:
Initial recovery between relapses.
Most common form -85%
Acute attacks (1-2 months) followed by periods of remission

Secondary progressive disease
With time, remission becomes incomplete and so disability accumulates.
Neurological signs and symptoms between relapses

Primary progressive disease
10% of patients steadily progressive disability in the absence of relapses

Question 4

What are poor prognostic signs in MS?

Answer 4

Older male
Motor signs at onset
Many early relapses
Many MRI lesions
Axonal loss

Question 5

What are visual features of MS?

Answer 5

Optic neuritis: common presenting feature
Optic atrophy
Uhthoff’s phenomenon: worsening vision following rise in body temperature (e.g. exercise)
Internuclear ophthalmoplegia

Question 6

What are sensory features of MS?

Answer 6

Pins and needles
Numbness
Trigeminal neuralgia
Lhermitte’s syndrome: paraesthesiae in limbs on neck flexion

Question 7

What are motor features of MS?

Answer 7

Spastic weakness (legs)
Myelitis

Cerebellar:
Ataxia
Intention tremor
Scanning speech
Falls

Question 8

What are other features of MS?

Answer 8

Sexual:
Erectile dysfucntion
Anorgasmia
URine retention
Incontinecne
Intellectual deterioration

Question 9

How is MS diagnosed?

Answer 9

Two or more relapses wand either objective clinical evidence of two or more lesions or objective clinical evidence of one lesion with reasonable historical evidence

Question 10

What investigations in MS?

Answer 10

MRI: white matter lesions
CSF: Oligoclonal bands of IgG on electrophoresis that are not present in serum suggest CNS inflammation

Question 11

What management for MS?

Answer 11

Conservative:
Regular exercise
Stop smoking
Avoid stress

Disease modifying drugs:
Beta-interferon reduces relapse rate
Dimethyl fumerate is an option

Natalizumab: recombinant monoclonal antibody against leucocyte surface antigen that inhibits migration of leucocytes across the endothelium and BBB

Fingolimid - prevents lymphocytes from leaving lymph nodes

Question 12

How is acute relapse treated in MS?

Answer 12

Methylprednisolone IV/PO high dose
5 days
Shorten length of acute relapse and do not alter degree of revovery

Question 13

What is used to treat fatigue?

Answer 13

Exclude anaemia, thyroid, depression

Trial of amantadine CBT, exercise

Question 14

What is used to treat spasticity?

Answer 14

Baclofen/gabapentin
Tizanidine, dantrolene 2nd line
Physiotherapy

Question 15

What is used to treat bladder dysfunction?

Answer 15

Urgency, frequency, incontinence, overflow
Get US first tosses bladder emptying
If significant residual volume >100ml teach intermittent self catheterisation
If residual volume < 100ml anticholinergics. tolterodine

Question 16

What is used to treat oscillopsia?

Answer 16

Visual fields appear to oscillate

Gabapentin

Question 17

What is used to treat tremor

Answer 17

Botox type A

Question 18

What is Lhermitte’s sign?

Answer 18

Neck flexion causes paraesthesia electric shock in limbs (seen in cervical spondylosis, cord tumour, B12 deficiency and MS)

Question 19

What is Devic’s syndrom

Answer 19

MS variant with transverse myelitis (loss of motor, sensory, autonomic, reflex, and sphincter function below the level of lesion, optic atrophy

Question 20

What is Uhthoff’s phenomenon

Answer 20

Worsening of symptoms with heat (e.g. bath)

Question 21

What is Charles Bonnet syndrome?

Answer 21

Reduced acuity/temporary blindness ± complex visual hallucinations of faces, plants, animals and trees

Question 22

What rehabilitation in MS

Answer 22

Physiotherapy:
Strengthening exercises, gait training, balance, endurance, stamina, joint function ** do not overheat person due to Uhthoff’s phenomenon
Cold showers, ice packs, cold temperature

Neurorehabiltiation
Neurologists
SALT - dysphagia and dysarthria
OT
Therapists, psychologists, psychiatrists - clinical depression, emotional distress management
 - psychological therapies, CBT