Multiple sclerosis Flashcards
Immune-related response in which antibodies induce demyelination by antibody-dependent, cell-mediated cytotoxicity.
Cytokines attack myelin, macrophages help uptake myelin, oligodendrocyte apoptosis leads to an increase in demyelination, increased axonal injury occurs and becomes sclerosed.
-Inflammatory
-Demyelinating
-CNS- white matter in SC, brainstem, or cerebral hemispheres
-Plaques
Multiple Sclerosis
Environmental risk factors for MS
- Vitamin D deficiency (people living further from the equator have a greater risk)
- smoking
- infection (people w/ hx of Epstein-Barr virus or HHV-6 have greater risk)
Genetic risk factors for MS
- First degree relative w/ MS
- Female > Male
What is the most common age for MS diagnosis?
20-50
Types of MS
Clinically isolated syndrome
Relapsing Remitting
Primary Progressive
Secondary Progressive
Clinically isolated syndrome
- First episode of neuro symptoms that lasts at least 24 hours
- Mono-focal lesion: single neurologic sign or symptom that’s caused by a single lesion
- Multifocal lesion: more than one sign or symptom caused by lesions in more than one place
- usually no association with fever or infection
- followed by a complete or partial recovery
Relapsing Remitting
- Most common disease course
- clearly defined attacks of new or increasing neurologic symptoms
- increase in disability is confirmed when the person exhibits the same level of disability at the next scheduled neurological evaluation, typically 6-12 months later
Primary progressive
-Worsening neurologic function from the onset of symptoms, without early relapses or remissions
Secondary progressive
- follows initial relapsing-remitting course
- most who are diagnosed with RRMS will eventually transition to secondary progressive worsening of neurologic function over time.
Activity of disease
Relapses or new increasing neurologic dysfunction, followed by full or potential recovery in the absence of fever or infection
(active or not active)
Progression of disease
steadily increasing neurologic dysfunction without recovery
progressive or not progressive
Traditional diagnosis of MS
- Evidence of damage in at least two separate areas of the CNS
- Evidence that the damage occurred at two distinct points in time, at least one month apart
- Other possible causes for the symptoms ruled out
Revised diagnosis of MS
“In patients with a typical clinically isolated syndrome and clinical or MRI demonstration of dissemination in space, the presence of CSF-specific oligoclonal bands allows a diagnosis of Multiple Sclerosis”
Clinical features of MS
- Optic neuritis (vision loss, pain w eye movement, usually unilateral)
- brainstem/cerebellar dysfunction (ataxia, dysarthria, intention tremor, nystagmus, balance dysfunction)
- pyramidal symptoms (UMN, paresthesia, spasticity, loss of dexterity)
- spinal cord involvement (spasticity/flaccidity, sensory loss, motor loss, loss of bowel/bladder control)
- fatigue(exacerbated by heat)
- heat tolerance
- cognitive dysfunction
- depression
- sexual dysfunction
Medical management of MS
Medications to…
- modify disease course
- manage relapses
- manage symptoms
Good prognosis of MS
Few attacks
good recovery from attacks
relapsing-remitting
early medical management and adherence
Poor prognosis of MS
multiple attacks poor recovery from attacks primary progressive type pyramidal brainstem cerebellar signs
Prognosis is better depending on…
Gender (women > men)
Age of onset (< 35 at onset)
length between exacerbations (longer durations)
duration of impairments during exacerbation (shorter duration, < 1 month)
remission of initial impairments
only 1 impairment during the first year (fewer impairments early in dx)
Prognosis is worse depending on…
pyramidal tract impairments at onset
cerebellar impairments at onset
sphincter impairments at onset
progressive course at onset
Possible impairments causing limitations in rolling and coming to sit
spasticity
timing & sequencing
central weakness
cerebellar ataxia
Possible impairments causing limitations in sitting balance
spasticity timing & sequencing of strategy central weakness cerebellar ataxia sensory system impaired for strategies inadequate vestibular function
Possible impairments causing limitations in sit to stand
spasticity timing & sequencing of strategy central weakness cerebellar ataxia sensory system impaired for strategies inadequate vestibular function
Possible impairments causing limitations in standing balance
spasticity timing & sequencing of strategy central weakness cerebellar ataxia somatosensory impaired for reaction time inadequate vestibular function fatigue
Possible impairments causing limitations in walking
spasticity timing & sequencing of strategy central weakness cerebellar ataxia somatosensory impaired for reaction time inadequate vestibular function fatigue
Possible impairments causing limitations in ADLs: grooming, bathing, cooking, feeding, etc.
UE central weakness
spasticity, timing & sequencing, ataxia, dysmetria, tremor, fatigue
Most common problems in MS ranked
- fatigue
- walking and balance deficits
- bowel and bladder dysfunction
- pain/abnormal sensations
- visual disturbance
- cognitive dysfunction
- ataxia
Acute fatigue
fatigue that has been present on >50% of the days or if there has been a significant development or increase of fatigue in the past 6 weeks, AND if fatigue is reported to limit functional activities or interfere with quality of life
chronic fatigue
lasts longer than 6 weeks and is frequently present
Recommended tool for measurement of fatigue in people with MS
MS edge: Modified Fatigue Impact Scale (MFIS)
T/F: In ataxic gait, balance is typically less of an issue than lower limb incoordination
False.
In ataxic gait, balance (postural instability) may be more of an issue than lower limb incoordination.
Recommended tool for measurement of gait in people with MS
Expanded Disability Status Scale (EDSS)
0.0-4.0 – able to walk without assistance
4.0-7.5 – primarily walking distance and assistance levels
6.0– walking with a cane
7.5-9.5 – main determinants are ability to transfer from w/c to bed and self-care
10 = death from MS
MS EDGE recommendations for gait measurement
12-item MS walking scale 6MWT DGI TUG Timed 25-foot walk
MS-EDGE recommendations for balance measurement
Activities-specific balance confidence scale (ABC)
Berg Balance Scale
Functional Reach
Presentation of Bladder and Bowel dysfunction in patient’s with MS
Bladder: most commonly, neurogenic overactive bladder.
-urgency, frequency, incontinence, difficulty emptying bladder
Bowel:
-constipation, involuntary loss of bowel control
can cause withdrawal, limited interpersonal relationships, UTIs, urinary retention, safety/fall risk
Presentation of pain and abnormal sensation in patient’s with MS
headache
neuropathic extremity pain
low back pain
Lhermitte’s sign
trigeminal neuralgia
Pain is often from altered sensation: dysesthesia
hypersensitivity (allodynia, hyperalgesia)
sensory loss:
-spinal cord involvement – dermatomal
-brain involvement – homunculus distribution
pain classifications
central neuropathic: -continuous (dysesthesia) -intermittent (spontaneous, paroxysmal) Non-neuropathic: -musculoskeletal, LBP, HA's -treatment induced
presentation of weakness is people with MS
axonal damage reduced/slowed force production peripheral muscle fiber changes disuse atrophy Test with MMT, dynamometry
presentation of spasticity in pts with MS
Common in LE’s with MS
-flexor spasticity- hip and knee flexion, hamstring
-extensor spasticity- quads, adductors
interferes with activation, timing & sequencing
impairs gait and functional movement
can contribute to fatigue
Testing: modified Ashworth, Tardieu
Presentation of cerebellar involvement in pt’s with MS
Ataxia -dysdiadochokinesia-- timing of agonist/antagonist -rebound-- delayed response -dysmetria--amplitude problem -dyssynergia-- sequencing problem Intention tremor Hypotonia Vestibular inputs to cerebellum-balance
How do you test disdiadochokinesia?
Rapid alternating pronation/supination (loses rhythm and range) walk fast (gait impairment pronounced with increased speed)
How do you test for rebound?
resist flexion of joint and let go (large movement of resisted limb when released)
How do you test for dysmetria?
finger-to-nose, heel-to-shin
peg test
circle trace
How do you test for Dyssynergia/decomposition of movement?
touch heel to opposite knee/hand to opposite elbow supine (movement slow and looks broken into phases) dual task (worsens performance)
How do you test for intention tremor?
Have patient move finger or foot toward your finger or a target (look for increased deviation from the path when the finger or foot approaches the target)
How do you test for hypotonia?
passive limb movement (detect decreased resistance)
Muscle palpation (reduced firmness)
DTRs (decreased pendular swing with leg drop)
Hold object while conversing (drops object)
What are the 3 direct predictors of participation limitations?
- Fatigue (most significant contributor)
- Physical Function
- Psychological variables
MS-EDGE recommended measures for participation restrictions
Multiple Sclerosis Impact Scale (MSIS-29)
-physical scale (20 items)
-psychological scale (9 items)
Multiple Sclerosis Quality of Life (MS-QOL 54)
-12 sub-scales: physical function, role limitations-physical/emotional, pain, emotional well-being, energy, health perceptions, social function, cognitive function, health distress, overall quality of life, and sexual function
What is important to remember about exercise and MS?
- potential of elevated temperature to exacerbate weakness/fatigue
- potential for medications to impact weakness/fatigue
- decreased activity levels –> deconditioning/obesity
- sleep disruptions could impact fatigue levels
- depression
overarching goals of PT for pt’s with MS
Help patient achieve/maintain optimal... -functional independence -safety -quality of life Provide resources for... -equipment needs -community support/programs -education
Keys for goal setting/treatment planning
Patient driven Functional Principle of task specificity provide rest intervals avoid overheating transition to home/community program
Goal/interventions at diagnosis
education connection with support systems exercise/activity guidelines fatigue issues gait/balance or other impairments follow up as needed
Goals/interventions after relapse/attack
goal of returning to baseline function
may wait a couple weeks after onset to resume therapy
(could have new symptom, lack of sleep due to pain, etc.)
Goals/interventions with progressive disease
avoid deconditioning
maximizing independent function
assessing for mobility aids
Goals/interventions with advanced disease
seated trunk positioning/control transfers upper limb strength/function respiratory function equipment needs: standing devices can help with weight-bearing, stretching, b/b relief, respiration.
Keys to successful compliance for HEPs
goal-oriented
meaningful
variable
enjoyable
possible issues affecting compliance to HEPs
fatigue
depression
lack of support
cognitive function
What can exercise improve for pts with MS?
aerobic and muscular fitness fatigue depression walking balance cognition QOL sleep quality exercise is also associated with: reduced rates of relapses slowed disability progression
Exercise guidelines for pts with MS
30 min of moderate intensity aerobic activity 2x/week
strength training exercises for major muscle groups 2x/week
*may reduce fatigue, improve mobility, and enhance elements of health-related quality of life
