Multiple Sclerosis

Question 1

Definition

Answer 1

> Chronic demyelinating disease of CNS

> Inflammatory process that leads to widespread degeneration of CNS = severe neurological deficit

Question 2

Facts

Answer 2

> ~ 1:1000 people 
> usually diagnosed between 20-40yrs old
> females 3x more likely
> more temperate climates 
> higher socio-economic classes
> Caucasian ethnicity

Question 3

Triggers

Answer 3

> No definite cause
> Suspected triggers:
- Infection
- vaccination
- pregnancy
- trauma
- emotional stress
- environmental factors
- viral factors (epstein-barr virus)
- genetic factors (1.5% chance of inheritance)
- Diet deficiencies - VIT D

Question 4

Pathophysiology

Answer 4

> Disruption of blood-brain barrier
- allows inflammatory cells into CNS (T cells have been misprogrammed to attack myelin - release cytokines which also recruit other immune cells)
Immune cells attack myelin sheaths, oligodendrocytes (cover axons of CNS) + axons of CNS cells
Nerve conduction is slowed/disrupted
Plaques can form throughout CNS (visible on MRI)
- sclerosis means scarring

Question 5

Four types of MS

Answer 5

> Categorized by rate of damage to axons + sheaths

1. Benign
   - inflammatory episodes (may still cause problems)
2. Relapsing Remitting
   - progressively worsening inflammatory episodes
   - some symptoms may stay after an episode
3. Secondary Chronic progressive
   - advanced relapsing remitting
   - steady degradation
4. Primary Progressive (10-20% of patients)
   - gradually degrading over time

Question 6

Signs + symptoms

area dependent

Answer 6

• Occipital lobe/thalamus/optic nerve = visual problems
• motor cortex/descending pathways = weakness
• Cerebellum = ataxia/poor co-ordination + balance
• Sensory cortex/ascending pathways = sensory loss
• Vestibular system = poor balance/dizziness
• Spinal cord = sphincter disturbance/sexual dysfunction
• Limbic system/ dopamine system/hypothalamus = emotional changes
• Frontal lobe = decreased intellectual ability
• Many reasons = spasticity + hyperreflexia
  = fatigue (could be due to CNS damage or deconditioning of PNS

Question 7

Likely initial symptoms

Answer 7

> Limb weakness (tripping)
Optic neuritis - inflammation of optic nerve
Paraesthesia - altered sensation
Diplopia - double vision
Vertigo - dizziness/nausea/movement felt when static
Micturition difficulty

Question 8

Diagnosis

Answer 8

> By exclusion - rule other things out

• Clinical history
• lumbar puncture - tests CSF for oligoclonal bands
• Nerve conduction tests
• MRI scan - visible plaques (may not have developed in early stages

Question 9

MS relapse

Answer 9

> Event typical of MS with no other cause
longer than 24 hours
longer than 30 days since last attach (qualifies as new attack)
Objective findings (not just symptoms)
multiple paroxysmal (sudden) attacks over 24 hours or more

Treatment of relapse (exclude UTI first)
> IV methyl prednisolone - 3 days
> oral methyl prednisolone - 10 days
*steroids (low dose + prolonged = less effective)
> EARLY TREATMENT CAN PREVENT PERMANENT SYMPTOMS
+ Plasmapheresis = removal of plasma - eliminate problematic antibodies - replaced in body

Question 10

Treatment of MS

Answer 10

Whole MDT
> Disease-modifying drugs (aim is remove inflammatory cells but are also fairly toxic so cause side-effects)
> Anti-spasmodics + relaxants e.g baclofen (fatigue is a side effect)
> Drugs for neuropathic pain e.g gabapentin/pregabalin
> Anti-depressants
> analgesia
> bladder problems - pelvic floor exercises
> diet - vit D, fish oils, linoleic acid
> hyperbaric oxygen (reduces impact of relapse + boosts recovery)

Question 11

Physio role in MS

Answer 11

> Stretches
> Strengthening
> balance
> gait re-education
> transfers practice
> functional activity practice
> pain management
> fatigue management
> compensatory strategies
> education

Question 12

Prognosis

Answer 12

> v. variable
- higher age = faster degradation (regardless of type of MS)
50% walk unaided after 15 yrs
QoL = 30% lower than average
Suicide rate is 7.5x higher
Exaggerates other killers e.g. sepsis/pneumonia

Question 13

Assessment

Answer 13

> Stage/severity of disease
- Expanded disability status scale (EDSS) = 0-8 assessing independence/gait/disability
> Impact on daily life (participation)
- MSIS - 29 
> Impact on mobility 
- MSWS - 12
> Impairments
- dependent on impairment e.g balance - berg balance scale