Multiple Sclerosis (MS) Flashcards
Describe the presentation of MS
- No stereotypical presentation: any part of the CNS could be a target
- UMN disease
- Can vary by signs and symptoms, location, intensities, timeframes, & prognosis
- Cann also vary depending on age
What is a sig of MS when looking at imaging
- Demyelinating plaques will show in neuroimages
Describe MS
- Progressive demyelinating disease
- Working with MS patients is a lifelong commitment with the patient’s needs changing as disease progresses
What are the 4 types of MS progression in order
- Relapsing remitting MS (RRMS)
- Secondary progressive MS (SPMS)
- Primary progressive MS (PPMS)
- Progressive relapsing MS (PRMS)
How long should true relapses last and how far apart from other relates should they be
- Should last at least 24hrs
- Should be separated from other relates by at least 30 days
Define pseudoexacerbations
- Last less than 2hrs due to stressors like heat, fatigue, and/or infections
Describe the McDonald criteria for diagnosis of MS
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Describe the Kurtzke EDSS
- Quantifies disability and documents disease progression
- Defines function systems into: pyramidal, cerebellar, brainstem, sensory, bowel/bladder, visual, cerebral, & other
- Each functions system is scored from 0-9 (zero being normal)
Describe the categorization of MS per the EDSS scores
- EDSS 0-3.5 = mild disability, fully ambulatory w/o assistive device
- EDSS 4-6.5 = moderate disability, ambulatory to specific distances w/o or w/ assistive device
- EDSS 7-9.5 = severe disability, very limited ambulation even w/ aid, W/C or bed bound
Epidemiology of MS
- Age of onset is 20-50yrs
- Females affect more than men
- Most commonly Dx b/w 30-35yrs, uncommon after 60yrs, disease could be very mild until 60yrs, the MS symptoms+geriatric processes can lead to progression
What are the top three most common symptom of MS in order from most prevalent to least prevalent
- Fatigue
- Heat sensitivity
- Difficulty with walking & balance
What is the most common reason for disability & limitations in mobility for MS patients
- Fatigue
- Also the earliest symptom
Define fatigue
- Subjective feeling of tiredness
- Recognized by patients avoidance of exercise/physical activity
- Reported by caregivers
- Decreased scores win self-report fatigue measures (MFIS, FSMC)
- Depression/anxiety
Define fatigabiliity
- Objective measure of how fast someone gets tired with a specific repetitive task
- Observed by progressive slowing of gait speed/distance, progressive weakening of specific contractions, worsening of sensation/speech/vision with a repetitive task
Describe central type fatigue
- Comes abruptly with or without exertion
- Triggering factors: exertion, heat, humidity, reduced sleep
- Occurs along with mental confusion/dullness: brain fog/brain fatigue/Cog Fog
Describe the modified fatigue impact scale
- Assessment for impact of fatigue on physical, cognitive, & psychosocial function
- Recommended best for comprehensive assessment by a recent systematic review
Describe the fatigue severity scale
- Assessment for impact of fatigue on daily activities
- Recommended best for quick screening by a recent systematic review
List the assessments for fatigue
- Modified fatigue impact scale
- Fatigue severity scale
- Fatigue scale for motor & cognitive functions
List the assessments for fatiguability
- Visual analog scale
- # of steeps in the last minute of 6MWT
- # of hip flex reps in supine
UMN signs associated with MS
- Weakness (paresis): MMT of ≤3/5 min once or more muscle groups
- Spasticity
- Brisk DTRs
- Clonus
- Babinski’s sign (toes flare up/out)
- ROM limitations
Coordination problems associated with MS
- Mainly from cerebellar & posterior column lesions
- Cerebellar: ataxia, intention tremor, dysdiiadokokinesia, dysmetria, dyssynergia
- Tests: finger to nose, RAM
- Outcome measures: 9 hole peg test, Box and Blocks test
What balance outcome measures can be used for MS patients
- Berg balance scale (BBS)
- Dynamic gait index (DGI)
- ABC (activities specific balance confidence)
Vestibular problems associated with MS
- Presence of dizziness, vertigo, nystagmus, imbalance with head movements
- Careful exam required: large number of new vestibular symptoms ion MS are found to be BPPV or other peripheral problems
Functional mobility assessment outcome measures that can be used for MS patients
- Timed 25 ft walk: gait speed
- TUG and TUG Cognitive
- Riveremead Mobility Index
- 12 item walking scale: self report
Gait and mobility problems associated with MS
- Reduced stride length
- Prolonged double support time
- Slow gait speed
- Hip flexor & DF weakness (steppage gait)
- Hip ABD weakness (Trendelenburg gait)
- Hip ADD tightness (Scissoring)
- Cerebellar lesion (Ataxia)
Visual problems associated with MS patients
- Ice pick pain due to optic neuritis
- Marcus gunn pupil (RAPD - detected by swinging flashlight test)
- Vertical nystagmus
- Diplopia
- Scotoma
Sensation problems associated with MS patients
- Numbness, tingling, parasthesia
- Impaired vibration/position sense: more in LEs; Positive Romberg
- Outcome measures: Erasmus modifications to the Nottingham sensory assessment (EmNSA)
Pain problems associated with MS patients
- Parathesia/Dysesthesia: pins and needles, hypersensitivity, burning, neuropathic type
- Trigeminal neuralgia
- Lhermitte’s sign
- MSK strain/joint malalignment from chronic muscle imbalance
- Pain scales: DN4, PainDETECT
Define Uhthoff’s phenomenon
- Temporary worsening of neurological symptoms mostly with heat sensitivity
Other motor neuron problems associated with MS patients
- Bladder/bowel dysfunction: small/spastic, flaccid/big, or dyssynergic bladder
- Scaling dysarthria
- Depression & pseudo bulbar effects
List the MS specific outcome measures
- MS Impact Scale (MSIS-29)
- MS Quality of Life (MS Qol-54)
- Dizziness Handicap Inventory
What should you do before performing a fatiguing activity
- Assess strength before & after
- Assess muscle endurance before & after
- Assess balance before & after
- Assess gait and mobility before & after
- Assess somatosensation and vision before & after
- Assess vestibular function before & after
What are the effects of fatigue on a MS patients gait and mobility
- Gait and functional mobility deteriorates after fatigue
MS specific considerations for examination
- May need to assess w/o fatigue & after fatigue specifically in mild cases/initial stages
- Good idea to assess during relapse & remission
- May need observation over days to get good baseline functional level
- May need to identify factors that exacerbate patient’s symptoms
Factors that indicate poor prognosis for MS
- Male
- Onset of Sx after age 40
- Initial Sx involving cerebellum, mental function, or urinary control
- Initial Sx that affect multiple regions of the body
- In the first years after onset, attacks that are frequent or a short time b/w the first 2 attacks
- Incomplete remissions
Factors that indicate better prognosis for MS
- Relapsing remitting presentation has better prognosis than progressive
- Univocal presentation has batter prognosis than multifocal
- Afferent pathway involvement has better prognosis than efferent
Approach for rehab based on patient’s EDSS score
- EDSS 0-3.5 (mild disability): restorative/preventative rehab
- EDSS 4-6.5 (moderate disability): restorative/compensatory rehab
- EEDSS 7-9.5 (severe disability): compensatory/maintenance rehab
Evidence for physical rehab for MS patients
- Strong evidence for rehab to prevent or slow down disability
- Improvements at impairment, activity, & participation levels
- Refer for therapy when there is abrupt/gradual worsening that affects mobility, safety, QOL
Excessive exercise may cause pseudo-exacerbations/pseudo-attacks which are
- Transient worsening of symptoms due to fatigue, rise in body temperature, stress and patients may complain after exercise but exercise does not cause exacerbations/attacks/relapes
Exercise and physical activity have been associated with
- Reduced relapse rates
- Decreased mobility-related disability and its progression
- Decreased lesion volume, improved neuroperformance
- Improved gait outcomes
- Exercising is safe for MS population and does not cause relapse
Describe aerobic endurance training and MS
- Pts show normal CV responses to submit exercise: HR, VO2, BP increase
- CV response may be blunted if autonomic system is affected then need to use RPE
- Need to monitor for fatigue by observing s/s of overexertion
- Use of cooling fans/vests to maintain body temp.
- No exercise during relapse
- PPMS types also benefit from exercise
- EEDSS ≤2.5: 3-5days/wk; 60-85% HRpeak or 50-70% VO2peak; 30 min total in 10 min sessions with rest breaks; recumbent cycle/walking/swimming
Strength recommendations for EDSS ≤2.5 MS patients
-Weight machine, free weights, therabands
- 2days/wk
- 60-80% 1RM, 1-2 sets of 8-15 reps; increased rest time b/w sets (2-5min) to avoid fatigue
- Progression slower use cooling fans/vests to maintain body temp.
Stretching recommendations for MS patients
- Daily
- Static stretches with 30-60sec holds
-Needs volume, use of orthoses/night splints as needed to prevent contractures - Stretching only his net enough so combine with strengthening thee antagonists & progress to functional use
-Identify if decreased ROM is due to actual weakness or secondary disuse
Gait training for ataxic gait
- Proprioceptive loading of UB, ex at modified plantigrade posture, weighted vests, weighted walker/cane
Gait training for Trendelenburg gait
- SLS ex against wall, proprioceptive touch to improve glut med contraction during affected limb stance phase
Gait training for Steppage gait
- Strengthening DF or use of AFOs or Bioness (AFO/FES CPG)
Gait training for restoration vs compensation
- Think Forced-use techniques for affected LE for restoration, NDT-based techniques for maintenance
- May need AD/walker with disease progression – compensatory approach
What is the best type of practice for MS patients
- Distributed practice sessions over massed practice
Management of fatigue during daily activities
- Energy effectiveness strategies (EES)
- Maintain daily activity diary: comment on temp, MS symptoms during activity
- Rate each activity by fatigue (F), value(V), satisfaction (S): Look for higher rated V and S, prioritize by high F values
- Use energy conservation techniques: modify task (task analysis), modify home/environment, activity scheduling/pacing (doing laundry throughout the day), Preplanned rest-activity ratios
Interventions for advanced stags of MS EDSS >7-9.5
- Teach compensatory techniques for maintaining functional mobility
- Wheeled mobility devices: scooter, powered chair
- ADL training: transfer training to/from wheeled mobility devices
- With disease progression: positioning, will need trunk supports for correct alignment in wheel chair, belt for safety (extensor spasms, pelvis tend to rotate posteriorly and slip)
- Contracture management: continued stretching, splinting
- Maintaining skin integrity: pressure relieving techniques
- Caregiver training
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