Multiple Sclerosis Reading Flashcards
What is MS?
Multiple Sclerosis is a chronic inflammatory disease of the central nervous system (CNS) that breaks down myelin and inadequately repairs it, resulting in degeneration and involvement of various parts of the immune system. [1]
What approach is used to diagnose MS?
MS is a clinical diagnosis made by doctors based on the patient’s history and a physical examination
What does a doctor look for during the history and physical examination to make an MS diagnosis?
Doctors look for a history of clinical relapses and focal neurological changes on the exam
What are red flags that can point to a diagnosis of MS?
Age: Younger patients are more likely to have MS.
Definitive Symptoms: Symptoms that clearly worsen, plateau, and then get better fit with MS.
Impactful Symptoms: The symptoms really affect the patient’s life.
Heat Sensitivity: Symptoms worsen with exertion and heat.
Specific Neurological
Symptoms: Symptoms like weakness on one side, tingling, or double-vision
What other tools, besides the history and physical, help doctors diagnose MS?
MRI: Doctors can identify lesions in the brain characteristic of MS.
Cerebrospinal Fluid
Analysis: Doctors can look for oligoclonal banding in the cerebrospinal fluid, which is a sign of CNS inflammation and can help diagnose MS.
What are common conditions that can mimic MS?
Conditions that can mimic MS include normal aging, hypertension, smoking, and migraine.
What are some key things a doctor considers to rule out conditions that mimic MS?
Atypical history: The patient’s history does not fit the typical presentation of MS. [5]
Normal Exam: The neurological exam is normal. [5]
Nonspecific White Matter Lesions: MRI findings look more like normal aging than MS. [5]
Normal Spinal Fluid: Cerebrospinal fluid analysis is normal.
What is radiologically isolated syndrome (RIS)?
Radiologically isolated syndrome (RIS) is when a patient has an MRI that looks like MS, but the patient does not have any MS symptoms. [6] About 10% of RIS patients will convert to MS, meaning they will develop symptoms within 3 years. [4] Some RIS patients are followed for more than 20 years without developing MS. [4]
What is clinically isolated syndrome (CIS)?
Clinically isolated syndrome (CIS) is when a patient has their first clinical attack of demyelination. [4] If a patient with CIS has an abnormal MRI, they are much more likely to develop MS later in life. [4]
What are the new clinical criteria for diagnosing MS that were established in 2017?
The new 2017 McDonald criteria allow for earlier and more accurate diagnoses of MS. [2] Some key features of these criteria include:
Lesion Location: The criteria emphasize the presence of specific lesions in characteristic locations in the brain. [2]
Cerebrospinal Fluid Analysis: The criteria incorporate the use of cerebrospinal fluid analysis to demonstrate dissemination in time, meaning there is evidence of the disease process happening at different points in time. [2]
Simplified Criteria: The criteria are designed to be simpler than previous criteria to reduce delays in diagnosis so treatment can begin earlier. [
Can MS be diagnosed based on fatigue, depression, anxiety, cognitive issues, or sleep problems alone?
No. MS cannot be diagnosed based only on fatigue, depression, anxiety, cognitive issues, or sleep problems. [3] These symptoms are common in MS, but they are not specific to MS and could be due to other conditions. [3] A diagnosis of MS requires other neurological symptoms.
What are the 4 standard clinical measures used to monitor MS progression?
Clinical exams, using the Expanded Disability Status Scale (EDSS)
MRI
Timed 25-Foot Walk Test
Symbol Digit Modalities Test (SDMT)
What is the Expanded Disability Status Scale (EDSS)?
A method of quantifying disability in MS, ranging from 0 (normal neurological exam) to 10 (death due to MS). The EDSS is based on the neurological exam and focuses primarily on motor function.
How is MRI used to monitor MS progression?
Doctors use MRI to look for new areas of inflammation and disease activity over time. They are particularly interested in new or enlarging T2 lesions, and the presence of gadolinium-enhancing lesions, which indicate active inflammation.
What does the Timed 25-Foot Walk Test measure?
How quickly a person can walk 25 feet. It provides an objective measure of walking ability and can help determine if a person’s MS has progressed
What is the Symbol Digit Modalities Test (SDMT)?
A brief (92 second) cognitive screening test that can help doctors track changes in cognitive function over time.
What does it mean if a person with MS is classified as “not active?”
They are stable. There is no evidence of new disease activity on MRI, and they have not had any clinical relapses.
What does it mean if a person with MS is classified as “active?”
They have ongoing disease activity. This is indicated by new or gadolinium-enhancing lesions on MRI, or the occurrence of new clinical relapses.
What is the goal of disease-modifying therapies (DMTs) in MS?
To move patients from the “active” category to the “not active” category by reducing disease activity, preventing relapses, and slowing or stopping the progression of disability.
Which of the standard clinical measures for monitoring MS is most directly related to classifying MS as “active” or “not active?”
MRI. A doctor looks at a patient’s MRI to see if there are new or enlarging lesions, or gadolinium-enhancing lesions, which would indicate active inflammation.
How might the other standard clinical measures be used to determine if someone’s MS is active or not active?
EDSS: If a patient’s EDSS score worsens, it could be a sign that their MS is active and progressing. However, it is important to note that progression can also occur in the absence of new relapses or new MRI activity. [6, 7]
Timed 25-Foot Walk and SDMT: Changes in these measures may also suggest disease progression, but they do not directly indicate whether the MS is currently “active” in terms of new inflammation. [1]
What are the 4 main categories of treatment for MS?
Relapse Treatment
Disease-Modifying Therapy (DMT)
Symptomatic Treatment
Lifestyle/Comorbidity Treatment
Which categories of MS treatment aim to modify the disease process itself?
Disease-Modifying Therapy (DMT)
Lifestyle/Comorbidity Treatment
What is the goal of relapse treatment?
To reduce the severity and duration of a relapse and to speed up recovery.
How does relapse treatment work?
Relapse treatment usually involves high-dose corticosteroids, given intravenously or orally. Corticosteroids suppress the immune system and help to reduce inflammation in the central nervous system.
Does relapse treatment alter the long-term course of MS?
No. Relapse treatment only addresses the acute inflammation of a relapse. It does not modify the underlying disease process or prevent future relapses.
What is the goal of disease-modifying therapies (DMTs)?
To slow or stop the progression of MS, reduce the frequency and severity of relapses, and limit the accumulation of disability.
How do DMTs work?
DMTs work in various ways to modulate or suppress the immune system. Different DMTs have different mechanisms of action, and some are more effective than others
Do DMTs alter the long-term course of MS?
Yes. There is evidence that DMTs, particularly the more effective ones, can significantly delay the progression of disability.
When is the best time to start DMTs?
As early in the disease course as possible, ideally within 2 years of the first symptoms or diagnosis.
What is the goal of symptomatic treatment?
To relieve symptoms of MS and improve quality of life. Symptomatic treatments do not modify the underlying disease process
What are some examples of symptomatic treatments?
Medications for pain, fatigue, spasticity, bladder problems, and bowel problems
Physical therapy
Occupational therapy
Speech therapy
Cognitive rehabilitation
Psychotherapy
How does lifestyle/comorbidity treatment aim to modify the course of MS?
By addressing modifiable risk factors that can influence the disease process and by promoting overall health and well-being
What are some examples of lifestyle and comorbidity treatments that may benefit people with MS?
Smoking cessation
Healthy diet
Regular exercise
Stress management
Treatment of comorbidities such as hypertension, diabetes, and depression
Vitamin D supplementation
Ensuring good sleep hygiene
Do lifestyle modifications alter the pathophysiology of MS?
The sources suggest that lifestyle factors and comorbidities can influence the disease course, but they don’t provide definitive evidence that these modifications directly alter the underlying pathophysiology. [4, 5] More research is needed in this area
What does Dr. Smyth mean by “Red Flags” for MS?
Red Flags” are characteristic signs and symptoms, and patient history details that help a doctor determine the likelihood that a patient’s symptoms are caused by MS, rather than another condition
What are some “Red Flags” that suggest a patient may have MS?
The patient is younger, in the 20-40 year old age range. [2, 6]
Symptoms came on suddenly and definitively, worsened, plateaued, then improved. [2, 3]
Symptoms worsen with heat or physical exertion. [2, 7]
Symptoms are localized to a particular area, like one side of the body. [2]
What are some “Red Flags” that suggest a patient’s symptoms are unlikely to be caused by MS?
The patient is older. [2, 6]
Symptoms are vague and ill-defined, or have remained constant for months. [2]
Symptoms are relieved by changing positions. [2]
The patient has a normal neurological exam despite their symptoms. [4]
MRI shows white spots that look like normal aging, or are related to other conditions like hypertension, smoking, or migraine. [4]
Spinal fluid analysis is normal. [4]
What conditions can cause “white spots” to appear on an MRI, other than MS?
Normal aging, hypertension, smoking, and migraine can all cause white spots on an MRI that may be mistaken for signs of MS. [
What is the most important factor in diagnosing MS?
A clinical diagnosis, based primarily on the patient’s history and a neurological exam. MRI and spinal fluid analysis can support a clinical diagnosis, but cannot replace it.
What is Clinically Isolated Syndrome (CIS)?
The first episode of neurological symptoms caused by inflammation and demyelination in the central nervous system (CNS).
Symptoms last at least 24 hours.
Most patients experience CIS as the first phase of MS.
Approximately 85% of MS patients initially present with CIS.
What is a relapse in Clinically Isolated Syndrome (CIS)?
A single, isolated neurological event. [2, 5] A second clinical attack would lead to a diagnosis of relapsing-remitting MS.
What is Relapsing-Remitting MS (RRMS)?
Characterized by clearly defined attacks of new or increasing neurological symptoms (also called relapses or exacerbations). [2, 6]
These are followed by periods of partial or complete recovery (remissions). [2, 6]
Most patients initially diagnosed with RRMS will eventually transition to a secondary progressive course at a rate of about 2-3% per year. [2, 7]
What is the relapse frequency in Relapsing-Remitting MS (RRMS)?
The average early relapse frequency is about 1.1 per year, but this tends to decrease with advancing disease, age, and increasing neurological dysfunction
What is Secondary Progressive MS (SPMS)?
Follows an initial relapsing-remitting course. [1, 2, 9]
Characterized by a gradual worsening of neurological function over time, independent of relapses. [1, 2, 9]
Disability steadily worsens, with or without the occurrence of relapses and plateaus. [2, 10]
Relapses may or may not occur during the progressive phase. [2, 11]
What is Primary Progressive MS (PPMS)?
Characterized by slowly worsening neurological function from the onset of symptoms, without early relapses or remissions. [2, 12]
Patients experience a gradual but steady increase in disability, without periods of remission. [2, 13]
Acute attacks do not typically occur. [2, 14]
What is Progressive-Relapsing MS (PRMS)?
A rare form of MS with progressive disease from the onset. [2, 15]
Acute relapses with or without full recovery. [2, 15]
Continued progression between relapses. [2, 15]
A steady decline with superimposed relapses. [2, 16]
Relapses are present, unlike PPMS. [2, 17]
How are different MS subtypes classified as active or inactive?
Each subtype is classified as active or inactive based on relapses or new lesions on MRI. [1, 18]
How is disability progression classified in PPMS and SPMS?
Progression over a specific time is a key classification factor for PPMS and SPMS.
How do lesions differ in the different MS subtypes?
Active demyelinating lesions are more frequent in CIS and RRMS, while inactive lesions are more common in PPMS and SPMS.
What is the general trend between latitude and MS prevalence?
Higher latitude is correlated with increased prevalence and incidence of MS, especially in Europe and North America.
What is the range of MS prevalence globally?
Estimates range from 2 per 100,000 individuals in Asia to approximately 1 per 1,000 individuals in Western countries. [2] In some high-latitude countries, the prevalence can be as high as 1 per 400 individuals.
