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Sub-Acute (Theory) > W12: Multiple Sclerosis > Flashcards

W12: Multiple Sclerosis Flashcards

1
Q

What is the prevalence of MS in Aus?

A

104/100,000

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2
Q

How does latitude affect the incidence of MS & why?

A

The further away from the equator people live the higher the prevalence of MS. Tasmania has twice the prevalence of MS than Queensland.

This is likely because vitamin D insufficiency is a risk factor for MS & the UV is less intense further from the equator.

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3
Q

Is the mean age of onset of MS typically younger or older?

A

Younger

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4
Q

Is MS more common in males or females?

A

Females

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5
Q

What are the financial costs of MS yearly?

A

2 billion AUD

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6
Q

What percentage of people have progressive MS?

A

15%

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7
Q

What percentage of people have relapsing remitting MS?

A

85%

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8
Q

List the potential risk factors of MS?

A
  • Genetic
  • Dysfunction in human leukocyte antigen gene
  • Latitude/sunlight
  • Exposure to some type of viruses
  • Smoking & obesity
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9
Q

What is myelin sheath made of and what is its role?

A

Myelin sheath is made of fat & aims to increase conductivity

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10
Q

What is the pathophysiology of MS?

A

1: T cells enter the brain via the blood brain barrier (occurs due to a break-down in the tight junctions that normally restrict entry of substances/cells)
2. The t-cells recognise the myelin as foreign & begin to attack/degrade the myelin + oligodendrocytes
3. T cells release cytokines which amplifies the immune response by recruiting more immune cells eg B cells and macrophages
4. B cells create antibodies for the myelin which results in being targeted for further degradation & the macrophages phagocytise the myelin.

Note: typically the blood-brain barrier (BBB) restricts, substances and cells that would normally be restricted. However in MS it loses its integrity allowing substances to enter

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11
Q

What are oligodendrocytes?

A

Cells that produce myelin!

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12
Q

How would MS present on an MRI?

A

Fibrotic white scar tissue in the brain and SC is present.

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13
Q

What are the three types of MS?

A
  • Relapsing remitting MS (RRMS)
  • Secondary progressive MS (SPMS)
  • Primary progressive MS (PPMS)
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14
Q

What type of MS has a higher incidence in M than W?

A

Primary progressive MS

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15
Q

What is relapsing remitting MS?

A

Initially RRMS is characterised by episodes of new or worsening symptoms (relapses) followed by periods of partial or complete recovery (remissions). During remissions symptoms may disappear entirely or persist at a reduced level).

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16
Q

Describe the disease progression of RRMS?

A

Early stages: disability may be minimal.

Progression: over time some individuals may experience an accumulation in the level of disability. This means that after each relapse there may be residual symptoms that do not fully resolve, leading to a gradual increase in disability

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17
Q

Summarise the steps of RRMS?

A
  1. Inflammation: immune cells attack brain (relapse)
    2: Immune cells stop attacking the brain
  2. Myelin repairs itself (remission) –> partial or full recovery (worsening or non-worsening)
  3. Period of stability
  4. Another relapse (may occur with days to years between)
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18
Q

What is SPMS?

A

Secondary progressive MS
- Follows an initial RRMS course
- After the RRMS course, progressive worsening of neurological function (accumulation of disability over time)

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19
Q

What is primary progressive MS?

A

Worsening neurological function ie accumulation of disability from the onset of symptoms without early relapses or remissions

20
Q

What is clinically isolated syndrome?

A

Refers to a first episode of inflammatory demyelination in the CNS (at least 24 hrs).

Its characteristic of MS but does not meet diagnostic criteria.

People may or may not go onto develop MS

21
Q

In clinically isolated MS, what percentage with MRI changes go onto develop MS?

What percentage without MRI changes go onto develop MS?

A
  • If MRI changes = highly likely to get MS (60-80%)
  • If no MRI changes = less likely to get MS (20%)
22
Q

What are the two key difficulties in defining prognosis in people with MS?

A

Prognosis varies based on the type of MS and differences across studies eg can be up to a 5-10 year difference

There is also a lack of good epidemiological data on prognosis

23
Q

Why is there a lack of good epidemiological data for people with MS?

A
  • Diagnosis difficulty often requires 1-2 years, >1 episode)
  • MS classification type difficulty, initially
  • No central database in Australia
  • On first diagnosis, few people get admitted to hospital
24
Q

List 10 symptoms of MS
- Hint: 3 CNS symptoms, 1 throat symptom, 2 muscular symptoms, 2 visual symptoms, 1 sense symptom & 1 digestion related

A

CNS symptoms: fatigue, cognitive impairment and unstable mood

Throat: dysphagia

Muscular: weakness & loss of coordination

Visual: diplopia & nystagmus

Sensory: pins and needles

Digestion issues eg constipation or sudden change in urinary frequency

25
Q

What is the EDSS & the difference between 1-4.5 and 5-9.5. List some of the functional systems it assesses? List one disadvantage?

A

The EDSS = explained disability status scale

It assesses 8 functional systems eg pyramidal (corticospinal and corticobulbar tracts), cerebellar, brainstem, sensory, visual function, etc

0-4.5: all patients can walk and EDSS is primarily defined by the problems due to the functional systems

5.0-9.5: defined primarily by the problems of walking

Dis: doesn’t cover emotional factors eg fatigue/tiredness & places a strong focus on ambulation and walking ability, which can overshadow other relevant areas of disability in stroke, like upper limb function, cognition, and speech.

26
Q

Describe management strategies for impairments in people with MS?

A
  • Repetitive task specific training (goal is to re-educate + maintain all their available voluntary control)
  • General exercise
  • Falls prevention: common to have poor postural control. balance training is therefore important!

Note: impairments/activity limitations are similar to stroke because it affects the CNS

27
Q

Discuss and describe fatigue in people with MS (as a primary and secondary impairment)

  • In what percentage of patients is fatigue felt to be the hardest symptom to manage?
  • Define fatigue
A

82% (often the most disabling symptom)

Fatigue is an overwhelming sense of tiredness, lack of energy and feeling of exhaustion (commonly feel that the effort required to perform actions is disproportionately high)

28
Q

Discuss and describe fatigue in people with MS (as a primary and secondary impairment)

  • Is fatigue more common in RRMS or progressive MS?
  • What can aggravate fatigue in MS patients
A
  • More common in patients with progressive
  • Heat, pain, depression + excessive exertion
29
Q

How would fatigue influence physio for MS patients?

A
  • Acknowledge that it is a genuine symptom which can be a direct result of the disease
  • Pacing activity/exercise
  • Timing treatment
  • Management eg heat sensitivity during sessions
30
Q

How can you use a fatigue diary to structure physio?

A
  • By tracking daily fatigue you can identify when the patient has the most + least energy = scheduling more demanding exercises during peak energy
  • Guide goals eg if they can tolerate 15 mins before fatigue build from here
  • Empower the patient to integrate changes at home eg they can understand when rest breaks may be needed/when to time exercise
31
Q

What are the primary non-motor impairments of MS (consider how this would affect physio management)?

A
  • Decreased vision
  • Decreased sensation
  • Decreased proprioception
  • Decreased speech and language
  • Decreased vestibular function
  • Decreased perceptual-cognitive function
32
Q

Discuss management strategies for fatigue

A
  1. Monitor fatigue (with a diary)
  2. Medication
  3. Energy conservation courses: 2hrs/week for 6 wks (evidence found reduced fatigue + increased self-efficacy)
  4. Address heat sensitivity (pain is aggravated by heat - cooling strategies + regular hydration)
  5. Appropriate exercise can reduce fatigue
  6. Support offered by MS society (can help emotional consequences of fatigue)
33
Q

What are the secondary non-motor impairments of MS?

A

Pain
Fatigue
Depression

How would this affect physio –> MDT

34
Q

What medication can be used for MS fatigue?

A

Mild = amandtadine
Moderate/Severe = Madafinal

35
Q

What does the cochrane review report regarding exercise therapy for MS?

A

Exercise therapy can be prescribed in people with MS without harm.

Exercise therapy particularly endurance, mixed or “other” training may reduce self-reported fatigue

36
Q

Define ataxia?
What accuracy is affected?

A
  • Loss of dexterity/co-ordination
  • ## Reduced spatial and temporal movement accuracy
37
Q

What are the common movement deficits in MS patients?

A
  • Speed/timing
  • Amplitude
  • Direction
  • Force
38
Q

Common symptoms associated with ataxia

A

Dysmetria (overshooting/undershooting)
Dyssnergia
Dysdiadochokinesia
Tremor
Dysarthria
Nystagmus

39
Q

Outline some adaptive motor behaviours that people with ataxia present with?

A
  • Excessive pre-shaping when grasping objects
  • Decreased movement amplitude = easier to control DOF
  • Increased base of support (increases stability)
  • Excessive stepping (cerebellum is impaired which makes it challenging to control length and rhythm of steps)
40
Q

Potential treatment strategies for MS?

A
  • Use of external cues eg visual, auditory and proprioceptive ie taping, clapping, etc
  • Aids eg parallel bars
  • Training closed tasks that require rhythm eg stepping and open tasks that require prediction eg catching
  • Whole task training
  • Weights can reduce tremor in 58% (note: this doesn’t increase performance)

Note: closed = stable/predictable environments vs open = dynamic/unpredictable environments

41
Q

Briefly outline the cochrane evidence for treating ataxia: pharmacotherapies & neurosurgery/neurorehab

A

No recommendations can be made to guide prescribing pharmacotherapies.

Although studies on neurosurgery/neurorehab show promising results

42
Q

Briefly outline the cochrane evidence for treating ataxia: exercise therapy

A

Strong evidence in favour of exercise therapy compared to no exercise therapy in terms of muscle power function, exercise tolerance & mobility related activites.

Moderate evidence was found for improving mood.

Note: no evidence was found that specific exercise therapy programs were more successful in improving activities and participation than other exercise treatments

Conclusion: exercise therapy can be beneficial for patients with MS not experiencing an exacerbation

43
Q

Outline the types of drug therapy in people with MS?
What is the goal of drug therapy?

A

Aims to reduce progression of disease not treat symptoms. Commonly used to control MS attacks.

Drugs:
- Corticosteroids
- Plasma exchange
- Beta interferons
- Ocrevus

44
Q

Purpose of corticosteroids for MS?

A

Corticosteroids = decrease nerve inflammation

45
Q

Purpose of plasma exchange (drug) for MS?

A

Remove proteins that are “attacking” the body

46
Q

Purpose of beta interferons for MS? What type of MS is it used for?

A

Used for RRMS (most commonly prescribed for this type of MS)

Aims to decrease the frequency and severity of relapses

47
Q

What is ocrevus? What type of MS does it treat?

A
  • Only approved treatment for PPMS. Slows worsening of disability in people with PPMS (& RRMS)
  • Reduces relapse rates in RRMS

Sub-Acute (Theory) (10 decks)

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