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S6- Neuro 2 > Week 5- Multiple Sclerosis > Flashcards

Week 5- Multiple Sclerosis Flashcards

1
Q

PART 1: INTRO AND BACKGROUND

A

PART 1: INTRO AND BACKGROUND

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2
Q

What is multiple sclerosis (MS)?

A

-Disease that impacts CNS, in which immune system is triggered to attack it.

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3
Q

What is MS characterized by?

A

Course of demyelination mediated relapses and remissions with an unpredictable course.

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4
Q

Pathophysiology:

  • Abnormal immuno-mediated response attacks ________, ___________, and the axons themselves through the CNS. Creates “holes” which slows AP and saltatory conduction.
  • Activation of immune cells that cross BBB, enter CNS, and initiate damaging inflammatory cascade of events.
A

-myelin, oligodendrocytes, and axons

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5
Q
  • Is MS a gradual continuous attack?

- Remyelination occurs but is often __________.

A
  • No, the nervous system is able to regain composure (REMISSION) until next attack happens.
  • Incomplete
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6
Q
  • With time, anti-inflammatory responses/remyelination cannot keep up and we see demyelinated areas undergo ________, what is this?
  • ______ matter > ______ matter
A
  • Gliosis, which is a proliferation of neurological tissues resulting in scarring.
  • white matter > gray matter (as desease progresses)
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7
Q
  • MS is the most common cause of disability in what populations?
  • What is the average age of onset?
A
  • young, middle-aged adults

- 15-50

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8
Q

What is the cause of MS?

A

-Largely unknown (idiopathic)

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9
Q

What is the hypothesis for MS?

A

-Perfect storm between genetic predisposition and environmental antigens resulting in auto-immune response.

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10
Q

What are some predisposing factors to MS?

A
  • Women > Men (3:1)
  • Caucasian/Nordic
  • Higher income contries
  • Temp Zones (Western EU and NA)
  • Low vitamin D exposure during childhood/teenage years.
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11
Q

What are the (3) things that help with diagnosis of MS?

A
  • Clinical Presentation
  • MRI
  • Additional laboratory tests
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12
Q

With clinical presentation, patient must show S/Sx consistent with ____________.

A

-demyelination

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13
Q
  • On a MRI we are looking for the signs of ________ (________ build up) which often take time to show.
  • We are looking for dissemination in ________ and ______. What does this mean?
  • With MS, we need to see lesions in 2 of what 4 MS typical areas to get a diagnosis.
A
  • gliosis, plaque build up
  • space and time, different areas of CNS and changes of plaque over time.
  • Periventricular, juxtacortical, infratentorial, spinal cord
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14
Q

What are some additional lab tests that can be used to help with diagnosis of MS?

A
  • Visual evoked potentials

- Lumbar puncture

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15
Q

SIGNIFICANT decline in number of attacks, lesion sites, and disability in patients that participate in ________ ______ _________ protocols.

A

-early drug treatment protocols

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16
Q

PART 2: S/Sx OF MS

A

PART 2: S/Sx OF MS

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17
Q
  • What is a Clinically Isolated Syndrome (CIS)?

- Is it monofocal or multifocal?

A
  • First episode of neurologic symptoms that lasts at least 24 hrs and is later on determined to be caused by demyelination.
  • Can be either monofocal or multifocal.
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18
Q
  • Clinically Isolated Syndrome most commonly affects what 3 areas?
  • How are they initially treated?
A
  • Optic nerves, brainstem, or spinal cord

- High-dose glucocorticoids for acute symptoms.

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19
Q

Do all CIS progress to MS?

A

-No, there are some cases of one big attack then lies dormant.

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20
Q

Risk factors for progression from CIS to MS:

  • ____________ presentation
  • > /=__ T2 MRI lesions
  • Oligoclonal bands present in ______, not in serum.
A
  • polysymptomatic presentation
  • > /=2 T2 MRI lesions
  • present in CSF, not in serum
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21
Q
  • ____ + _____ findings indicative of earlier events = confirmed MS Diagnosis
  • Why is this common?
A
  • CIS + MRI
  • Because a lot of times, the first couple of events the patient won’t have anything or an MRI or think anything is going on.
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22
Q
  • CIS + MRI findings = __-__% chance of MS developing.

- CIS without MRI findings = __% chance of MS developing.

A
  • 60-80%

- 20%

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23
Q

What are the (3) most common early involved structures with CIS?

A
  • Optic Nerve
  • Brainstem
  • Spinal Cord
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24
Q

Optic Neuritis:

  • Unilateral reduced visual _______.
  • Orbital pain particularly with _____ _________.
  • Reduced ________ vision.
  • Afferent ________ defect.
  • Retrobulbar or mild _____ swelling.
A
  • Unilateral reduced visual acuity.
  • Orbital pain particularly with eye movement.
  • Reduced color vision.
  • Afferent pupillary defect.
  • Retrobulbar or mild disc swelling.
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25
Q

Brainstem:

  • Bilateral internuclear __________.
  • Ataxia and gaze evoked __________.
  • ____ nerve palsy.
  • _____-_____ symptoms.
  • Facial ________ loss.
  • ________
  • ________
  • ________
A
  • Bilateral internuclear ophthalmoplegia.
  • Ataxia and gaze evoked nystagmus.
  • 6th nerve palsy.
  • Multi-focal symptoms.
  • Facial sensory loss.
  • Vertigo
  • Ataxia
  • Dysarthria
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26
Q

Spinal Cord:

  • Incomplete transverse myelitis.
  • Positive _________ sign.
  • _________ symptoms.
  • Asymmetric limb ________.
  • Symptom progression between __ hours and ___ days.
A
  • Incomplete transverse myelitis.
  • Positive Lhermitte’s sign.
  • Sphincter symptoms.
  • Asymmetric limb weakness.
  • Symptom progression between 4 hours and 21 days.
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27
Q

What is a Lhermitte’s sign?

A

-When bending neck and tucking chin to chest, complain of jolt sensation passing neck and into back.

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28
Q

List of MS Clinical S/Sx:

A
  • Motor function
  • Sensory function
  • Visual deficits
  • Cognitive function
  • Poor tolerance to temp increases***
  • Fatigue***
  • Pain
  • Sleep Disorders
  • Speech and swallow impairments
  • Dizziness
  • Bowel and Bladder dysfunction
29
Q
  • Motor impairments of MS tend to be _________.

- Include things such as _______, ________, and __________.

A
  • asymmetrical

- weakness, spasticity, coordination

30
Q

Loss of sensation tends to be ______, usually we will see ____________.

A
  • rare

- paresthesias

31
Q

What visual deficit is most commonly seen in MS?

A

-Optic neuritis

32
Q

What is the hallmark sign of cognitive dysfunction?

A

-Slowed information processing speed.

33
Q

Pain following MS:

  • _____________ most common.
  • ___________ _______ presents as brief shooting pain in extremities.
  • ____
  • _________ ________ pain can result from ascending sensory tracts getting damaged and see demyelination.
A
  • Trigeminal Neuralgia
  • Paroxysmal limb pain
  • HA
  • Chronic Neuropathic pain
34
Q

MS and Heat Insensitivity:

  • ___% of MS patients are sensitive to increases in core body temp.
  • What is the neuroblockade hypothesis?
  • What is Uhthoff symptom?
A
  • 80%
  • De-myelinated neurons ability to conduct APs decreases as temp increases.
  • Increase in presence of neurological symptoms in response to heating condition. (known as pseudo-exacerbation)
35
Q

MS and Fatigue:

  • Up to ___% of MS patients experience some type of acute chronic fatigue.
  • Does it worsen as the day progresses?
  • What exacerbates it?
  • What do we see with both primary and secondary fatigue?
  • What can fatigue ultimately lead to?
A
  • 80%
  • Yes
  • Heat and exercises
  • central, peripheral, psychological factors
  • Can often lead to fear of fatigue → decreased physical activity → disuse → worsening disability
36
Q
  • MS Exacerbation: new and recurrent MS symptoms lasting >___ hours.
  • _____________ are transient worsening of symptoms that occurs due to stress, infection, overheating, or overexertion and are
A
  • 24 hours

- pseudo-exacerbations, <24 hours

37
Q

PART 3: MS SUBTYPES AND MEDICAL MANAGEMENT

A

PART 3: MS SUBTYPES AND MEDICAL MANAGEMENT

38
Q

What are the (3) major types of MS?

A
  • Relapsing-Remitting MS (RRMS)
  • Secondary Progressive MS (SPMS)
  • Primary Progressive MS (PPMS)
39
Q

Relapsing Remitting MS:

  • Approximately ___% are initially diagnosed with RRMS.
  • Clearly defined episodes of acute worsening of neurologic function (_______), followed by partial or complete recovery (_________) with periods of time between that patients are clinical free of disease progression.
  • Relapses with either full recovery or some remaining neurological signs/symptoms and residual deficit on recovery.
A
  • 85%

- relapses, remissions

40
Q

Secondary Progressive MS (SPMS):

  • Initially presents as ___ period followed by a steady worsening of neurological function, with or without relapses.
  • Remissions are _____, or can have ________.
A
  • RRMS

- Remissions are minor, or can have plateau.

41
Q

What is the average time it will take someone with RRMS to progress to rediagnosis of SPMS?

A

-20 years

42
Q

Primary Progressive MS (PPMS):

  • Continuous worsening from initial onset without distinct ________ or ________.
  • May have occasional plateaus and temporary ________ improvements.
A
  • relapses or remissions

- minor improvements

43
Q

What is the 4th declassified type of MS?

A

Progressive Relapsing MS (PRMS)

44
Q

Progressive Relapsing MS (PRMS):

  • Steady worsening with ________ and _________.
  • Why has this gone away?
A
  • relapses and remissions

- These patients could have been classified into the other subtypes.

45
Q

What are the (3) goals taken for medical management of MS?

A
  • Acute Exacerbation Treatment
  • Disease Modifying Medications
  • Symptom Management
46
Q

What is the main way we deal with acute exacerbations of MS?

A

Immunosuppression drugs to treat acute flare ups and shorten duration of episode.

  • Adrenocorticotropic hormone (ACTH)
  • Methylprednisolone
  • Prednisone
47
Q

Disease modifying drugs are used for what purpose?

A

-Reduce frequency and severity of clinical attacks, educe development of lesion sites, slow down the progression of disability.

48
Q
  • _________ drugs are used to slow progression of disease and decrease symptoms. What is the downside?
  • _________ are daily subcutaneous injections aimed to mimic the effects of myelin protein.
  • _________ and _________ are the last line of defense.
A
  • Interferon (make you feel like crap)
  • Copaxone
  • Tysabri and Novantrone
49
Q

What are the (4) main things symptom management is aimed at with MS?

A
  • Fatigue
  • Spasticity
  • Pain
  • Urinary dysfunction
50
Q

PART 4: OUTCOME MEASURES AND PROGNOSIS

A

PART 4: OUTCOME MEASURES AND PROGNOSIS

51
Q

What is the EDSS?

A

Expanded Disability Status Scale

-Best and most widely known scale for quantifying disability in MS.

52
Q

What are the (8) functional systems of the EDSS? (Looking at “do these patients have impairments in these functional systems”)

A
  • Pyramidal (motor impairments)
  • Cerebellar (trunk/limb ataxia)
  • Brainstem (CN, extraoccular)
  • Sensory (rarely full loss)
  • Bowel and Bladder (Spinal Cord)
  • Visual (common)
  • Cerebral (cognitive, behavioral alterations)
  • Other (any other neurological)
53
Q

EDSS Levels 0-10:

  • 0 = _____ neurological exam
  • 1 = No disability, minimal signs in ____ FS
  • 1.5 = No disability, minimal signs in _____ FS
  • 2 = Minimal disability in ____ FS
  • 2.5 = Minimal disability in _____ FS
  • 3 = Fully ambulatory, moderate disability in ____ FS, or mild disability in __-__ FS
    3. 5 = Fully ambulatory but with moderate disability in _____ FS and minimal or more disability in several other FS
  • 4 = Fully ambulatory without aid, self-sufficient, up and about some 12 hours a day, able to walk without aid or rest at least 500m without aid/rest.
  • 4.5 = Fully ambulatory without aid, up and about much of the day, able to work a full day, may otherwise have some limitation of full activity or require minimal assistance, able to walk without aid or rest at least 300 meters.
  • 5 = Ambulatory without aid/rest for about 200 meters; disability significant enough to impair full daily activities (e.g., to work a full day without special provisions)
  • 5.5 = Ambulatory without aid for about 100 meters; disability significant enough to preclude full daily activities
  • 6 = Intermittent or unilateral constant assistance (cane, crutch, brace) required to walk about 100 meters with or without resting
  • 6.5 = Constant bilateral assistance (canes, crutches, braces) required to walk about 20 meters without resting
  • 7 = Unable to walk beyond approximately 5 meters even with aid, essentially restricted to wheelchair; wheels self in standard wheelchair and transfers alone; up and about in wheelchair some 12 hours a day
  • 7.5 = Unable to take more than a few steps; restricted to wheelchair; may need aid in transfer; wheels self but cannot carry on in standard wheelchair a full day; May require motorized wheelchair
  • 8 = Essentially restricted to bed or chair or perambulated in wheelchair, but may be out of bed itself much of the day; retains many self-care functions; generally has effective use of arms
A

1

54
Q

Disability Categorization by EDSS Score:

  • __-__ = normal to mild disability
  • __-__ = mild to moderate disability
  • __-__ = moderate to severe disability
  • __-__ = severe disability with restriction to bed or WC
A
  • 0-3.5 = normal to mild disability
  • 4-5.5 = mild to moderate disability
  • 6-7.5 = moderate to severe disability
  • 8-9.5 = severe disability with restriction to bed or WC
55
Q

What is the main criteria to the EDSS?

A
  • High criteria on ambulation, not looking at a lot other.
  • Decrease in interrater reliability with lower scores.
  • Not perfectly linear.
  • COGNITION is never mentioned.
56
Q
  • What is another scale for quantifying disability in MS that is used less often?
  • It is a simple measure that is entirely based off of ________ ability.
A
  • Disease Step Scale

- ambulation

57
Q

Disease Steps Scale:

  • 1 = Functionally ______ with no limitations on activity or lifestyle.
  • 2 = _____ disability, mild symptoms or signs.
  • 3 = Early cane, use of a cane or other form of unilateral support for greater distances, but can walk at least ___ feet without it.
  • 4 = Late cane, cane dependent, unable to walk ___ feet without a cone or other form of unilateral support.
  • 5 = Bilateral support, requires _______ support to walk 25 feet.
  • 6 = Confined to _______.
  • U = Unclassifiable, used for patients who do not fit above classification.
A
  • normal
  • mild
  • 25 feet
  • 25 feet
  • bilateral
  • WC
58
Q

What are some MS Subjective Outcome Measures. (5)

A
  • 12-Item MS Walking Scale
  • Fatigue Scale for Motor and Cognitive Function
  • MSQOL-54
  • Modified Fatigue Impact Scale
  • Multiple Sclerosis Impact Scale (MSIS-29)
59
Q

What is the cutoff score for call risk with the 12-Item MS Walking Scale?

A
  • > /=75
60
Q

Why is the Fatigue Scale for Motor and Cognitive Function good?

A

-Able to differentiate between motor and cognitive aspects of fatigue.

61
Q

Modified Fatigue Impact scale looks at fatigues impact on what 3 aspects (wasn’t initially used/intended for MS)?

A
  • Physical
  • Cognitive
  • Psychosocial
62
Q

MSIS-29 looks at physical (20) and psychosocial (9) difficulties related in MS in past ____ weeks.

A

-2 weeks

63
Q

1

A

1

64
Q

Disease Progression:

  • Varied and inconsistent response ________ patients.
  • Patterns typically similar _______ patients.
  • What is the mean time before use of unilateral AD?
  • Life expectancy ~___ years less than age-matched peers.
A
  • between
  • within
  • 15-20 years
  • 10 years
65
Q

What EDSS levels do PTs tend to be the most helpful with MS?

A

-Levels 3-6

66
Q

Disease Prognosis:

  • White matter lesions on MRI at initial clinical presentation demonstrated an ___% chance of developing MS in 7-10 years.
  • Appearance of a new lesion on T2 weighted MRI < ___ months after initial clinical episode = poor prognosis.
  • MRI Findings: Favorable prognostic factors including low total lesion burden, low active lesion formation, and negligible myelin or axon loss.
A
  • 88%

- 3 months

67
Q

Disease Prognosis:

  • _____ of MS
  • Level of recovery after ________ insult
  • Time between ________
  • Location of _____ lesion site
  • Initiation of medical management
  • Type of _________ at initial insult
  • Gender
  • Age of onset
  • NEUROLOGICAL FINDINGS AFTER ___ YEARS
A
  • Type
  • initial insult
  • relapses
  • 2nd lesion
  • symptoms
  • 5 years
68
Q
  • If a patient has ________ impairments at diagnosis, this is indicative of a quicker overall progression.
  • Males or females have faster progression?
  • Neurological findings at ___ years is one of the most important prognostic factors for MS.
A
  • cognitive
  • males
  • 5 years

S6- Neuro 2 (18 decks)

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