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Flashcards in Multiple Sclerosis Deck (90):
1

Objectives

  • Define Multiple Sclerosis (MS) and describe the associated pathology
  • Describe the general goals and treatment appropriate for a patient with MS 

fyi

2

  • Demyelinating disease of CNS
  • Usually affects people between ages 20 and 40
  • Unpredictable course
  • Charcot’s triad: paralysis, intention tremor, scanning speech, nystagmus

 Multiple Sclerosis

3

Epidemiology-Multiple Sclerosis

  • Onset usually between 15 and 50 years of age
  • Very rare in children or over age 50
  • More common in women (2:1)
  • 400,000 people in US
  • Mostly seen in white population
  • 2 epidemics have been reported ? A slow virus perhaps?

4

Etiology  of MS

  • Unknown
  • Theories: autoimmune mediated pathogen or possibly induced by virus
  • 15% positive family history
  • May inherit genetic susceptibility: see increase incidence in twins
  • May have and environmental trigger that occurs in genetically susceptible people

5

Mortality of MS

  • Most patients survive 22 - 25 yrs
  • Death caused by infection (respiratory, UTI)

6

Pathophysiology of MS

  • Immune response-> produce T-lymphocytes, macrophages, immunoglubulins antigen is activated produces autoimmune cytotoxic effects
  • T-lymphocytes attack myelin: slows neural transmission: nerves fatigue or can disrupt function if severe
  •  

7

Diagnosis of MS

  • No reliable, specific test (increased immunoglobulin & oligoclonal bands in CSF in 65-95% of cases)
  • Plaques observed on MRI
  • Acute lesion with inflammation
  • Older lesions: lack myelin
  • Clinical criteria: evidence of:
  • Multiple CNS lesions
  • Discrete episodes of neurological disturbance or progression over time
  • No better neurological explanation

8

What are the  6  types of MS…???
P779, Box 19.1

  1. Relapsing-remitting MS
  2. Primary-progressive MS

  3. Secondary-progressive MS
  4. Progressive-relapsing MS

  5. Benign MS
  6. Malignant MS (Marburg’s)

9

what is the pathophysiology of MS Over time: 

  • Over time: neuroglial tissue proliferates and creates plaques: then the axons undergo retrograde degeneration
  • Lesions occur in cerebrum, brainstem, cerebellum, dorsal spinal cord
  • Affects white matter more than gray matter

10


this type of MS 
  • will have periods without acute worsening, will have periods with partial or complete abatement of symptoms
  • 80% of time will develop secondary progressive course
  • The course of the disease may change over time

Relapsing remitting

 

see the most

 

11

  • New and recurrent MS symptoms that last > 24hours
  • Health deterioration
  • Viral or bacterial infections
  • Diseases of major organ systems
  • Stress can lead to acute attack
  • Adverse reaction to heat (Udoff’s symptom)
  • Psuedoexacerbation : temporary worsening of symptoms, lasts <24 hrs

Exacerbations of MS

12

Clinical Symptoms of MS

Can vary

  • Visual disturbances
  • Parasthesias: can lead to numbness, weakness, fatigability
  • Onset can be rapid (m0re common)or insidious

13

common Motor Symptoms of MS

  • Spasticity and reflex spasms
  • Weakness
  • Gait disturbance
  • Fatigue
  • Cerebellar and bulbar symptoms
    • Swallowing/Respiratory difficulties
    • Nystagmus
    • Intention tremor
    • Dysphagia

14

common Sensory symptoms of MS

  • Numbness
  • Pain (usually of musculoskeletal origin)
  • Paresthesia
  • Dysesthesia
  • Distortion of superficial sensation

15

common Visual symptoms of MS

  • Diminished acuity
  • Double vision
  • Scotoma- dark spot in center of field of vision
  • Ocular pain

16

common Bowl and bladder symptoms of MS

  • Urgency
  • Frequency
  • Incontinence
  • Urinary retention
  • Constipation

17

common Sexual symptoms of MS

  • Impotence
  • Diminished genital sensation
  • Diminished genital lubrication

18

common Cognitive and emotional symptoms (50-70%) of MS

  • Depression
  • Lability
  • Disorders of judgment
  • Agnosia-
  • Memory disturbance
  • Diminished conceptual thinking
  • Decreased attention and concentration

19

Precipitating Factors (things that can bring on MS) of Changes in health status with MS

  • Viral or bacterial infections (cold, flu, bladder infection)
  • Physical injury (lumbar puncture)
  • Pregnancy 

20

Transient deterioration of MS 

  • Adverse reaction to heat: modalities, prolonged exercise, fever
  • Hyperventilation
  • Stress: physiological or psychological
  • Exhaustion
  • Dehydration
  • Malnutrition
  • Sleep deprivation

21

Predictors of Good Outcome of MS

Female
Onset with only one symptom (strong indicator)
Complete recovery after attacks
Onset < 40 y/o

22

Predictors of Bad Outcome of MS

  • Progressive course is ominous
  • Male
  • Onset > 40 y/o
  • Significant cerebellar signs at 5 yrs (nystagmus, tremor, ataxia, dysarthria)
  • High frequency of attacks with incomplete recovery

23

Adverse affects of treatment medications of MS

  • Injection site reactions
  • Flu-like symptoms
  • Depression, allergic reaction, liver reaction
  • Flushing, anxiety, pain, palpitations, SOB: Copazone
  • Support pts hope for positive outcome

24

Overly aggressive PT Rx can cause exacerbation ***

Treatment is intended to ?

  • provide symptomatic relief, prevent secondary complications, and maintain optimal functioning as long as possible.
  • Rx does not alter the underlying pathology or course of the disease

provide the least that they need to be functional, we are not chaning the course of disease.  We can educate them. To not overdo 

25

LTGs of MS

  • Maximize functional status and independence
  • Prevent/ retard development of secondary impairments
  • Promote emotional and social adjustment of patient and family
  • Maintain employment as long as possible
  • Educate patient/ family to maximize retention of rehab gains

26

Global  things for MS 

  • Maximize functional independence
  • Minimize complications secondary to decreased mobility
  • Compensation for loss of function
  • Education: psychosocial adjustment, vocational training, family issues

27

Assistive Devices/Equipment for someone with MS

what is the Guiding philosophy ?  and what are some examples of devices.

  • assistive devices/equipment is selected to provide maximum stress relief so patients can make the best use of the limited energy stores
    • AFO: rigid/hinged polypropylene, double upright
    • Gait assistive device: cane, crutch, walker, w/c
    • IADL equipment: bathing, dressing, utensils
    • Safety: mobile phone

28

Sensory changes with MS

  • Very common
  • Usually parasthesias or numbness of face, body, extremities
  • Problems with position sense or  vibratory sense

29

Pain with MS

  • 80% have pain,, in 55% of cases it is clinically significant
  • Pain can be acute and paroxysmal: sudden, spontaneous
  • Intense, sharp, shooting, electric shock, burning
  • Trigeminal neuralgia, headache, paroxysmal limb pain
  • Paroxysmal limb pain: usually worse at night and with exercise
  • Aggravated by change; high temperature
  • Hyperpathia: hypersensitive to minor stimuli
  • Headaches are common
  • Neuropathic pain: burning sensation (comparable to pain of disc herniation)
  • Musculoskeletal pain: due to many factors. Can have spasticity and tonic spasms

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definition 

hypersensitive to minor stimuli

Hyperpathia

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what kind of pain is a burning sensation (comparable to pain of disc herniation)

Neuropathic pain

32

common, feels like ice pick pain behind eye, accompanied by blurring or graying of vision or blindness in one eye

Optic neuritis

33

Visual changes with MS

  • Nystagmus is common
  • Internuclear opthalmoplegia:
  • Impaired conjugate gaze, 

34

Motor dysfunction with MS

  • Weakness: corticospinal lesion:
  • Movement can be slow, stiff, weak
  • Decreased strength, power, endurance
  • Poor synergistic movements
  • Cerebellar lesion: asthenia, generalized muscle weakness  and ataxia
  • As disease progresses can have total paralysis

35

Fatigue with MS

  • 75-95% of individuals
  • More than half: most troubling symptom
  • 79%: interferes with physical functioning
  • 67% overall performance
  • Can come on abruptly

36

Fatigue Precipitating factors (what brings it on?)

  •  physical exertion, exposure to heat and humidity, depression, , sleep disorders, mood disorders, low self esteem, medical conditions, secondary complications from MS, medication side effects
  • If person feels in control of his environment, less likely to have fatigue

37

Spasticity with MS

  • Common: 80%
  • Mild to severe: affects extremities
  • Impaired voluntary control of muscles
  • Increased DTR, clonus, flex or ext synergy, decreased ROM
  • Decreases functional mobility, problems with ADL’s
  • Problems with contractures, posturing, skin integrity
  • Can fluctuate: fatigue, stress, temp extremes, humidity, noxious stim

38

Balance and coordination with MS

  • See a lot of cerebellar symptoms
  • Ataxia, tremors (postural and intention) hypotonia, trunk weakness
  • Dysmetria, dyssynergia, dysdiadochokinisia
  • Can see progressive ataxia
  • Tremors exacerbated by stress, excitement and anxiety
  • Dizziness is common (cerebellar lesion)
  • Problems with balance, vertigo, nausea

39

Ambulation problems for someone with MS

  • Problems due to weakness, fatigue, spasticity, impaired sensation, visual problems, ataxia
  • Many need assistive devices for ambulation
  • Stagger, uneven steps, poor foot placement, uncoordinated movements, frequent LOB
  • Look as if drunk

40

Speech and Swallowing  for someone with MS

  • Due to muscle weakness, spasticity, tremor or ataxia
  • Dysarthria
  • Dysphonia: change in vocal quality
  • Dysphagia: cant keep lips sealed, inability to swallow, spitting of food or coughing during meals

41

definition

change in vocal quality (nasaly)

Dysphonia

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definition:

cant keep lips sealed, inability to swallow, spitting of food or coughing during meals

Dysphagia

43

Cognitive impairments for someone with MS

  • Common (50%)
  • Mild to moderate
  • Depends on distribution of lesions
  • Impaired attention, concentration
  • Slow processing of information
  • Impaired higher level functions: concepts, abstract thinking, problem solving
  • Inflexibility (frontal lobe)

44

Depression assosiated with MS

  • Common: 50% of people with MS have a major depressive disorder
  • Hopelessness or despair, decreased  interest in activities, decreased appetite,
  • change in appetite, change in weight, insomnia or hypersomnia, feelings of lethargy or worthlessness, fatigue, decreased concentration, , recurrent thoughts of death and suicide. 

45

Affective disorder for about 10% of MS pts

Problems with mood, feelings, emotional expression and control

46

defiiniton:
  • Autonomic nerves are affected
  • Decreased blood pressure responses during exercises
  • Can have attenuated or absent sweating response

Cardiovascular Dysautonomia

47


Bladder dysfunction for someone with MS

  • 80% of patients
  • Loss of volitional and synergistic control of micturation reflex
  • Can have difficulty with small spastic bladder or big, flaccid bladder
  • Can have problem with coordinating bladder contraction with sphincter relaxation: will have urgency, frequency, hesitancy, nocturia, dribbling, incontinence
  • Can have increase in UTI’s if cannot empty bladder

48

Bowel dysfunction for someone with MS

  • Constipation
  • Spasticity of pelvic floor muscles, lack of activity, lack of fluid intake, poor diet, poor bowel habits, depression, medication SE
  • Can have bowel impaction
  • Can have diarrhea and incontinence

49

Bladder and bowel assosiated problems: 

  • The specific cause needs to be identified
  • Overactive, spastic bladder: anticholinergic meds, meds to regulate bladder emptying,
  • SE: dry mouth, tachycardia, accommodation disturbances
  • Encourage pt to drink plenty of water, limit caffeine or alcohol,
  • Flaccid bladder: manual pressure over bladder, intermittent self catheterization
  • Limit citrus juice
  • Increase cranberry juice

50

 

manage with alpha-adrenergic blocking agents and antispasticity agents (blacofen, Zanaflex)
Sometimes have to resort to indwelling catheter or suprapubic catheter

Dyssynergic  bladder

51

Sexual dysfunction of someone with MS

  • 91% of men, 72% of women
  • Women: changes in sensation, vaginal dryness, trouble with orgasm, loss of libido,
  • Men: impotence, decrease sensation, difficulty with ejaculation, loss of libido
  • Problems with spasticity, spasms, pain, weakness, fatigue, incontinence, loss in functional mobility, change in self image

52

Prognosis for someone with MS

  • Most MS patients life expectancy is not reduced
  • 74% of patients survive at least 25 years after diagnosis
  • Minority of patients are still in work force 10 years after diagnosis
  • 15 years after diagnosis 50% have to use assistive device
  • 20 years after diagnosis: 50% will need a wheelchair
  • Symptoms: 1 symptom: favorable prognosis
  • Course of disease: Benign and RRMS: more favorable prognosis than PPMS
  • Age: young age has more favorable outcome
  • Neurological findings at 5 years: significant pyramidal and cerebellar signs with involvement at multiple sights at 5 years is associated with poorer prognosis and more severe disability
  • MRI findings: less numbers of lesions, less active lesions, more favorable outcome

53

Rehabilitation for MS pts

 

  • Restorative intervention: improve impairments and limitations
  • If have early or middle stage impairments: work on strength can improve balance and gait
  • Help improve impairments and regain functional independence
  • Help with acceptance and adjust to limitations

54

Compensatory intervention for someone with MS

Look for ways to modify tasks so that the patient can be functional within the scope of existing impairments

Maintenance therapy: helps patient maintain the level of function that they currently have

Private insurance does not fund maintenance therapy well, so must educate patient well when have the opportunity

Medicare will cover if skills of a therapist are necessary

Need to have an interdisciplinary team to address the comprehensive approach to the complex and multifaceted problems

PT, OT, Speech-Language Pathologist, Nutritionist, Social Worker

  •  

55

Physical Therapy Examination for MS pts

  • Therapist will examine the extent of the neurological and functional involvement of the patient
  • Patients with MS can have symptoms vary day to day due to fatigue and factors that can exacerbate symptoms, so evaluations can take place over several days

56

What function should you work on with someone with MS?

  • Functional mobility skills
  • Basic Activities of Daily Living
  • Instrumental Activities of Daily living
  • Use Functional Independence Measure

57

how does Physical Therapy Intervention help someone with MS and what are someone things you should be aware of when getting ready to tx the ptHelp pts increase awareness of sensory deficits

  • Help pts increase awareness of sensory deficits
  • Help compensate for sensory loss
  • Compensate for vision impairment
  • Proprioceptive loss: use other  sensory systems: tapping, verbal cueing, biofeedback, light tracking resistance
  • Use adequate light
  • Double vision: use a patch
  • Manage fatigue

58

If a pt has sensory issues educate them on appropriate care of _________: 

skin

59

what are some Pressure relieving devices for someone with MS?

  • Can use mattresses, sheepskin, cuffs, boots, cushions: protect pressure areas and distribute body weight
  • Prevention is important

60

how can PT help with Pain Management?

first find the cause
  • stretching, exercise and massage and US
  • Orthotics, adaptive seating
  • Lhermitte’s sign- flexion of neck produces “shock” sensations down the spine (posterior column damage)
  • Hydrotherapy LUKEWARM water
  • TENS

61

What is a  Lhermitte’s sign

 flexion of neck produces “shock” sensations down the spine (posterior column damage)

62

Exercise Training:  What are some things to know or think about?

  • Muscle weakness and decreased endurance
  • Exercise can improve function and limit disability
  • EDSS (expanded disability  status score)score of 1-6 do best with exercise
  • Encourage pts who are depressed

63

Strength and Conditioning:

MS pts have difficulty with producing ________force

 maximal 

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Strength and Conditioning:

Be careful with level of exercise: improve strength and endurance  without pressing too much what?

 

Frequency
Intensity
Type of exercise
Time or duration

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What are some things to think about with Strength and Conditioning an MS pt?

 

  • Don’t schedule sessions on back to back days
  • Submax exercise intensity
  • Can use resistance
  • Circuit training: alternate between UE and LE work
  • Balance  exercise and balance
  • Progress may be slow
  • Do not exercise to point of fatigue
  • Monitor affects of fatigue

66

Strength and Conditioning:

Prevent overheating by what? 

(we do live in Arizona!)

Use fans
Air conditioning
Neck wraps
Spray bottles

67

Strength and Conditioning:

Adjust exercise according to pts what?

impairments

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Strength and Conditioning:

use ________chain activities: may have to do lower level exercise depending on balance issues

closed 

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Group exercise is good why?

Provides support and motivation

70

Measure outcomes: what are something your measuring?

  • MMT,
  • isokinetic testing,
  • body composition,
  • fatigue,
  • functional tests,
  • quality of life measures

71

Cardiovascular Condition with MS pt

  • HR and BP response can be blunted due to CV dysautonomia
  • Respiratory dysfunction can be exist: reduces exercise tolerance
  • Exercise tolerance reduced in patients with decreased cardiorespiratory fitness due to physical inactivity

72

CardioVascular exercise:

what are some things to think about or watch when exercising?

  • Leg cycle ergometer
  • Can use UE ergometer also
  • Use 3-5 minute stages
  • Monitor BP, Percieved exertion, VO2
  • Use 70-85 percent of age predicted maximum
  • SBP > 200 or DBP >115, stop ex
  • Watch core body temp
  • Avoid over work

73

good Exercise education for MS pt

  1. 3 times per week
  2. Daily if cannot tolerate a lot of exercise
  3. Limit to 60-75% peak hr or 50-65% peak VO2
  4. Cycle, walk, swim, water aerobics
  5. Circuit training: may optimize training
  6. 30 min/day or 3 10 min sessions
  7. Use precautions as discussed
  8. If depressed may need more encouragement
  9. Outcome measures

74

Flexibility

  1. Need flexibility exercises especially if WC bound: mm will be ______
  2. Limited overhead______
  3. Bed ridden: other mm are tight
  4. Tai chi: relaxation and balance training

 tight

 ROM

75

Manage fatigue with MS pt

  • Overwhelming sleepiness, excessive tiredness, sense of weakness
  • Comes on suddenly
  • Fear of bringing on fatigue
  • Balance exercise training without causing fatigue
  • Have pt maintain log: level of fatigue and importance of activity and satisfaction
  • Energy conservation:  find ways to reduce overall energy requirements
  • Modify task or modify environment
  • Activity pacing
  • Balance activity and rest periods
  • OT and Voc rehab should be involved
  • Examine home and work site

76

Management of Spasticity

  • Can develop contractures, postural deformities and ulcers
  • Cryotherapy, hydrotherapy, ther ex, positioning may help
  • Monitor pt
  • Pt on baclofen: will do better if stretch in middle of med cycle
  • Infection or fever will increase spasticity
  • Avoid heat, humidity and stress
  • Cold packs or cool hydrotherapy: will reduce spasticity
  • Affects may be short lived
  • Watch for flight or fight response (inc HR, nausea, inc resp rate)
  • Help to maintain ROM and mobility
  • Static stretch 30-60 seconds
  • Movements with rot or PNF hold relax, contract relax
  • Other slow stretch activities

77

more Management of spasticity

sorry other one was way too long

  • Spasticity tends to be worse in the lower extremities
  • Use slow active exercises
  • Contract the antagonist mm
  • Work on timing exercises; tai chi, aquatic exercises
  • Functional activities: trunk and proximal segments
  • Use LE flex ex and trunk rotation ex
  • Lower trunk rot with pt in hooklying: help decrease tone
  • Ball ex in hooklying
  • Use positioning schedule to vary position so pt does not get “stuck “ in a position

78

Coordination and Balance Deficit

Cerebellar deficits

 

  • Promote static postural control
  • Ex in WB antigravity position
  • Gradually increase postural demands
  • Increase number of body segments that must be controlled
  • Ataxia: PNF slow reversals, water ex.

79

Coordination and Balance Deficit: As progress exercise modify to make more difficult

  • Helps with adaptation of skills
  • Change sensory conditions
  • Platform training if available
  • Limits of stability training: teach them what their limits are
  • Can use PNF with ataxia: proprioceptive loading with light tracking, use light cuff weights
  • Weighted walker, weighted utensils

80

frenkel's exercises: Big red p 802

  • Performed in supine sitting and standing
  • Perform slowly
  • Can do with eyes closed
  • Keep stress level low
  • Use verbal cueing
  • Repetition

p802

81

Locomotor Training for MS pt

  1. 65% of pts walking after 20 years
  2. Poor balance or heaviness
  3. Hip flexor weakness, weak dorsiflexors
  4. Circumduction (foot drop)
  5. Weakness gets worse with time (quads, hip abd)
  6. Knee hyper extension/Trendelenburg gait
  7. May need canes, forearm crutches, walker
  8. Pt needs to find what will work best for them
  9. May need to progress to wheeled mobility device

82

Mobility devices

  • Look at course and progression of disease
  • Scooters: good mobility, less stigma, need more trunk and UE control
  • WC: use for those who need trunk control, need powered WC
  • Document well so that insurance will meet needs

83

Functional Training for MS pt and problem solving:

  1. Practice skills: bed mobility, transfers, locomotion
  2. Adaptive devices: grab bars in bathroom, overhead trapeze, raised seat, transfer board, hydraulic lift, wrist wrests, etc

84

Speech and Swallowing management for MS pt

  • Must mange respiratory problems
  • Use manual contacts, resistance,  incentive spirometry
  • Diaphragmatic and segmental chest expansion
  • Sitting position, head control, oral-motor coordination

85

Cognitive training for MS pt

not in pta scope

  • Present a lot of difficulties
  • Refer to a neuropsychologist: helps determine ways pt can compensate,
    • Can give pt help with memory issues: timing devices, labeling, directions written

86

Psychosocial issues for MS pts

  • Lot of losses: socially, employment, interpersonal relations, independence
  • Will see anger, denial, depression,
  • Readjustment
  • Use stress reduction techniques
  • Depression is common

87

Patient and family education for MS pt

  • Positive attitude
  • Collaborate with the patient and family
  • Maintain hope and encouragement
  • Educate on disease, prevention of complications, rehab process, HEP, monitor medication effects, assistive devices, health management and community resources
  • www.nationalmssociety.org
  • caregivers

88

Could You Answer These Questions??

  1. Define Multiple Sclerosis (MS) and describe the associated pathology
  2. Describe the general goals and treatment appropriate for a patient with MS 

can you

89

Big take home message for MS pt as per Dr. C.

Don't wear them out!!!

90