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Flashcards in Multiple Sclerosis (MS) Deck (39):
1

Function and location of neurons (oligodendrocytes, ependymal cells, astrocytes, microglia)

Oliogdendrocytes: CNS myelination
Ependymal Cells: line the ventricles, circulate in CSF
Astrocytes: throughout parenchyma, formulate BBB
Microglia: phagocytes in CNS, very close to blood vessels

2

Etiology/Pathogenesis

Autoimmune disorder
acute inflammation and demyelination of CNS (like GBS, only CNS involvement)

3

3 patterns of MS

pattern 1: macrophage mediated demyelination
pattern 2: immunoglobulin depositions and complement activities within the plaques
pattern 3: primary oligodendropathy (more detrimental than demyelination)

* IDed by Leucchinetti

4

Fibrous Gliosis

"Sclerotic Plaque" formation
disrupted BBB --> WBC/monocytes/macrophages enter the brain --> intra + extracellular swelling --> scarring/sclerotic plaques --> secondary axonal degeneration

5

T2 v T1 imaging on MRI

T2 - presence of lesions on gross pathology (bright white signal)
T1 - visualization of axonal dropout (during acute phase, could be secondary to edema and resolve

6

age of onset, gender, race, geographics

Age of onset: 15-50 (pediatric = 2-5%)
Gender: F>M
Race: Caucasians
Geography: higher prevalence further from equator (incidence highest in UK)

7

Cause of MS: genetic or viral?

unknown, but both thought to be involved
EBV: MS pt more likely (+) for EBV

8

Types of MS (based on clinical presentation)

1. Relapsing/Remitting MS (RR-MS)
2. Primary Progressive MS (PP-MS)
3. Secondary Progressive MS (SP-MS)
4. Progressive Relapsing (PR-MS)

9

RR-MS

85%- most common
episodes of exacerbation + recovery (almost full) --> Accumulation of deficits
Exacerbations not always in the same place

*Subtype = benign RR-MS = infrequent relapse rate (years in between replaces)

10

PP-MS

10%
male more likely
steady degredation/decline (no clear relapse + recovery rate)

11

SP-MS

>50% RR-MS turn into SP-MS >15yrs after diagnosis
now pt's on a downward trend- some relapses+ recovery, but less recovery before next relapse

12

PR-MS

5%
a couple small relapse + slight recovery episodes, then decline smooths off
looks very similar to PP-MS; difference = slight recovery at the beginning of PR-MS

13

Clinically Isolated Syndrome (CIS)

1st sign of anything- first demyelinated episode
50-80% conversion risk to MS
treatment with immunosuppressant drugs (IVIG- prevent progression to CDMS)
evidence is seen on MRI- ONLY 1 lesion!

14

Clinically Definite MS (CDMS)

Multiple lesions in the CNS on MRI
Evidence of >/= 2 distinct episodes (MD will have to figure this out with interview)

15

Signs and Symptoms: Visual system

visual = common 1st clinical exacerbation (although sx vary)
- worsening throughout the day
- optomologist doesn't see anything on eye exam

16

Signs and symptoms: non-visual

1. weakness (rapid onset of shutdown in particular function)
2. tremor
3. paresthesias
4. incoordination
5. cognitive complaints
6. fatigue

insidious onset! pt may not even pay attention to it

17

Prognosis
- AD use
- non-ambulatory status
- life-span (pre and post IMD)

AD use: 50% with dx >/= 15yrs
Non-ambulatory status: 40% with an attack that renders them non-ambulatory
Life span pre IMD: 15-40yrs
Life span post IMD: similar to normal population (mortality by other diseases, not MS)

*depends on relapse rate; RR-MS = best prognosis

18

When a pt complains of cognitive symptoms (impaired memory/not thinking clearly), do they actually have these issues?

YES!- seen biologically
treat pt with TBI techniques
cognitive issues in large % of MS and non related to severity

19

Medical Management during acute exacerbation

High does steroids for 3-5 days via IV (taper with oral)
*prevention of inflammation

20

Medical management: long term immune modulating drugs:

1. Interferons beta 1a/1b (IFNB)
2. Glatiramer Acetate (copaxone)
3. IVIG- prevention of CIS to CDMS; does nothing to RR-MS
4. Plasma exchange (only for certain subtypes)
5. Texadera

21

Interferons beta 1a/1b (IFNB)
- dosage
- administration
- subtypes useful in

1a = ayonex --> 1x/wk
1b = betaseron --> every other day

- injection into muscle
- subtypes: RR-MS, CIS (50% reduced conversion to CDMS), not useful in PP-MS

22

Glatiramer Acetate (copaxone)
- dosage
- administration
- subtypes useful in

administered every day
injection into muscle
Subtypes: RR-MS, NOT in PP-MS
*higher reduction in relpase than IFNB, but still not preferred due to every day injection

23

Studies examining IFNB and copaxone- effect on prognosis

included MS pts with at least 2x/year relapse rate and RR-MS for 5 years
- found decreased accumulation of lesion size and number of relapses that the pt has in a 1 or 2yr period
*huge reduction in rate of relapse
* less lesion load in MRI
*pts able to do more for a longer time
*decreased cognitive defects

24

Texadera
- adminiatration
- dosage
- side effect

Oral pill
every day
decreases lymphocyte count --> more susceptible to infections

25

Ion channel medication: fampridine/ampyra-4aminopyridine
- purpose/use
- dosage

purpose: useful in increasing ambulation speed
dosage: 10 and 15mg, 2x/day

26

Spasticity medications

antispasticity drugs, baclofen pump (spinal precautions), botox

27

Amantadine (what does this medication address)

fatigue

28

Kurtzke Expanded Disability Status Scale (EDSS/FSS)

ordinal scale- 0-6; grades MS based on severity (determined by ambulation status and AD use)
0 = best score; higher score = worse prognosis
5.5 = ambulating without AD
6 = ambulating with AD

29

How is nerve conduction velocity affected by temperature changes

increase in core temperature = decrease in conductivity speed
- ability to jump over several nodes is impaired
- AP may be stopped all together
*note: 80% of MS pts have heat sensitivity

30

What pt responses may make you think the pt has a heat sensitivity problem?

"I take cold showers every day"
"I really need to stay in the AC"
"Evening is much more difficult/uncomportable for me"

31

Measures useful in gait evaluation of MS population

1. 6MWT (endurance is the biggest consideration)
2. velocity (10m/25ft)
3. MSWS-12
4. AI

32

Measures useful in balance evaluation of MS population

1. DGI
2. BBS
3. Foam and dome
4. TUG cog/man (dual task is a particular issue)

33

MSWS-12

MS walking scale- pt rates themselves
ordinal scale
problem: doesn't look at speed or endurance

34

MFIS

Pt qualifies how fatigue impacts their day
Ordinal scale

35

MSQOL 54

Measure of health related QOL
12 subscales: physical function, role limitations-physical, role limitations-emotional, pain, emotional well-being, energy, health perceptions, social function, cognitive function, health distress, overall quality of life, and sexual function

36

Impairments commonly treated by PTs

1. Deconditioned and reduced fitness
2. Fatigue
3. Weakness
4. Spasticity
5. Balance and coordination ****
6. Sensory dysfunction
7. Cognitive dysfunction
8. Dysphagia/Dysarthria

37

Difference between MS Fatigue and regular fatigue

MS fatigue: inability to recover 20-30min post exercise with rest; increased fatigue as the day wears on- limits ADL functioning
*rest is required, not prefered with MS fatigue

38

How to avoid MS fatigue

1. exercise in the morning- at the lowest core body temperature
2. everything in intermittent fashion (built in rests)
3. teach energy conservation techniques

*will have to ask them after every session if it took more than 30min for them to recover

39

Main targets of comprehensive rehabilitation program

1. flexibility
2. strengthening
3. aerobic
4. balance