MS

Question 1

what is multiple sclerosis or, MS?

Answer 1

• immune-mediated,…
• inflammatory,…
• neruodegenergitive disease of the CNS

Question 2

Symptoms of MS may include:

Answer 2

• cognitive dysfunction
• depression
• fatigue
• gait impairment

Question 3

Describe the pathophysiology of MS

Answer 3

• heterogenous disorder characterized by
  
  • inflammation
  • dymelination
  • axonal degeneration
• Early Disease
  
  • autoreactive lympocytes cause inflammation (with BBB disruption)
• Late Disease
  
  • microgrial activation
  • chornic neurodegeneration
• Outside-in vs inside out
  
  • outside-in = abnormal immune response crosses BBB to enter CNS, resulting in an inflammatory process => myelin, oligodendrocytes, and nerve fibers are attacked
  • inside out = oligodendrocyte damage occurs first, triggering immune attack within CNS
• Focal deymylenating plaques, or glial scars, in both white and gray matter of the CNS
  
  • Gliosis = nonspecific reaction of CNS tissue to injury
• Inflammatory/Immune response
  
  • T cells, B cells, macrophages seen in biopsies
  • Myelin reactive T cells in ms plaques and csf
  • B cells found in csf

Question 4

Epidemiology of MS

Answer 4

• young adults, aged 20-40, typically affected
• F > M- 3:1
• Pediatric Cases (onset before age 18): 3-4%
• Prevalnce = 1 million people in the US
• geographic revleance decreases with sunlight exposure
  
  • highest prevlance in Eurpe and North America => very low risk in Asia and Africa

Question 5

Medical Diagnosis of MS

Answer 5

• McDonald criteria, MRI, Differential Diagonsis, Lumbar Puncture, Medical History, Neurological exam, evoked potential tests
• MRI: recent neural plaques = “bright spots”
  
  • evidence of damage in 2 seperate CNS locations AND
  • at 2 seperate time points at least 1 month apart for diagnosis
  • long-term disease activity seen as “black holes” via contrast T1 MRI
• evoked potentials
  
  • electrophysiological responses of CNS to stimuli
  • 90% experience slowed conduction, particuarly of visual evoked potentials (VEPS = measure function of visual pathway from retina to occiptal cortex => useful for testing optic nerve function)
  • auditory and somatosensory EPS also impaired
• Lumbar puncture
  
  • elevated total immuoglobulins (IGG) in CSF
  • oligoclonal IGG bands (2⁰ inflammatory demyelinating lesions)
    • 90%-95% of cases
    • This is higher in PPMS type than RRMS type

Question 6

Which subtype of MS has the following characteristics?

• 85% of case
• 1-2 attacks (relapses) every 1-3 years, followed by remission periods
• Relapses appear suddenly; last weeks to months; gradually disappear
• Neurological function worsens
• may resolve, or not progress, during remissions

Answer 6

Relapsing-Remitting MS (RRMS)

Question 7

Which subtype of MS has the following characteristics?

• In the past, progressed from RRMS
• Continuous deterioration after years of RRMS
• Disease-Modifying Medications have reduced this course

Answer 7

Secondary Progressive MS

Question 8

Which subtype of MS has the following characteristics?

• 10% of cases
• neurological function deteriorates from first occurrence
• No distinct attacks

Answer 8

Primary Progressive MS

Question 9

Which of subtype of MS has the following characteristics?

• 5% of cases
• Primary progressive MS with the addition of sudden, Distinct attacks

Answer 9

Progressive Relapsing MS

Question 10

Which subtype of MS has the following characteristics?

• pt remains fully functional 15 years after Dx

Answer 10

Benign

Question 11

Which subtype of MS has the following characteristics?

• Rapid onset with continual progression

Answer 11

Malignant

Question 12

What is the prognosis for MS?

Answer 12

• Variable Disease course
  
  • Severity of signs/symptoms
  • Frequency of relapses
  • Rate of worsening
  • Residual disability (after exacerbation)
• Mortality
  
  • Life expectancy generally reduced by 7 – 14 years
    
    • ½ or more of deaths directly related to complications of MS
  • Increased rate of death from infection, respiratory diseases, suicide, and cardiovascular disease

Question 13

What are signs and symptoms of MS?

Answer 13

Exacerbating Factors

• general factors
  
  • poor or failing health
  • viral or bacterial infections
  • stress
• Uthoff’s symptom
  
  • adverse reaction to heat => acute loss of function + increased fatigue

Question 14

what is the use of immune-modulating drugs = disease-modifying therapy (DMT)

• ex: copaxone, avonex

Answer 14

• Used in the management of:
  
  • RRMS (14 drugs now approved),
  • SPMS (2 drugs) and
  • PPMS (only 1 approved: ocrelizumab)
• For recently diagnosed RRMS, DMTS should be initiated with all patients
  
  • administration methods include injectable, oral or infused modes
  • Consistently shown to decrease relapse rate, with a slower accumulation of brain lesions on mri

Question 15

Medications for 2⁰ MS Symptoms include:

Answer 15

Muscle Spasms

• Baclofen (may cause mm weakness)
• Tizanidine hydrochloride (Zanaflex)

Bladder dysfunction

• Anticholinergic and antimuscarinic drugs to relax detrusor and enhance urine storage
• Botox in detrusor muscle to relax it
• Alpha antagonist medications to facilitate bladder emptying

Bowel dysfunction

• Laxatives, enemas, high fiber diet

Cognitive impairments

• Disease modifying drugs may slow progression of cognitive decline

Fatigue

• Insure it is not related to depression or medication side effects
• Various pharmacological interventions

Depression

• antidepressants; specific selection depends on Co-Morbid presentation (ie, pain, anxiety, fatigue, incontinence)
• If no other symptoms, SSRI is appropriate

Question 16

What is MS Edge?

Answer 16

“highly recommended” outmeasures for in and out patient rehab

• 12 Item MS Walking Scale
• 6-Minute Walk Test
• 9-Hole Peg Test
• Berg Balance Scale
• Dizziness Handicap Inventory (Outpt only)
• MS Functional Composite (Outpt ONLY)
• MS Impact Scale (MSIS-29)
• MS Quality of Life (MS Qol-54)
• Timed 25 Foot Walk
• Timed Up & Go (TUG) with Cognitive & Manual

Question 17

The following are characteristics of which outcome assessment?

• Self-report questionnaire
• takes 11 – 18 min to complete
• Includes both generic and ms-specific questions
  
  • 18 ms-specific issues (fatigue, cognitive function for example)
• Based on sf-36
• Rating varies with question
• Lower score = HIGHER function

Answer 17

MS-QOL-54

Question 18

Patient education for MS should include:

Answer 18

• Disease types and prognosis
• Rehabilitation process
• self-management skills
• Coping, acceptance, adjustment to disability
  
  • Community support Resources
• Preventative interventions
• Managing fatigue
• Managing psychosocial issues
• Early VS Middle VS Late Stage