1
Q
What causes MS? increased and decreased risks
A
- etiology is largely unknown, but most likely multifactorial - Environment: lower risk closer to the equator perhaps due to increased vit D from the sun. Smoking increases risk and progression - Genetic factors: non hereditary, but increased risk if parent or sibling has MS. Thought genetic predisposition with environmental factors - Infectious disease (human herpes virus-6, epstein barr virus, etc ) can cause demyelination and inflammation but are not known to cause MS
2
Q
how is MS diagnosed ?
A
- no one test - signs, symptoms, imaging, and exclusion of other dx - McDonald criteria: need 2 or more distinct attacks and 2 or more lesions in the CNS; OR progressive neuro sx > 1 year and 2 lesions
3
Q
What imaging/tests can be done to help dx MS ?
A
- MRI - Evoked potentials (only visual has been proven to be helpful in dx MS) - CSF analysis
4
Q
what can an MRI show you?
A
- detects plaque caused by myelin destruction and cerebral/SC atrophy - T1: active inflammation - T2: old and new lesions - FLAIR: displays brain or SC structures without CSF
5
Q
How is visual evoked potential tested and what does it test?
A
- use of alternating checkerboard pattern - identifies pathologic transmission along the optic nerve pathway
6
Q
What CSF findings are consistent with immune related conditions?
A
- Elevated IgG antibodies - Presence of oligoclonal bands - Certain proteins common with breakdown of myelin * these findings are not specific to MS and not all individuals with MS have CSF abnormalities
7
Q
General clinical presentation of MS
A
- Motor weakness and spasticity - Sensory changes and pain - Vision - Heat intolerance - Fatigue - Cerebellar dysfunction - Urinary changes - Cognitive changes
8
Q
Sensory changes
A
- Paresthesia - Loss of proprioception and vibratory sense - dysesthesia (more common than numbness)
9
Q
Vision changes
A
- optic neuritis (most common), blurred vision, changes in color perception, visual field deficit - nystagmus - oscillopsia -intranuclear opthalmoplegia (disruption of conjugate eye movements) - optic disc pallor: indicated optic disc atrophy
10
Q
Heat intolerance. Phenomenon and possible cause
A
- sensitivity to changes in core body temperature from internal and external sources - Uhthoff phenomenon: increased body temperature causes increased neurologic symptoms - neurobockade hypothesis: rise in temperature decreases nerve conduction in partially demyelinated fibers
11
Q
Fatigue
A
- very common symptom (`80%) - primary MS fatigue (caused by the disease): central or peripheral - central cause: failure of motor pathway during rapid activity due to demyelination - peripheral: overall decreased efficiency of motor unit activation: decreased oxidative capacity, slowing on contractile properties, decreased number of slow twitch fibers, lower tetanic and twitch tension in mms
12
Q
Cerebellar dysfunction
A
ataxia, incoordination, dizziness, and imbalance
13
Q
Urinary changes
A
- incontinence - incomplete emptying - increased frequency - at increased risk for UTI
14
Q
Cognitive changes
A
- depression - emotional liability - anxiety - decreased executive functioning
15
Q
Scale used for classification of MS disability. Levels and meaning
A
- Kurtzke Expanded Disability status scale (EDSS) - scale ranges from 0 (no disability) to 10 (death) - stages 0 -4.5 : able to walk independently - stages 5-10 have impaired ambulation
16
Q
Relapse remitting MS
A
- most common initial type of MS (80%) - increase systems lasting 1-3 months with full or partial return to baseline
17
Q
secondary progressive
A
- second stage of relapsing remitting (happens quicker if MS is untreated) - progressive worsening of sx - may or may not have relapses and remissions
18
Q
primary progressive
A
- more severe - steady worsening of symptoms - no relapses or remissions
19
Q
A
20
Q
progressive relapsing
A
- steadying worsening of symptoms - may experience intermittent acute flare ups where they return to their steady decline of function
21
Q
malignant
A
- the most aggressive - very rapid and progressive timeline
22
Q
life expectancy
A
~6 years less than those without MS
23
Q
positive prognostic factors
A
having relapsing remitting only one sx at onset
24
Q
negative prognostic factors
A
- Primary progressive - older age at onset - males - african americans - early cerebellar or pyramidal signs - smoking - low vitamin D levels
25
medication for relapse / exacerbation management
- corticosteriods - usually high dose and short duration (3-5 days) - decreased inflammation and ends relapse more quickly - no longer term benefit
26
disease modifying drugs
- 10 FDA approved medications (injection, infusion, or oral) - most act as immune system modulators - reduce the number of severity of relapses, reduce development of new areas of inflammation, and delay progression of disability
27
injectable disease modifying drugs
Avonex Betaseron Copaxone Rebif
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oral disease modifying drug
Aubagio Gilenya Tecfidera
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infused disease modifying drug
Novantrone Tysabri Lemtrada
30
Exercise Rx recommendations for people with MS
-Duration: 10 - 40 mins -Frequency: ≥ 2 - 3 days a week -Intensity: 50 - 70% maximum oxygen consumption - Repetitions: 10 - 12 rep max (1- 3 sets)
31
MS and gait training
- resistance training may increase gait and functional mobility with persons with MS - treadmill training improved gait speed, endurance, and fatigue, however results did not last suggesting faster rate of detraining in person with MS and that an ongoing maintenance program may be more effective
32
MS and aquatic therapy
- Benefits: buoyancy, viscosity, and thermodynamics - improved QOL, decreased fatigue, gait speed, BERG, TUG, grip strength, and decreased neuromuscular deficits
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Exercise and impact on symptoms/fatigue
- symptoms may worsen with exercise but most resolve within several hours - exercise demonstrates the potential to decrease MS fatigue, multidisciplinary approach for secondary causes of fatigue
34
recommended functional outcome measures in the Acute care setting
- 12 item MS walking scale -9 hole Peg test (9HPT) - BERG balance -MS impact scale (MSIS- 29) -Timed 25 foot walk
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recommended functional outcome measures in the in-patient setting
- 6 MWT - MS Quality of life - 12 item MS walking scale -9 hole Peg test (9HPT) - BERG balance -MS impact scale (MSIS- 29) -Timed 25 foot walk
36
recommended functional outcome measures in the out-patient setting
- 6 MWT - MS Quality of life (MS QOL- 54) - Dizziness Handicap inventory - MS functional composite - 12 item MS walking scale -9 hole Peg test (9HPT) - BERG balance -MS impact scale (MSIS- 29) -Timed 25 foot walk
37
12 item walking scale (MSWS-12)
* self reported measure of the impaire of MS on the individuals walking ability
* "in the past two weeks, how much has your MS...
* items are rated 1 (not at all) to 5 (extremely)
* score: 12 -60 points
* higher score indicated greater impact of MS on walking
* no cut off score
38
9 hole peg test
* timed test for UE fine motor function
* there are healthy norms based on age
* no cut off scores
39
BERG
* score \< 45 = fall risk
* no cut off scores for MS
40
MS impact scale MSIS-29
* 29 item self reported measure asking about the impact of MS on day to day life in the past two weeks
* 20 related to function and 9 psyhological
* scored 1 ( not at all ) to 5 (extremely)
* score: 26- 145 lower score indicated decreased impact of MS on daily life
41
TUG cognitive and manual
* TUG: walk 3 meter as quickly and safely as possible
* cognitive: count backwards by 3 from a randomly selected number between 20-100
* manually walk holding a cup filled with water
* cut off scores: (for MS?)
* cognitive: 15 sec
* manually: 14.5
* if the difference between the two \> 4.5 = fall risk
42
Timed 25ft walk test
* tests mobility and leg function
* specifically for MS population
* average score of two trials
* there is normative data for healthy controls and MS patients
* no cut off score
43
6 MWT
* highly recommended for EDSS: 0 - 5.5
* recommended for EDSS: 6.0 - 7.5
* not recommended for EDSS 8.0 - 9.5
* no cut off scores
44
dizziness handicap inventory (DHI)
* recommended for out-patient only
* self reported scale
* amount of limitation perceived due to the effects of dizziness
* score: 0 -100
* higher score = more handicap
* score \> 59 suggests increased risk of falls in individuals with MS
45
MS functional composite
* evaluates cognitive, gait, and UE function in individuals with MS
* included timed 25ft walk test, 9 hole peg test, and paced auditory serial addition test
* no establish cut offs
46
