Karpatkin spring 2013 3
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EDSS stands for what?
expanded disability standard scale
what ranges represent mild, mod, severe disability on the EDSS?
- 0-3.5 = mild
- 4-6.5 = mod
- 7-9.5 = severe
- 10 = dead
EDSS - score up to what is ambulatory
EDSS 2.5-6.5 is based on what?
7-9.5 on what?
- based on severity of impact on amb
- based on time spent in bed
one activity that weakens the BBB
one weakness of the EDSS
if you work on improving posture and gait, stretching hip flexors, treating 2ndary complications, you can decrease the score w/o impacting the underlying MS
2 causes of osteoporosis in MS pts
- disuse of body (even just standing can improve DEXA scans)
- steroid use
why are infections common in MS pts? ---> what?
- they're on immunosuppressant drugs
- can lead to fever, which is rough on a thermosensitive pt, and can look like a flare-up
8 primary causes of balance loss
- sensory loss
- diminished motor control
- visual loss
(secondary causes: secondary weakness, contractures)
4 positives about MS treatment these days
- earlier diagnosis
- earlier treatment (this can limit severity & extent of disease)
- decreased lesion load (the number and severity of lesions)
- more effective rehab
3 classes of MS meds
- symptom management
the CRAB drugs - names, and what are they?
the use of immunomoulators on MS
- effective in decreasing frequency and severity of relapsing-remitting MS
- less effective in chronic progressive
common side effect of immunomodulators
tysabri - what's the side effect?
PML: progressive multifocal leukoencephelopathy - it's in our brains already, but it's inhibited. tysabri can disinhibit it and kill you, but does this in less than 1% of cases, so he'd take it
best immunomodulator for controling relapsing-remitting MS
tysabri (tho it has the PML risk) - aka natalizumab
6 chemotherapeutics that are 2nd order drugs, used if the first batch fail
- IV immunoglobulin G (IVIG)
- mitoxantronone (novantronone)
- methotrexate (cytoxan)
another name for tysabri
4 benefits of steroids
- limits the inflam response
- reduces tissue edema
- restores the BBB
- immunomodulator effects
also, gives a burst of energy, so when a pt is on steroids can work'em harder
steroid of choice for MS pts
- methylprednisolone (also for SCIs w/i 8 hrs of trauma)
- give it at first sign of exacerbation to fight inflam
6 complications of steroids
- less effective w repeated use
- fluid retention
- osteoporosis (for chronic use)
often tx of choice for acute exacerbations -- can be used chronically in lower doses, but takes a serious toll on the body
2 drugs to manage spasticity
- baclofen (oral, or intrathecal if spasticity is refractory to oral med)
dangers of baclofen and zanaflex
- they reduce spasticity
- complete eradication can leave pt too weak -- the drugs can diminish underlying strength
- (some MDs will over-medicate --> weakness)
his favorite drug for managing fatigue, what type of fatigue it manages, and its nickname
- fights motor fatigue (as opposed to lassitude)
- "the walking drug"
provigil - its nickname? what's it for?
- lassitude, general fatigue
- if an MD gives this to a pt the pt will be more awake, but bc it doesn't address motor fatigue (ampyra does) it'll leave the person more awake but still with difficulty with motion
4 drug names and 1 class of drugs that can be used to manage fatigue
- ampyra - motor fatigue
- provigil (modafinal) - lassitude
- ritalin (paradoxical affect of calming kids)
antidepressants - they'll increase energy
"abnormal flow of ___ ions in demyelinated axons interfere with nerve impulses"
___ drug addresses this
ampyra blocks the channels, stopping the leakage, ... improves nerve impulse conduction
limitations & risks of ampyra
it treats the symptoms of fatigue but can't replace immunosuppresants
can cause "status epilecticus" seizures if taken in high doses (but the higher the dose, the fewer the MS symptoms)
contraindicated for pts w hx of seizures or w kidney problems (can't properly secrete it, so the buildup can --> seizures)
two drugs for treating frequent & urgent urination
- ditropan - muscle relaxer
a drug for treating urine retention in bladder
how to treat UTIs
what is given prophylactically to keep normal bladder pH?
the rundown on bladder issues
- frequency & urgency can be an issue
- retention is another
- can get UTIs
- if catheterizing, be careful to keep it sterile
- pts live longer w improved bladder management
- UTI may present very similarly to an exacerbation
- catheterization can lead to a chronic level of infection - got to test blood & urine often, can give vit C as a prophylactic to keep bladder pH normal
two drugs for dysesthesia pain management (and their nicknames)
- neurontin (gabapentin)
- cymbalta (pregabalin)
4 strategies for pain management
- drugs (neurontin/gabapentin and cymbalta/pregabalin)
- PT/OT for msk/mechanical pain
- intrathecal anaesthesia
- selective serotonin re-uptake inhibitor
- (so, of course, it also can diminish fatigue)
a few special qualities of MS that make it a psychosocial clusterfuck
- unpredicability - can present so differently day to day
- ambiguity - difficulty diagnosing it
- covert sx - a pt may be left feeling lazy or weird for a long time til dx is made
- demands on caregivers
- chronic sorrow
how to differentiate primary from secondary symptoms
treat them, see if they go away (in ~2 weeks)
fundamental problem of PT and MS, and his work-around?
- the volume problem: need a good volume of exercise to get change and reduce fatigue, but exercise leads to fatigue, so it's tough to get the volume
- intermittent training!
glories of intermittent training
- less fatigue
- greater amounts of work can be done
keys to intermittent exercise
- give rest breaks prior to onset of fatigue (he'll look for the first sign, maybe a hint of foot drop, and have the pt take a rest at that point)
- lets more work, more volume of exercise, be performed
- can be used in gait, strengthening, functional activities
- bottom line: more rest --> more exercise
what to do during rest breaks in an intermittent exercise plan?
- cool down (externally a/o in)
- passive stretching
- meditate (one study found it reduced fatigue in MS)
- visualize exercise (for neuroplasticity)
Petajean's study on aerobic exercise found...
- that exercise gives MS pts significant improvements, just as it does other folks, in the following categories
- VO2 max
- UE & LE strength
- decreases in skinfolds
- depression, anger, fatigue
Kraft's study's findings about strength training for MS pts
the pts had improvements in functional tasks & muscle strength, combined w transient fatigue lasting 24-48 hours
exacerbation vs pseudo-exacerbation
- exacerbation = acute demyelinating event (exercise can't cause this)
- pseudo-exacerbation = temporary conduction block w recovery in a few hours (ex. from infection)
new flare-up vs infection presentation
- new flare-up: exacerbation of existing symptoms plus new ones
- infection: just the exacerbation
Smelter's study of training expiratory muscles in pts w mod-sever MS
Fry-Welch's study on resp dysfunction in pt's w minimal MS disability
- if you look close you'll see some res dysfunction even in high functioning pts
- ... so you can treat it at that level and retard its progression...
about temp and exercise in MS
exercising raises core temp, can lead to fatigue, so got to give rests or cool off the pt or keep the room cold
White's study on precooling MS pts before exercise found...
- it improved the work out - lowered HR, improved 25 ft walk time, decreased fatigue
- but, improvements didn't persist after the cooling wore off
aquatic therapy - good, bad?
- folks enjoy it, but it hasn't been proven beneficial
- Gehlsen study found that
7 considerations before exercising an MS pt to manage fatigue
- medication: make sure doses are good
- lower core temp: via drinks, room temp, ice...
- diminish energy cost of activity: stretch out foot drop, etc
- remediate underlying impairments: such as posture
- address secondary weaknesses: .
- intermittent exercise: his baby
- task oriented vs. facilitation: practice the task vs practice elements of the motion
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