Multiple Sclerosis

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Multiple Sclerosis
2014-05-03 22:33:26
ms neuro

review of MS lecture 4/30
Show Answers:

  1. MS:
    autoimmune disease that affects the brain and spinal cord
  2. In MS, the myelin sheaths that cover the axons of the nn become:
    • progressively destroyed, causing the nerves to malfunction
    • destroyed w/ inflammation and scarring
  3. Epidemiology
    more common the further from the equator
  4. MS peaks b/w ages:
  5. Who is more affected, males or females?
    like other immuno-mediated diseases, females are affected more
  6. First, second and third degree relatives of people with MS are at...
    increased risk
  7. Due to the broad range and subtleties of symptoms, MS may not be diagnosed for months to years after the onset of symptoms.
    • Neurologists, take detailed histories and perform complete physical and neurological exams
    • in addition, 3 tests are used to diagnose MS
    • usually, despite advanced diagnostics, MS is still a diagnosis of exclusion
  8. What are the 3 tests to diagnose MS?
    • MRI scans
    • evoked potentials test
    • spinal tap
  9. MRI Scan to diagnose:
    sometimes w/ intravenous gadolinium, it helps to identify, describe, and date lesions in the brain
  10. evoked potentials test to diagnose MS:
    examines impulses traveling through the nn to determine if the impulses are moving normally or too slowly
  11. spinal tap to diagnose MS:
    examine CSF may identify abnormal chemicals or cells that suggest the presence of MS
  12. For a definite diagnosis of MS,
    • dissemination in time (at least two separate symptomatic events or changes on MRI over time)
    • dissemination in anatomical space (at least two separate locations w/in CNS which can be demonstrated by MRI or neurological exam) must be demonstrated
  13. Signs and symptoms:
    • fatigue
    • walking problems
    • bowel and bladder problems
    • pain
    • vision disturbances
    • cognitive problems
    • tremors
  14. Relapsing/Remitting MS characterized by:
    • exacerbations when new symptoms appear and old ones resurface or worsen
    • relapses are followed by remission - the person fully or partially recovers
    • relapses can last weeks or months
    • recovery is slow or instantaneous
  15. The majority of people presenting with MS are first diagnoses w/:
  16. Many people who have had relapsing/remitting MS move into...
    Secondary Progressive MS (SPMS)
  17. SPMS is characterized by:
    • a gradual worsening of the disease b/w relapses
    • may experience good and bad days or weeks, but no real recovery
  18. After 10 years, 50% of people w/ relapsing/remitting MS will have developed:
    secondary progressive
  19. Progressive relapsing MS follows course from onset, punctuated by:
  20. Progressive relapsing MS
    there is significant recovery immediately following a relapse but b/w relapses there is a gradual worsening of symptoms
  21. Primary Progressive MS occurs __%
  22. Primary Progressive MS is characterized by:
    gradual progression of the disease from its onset w/ no remissions at all
  23. How does PPMS differ from relapsing-remitting and SPMS?
    onset is typically in the late 30s or early 40s, men are as likely as women to develop it and initial disease activity is in the spinal cord and not in the brain
  24. Primary Progressive MS often migrates into the brain, but is less likely to cause:
    cognitive problems
  25. Medications:
    • steroids
    • disease modifying agents
    • medications given to modify problems associated w/ MS
    • -spasticity meds
    • -fatigue meds
    • -meds for bowel and bladder
    • -anti depressants
  26. Steroids:
    • corticosteroids are hormones normally produced in the human body by the adrenal glands, widely used for their anti-inflammatory actions
    • steroids were among the first agents used to treat MS and remain the tx of choice for managing acute exacerbations
    • not all MS exacerbations require tx. for any attack that is significantly impacting a person's ability to fxn at home or at work, most MS specialists recommend a 3-5 day course of high dose intravenous steroids. Data from clinical studies suggest that this short course of high-dose, given intravenously, provides maximum benefit w/ fewest side effects
    • ACTH, administered by injection, is also a recognized tx for exacerbations of MS
  27. Disease modifying agents:
    • reduce the number or severity of MS exacerbation
    • reduce the accumulation of lesions
    • slow the accumulation of the disability
    • the following slides list some disease modifying agents. Most are expensive. Most have to be given by injection. Most have side effects.  The decision about taking disease modifying agents is difficult
  28. Aubagio (teriflunomide) A pyrimidine synthesis inhibitor:
    • taken orally
    • inhibits the function of specific immune cells that have been implicated in MS
    • inhibit a key enzyme required by white blood cells - which in turn reduces the proliferation of T and B immune cells that are active in MS and also inhibits the production of immune messenger chemicals by T cells
  29. Avonex (Interferon Beta 1b)
    • manufactured from one of the naturally-occurring interferons (a type of protein)
    • in controlled clinical trials in relapsing MS, those taking the medication had a reduced risk of disability progression, experienced fewer exacerbations, and showed a reduction in number and size of active lesions in the brain (as shown on MRI) when compared w/ the group taking a placebo
    • in a subsequent study of pts who had experienced a single demyelinating event in the optic nerve, spinal cord, or brainstem, and had lesions typical of MS on brain MRI, Avonex significantly delayed the time to a second exacerbation, and thus to a clinically definite diagnosis of MS
    • given as a once-a-week intramuscular injection in the thigh and upper arm
  30. Betaseron and Extavia Interferon Beta 1b
    • manufactured from one of the naturally occurring interferons (a type of protein)
    • in a clinical trial of 372 ambulatory pts w/ relapsing-remitting MS, those taking the currently recommended dose of the medication experienced fewer exacerbations, a longer time b/w exacerbations, and exacerbations that were generally less severe than those of pts taking a lower dose of the medication or a placebo
    • additionally, pts on interferon beta-1b had no increase in total lesion area, as shown on MRI, in contrast to the placebo group, that had a significant increase
    • this drug is injected subcutaneously (b/w the fat layer just under the skin and the muscles beneath) every other day
  31. Copaxone (Glatiramer Acetate)
    • a synthetic protein that simulates myelin basic protein, a component of the myelin that insulates nerve fibers in the brain and spinal cord
    • blocks myelin-damaging T-cells
    • in controlled clinical trials w/ relapsing-remitting MS, those taking the glatiramer acetate had a significant reduction in annual relapse rate and a reduction in new lesions as shown on MRI, when compared to control subjects who were given a placebo
    • injected subcutaneously once a day
  32. Tysabri (Natalizumab)
    • a monoclonal antibody designed to hamper movement of potentially damaging immune cells from the bloodstream, across the blood brain barrier into the brain and spinal cord
    • given once every 4 weeks by IV only
  33. Assessments:
    EDSS - Expanded Disability Status Scale
  34. Expanded Disability Status Scale
    • Evaluates: pyramidal, cerebellar, brainstem, sensory, bowel and bladder, visual, cerebral, and other
    • performed only by a doctor (neurologist) and only after the diagnosis of MS is complete via MRI and clinical course
  35. assessments therapists use:
    • 6-minute walk test
    • falls diaries
    • timed 25 foot walk test
    • dynamic gait index
    • 12 item MS walking scale
    • modified fatigue impact scale
    • balance tests
    • quality of life scales
  36. significant problems patients have:
    • gait
    • balance
    • fatigue
    • spasticity
  37. People w/ MS fall an average of __ times per year.
  38. common gait abnormalities:
    • decreased velocity
    • reduced stride length
    • increased double limb support
    • asymmetry
    • early fatigue onset compared to healthy controls
    • impaired timing of muscle firing
    • alterations in normal ankle motion
  39. Rehab programs can reduce disability in people w/ MS:
    • balance rehab consisting of sensory and motor strategies reduced falls and improved balance skills in a pilot study
    • aerobic treadmill training increased walking speed and endurance w/ no reported increase in fatigue; however training effects were not lasting in a study
    • Locomotor training using body weight supported treadmill training decreased spasticity and improved strength, endurance, balance, walking speed, and QoL in a pilot study
  40. MS and Aerobic Exercise:
    • no evidence of detrimental effects of neurological status or disease activity
    • huge improvements in aerobic quality, strength, functional mobility fatigue, and QoL results
  41. MS and resisted exercise training:
    • no evidence of detrimental effects on muscle neurological status or disease activity
    • huge improvements in strength, functional mobility, fatigue, and QoL
  42. Parameters for Aerobic Activity:
    • 20-60 min per session
    • 3-5 times/week
    • multiple shorter bouts of aerobic activity may assist people w/ low capacity
  43. Parameters for resistance training:
    • 4-10 total exercises
    • 1 set, 15-20 reps (endurance)
    • 2-3 days per week
    • protect severely weak mm w/ splints or AFOs
    • carefully monitor strength changes in at risk pts
  44. Parameters for flexibility exercise:
    • 2-3 days/wk of stretching major mm
    • stretch tight mm daily
    • use splints, casts, and dynamic splints