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161 Cards in this Set
- Front
- Back
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Profile of MS (gender, geographic, age)
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1. women more than men
2. regions further from the equator are at higher risks 3. younger disease 15-50 yo |
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What is the highest peak age of MS diagnosis?
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Around 30 yo
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What age of diagnosis leads to less favorable prognosis?
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Over 35 yo
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What makes for a worse prognosis of MS? (6)
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1. men
2. diagnosed after 35 yo 3. BS, cerebellar/vestibular problems as initial symptoms 4. increase frequency of attacks with less time in between 5. poor recovery after exacerbation 6. neuro findings: significant pyramidal and cerebellar signs |
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What are 5 pyramidal symptoms associated with MS?
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1. ataxia
2. nystagmus 3. intention tremors 4. dysarthria |
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What is the etiology of MS?
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attacks myelin, sc and cns (think it's autoimmune, but is debatable; could be virus or genetic components)
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Describe relapsing-remitting MS
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--symptoms onset quickly and last for 4-12 wks (ex. numbness in extremities, drop foot)
--symptoms clear/remits completely --can repeat this cycle *no residual effects and is most common form |
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Describe 2nd type of relapsing-remitting MS
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--starts out with exacerbation for 4-6wks
--gets better, but won't completely return (retains disability) --disability adds up each time having an exacerbation |
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Describe primary progressive MS
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--insidious onset and disability keeps adding on
--never has remission; continual --more common in older population *progression of disability |
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Describe 2nd type of primary progressive MS
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--insidious onset and progressive
--plateaus and continues to get worse |
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Describe secondary progressive MS
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--starts as relapse-remitting
--person usually ignores symptoms (ex. optic neuritis or numbness in arms) --remits and then suddenly develops disability *insidious onset that may or may not plateau (2nd most common form) |
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What is the most common form of MS?
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Relapsing-remitting
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What is the 2nd most common form of MS?
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Secondary progressive
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Which form of MS is described as starting with relapse-remitting and then has insidious onset of progression that may or may not plateau
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Secondary progressive
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Which form of MS is considered a progression of disability and never remits?
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Primary progressive
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Which form of MS is most popular among the older population?
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Primary progressive
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Describe a 2nd type of secondary progressive form of MS
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--starts relapse-remitting
--then have exacerbation without a full recovery --have another exacerbation which becomes progressive |
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Describe progressive-relapsing
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--starts with insidious onset of progressive disabilities followed by sudden exacerbation
--return to prior level before exacerbation, but continues to get worse with abnormal exacerbation |
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What are 4 early signs of MS?
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1. optic neuritis
2. fatigue 3. sudden weakness (ex. drop foot) 4. balance or cerebellar/vestibular deficits |
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What is optic neuritis? What are its symptoms?
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inflammation of the optic nerve
blurred vision when reading (not double) notices pain behind eye will see optometrist *most common sign of MS |
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What is the most common sign of MS?
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optic neuritis
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Describe what a neurologist will do to diagnose MS
What are they looking for? |
Will do an MRI without contrast first, then injects contrast (gadolinium)
Looking for bright spots signifying acute inflammation (brain first, then SC) |
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What is the most common area to have lesions indicating MS within the SC?
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cervical region
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Why is looking at the brain difficult for neurologists to diagnose MS?
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B/c sometimes middle-aged brains have bright spots too, which is normal
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What must you have in order to diagnose MS?
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A separation in time and space (dissemination in time and space)
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What are 2 examples of disseminating in time to diagnose MS?
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1. person must have 2 clinical attacks indicating disseminating in time
OR 2. 1 bright spot with 1 or more dark spots present on MRI (dark=old lesions) |
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What is an example of disseminating space to diagnose MS?
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2 different lesions or bright spots in the brain indicating dissemination in space
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Is 1 bright spot on a MRI indicative of MS?
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No, must have 2 different lesions or bright spots along with dissemination of time
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What are 2 other exams that can be done to diagnose MS?
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1. evoked potentials
2. examine CSF from SC with lumbar puncture |
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What are 3 different kinds of evoked potentials?
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1. visual
2. somatosensory 3. auditory |
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How are visual evoked potentials measured?
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Show visual stimulus to patient with electrodes on scalp to pick the signals sent to the brain
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How are somatosensory evoked potentials measured?
What are you looking for with this test? |
Electrodes on scalp to pick up signals in brain while stimulating hand
Looking for latencies or slowed responses |
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What is a neurologist looking for when examining CSF by lumbar puncture for MS?
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Looking for immunogloblin (IGg) >15% of the proteins in CSF and also oligoclonal bands
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What are 10 common signs of MS after being diagnosed?
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1. fatigue
2. difficulty walking 3. visual disturbances 4. congitive issues 5. bowel and bladder problems 6. sexual disturbances 7. sensory deficits 8. motor disturbances 9. balance difficulties 10. swallow/speech difficulties |
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What is the most common sign of MS after being diagnosed?
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Fatigue (80% of the cases)
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How can fatigue be made worse for MS pts?
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Made worse with heat
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How can fatigue be peripheral with MS?
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Fatigue can be peripheral b/c of demyelination
Nerve fatigues and takes more energy to propagate impulses down a nerve |
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What can severe disruption of the myelin result in?
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Result in conduction nerve blocks
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How can fatigue be central with MS?
What structures are affected? What does it feel like? |
Can have central fatigue due to disruptive pathways to the brain
From BS to BG to thalamus to cortex feeling like the person cannot move (loss of thalamocortical drive) |
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What is called when a person feels like they cannot produce movement?
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Loss of thalamocortical drive
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What 3 types of fatigue that can occur with MS?
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1. peripheral fatigue
2. central fatigue 3. disuse fatigue |
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What results in disuse fatigue?
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deconditioning (no movement)
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What can also cause fatigue aside from peripheral, central and disuse?
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Medications
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What 2 drugs can manage fatigue?
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1. symmetral (Amantadine) dopamine agonist--anti-viral
2. modafanil (Provigil)--not an agonist |
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What is the difficulty with walking in MS pts due to? (3)
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1. weakness or paresis (demyelination of the long tracts)
2. spasticity/hypertonicity 3. sometimes cerebellar issues (LOB, ataxia) |
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What are 3 examples of visual disturbances with MS pts?
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1. optic neuritis
2. double vision b/c CN involvement (weak ocular muscles) 3. peripheral visual deficits or field cuts (blind spots) |
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What are some cognitive issues that occur with MS pts?
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1. memory deficits
2. executive functions such as judgment, problem-solving, impulsivity, decreased attention and processing *lesions on frontal-parietal lobes |
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How is bowel and bladder affected by MS?
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Can start out spastic and become flaccid over time
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How do sexual disturbances affect MS pts?
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1. impotency in men
2. difficulty in intercourse with women |
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What are 3 sensory disturbances with MS pts?
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1. decreased sensitivity
2. dysesthesias 3. Lhermitte's sign |
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What are dysesthesias with MS pts?
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sensation is uncomfortable and painful (burning, stabbing and painful sensory--allodynia is a type)
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What is Lhermitte's sign?
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When pt flexes neck and has sharp pain down the arms
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What are 5 motor disturbances common in MS pts?
What are all of these referred as? |
1. weak and paresis
2. spasticity 3. increased DTRs 4. clonus 5. babinski signs Referred as UMN lesions |
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What causes balance difficulties in MS pts?
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Either from weakness or involvement with cerebellar/vestibular problems
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What are 4 common CN symptoms in MS pts?
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1. dysarthria
2. dysphonia 3. dysphagia 4. decreased verbal fluency |
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What is dysarthia?
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Difficulty forming words due to weak muscles around the mouth, face and respiratory
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What is dysphonia?
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Hoarseness
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What is dysphagia?
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Difficulty swallowing and eating
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What scale is used to classify MS pts from 1-10?
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Expanded Disability Status Scale (EDSS)
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What is indicative of MS pts with scores of 1-6?
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Walking without an AD
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What is a MS pt's gait like after diagnosis if slow progression diagnosis?
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Most likely will be walking 20 years after dx
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Do pts die from MS?
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No, rather from complications of MS
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MS pts have certain predilection for what 4 certain areas of the nervous system?
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1. cerebellum
2. CST 3. brainstem 4. optic nerves |
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What 6 areas does the EDSS look at?
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1. pyramidal function
2. cerebellar function 3. brainstem (cn) function 4. sensory function 5. bowel and bladder function 6. visual function |
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What is the EDSS looking for when evaluating the pyramidal function?
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CST--looking for hemi-, para- or quadiplegia
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What is a MS pt's gait like after diagnosis if slow progression diagnosis?
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Most likely will be walking 20 years after dx
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Do pts die from MS?
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No, rather from complications of MS
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MS pts have certain predilection for what 4 certain areas of the nervous system?
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1. cerebellum
2. CST 3. brainstem 4. optic nerves |
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What 6 areas does the EDSS look at?
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1. pyramidal function
2. cerebellar function 3. brainstem (cn) function 4. sensory function 5. bowel and bladder function 6. visual function |
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What is the EDSS looking for when evaluating the pyramidal function?
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CST--looking for hemi-, para- or quadiplegia
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What does the EDSS evaluate with the cerebellar functions? (2)
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1. grades ataxia (mild, mod, severe)
2. coordination |
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What does the EDSS evaluate with the brainstem (cn) functions? (3)
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1. nystagmus
2. extraocular weakness 3. inability to swallow or speak (dysphagia) |
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What does the EDSS evaluate with the cerebral functions? (3)
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1. mood
2. mentation 3. memory |
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What are 5 disease modifiers (triggers) for MS?
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1. heat
2. stress 3. fatigue 4. infections 5. trauma |
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How does heat trigger exacerbation in MS pts?
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Fever or rise in temp will change nerve conduction velocity by making it slower and cause inflammation
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What is the Uhtoff's sign?
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MS pt will show a worsening of symptoms with an increase in body temperature (heat sensitive)
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What do MS pts need to avoid or be careful of with heat?
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1. avoid hot baths, whirlpools, hot summer days
2. careful with exercise with increase core temp causing weakness 3. keep environment cool (cooling vests) |
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How can stress be managed with MS pts?
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Might do yoga, pilates, tai chi, etc
Relaxation technique to reduce emotional stress and anxiety |
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How can fatigue be managed with MS pts?
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Conserve energy:
Do activities and then rest Plan their day (more activity in morning than afternoon) |
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Why are infections a problem with MS pts? How can it be managed?
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Infections can raise core temperature
Managed by immunosuppressants; however susceptible to infections (cycle) |
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How can pregnancy be a problem with MS pts?
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Giving birth is traumatic to the body and most MS pts will have relapse after 3 mo of giving birth
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What are some possible viral causes of MS? (4)
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1. measles
2. K9 distemper 3. chlamydia 4. episteme barr (lies dormant for years) |
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What do scientists say about genetic factors for causing MS?
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There is a genetic susceptibility, but takes an environmental trigger to express itself
*chromosome 6 associated with MS |
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What makes for a better prognosis for those with MS? (4)
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1. better if female and onset of <35 yo
2. have only 1 area involved in attack (ex. just optic neuritis or dropped foot) 3. have complete recovery after attack 4. have lower lesion # seen on MRI (fewer, smaller lesions) |
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Can a person with MS be asymptomatic?
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YES! Benign MS pts will show lesions on MRI, but have no signs or symptoms
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What is Marburg's variant of MS?
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A very aggressive form of MS where the disease advances quickly and relentlessly (leads to rapid disability and death)
Rare |
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How does the immune system begin to respond when pt has MS?
What does it recognize it as? |
Starts with some antigen being recognized as a foreign object
Recognizes antigen as either myelin protein or epitope of a virus |
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What do antigen presenting cells (macrophages or dendrocytes) do?
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Engulfs antigen and breaks it down into peptides; presents it to resting T-cell
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What can resting T-cells become?
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Either CD8 cells or CD4 cells
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What do CD8 cells do?
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Killer cells emit cytokines (interferon gamma and interleukins) which will kill the antigen
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What do CD4 (helper) cells do?
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Emit cytokines (interferon gamma and interleukins) which can recruit other kinds of immune cells and stimulate beta (B-cells) cells to produce antibodies
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When looking at medications, what do we want to happen with our immune system?
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Want to stop the proliferation or resting T-cells b/c they initiate the inflammatory process
Cytokines can also increase permeability to allow T-cells to enter BBB into the CNS (proliferate and attack central myelin) |
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Some researchers think the immune response to MS is a T-cell proliferating problem or what other possibility? Why?
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Beta cell problem, b/c they produce antibodies (IGg in CSF) causing the gliosis or scarring in MS
(If prevent scarring, then nerve impulses will still propagate) |
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What levels can medication intervene with MS conditions?
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1. T-cells
2. B-cells |
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What do astrocytes do? How do they influence nerve conduction?
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Come into demyelinated areas and attach themselves to prevent remyelination
They set up plaque formation (scarring); therefore nerve transmission is difficult |
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What is inflammation like in relapsing-remitting? Is the person always inflamed?
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Inflammation occurs all the time, but oligodendrocytes are able to produce more myelin and nerves become re-myelinated
However, have limited # of oligodendrocytes |
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Is glial cells research successful?
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No, trying to put stem cells into CNS to mature into oligodendrocytes to improve myelination has not been proven to be effective
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What medications are often prescribed when MS pts have attacks?
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High levels of corticosteroids x 3-5 days (by IV or mouth)
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What corticosteroid is often given orally for MS symptoms?
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Dexamethasone (tablets with same side effects)
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What corticosteroid is often given IV?
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Solumedrol
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What are some SE of corticosteroids? (6)
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1. nervousness
2. agitation 3. psychoses 4. no sleep 5. GI disturbances 6. may inhibit re-myelination |
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Are corticosteroids DMDs?
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Some say yes b/c they have a protective effect by decreasing the # of exacerbations if taking in intervals
Believe that doses taken every 6 wks may have some altering life course effect on disease Others say they do not do anything to modify the disease process and most people can't tolerate them |
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When diagnosed with MS, what drugs are recommended? Why?
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DMDs b/c they are found to decrease the # of exacerbations and increase the time between them
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What drugs can still be used to treat acute attacks with MS pts?
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Corticosteroids
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What is copaxone?
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A myelin basic protein that acts as a decoy for the immune system to attack in MS pts
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How is copaxone administered?
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Subcutaneous every day
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What form of MS is copaxone most effective?
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Relapsing-remitting MS
Sometimes used for secondary progressive MS |
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What is a side effect of copaxone?
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Injection site reactions
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What do DMDs do?
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Decrease the # of exacerbations and increase the time between episodes
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How do DMDs affect T-cells? (2)
How are the substances used? |
1. Decrease T-cell migration into CNS and won't affect myelin
2. Decrease T-cell proliferation Used as interferons (cytokines) |
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What are 3 types of interferon B medications that are directed at the T-cells?
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1. interferon B 1b (Betaseron)
2. interferon B 1a (Avonex) 3. interferon Beta 1a (Rebif) |
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What are the side effects of Betaseron, Avonex and Rebif? (4)
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1. achiness
2. nausea 3. fever 4. flu-like symptoms |
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How is Betaseron used?
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Subcutaneous, every other day
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What is Betaseron?
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DMDs (Interferon B 1b) that decreases immune system and increases the time between attacks
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What form of MS is Betaseron most effective in treating?
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Relapsing-remitting MS
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What interferon DMD was the first to develop?
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Avonex (interferon B 1a)
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How is Avonex administered?
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Intramuscular injection, 1 x week
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What form of MS is Avonex most effective in treating?
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Relapsing-remitting MS
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What are the side effects of Avonex? (3)
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1. flu-like symptoms
2. affects liver function 3. heart problems |
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Which interferon B type DMDs do some pts have a better reaction to?
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Rebif (Interferon B 1a)
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What are the side effects of Rebif? (2)
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1. flu-like symptoms
2. injection site reactions |
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How is Rebif administered?
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Subcutaneous, 3 x week
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What type of MS is Refib most effective in treating?
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Relapsing-remitting MS
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What are 3 treatment drugs directed at the B-cells (beta cells)?
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1. Tysabri (Natalizumab) (monoclonal antibody tx)
2. Rituximab (Rituxen) 3. Novantrone (Mitoxantrone) |
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What is Tysabri (Natalizumab) made to simulate in the body?
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Made to simulate the naturally occurring molecules that protect against infections
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What does Tysabri (Natalizumab) slow or stop?
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Slows or stops immune cells from moving out of the blood stream and into the CNS
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How is Tysabri (Natalizumab) administered?
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IV infusion, every 4 wks
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What form of MS is Tysabri (Natalizumab) most effective in treating?
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Relapsing-remitting MS
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What are 6 side effects of Tysabri (Natalizumab)?
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1. headache
2. fatigue 3. depression 4. urinary tract infections 5. joint pain 6. abdominal discomfort |
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What DMD was taken off the market due to tumor growth (encephalopathy) in some pts, then was returned to the market?
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Tysabri (Natalizumab)
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What 2 DMDs require close pt monitoring?
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1. Tysabri (Natalizumab)
2. Rituximab (Rituxen) |
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Which DMD has less side effects compared to Tysabri (Natalizumab)?
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Rituximab (Rituxen)
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Which DMD drug is being more used now?
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Rituximab (Rituxen)
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How is Rituximab (Rituxen) administered?
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IV infusion, every 6 months
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How does Rituximab (Rituxen) work?
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Drug destroys all of the beta cell (B-cell), bringing the count down to 0 (which causes the sclerosis) and the person cannot form antibodies
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What 2 DMDs are anti-cancer drugs to treat MS?
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1. Rituximab (Rituxen)
2. Novantrone (Mitoxantrone) |
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Which DMD is an anti-cancer drug and results in the pt not being able to benefit from vaccinations?
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Rituximab (Rituxen)
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Do pts on Rituximab (Rituxen) still have immune function? If so, how?
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Yes, still have T-cells generating some immune function by killing the antigens (CD8 cells)
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What form of MS is Rituximab (Rituxen) being used to treat?
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Secondary progressive and progressive MS
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What are the side effects of Rituximab (Rituxen)?
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Allergic reactions to drugs--anaphylatic shock
Others not known |
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What needs to be taken with Rituximab (Rituxen) to avoid severe allergic reactions?
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Corticosteroids (since immunosuppressed can develop pneumonia, UTIs, etc)
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What form of MS does Novantrone (Mitoxantrone) most effectively treat?
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Progressive-relapsing and secondary progressive MS
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What form of MS does Novantrone (Mitoxantrone) make worse?
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Relapsing-remitting
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How is Novantrone (Mitoxantrone) administered?
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IV infusion, 4 x year
(max dose of 12, 3 year span that must be used with other meds) |
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What are 6 side effects to using Novantrone (Mitoxantrone)?
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1. may cause heart and liver problems
2. infections 3. bone marrow suppression (fatigue, bruising, low blood cell count) 4. nausea 5. hair thinning 6. mouth sores |
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What DMDs are most effective for relapsing-remitting MS? (4)
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1. Betaseron (interferon B 1b)
2. Avonex (interferon B 1a) 3. Rebif (interferon B 1a) 4. Tysabri (Natalizumab) |
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What DMD can used for secondary progressive and progressive MS?
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Rituximab (Rituxen)
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What DMD is best used with progressive-relapsing or secondary progressive forms of MS?
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Novantrone (Mitoxantrone)
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What 2 drugs are used for spasticity in MS pts?
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1. baclofen (generalized weakness)
2. tizanidine (Zanaflex) |
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What is botox or phenol blocks used for in MS pts?
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Hypertonic muscles (high tone)
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What is Tegretol used for?
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Painful spasms used for neurogenic pain (anti-seizure med)
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What is Neurontin used for?
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Neurogenic pain
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Why do MS pts take Paxil or Zoloft?
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Sometimes used anti-depressants for pain, especially dysesthesias
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What 3 drugs are used for tremors in MS pts?
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1. diazepam (valium)
2. klonopin 3. inderal |
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What drug manages vertigo in MS pts?
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Meclozine
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What is Aricept used for in MS pts?
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Cognitive problems (used sparingly--typically used for Alzheimer's)
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What drug is used for fatigue in MS pts?
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Modafinil (Provigil)
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What drug addresses bladder spasticity in MS pts?
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Ditropan
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What are 3 general side effects of most medications MS pts take?
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1. fatigue
2. weakness 3. balance problems |
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What 4 systems must you test when examining a MS pt?
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1. neuromuscular
2. musculoskeletal 3. cardio/pulm 4. integumentary |
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What 14 tests can be done with MS pts?
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1. sensory
2. cognitive 3. aerobic capacity (response to ex) 4. integumentary 5. pain 6. joint integrity, alignment, mobility 7. posture 8. balance 9. muscle tests 10. gait 11. functional status 12. environment 13. work, community and leisure activities 14. psychosocial functions |
