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44 Cards in this Set
- Front
- Back
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Multiple Sclerosis: Definition
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Recurrent or progressive multifocal inflammatory demylenation which effects the white matter of the spinal cord and brain
Major cause of disability in young adults |
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Does MS affect males or females more?
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Greater incidence in females
2-3 x's as much |
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Multiple Sclerosis: When is the onset (age)
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Usually between 15-50 years old
Average 30 years old |
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Multiple Sclerosis: Primary Prevention
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None recommended
Increased risk living in in temperate zone first 15 years of life Higher risk with family history Northern European decent Urbanicity Affluence |
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Multiple Sclerosis: Secondary Prevention
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NONE
early diagnosis is dependent on a high index of suspicion |
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***what is important to know about MS symptoms?
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early symptoms may be intermittent
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Multiple Sclerosis: Symptomatology
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ataxia
clonus dysarthria fatigue paresthesias spasticity of lower (more pronounced) and upper extermities urinary frequency, hesitancy or incontinence visual changes clumsiness emotional lability genital anesthesia |
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What are the most common presenting complaints of multiple sclerosis?
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fatigue
diplopia vertigo hemiparesis paraparesis monoparesis numbness paresthesias ataxia cognitive urinary dysfunction |
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What is a common initial presentation of multiple sclerosis
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a sudden unilateral visual loss or double vision (optic neuritis)
vertigo pins and needles, or other paresthesias loss of balance THESE SYMPTOMS MAY BE INTERMITTENT OR MAY EVENTUALLY RESOLVE |
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Multiple Sclerosis: Differentials
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ALS
Bechet Cancer/tumor CNS infection Progressive multifocal leukoencephalopathy Pernicious anemia Vertebral disk disorders Infarct Sarcoidosis Syphilis SLE Lyme disease HIV |
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Intermittent vague symptoms with eyes, numbness and tingling and vertigo are highly suggestive of what?
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multiple sclerosis
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Significant findings on physical exam for Multiple Sclerosis
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Hyperactive deep tendon reflexes
loss of position sense loss vibratory sense |
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How to diagnosis MS
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MRI MOST EFFECTIVE DIAGNOSTIC TEST
to r/o differentials (usually ordered by neurologist) -CSF tap -FTA-ABS (syphilis) -ESR (autoimmune disorders, e.g. lupus) |
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What is the most effective diagnostic test of multiple sclerosis?
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MRI
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Diagnosis of MS is based on ________ supplemented by ___________ rather than the reverse
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Diagnosis of MS is based on CLINICAL FEATURES supplemented by DIAGNOSTIC TESTS rather than the reverse
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Schumacher criteria diagnose clinically definite MS when an appropriate clinical history is supported by the following
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1) Objective abnormalities of CNS function on the neurologic exam
2) Examination or history indicating involvement of two or more areas of CNS (paresthesias and clumsiness) |
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MULTIPLE SCLEROSIS AND MRI
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MRI is the most useful test for confirming the diagnosis or MS.
Lesions appear as areas of high signal on T2-weighted imaged, predominately in the cerebral white matter or spinal cord. When lesions are actively inflamed, gadolinium contrast often enhances them Has high degree of specificity and sensitivity in detecting demyelination in the cerebral hemispheres. |
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Sensory and Visual Evoked Potential Testing: MS
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most likely ordered my neurologist
can be used to measure conduction along visual, auditory, or somatosensory pathways measurement of the latency of the visual evoked potential (VEP) after a visual stimulus is most widely used. An increased latency indicates an abnormality in the optic nerve on the side that may not be evident on an MRI scan used because MS can cause blindness |
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NAME THE 4 FORMS OF MS
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Relapsing-remitting
Secondary Progressive Primary Progressive Progressive-relapsing |
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MS FORMS: Relapsing Remitting
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MOST COMMON
an attack or relapse is followed by a period of decreased or no symptoms (remission) until the next flare up. A flare up can leave some residual disability or it can resolve completely over the course of weeks or months 80% of MS begins in this matter Over time the course may change and the person moves into a different category. Approximately 50% will become progressive from the relapsing-remitting form of MS Relapsing remitting multiple sclerosis (rrms) is the most common form of the disease. The title can also be misleading. During this form of the disease, patients tend to experience an attack or series of attacks (exacerbations) followed by complete or partial remission. This is where the title, relapsing remitting multiple sclerosis (rrms), can prove misleading. Patients often assume that the remission stage of the disease will mean 100% recovery. While this can be true, particularly during the early stages of the disease, often the remission will only be a partial one, particularly as the disease progresses, thus leaving the patient with residual, usually permanent, symptoms. |
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What is the most common form of MS
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Relapsing- Remitting (80% of cases begin this way)
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MS FORMS: Secondary Progressive
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Begins with initial relapsing-remitting course followed by progression at a variable rate that may also include occasional relapses and minimal remissions
Secondary Progressive Multiple Sclerosis (spms) begins with relapsing remitting multiple sclerosis (rrms). The relapsing remitting (rrms) stage of the disease may persist for many years before the onset of secondary progressive ms. Secondary progressive multiple sclerosis is a second-stage, chronic, progressive form of the disease where, unlike the relapsing remitting (rrms) stage, there are no real periods of remission, only breaks in attack duration with no real recovery from symptoms although there may be minor relief from some. |
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MS FORMS: Primary Progressive
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10% of MS worsens right from the start and is termed this.
The disease shows progression of disability from its onset without plateaus or remission or with occasional plateaus and temporary minimal improvement. More common in those who develop the disease after 40 years of age Primary Progressive Multiple Sclerosis (PPMS) is most commonly found in men. It is characterized by gradual clinical decline with no real or distinct periods of remission. There may be temporary periods where the disease appears to plateau, or level out, and this may include some partial, yet minor, relief from some symptoms, however the course of the disease is one of continual decline from the outset. |
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What form of MS is common after 40 years of age?
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PRIMARY PROGRESSIVE
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FORMS OF MS: Progressive Relapsing
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5% of MS start with a progressive course and becomes more fluctuating.
This pattern shows progression from the onset but without clear acute relapses that may or may not have some recovery or remissions. Progressive Relapsing Multiple Sclerosis (PRMS) is a rarer form of multiple sclerosis where the disease takes a progressive form from the outset with acute attacks throughout and no relief from accumulated symptoms. Unlike Primary Progressive Multiple Sclerosis, Progressive Relapsing MS does not 'plateau'. |
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Management of MS
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No cure for MS, only management of Symptoms
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Acute management of MS
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any episode, including optic neuritis, sufficient enough to cause distressing symptoms or an increased limitation on activities should be offered a course of high dose corticosteroids
the course should be started as soon as possible after onset of the relapse |
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What do you give an MS patient in relapse
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high dose corticosteroids.
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Medical management of MS
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The FDA has approved 9 drugs to treat MS, 7 in the form of injection.
These drugs cannot reverse the damage already caused by the disease but can help prevent relapses and further damage. |
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Medications that are used for the treatment (prevention of relapses) of MS
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Avonex (beta-1a interferon)
Refib (beta-1a interferon) Betaseron (beta-1b interferon) Copaxone Novantrone Tysabri Gilenya Aubagio-(can be given PO) BG 12- expecting FDA approval this year Lemtrada- in trials COST OF DRUGS RANGE FROM $1200-$1500/month |
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Management of symptoms of MS: Spasticity
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Stretching and exercise programs per physical therapy
Baclofen, tizanidine (zanaflex), gabapentin (neurontin) and benzodiazepines Intrathecal baclofen therapy for medically intractable spasticity |
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Management of symptoms of MS: bladder dysfunction
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UA and culture to r/o infection: treatment prn
failure to store (ditropan or detrol) or failure to empty (questionable relief with alpha 1-adrenergic receptor antagonists; intermittent self cath may be necessary -PVR to determine urinary retention |
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Management of symptoms of MS: Fatigue
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frequent rest peroids
Amantadine (symmetrel) Modafinil (provigil) SSRI's- but have sexual side effects Monitor sleep patterns Above fatigue drugs not used routinely |
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Management of symptoms of MS: Depression
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Supportive measures for mild depression
For more severe depression, SSRI'- sexual side effects Effexor XR or Wellbutrin SR Amitriptylline with concomitant sleep disorders or headaches. |
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Management of symptoms of MS: bowel problems
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increased fluids and dietary changes including increased fiber; stool softeners or bulk laxatives prn
oral laxatives prn may consider routine suppositories or enemas if constipation is chronic or other treatment options fail |
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Management of symptoms of MS: visual problems
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routine visits to opthamologist or optometrist (every 6 months)
problematic nystagmus may try limited trial of oral gabapentin assess for low-vision equipment and adaptive technology |
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Management of symptoms of MS: Pain
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Pain is usually due to neuropathy or to musculoskeletal problems related to immobility
management exercise, passive movement, better seating offer analgesics if non-pharmacological methods fail carbamazepine, gabapentin, or amitriptilline for ___ |
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Management of symptoms of MS: Cognitive losses/emotionalism
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Assess for depression
Review medications Neuropsych assessment Tricyclic antidepressants or SSRI's if emotionalism causes distress to patient or family. |
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Management of symptoms of MS: Speech/Swallowing difficulty
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speech therapy evaluation
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Management of symptoms of MS: Sensory losses, ataxia and tremor
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evaluation by a rehabilitation team for advice on techniques and equipment to ameliorate their limitations and advice on personal safety
physical therapy to improve function and quality of life. |
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***WHAT ARE THE FOUR GOALS OF TREATMENT FOR MULTIPLE SCLEROSIS?
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1) stall progression
2) treat symptoms 3) treat relapses 4) provide support |
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MS treatment course includes....
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PT/OT
Counseling Avoid triggers |
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MS course of progression
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HIGHLY VARIABLE
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MS- TREATMENT (HEALTH PROMOTION)
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Avoid over work-fatigue
Remain active Rest during acute relapses High fluid intake High fiber diet Bladder training may be needed Report urinary symptoms/cough early Frequently "complementary" medicine used in patients with MS |
