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61 Cards in this Set

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What is MS?
Autoimmune dx thtattacks myelin in the CS. Episodes of inflammation that damage the myelin sheath causing scarring
4 types of MS
Relapsing/remitting
Primary progressive
Secondary progressive
Progressive relapsing
Describe relapsing/remitting MS
Clearly defined relapses, or episodes of acute worsening, followed by recovery and disease stability
S/s go away completely during remission
What is relapsing/remitting MS with exacerbation?
Starts with excacerbation, s/s decrease but don't go completely away. Disability adds up each time you have a relapse and you retain the defecits
Describe Primary Progressive MS?
Continuous worsening, or steady progression, not interupted by distinct relapses
Describe secondary progressive MS
Disease starts out as relapsing-remitting, but then becomes progressive. Have bouts, ignore it, and then all of the sudden you develop a linear progressive disabilit
Second type of Primary Progressive with plataue
You may plataeu for a period of time, but you continue to get worse - never better
Describe progressive relapsing MS
Characterized by progressive dx from the onset with clear, acute relapses that may or may not resolve; periods between relapses are characterized by continued progression.
Early signs of MS
Optic neuritis (notice blurred vision and slight pain when move eyes). Papillodema = INF of optic nerve and 95% of the time it is MS
Fatigue
Weakness
Balance, cerebellar defecits
How do you make a diagnosis of MS?
Separation of time and space
At least 2 bright spots on MRI (with contract gabolineum) and 2 attacks
How do you perform the MRI when trying to diagnose MS?
With contract gabolineum. First do brain and then SC. Lots of MS lesion in the C-sp
Keep in mind, sometimes normal brains have bright spots
10 common signs/symptoms after diagnosis of MS
Fatigue
Diff w/ AMB
Visual disturbances
Cognitive isues
B&B issues
Sexual issues
Sensory disturbances
Motor problems
Balance/vestibular problems
Swallowing/speaking problems
Two types of fatige expereinced by the MS patient
1. Peripheral fatigue causes by demyelination = mental and physical
2. Central fatigue - due to loss of thalamocortical drive = feeling that you can't move
Also have disuse fatigue and medicinal fatigue
Symmetrel
Dopamine agonist used to combat central fatigue
Modafanil
AKA profitual to combat central fatigue
Why does the MS pt often have trouble with AMB?
Weakness/paresis
Spasticity/hypertonicity
Cerebellar issues = uncoordination, wide gait, balance trouble
87% have gait problems
Typical visual distrubances experienced by MS patient?
Optic neuritis, double vision
Peripheral visual defecits and blind spots
What type of cognitive issues may an MS pt have?
Frontal/parietal involvement = memory, executive fxt, problem solving, judgement, impulsitivity, dec processing
What type of B&B problems do MS pts have?
Start out with spastic bladder that may become flaccid
65%
What type of sexual dysfxts may an MS pt have?
Impitence
"difficulty" wiht intercourse for females
What type of sensory distrubances do MS pts typically have?
Paresthesia, dysesthesia (burning, stabbing) in specific distributions, but non-dermatomal
Lhermitte's sign
Flex neck and pain goes down the arm..pins and needles.
Common for MS pts I guess
What type of motor problems does the MS patient have?
UMN issues
Weak, paresis, spasticity, Inc DTR, clonus, abnomral reflexs
What type of swallowing/speaking problems does the pt with MS typically have?
Once disease has progressed
Dysarthria, slurred speech, dysphonia (hoarsness), dysphagia - difficulty swallowing/eating
Bad prognostic indicators
Develop > 35 yo
Less time between attacks
Brainstem/cerebellar lesions early in dx process (nystagmus, ataxia, intention tremor)
Male
Dysarthria
Neurological findings after 5 years (pyramidal and cerebellar signs)
Good prognotic indicators
Female, <35 at onset
One area of involvement
Complete recovery after attacks
Lower lesion burden (count # on MRI)
5 disease modifiers for MS
Heat
Stress
Avoid fatigue (plan day out)
Infection
Trauma
Uhtoff sign
S/s of MS increase with warmth
Why may infection trigger a excaberation?
Inc body temp (heat).
These pts are given anti-immune drugs so they are at high risk for infection - inc heat associted with infection
What chromosome is implicated with MS?
6
Person may have genetic factor/suseptibility, but it takes an ENV trigger to express itself
2 clinical tests that may be performed to indicate MS as diagnosis?
Evoked potentials - stimulate some sense, and record potential when they reach brai. Look for latency/slowed response. Can also do motor
CSF extract - Greater than 15% of proteins being IGg is considered positive for MS or if they see oligoclonal cands
How may T cells or B cells be implicated in the dx process?
T cells: recognize myelin as foreign and launch attack
B cells: Produce ABs that cause scarring of tissue
What three types of cells may T cells differentiate into and how do they attack myelin?
T helper cells CD4: Secrete cytokines that recruit other cells and stimulate B cells to make ABs
T suppressor cells CD4: ????
T killer cells CD8: Kill directly
How can immune cells get through the BBB to attack myelin?
Soluble cytokines (ie. Interferon Gamma and interleukins) can get thru BBB of CNS and attack myelin due to increased permeability caused by the cytokines
What do oligodendrocytes do?
Can remyelinate, but can't keep up as disease progresss
Trying to use stem cells to inc oligodendrocyes
What do astrocytes do?
Come to demyelinated area, attach themselves and prevent remyelination and cause plaqu formation (scarring) of myelin
Research trying to decrease these
What is the FSS and EDSS?
Functional Systems Scores (FSS) and Expanded Disability Status Scale (EDSS)
FSS grades dif fxts and the EDSS evaluates these fxts
What systems does the Functional Systems Scores (FSS) look at?
Pryamidal (paraparesis to plegic, etc)
Cerebellar (tremor to ataxia, etc)
Brainstem (Nstagmus, eye mm, dysarthria, CNs)
Sensory
Bowel and bladder
Vision (Scotomas to dec visual acuity)
Cerebral (mental, mood, behavoir, dementia)
Graded 0 to 9 on all systems
How is the Expanded Disability Status Scale (EDSS) determine grading?
In 1/2 point increments from 0 to 10. It summarizes the FSS
1.0 to 4.5 = full AMB
5.0 to 9.5 = Impairemnt to AMB
6.0 = need AD
10 = death
When are corticosteroids used for MS? Are they dx-modifying?
Start with high doses initially in dx process. Some believe doses taken every 6 weeks may have some effect in altering the course of the dx... TO doesn't htink so tho
Adverse effects of glucosteroids?
Gives you energy
CAn't sleep, nervousness/agitation
Psychoses and anxiety
What glucosteroids may a pt be given? Names and administration?
Dexamethasone = oral
Solumedrol = IV
In general, what do dx-modifying drugs do?
Dec exacerbation severity
Inc time in between attacks
What is MBP? How does it work?
Myelin Basic Protein from cows
Affective for relapsin MS
What is Copaxone?
How does it work?
Administration?
Type of MS?
Side effects?
Drug given from relapsing-remitting MS, will use this OR dx-modifying drug
Acts as decoy: immune system will attack these particles instead of the myelin
SubQ every day
Injection site reaction
What is the purpose of dx-modifying drugs?
To stop proliferation of T cells
Stop B cells from making ABs
3 types of Interferons used to treat MS. What type of MS do each treat?
Interferon B Ib: Betaseron (relapsing)
Interferon B Ia: Avonex (replapsing)
Interferon B Ia: Rebif (relapsing)
Administration of Betaseron, Aonex, and Rebif
Betaseron: SubQ every other day
Avonex: Intramuscular 1/week
Rebif: SubQ 3x/wk
Adverse effects of Avonex and Rebif
Avonex: flu-like s/s, effect liver fxt and cardiac system
Rebif: flu-like that lessen and injection site rxt's
What do Interferons do in general?
Suppress immune fxt and action of T cells
What is Monoclonal Antibody Tx? Example of drug and how does it work?
Tysabri: Natalizumab
Directed at B cells; made to stimulate the naturally occuring molecules that protect against infection
Slows/stops immune cells from moving into the CNS from the blood stream
Administration for Tysabri (Natalizumab), type of MS and adverse effects
Every 4 weeks by IV infusion
Relapsing MS
HA, fatigue, depression, UTI, joint pain, abdominal discomfort
Tumors in some ppl (taken off market but back on now)
What is Rituximab (Rituxen)?
Administration
Type of MS
Side effects
Given to take the beta cell count down to 0 which are thought to cause the scarring
IV every 6 months
Starting to use with Progressive
Allergic rxts... also pneumonia, UTI, and such due to immunosuppresion
What do you need to take with Rituximab (Rituxen)? Why? Consequences?
Corticosteroids to avoid severe allergic rxts
Very immunosuppressed = pneumonia and UTI
However, side effects are less than Tysarbri (Natalizumab)
Two drugs aimed at the B cells
Tysabri (Natalizumab)
Rituximab (Rituxen)
What is Novantrone (Mitoxantrone)?
Type of MS?
Administration?
Side effects?
Immune system suppressor (ca. drug)
Progressive-relapsing, secondary progressive, or worsening relapsing-remitting
4x/yr by IV infusion
Infections, bone marrow suppression, nausea, hair thinning, mouth sores
Cardiac and liver conditions
Why do doc's not like to prescribe Novantrone (Mitoxantrone)?
Bone marrow suppression - fatigue, bruising, low blood cell count
What drugs can be used for the following associate conditions:
1. Spasticity
2 Hypertonic mm
3. Painful spasms
4. Pain/dysethesais
1. Baclofen (early) or tizanidine (Zanaflex)
2. Botox or phenol blocks
3. Tegretol
4. Neurotin or anti-depressants
What drugs can be used for teh following associated conditions:
1. Tremor
2. Vertigo
3. Cognitive issues
4. Depression
5. Fatigue
6. Bladder issues
1. Klonopin (diazepam) or Inderal
2. Meclzine
3 Aricept
4. Zoloft, Paxil
5. Modfinil or Provigil
6. Ditropan
Laundry list of things to include in PT eval
Mental status and communication
Vision and sensation
Endurance/fatigue, strength, ROM, tone
Coordination and balance
CV and CN
Functional activites (ADLs, bed mobility, transfers)
Laundry list of tx strategies you may use with your patient
Strengthening, ROM, and stretching
Balance trng
Sacaad, tracking, VOR trng
Endurane, AMB, mobility trng
PNF