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61 Cards in this Set
- Front
- Back
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What is MS?
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Autoimmune dx thtattacks myelin in the CS. Episodes of inflammation that damage the myelin sheath causing scarring
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4 types of MS
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Relapsing/remitting
Primary progressive Secondary progressive Progressive relapsing |
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Describe relapsing/remitting MS
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Clearly defined relapses, or episodes of acute worsening, followed by recovery and disease stability
S/s go away completely during remission |
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What is relapsing/remitting MS with exacerbation?
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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
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Describe Primary Progressive MS?
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Continuous worsening, or steady progression, not interupted by distinct relapses
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Describe secondary progressive MS
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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
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Second type of Primary Progressive with plataue
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You may plataeu for a period of time, but you continue to get worse - never better
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Describe progressive relapsing MS
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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.
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Early signs of MS
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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 |
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How do you make a diagnosis of MS?
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Separation of time and space
At least 2 bright spots on MRI (with contract gabolineum) and 2 attacks |
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How do you perform the MRI when trying to diagnose MS?
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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 |
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10 common signs/symptoms after diagnosis of MS
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Fatigue
Diff w/ AMB Visual disturbances Cognitive isues B&B issues Sexual issues Sensory disturbances Motor problems Balance/vestibular problems Swallowing/speaking problems |
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Two types of fatige expereinced by the MS patient
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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 |
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Symmetrel
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Dopamine agonist used to combat central fatigue
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Modafanil
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AKA profitual to combat central fatigue
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Why does the MS pt often have trouble with AMB?
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Weakness/paresis
Spasticity/hypertonicity Cerebellar issues = uncoordination, wide gait, balance trouble 87% have gait problems |
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Typical visual distrubances experienced by MS patient?
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Optic neuritis, double vision
Peripheral visual defecits and blind spots |
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What type of cognitive issues may an MS pt have?
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Frontal/parietal involvement = memory, executive fxt, problem solving, judgement, impulsitivity, dec processing
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What type of B&B problems do MS pts have?
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Start out with spastic bladder that may become flaccid
65% |
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What type of sexual dysfxts may an MS pt have?
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Impitence
"difficulty" wiht intercourse for females |
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What type of sensory distrubances do MS pts typically have?
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Paresthesia, dysesthesia (burning, stabbing) in specific distributions, but non-dermatomal
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Lhermitte's sign
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Flex neck and pain goes down the arm..pins and needles.
Common for MS pts I guess |
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What type of motor problems does the MS patient have?
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UMN issues
Weak, paresis, spasticity, Inc DTR, clonus, abnomral reflexs |
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What type of swallowing/speaking problems does the pt with MS typically have?
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Once disease has progressed
Dysarthria, slurred speech, dysphonia (hoarsness), dysphagia - difficulty swallowing/eating |
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Bad prognostic indicators
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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) |
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Good prognotic indicators
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Female, <35 at onset
One area of involvement Complete recovery after attacks Lower lesion burden (count # on MRI) |
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5 disease modifiers for MS
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Heat
Stress Avoid fatigue (plan day out) Infection Trauma |
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Uhtoff sign
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S/s of MS increase with warmth
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Why may infection trigger a excaberation?
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Inc body temp (heat).
These pts are given anti-immune drugs so they are at high risk for infection - inc heat associted with infection |
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What chromosome is implicated with MS?
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6
Person may have genetic factor/suseptibility, but it takes an ENV trigger to express itself |
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2 clinical tests that may be performed to indicate MS as diagnosis?
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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 |
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How may T cells or B cells be implicated in the dx process?
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T cells: recognize myelin as foreign and launch attack
B cells: Produce ABs that cause scarring of tissue |
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What three types of cells may T cells differentiate into and how do they attack myelin?
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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 |
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How can immune cells get through the BBB to attack myelin?
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Soluble cytokines (ie. Interferon Gamma and interleukins) can get thru BBB of CNS and attack myelin due to increased permeability caused by the cytokines
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What do oligodendrocytes do?
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Can remyelinate, but can't keep up as disease progresss
Trying to use stem cells to inc oligodendrocyes |
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What do astrocytes do?
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Come to demyelinated area, attach themselves and prevent remyelination and cause plaqu formation (scarring) of myelin
Research trying to decrease these |
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What is the FSS and EDSS?
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Functional Systems Scores (FSS) and Expanded Disability Status Scale (EDSS)
FSS grades dif fxts and the EDSS evaluates these fxts |
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What systems does the Functional Systems Scores (FSS) look at?
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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 |
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How is the Expanded Disability Status Scale (EDSS) determine grading?
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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 |
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When are corticosteroids used for MS? Are they dx-modifying?
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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
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Adverse effects of glucosteroids?
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Gives you energy
CAn't sleep, nervousness/agitation Psychoses and anxiety |
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What glucosteroids may a pt be given? Names and administration?
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Dexamethasone = oral
Solumedrol = IV |
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In general, what do dx-modifying drugs do?
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Dec exacerbation severity
Inc time in between attacks |
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What is MBP? How does it work?
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Myelin Basic Protein from cows
Affective for relapsin MS |
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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 |
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What is the purpose of dx-modifying drugs?
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To stop proliferation of T cells
Stop B cells from making ABs |
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3 types of Interferons used to treat MS. What type of MS do each treat?
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Interferon B Ib: Betaseron (relapsing)
Interferon B Ia: Avonex (replapsing) Interferon B Ia: Rebif (relapsing) |
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Administration of Betaseron, Aonex, and Rebif
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Betaseron: SubQ every other day
Avonex: Intramuscular 1/week Rebif: SubQ 3x/wk |
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Adverse effects of Avonex and Rebif
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Avonex: flu-like s/s, effect liver fxt and cardiac system
Rebif: flu-like that lessen and injection site rxt's |
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What do Interferons do in general?
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Suppress immune fxt and action of T cells
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What is Monoclonal Antibody Tx? Example of drug and how does it work?
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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 |
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Administration for Tysabri (Natalizumab), type of MS and adverse effects
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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) |
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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 |
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What do you need to take with Rituximab (Rituxen)? Why? Consequences?
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Corticosteroids to avoid severe allergic rxts
Very immunosuppressed = pneumonia and UTI However, side effects are less than Tysarbri (Natalizumab) |
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Two drugs aimed at the B cells
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Tysabri (Natalizumab)
Rituximab (Rituxen) |
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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 |
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Why do doc's not like to prescribe Novantrone (Mitoxantrone)?
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Bone marrow suppression - fatigue, bruising, low blood cell count
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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 |
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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 |
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Laundry list of things to include in PT eval
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Mental status and communication
Vision and sensation Endurance/fatigue, strength, ROM, tone Coordination and balance CV and CN Functional activites (ADLs, bed mobility, transfers) |
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Laundry list of tx strategies you may use with your patient
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Strengthening, ROM, and stretching
Balance trng Sacaad, tracking, VOR trng Endurane, AMB, mobility trng PNF |
