Multiple Sclerosis - Summary of MS PDF

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Multiple Sclerosis 02 November 2020 18:35

- Progressive Auto-immune inflammatory disease resulting in demyelination of CNS neurons ○ Varibale and unpredictable - Chronic inflammatory demylinating auto-immune disease ○ Characterized by chronic inflammation, demyelination, gliosis and neural loss ○ Inflammation stripes myeline from nerve --> leading to axonal death - Sclerosis = scarring (referred to as plagues) ○ Lesions in CNs occur at diff times and in diff CNS location ○ Involves Multiple Scars of the myeline Sheath (white Matter) - Starts in two ways: Individual relapses (atks/ exacerbations) or gradual progression - 4 Diff types of MS (see pathophysiology section) ○ Benign ○ Relapsing remitting MS ○ Secondary progressive MS ○ Primary progressive MS

Epidemi - Variability of prevalence of Ms with latitude (linked to Vit D deficiency ) iology • Equatorial region 100 per 100000 - Less clearly defined in Southern Hemisphere

Statistic - F:M = 2:1 or 3:2 (?) - Mean age at onset 30 yrs • Diagnosed between ages of 20-50 • 0.3% younger than 10 years • >50 yrs (rare) • Don’t seek medical attention until symptoms have progressed enough - UK MS poopulation: 110,000 - 127,000 (2010) - Number grows by approx. 2.4% per year

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• improved diagnostic testing --> accuracy and speed to identify • People at later stage of disease tend to survive longer now : meds, service - Prevalence in Scotland ↑209 per 100,000 Socio-economic impact 50% of people with MS leave their jobs within a decade of diagnosis Health & social services costs are £25,000 per person

Aetiolo - Specific cause unknown gy - Need more than just genes to cause MS Risk/ Causation Factors - Environment: Vitamin D • MS appears to be more common in areas farther from equator (colder climate area) • Vitamin D (from sun) may increase immune function, protect body against autoimmune disease • Low vitamin D • Low UV radiation exposure • EBV exposure - Genetic • Susceptibility is inhertited, but disease not inherited • Increase riks if first-degree family member has the disease • (But Ms is not considered hereditary) • MHC and non-MHC genes are risk factor for MS development ○ MHC -- determine immune repertoire ○ Non-MHC gene --- determine regulatory and tolerance mechanisms in MS - Infectious (trigger instead of immediate cause) • Virus and other infectious agents may possibly be triggers for onset of MS --> trigger immunipathology in MS - Cigarette smoking • Lung damage makes CNS more vulnerable to atk - Obesity -- esp if obese in early age

Signs Present typically with episodes of relapse initially but with accumulation of disability over time and Symptoms at any Stage of MS Sympto - Fatigue - Cognitive impairment ms - Sensory loss - Immobility - Incontinence - Pain - Spasticity - Ataxia - Tremor - Pressure Sores - Dysarthria - Dysphagia - Sexual dysfunction - Contractures Global Symptoms

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Early Symptoms (typically acute and followed by period of remission with complete/ partial recover) - Numbness and weakness in 1/+ limbs progressing from paresthesias - Fatigue - Respiratory problem: speech and breathing difficulty ○ Worsen as MS progress - (rare) hearing loss --> mostly can resolve on its own - Cranial Nerve symptoms ○ Difficulty speaking, swalling, ○ Vision problem: tracking object Other common sypmptoms - Pain: Headache, chronic neuropathic pain, paroxysmal limb pain - Cognitive symptoms: ○ One of the most disabling feature of MS ○ Progressive ○ Occur v early and often before onset of other symptoms ○ Short term memory deficit ○ Diminished executive function ○ Diminished attention/ concentration - Depression ○ Esp younger people - Anxiety - Motor system ○ Cerebellum Disruption -- spinal cerebellar tract ○ Ataxia (tremor) --- present in 58% of well-established MS cases ○ Nystagmus (eye movement) ○ Weakness, numbness, tingling ○ Spasticity ○ Tend to affect UL>LL ○ Spams ○ Difficulty walking ○ Muscle stiffness ○ Impaired balance and coordination - Dysarthria (speech) - Dysphonia - Cranial Nerves ○ 5th and 6th cranial nerve most commonly affected as disease progress ○ Trigeminal neuralgia ○ Dysphasia (sepaking)

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○ Dysphagia (swallowing) ○ Optic neuritis (presenting symptom in 20% of cases), saccades - Uhthoff's Sign - Response people have to heat --> heat increase fatigue - Worsening of neurological symptoms of MS after periods of exercise and increased body heat - Lhermitte's sign - Feeling like an electric shock down the spine - May radiate down arm and legs, when head is flexed forward

- Bladder/ Bowel symptoms ○ Spastic/ flaccid bladder ○ Constipation ○ Diarrhoea ○ Incontinence - Sexual symptoms ○ Due to damage in nerves that send info to sexual organs ○ Can also be caused by other MS symptoms eg) fatigue, spasticity and mood ○ Impotence ○ Decreased libido ○ Decreased ability to achieve orgasm Factors That Affects Symptoms - Symptoms develop as the cumulative result of multiple lesions in the CNS - Increase in symptoms can occur with an increase in body temp --> cuz many MS patients have sensitivity to heat - Type of MS - Stage of relapse/ remission Systemic Involvement - MSK system • Common symptoms: Muscle weakness, numbness, tingling --> due to demyelination • Complications: reduce coordination, balance, gait and fine motor skills --> due to difficulty of signal sending from brain to muscle through nerves • Symptoms may worsen as MS progress • Increase risk of bone fracture and osetoporosis --> due to use of steroid and inactivity • Sensory motor system ○ Due to involvement of corticospinal tract (demylinating affecting this particular dscendning spinal tract) ○ Esp motor singal from cerebral cortext to motor neuron in spinal cord ○ Sensory impairment ○ Weakness ○ LL flexors ○ UL extensors ○ High tone

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- Nervous system • Leads to expose of nerve --> creates disconnect between brain and body • impacts the brain with symptoms such as memory loss, confusion, dizziness, vertigo, personality changes, depression and less commonly, seizures • Cranial Nerve: - Emerge directly from brain and relay info to and from region of head and neck (primarily) - 5th and 6th cranial nerve most commonly affected as disease progress ○ Trigeminal Nerve and Ocular motor nerve - Common symptoms ○ Pain around jaw area ○ 5th Cranial nerve (speech) ○ Dysphasia: Difficulty speaking ○ Dysphagia: difficulty swallowing ○ 6th Cranial Nerve (visual) ○ Optic neuritis: difficulty scanning and tracking objects in the environment around

• Cerebellum - Spino-cerebellar tract (ant & post):  Controls non conscious coordination of mvt  Take info from muscle spindles and stretch receptors (for info on position and movement) --> for smooth coordination (non conscious) ○ Damage: lack of consistent messaging --> leads to inaccuracy ○ Common symptoms:  Ataxia: Fine tremour □ Lack of voluntary coordination of muscle activity □ Effects timing and duration of muscle acitivity □ Can be observed in other area of body --> affecting speech, eye mvt to tract object, swallowing - Visual system • Visual impairments due to inflammation and fatigue to eye muscles • Temporary in most cases • Common first symptom of MS : visual disturbance (one or both eyes) • (rare) hearing problem ○ Due to damage to brain stem ○ Most commonly resolve on their own - Respiratory System • Reduced function in respiratory muscles due to nerve damage • Can cause speech and breathing difficulties - Autonomic System • MS damage nerves that control bladder and sphincter function can occur • Bladder become ○ spastic: -- unable to empty urine properly ○ Flaccid --- unable to hold urine • Complication: loss of bowel control and constipation - Integumentary system • Higher risk of skin breakdown -- >due to sensation loss, heat sensitivity, muscle weakness/ paralysis and

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Pathop MS Type hysiolo gy

- Benign --- 5-10% ○ Mild symptoms with little permanent deficit ○ Little to no disease progression --> symptoms stable for 20-30 years - Relapsing/ Remitting (RRSMS) --- 85% (2-3X more common in Women) ○ Short attacks to CNS followed by a complete/ partial return to normal functioning ○ Remission  no symtpoms at all/ stable (vary intensity from day to day)  Can last for months to year ○ Relapse  sudden appearance of new symptom / reappearnace of all symtpoms  Usually after relapse, patient wont go back to previous level of activity □ Then there is a steady progression of symtpoms over prolonged period of time ○ Usually diagnosed when 20-30s ○ Common symtpoms during this stage  Problem with eye site  Reduce cognition  Pin and needles  fatigue ○ Periods of relapse followed by partial recovery  Relapse caused by resurgence of inflammatory process which increase symptoms  As inflammation is reduced, symptoms decrease ○ Overall presentation is of gradual deterioration

- Secondary Progressive ○ Usually after ~15 yrs of RRSM, developed by 2/3 of patients ○ Progression of RRSM, with longer period of deterioration that last >6 months  W/out remissions, but commonly Don’t get period of remission  Symptoms are less effected ○ More severe type of MS - Primary Progressive --- 10% ○ Progressive from the very start ○ No periods of remission ○ Subtle steady progress (decline)over time Process of MS In Summary - Inflammation in the area destroys the myelin and the oligodendrocytes - After tissue destruction, a scar forms = MS plaque/lesion - Inflammation and scarring reduce/ block impulse transmission - Intereference of impulse transmission between axons leads to altered functio

1)Auto immune response of CNS - Trigger often unknown - Autoreactive T cells against myelin compenets are exists in normal individuals --> do not cause diease

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- MS induced when pathgenic Th12 and Th1 type and CD8 myeline autoreactive T cells are induced ○ Progressive MS: chronic activation of peripheral T cells and innate cells - Immune system is directed against CNS ○ T cells become sensitized to CNS proteins ○ T cells activated and enter CNS through blood vessels --> produce damaging inflammation 2)Inflammation of CNS - Immune cause inflammation within CNS --> damage nerve structures - Inflammatory response causes furthur swelling, activation of macrophage ○ Start to indulge and digest body's own system

3)Demylination - Inflammation destroy ○ 1) myeline, ○ 2)oligodndrocytes (specialized cells that make myeline) ○ 3) axons - Demyelination result in thinning of myeline --> loss of nerve axons ○ Communicatino between diff parts of CNS is slow, inaccurate and non-functional - Common site of demyelination ○ Cerebral cortex --> M1, planning, organisation ○ Brain stem ○ Spinal cord ○ Basal ganglia --> learnin g and memory ○ Cranial Nerves ○ Cerebellum --> and its afferent and efferent fibres are commonly affected - Lesion/ plaques occur in white matter of CNS, where myeline is under demylination - Scar forms after tissue destruction --> MS plaque 4)Abnormal conduction of nerve impulses - Inflammation and scarring reduce/ block impulse transmission - Interference of impulse transmission between axons --> lead ot altered function

Structure affect - Lesions scattered randomly throughout ○ Cerebral hemispheres ○ Brainstem (including cranial nerves and vestibular system) ○ Cerebellum ○ Spinal cord (including descending and ascending tracts) ○ Optic nerve and chiasma Impact - Can cause lumbar radiculopathy Co-morbidities -

Ax - Diagnosis

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○ There must be a history of at least 2 atks and clinical evidence of 2 separate lesions ○ Corroborative clinical, laboratory and radiological evidence ○ MRI  To detect MS plaques (found in white matter of brain and spinal cord) ○ Lumbar puncture  local production of immunoglobulin within the CSP  Needle is inserted into the lumbar spine to remove a small amount of cerebral spinal fluid --> brought to lab for analysis  Fluid testing for abnormal amount of white blood cells, proteins and other abnormalities ○ Evoked potentials  measures electrical signals in nerves sent from brain in resposne to a stimulus  Stimulus can be visual/ electrical in origin  To detect is there a lesion to nerve in optic nerve, brain stem and spinal cord --> even if person is not showing any nerological signs/ nerve damage

- Aid in differrential diagnosis ○ Used by national multiple sclerosis society ○ "VITAMINS"  Vascular: Multiple lacunar infarcts; CADASIL; spinal arteriovenous malformation  Infectious: Lyme disease; syphilis; HIV myelopathy; PML; HTLV-1 myelopathy  Traumatic: Spondylitis myelopathy  Autoimmune: NMO; acute disseminated encephalomyelitis; CNS vasculitis; Behcet syndrome, sarcoidosis; SLE  Metabolic/Toxic: Central pontine myelinolysis; vitamin B12 deficiency; vitamin B6 deficiency; radiation; hypoxia  Idiopathic/Genetic: Spinocerebellar degeneration; Friedreich ataxia; Arnold-Chiari malformation; adrenoleukodystrophy; metachromatic dystrophy  Neoplastic: CNS lymphoma; glioma; paraneoplastic encephalomyelitis; metastatic cord compression  pSychiatric: Conversion disorder. - Track progression of MS --> be aware of relapsing and remiting stage - Posture - Movement - Function - Proprioception: only single joint mvt ○ Cuz prob have damage to both limbs --> mirroring not feasible: you dk is it cuz of signals or bad priocpetion Things to Consider when planning Ax - Cognitive function' ○ Affect how they engage with Ax and Tx  Attention, working memory, speed of info processing, learning --> tailor approach ○ Often not notice as its less obvious comparing to other symptoms in an early stage - Spasticity ○ Progress slowly to be more and more problematic ○ Ax of tone need to be accurate and reliable --> feel stiffness during all part of mvt

Tx Medical Management - Disease modifying drug therapy ○ https://www.mssociety.org.uk/about-ms/treatments-and-therapies/disease-modifyingtherapies ○ To slow preogress/ reduce no. of MS atks ○ Not cure for MS ○ Commonly used for decreasing relapses in patients with RRMS ○ Risk: can cause individual to become susceptible to serious side effects ○ Beta interfernon  In wales, can have interferon if: have relapsing Ms and had recent relapse/ MRI scan showing new signs that MS is active (new lesion)  Injected under skin everyday

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 1a (Avonex, Rebif)  1b Betafernon - Supportive drug therapy --> Relapses (Corticosteroids) General Management - Pain - Spasticity - Intention Tremor - Bladder - Bowels

PT management National clinical guideline: https://learningcentral.cf.ac.uk/courses/1/2021-HC2217/content/_ 5579604_1/NICE%20for%20%20MS.pdf - Resistance training ○ Supervision and education is key when introducing exs. ○ Closed chain exercises is preferred for safety ○ Frequency: 2-3 times weekly ○ Intensity: 8-15 RM with 60-70% of 1RM ○ Gradually progress to 8-10RM but be flexible (fatigue) ○ Whole body programme incorporating large muscle grou ○ with 5-10 multi-joint exercises ○ Special precaution should be given to fatigue, heat intolerance and falling - Hydrotherapy: promotes general health - Aerobic training ○ Recommended to work in submaximal level (40-60%)  use borg scale  RPE (Borg Scale) = 11-13

○ (low to moderate intensity) : aerobic fitness and reduction of fatigue ○ Split exercise duration depending upob ability - Balance ○ Postural control ○ Gait - Exercise --> cognitive and fatigue and motor impairment

Aim: - Re-educate and maintain all available voluntary control - Re-educate and maintain postural mechanism - Incorporate tx tech into ways of life --> daily living acitivty To be aWarE of - Fatigue ○ Due to sleep --> may need other proffesional to help ○ Prevent sections to be over structuring - Anxiety - Depression - Environment: temp of room

Early Stage (minimal impairment) - Educate on disease progression and compensatory strategies to conserve energy

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- Emphasis outdoor movement (esp with sun light) - Educate: ○ Structured and individually tailored exercise program have +ve effect on fatiguing symptoms - Facilitate normal - Avoid abnormal (compensations) - Maximise Postural control ( central stability) - Treat physical problems as appropriate - Refer on as appropriate - Advise – work, aerobic exercise, fatigue, re-access to services in the future

Moderate Stage (moderateimpairement + require assitance) - Maintain - strength, posture, ROM and standing - Maximise postural control (central stability) - Maintain/ adapt aerobic activity - Education - Advise and issue of orthotics/ walking aids - Improving and maintaining motor function: strength, endurance flexibility, balance, respiratory respiratory training and assistice device - Educate posture -> prevent furthur complications

Advance Stage (severe impairement) - Maintain ROM, posture - positioning - Transfers - Wheelchair mobility - Chest care - Skin care - Weight bearing activities - Education of carers - Maximize independence: ○ postural ○ ADL triaining ○ respiratory function ○ safety and prevention strategies (for contracture development/ pressure wouds) ○ equipment suggesions ○ Proper transfer technique MDT

- Clinical Specialist Nurse ○ Manage caseload of patients across the disease trajectory ○ New diagnosis support

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Patient education, focusing on self management Order diagnostic investigations Make & receive referrals Admit & discharge patients Run treatment assessment, initiation and monitoring clinics Telephone triage patients and help them access appropriate interventions – specialist MDT or local MDT support, rapid access clinics, secondary or tertiary admission, primary care support, social services, home visits or local symptom management clinics ○ Run symptom management clinics --> Relapse/ Exacerbation of symptoms? - MS relapse: □ old MS symptoms must have become worse or new symptoms appeared Most people with MS experience some symptoms continuously, but between relapses this background level will remain more or less stable. It’s when symptoms change that you may be having a relapse. □ symptoms must last for at least 24 hours However, relapse symptoms generally last for days, weeks, or even months. □ symptoms must occur at least 30 days from the start of the last relapse MS symptoms should have been stable for about one month before symptoms become worse or new symptoms appear. □ there must be no other explanation for the symptoms Heat, stress, infections and other factors can make symptoms worse and can be mistaken for the start of a relapse. When these factors are resolved, your symptoms should improve. ○ ○ ○ ○ ○ ○

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Prescribe, review or make recommendations around medication Advanced decision making Influence provision of local services Help patients negotiate their healthcare journey Coordinate care --- liaise with, educate and upskill other health professional and broker and plan care - When patient have bladder symptom --> consider possible reasons and possible referals

- determine normal (patient have diff perception of frequent urination) - Other Things to consider:

environmental change/ adaptation Key Guidelines

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- National clinical guideline: https://learningcentral.cf.ac.uk/courses/1/2021-HC2217/content/_ 5579604_1/NICE%20for%20%20MS.pdf - Convept of pacing ○ Preserve energy for patient to do what they wanna do the most ○ Therefore some days can be less active to conserve energy (less energy consupmtion activities)

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