Multiple Sclerosisa
- Neurologic disease that results in impaired and worsening function of voluntary muscles
- Autoimmune disorder affecting nerve cells in brain and spinal cord
- The primary symptoms of MS most commonly reported are fatigue,
depression, weakness, numbness, difficulty in coordination, loss of
balance, spasticity, and pain. Cognitive changes and contractures usually
occur later in the disease
- Causes: genetic, immune-mediated attack or infection
- Myelin is destroyed → demyelination of white matter of CNS
- Brain, spinal cord, optic nerves, pyramidal tracts
- Flow of nerve impulses is disrupted
- Plaque can occur on the demyelinated axon → axons
unable to regenerate → irreversible damage
- Most commonly affected areas: optic nerve, chiasm, and tracts; cerebrum,
brainstem, cerebellum, spinal cord
- Most common course is relapsing and remitting
- Chronic and progresses in severity over time
- Mostly found in northern temperate zones (europe, NZ, southern Australia,
northern US, southern Canada)
- Characterized by exacerbations and remissions
- Exacerbation - new symptoms appear and existing ones worsen
- Remissions - symptoms decrease or disappear
- Risk factors:
- 15-50 years old is most common age of onset (67% 20-40)
- Female
- Caucasian (asians least affected)
- Etiology unknown
- Not genetically transmitted
- Smoking
- Lack of vitamin D
- Exposure to Epstein-Barr virus
- Association with interleukin-7 and 2 receptor genes
- Relapse factors:
- Viruses
- Infectious agents
- Cold climate
- Physical injury
- Emotional stress
- Anxiety, loss of job, family issues
- Pregnancy
- Puts a great strain on the body - immune & circulatory especially
- Fatigue
- Overexertion
- Temp extremes
, - Hot shower/bath
- Pathophysiology
- Sensitized T cells stay in the CNS when they shouldn't → they
promote the infiltration of other agents that damage the
immune system → destroyed myelin + oligodendroglial cells
that produce the myelin
- Plaque appears on the demyelinated axon, which further
interrupts the transmission of impulses
- Demyelinated fibers
- Decreased nerve conduction
- Decreased nerve activity
- Initial myelin recovery
- Myelin destruction with disease progression
- Sclerotic plaque formation
- Research
- Environmental
- Virology
- Genetics
- No genetic link identified
- Immunology
- T-cell suppressor levels
- Activated T cells have the capability to open the blood brain
barrier to immune-cell trafficking. Once inside the CNS,
activated T cells secrete inflammatory cytokines that aid in
the destruction of myelin
- The balance between T helper cells 1 and 2 likely determines
the extent of disease
- B-cell response
- B cells secrete myelin-specific antibodies that may
contribute to MS pathogenesis by promoting phagocytosis
of myelin and lysis of oligodendrocytes by complement
fixation
- Types of MS
- Relapsing-Remitting - 85% of pt’s
- w/each relapse, there is usually complete recovery but
w/each relapse, residual deficits remain and accumulate over
time
- Relapse could occur every couple months or years or whenever.
Differs pt to pt
- Primary-progressive - 15%
- Causes debilitating symptoms w/o remission
- Disabling symptoms steadily increase with rare plateaus and
temporary minor improvement
- Can result in quadriparesis, cognitive dysfunction, visual loss,
brainstem syndromes
, - Secondary-progressive
- Most pt’s with RR progress to this
- Disease progression occurs with or without relapse
- Progressive-relapsing - 5%
- Relapses with continuous disabling progression b/w exacerbation
- This pop. Relapses w/ a continuous progression of the disease
process & its complications
- Signs & Symptoms
- Reflect on the location of the lesion (plaque) or lesions
- Mainly:
- Fatigue
- Weakness
- Depression
- Anxiety
- Emotional lability
- Go from flat affect to laughing at inappropriate times
- r/t meds and loss of control connections b/w cortex
and basal ganglia
- Anger
- Poor attention span & judgment
- Numbness
- Difficulty in coordination
- Loss of balance
- Ataxia or muscle weakness
- Ataxic gait
- Results from involvement of the cerebellum or basal
ganglia
- Spasticity in 90% of pts, usually in lower extremities
- Can include loss of abdominal reflexes
- Results from involvement of the main motor pathways
(pyramidal tracts) of the spinal cord
- Pain
- From lesions on sensory pathway
- Also: paresthesia, dysesthesia, proprioception loss
- CN 2, 3, 4, 6 are effected
- Visual disturbances due to lesions in optic nerves or their connections
- Blurring of vision
- Diplopia (double vision)
- Scotoma (patchy blindness)
- Total blindness
- Pain with eye movement
- Changes in peripheral vision
- Sexual dysfunction
, - Bowel dysfunction - constipation, incontinence
- Bladder dysfunction - areflexia, urgency, nocturia, incontinence
- Dysphagia & dysarthria (slurred and nasal speech)
- Assessment: Objective Data
- Motor Function
- checking for paresthesia, esp. in lower extremities
- When does it happen? What are you doing when it happens?
Intermittent or all the time?
- Strength of all muscles
- Romberg’s Sign (checks proprioception – stand up with feet
together, eyes closed; loss of balance = positive Romberg
sign)
- Sensory Function
- Cerebrum
- A&O x3? Judgement issues?
- Cerebellar Function
- Gait and balance check
- Cranial Nerves
- 2,3,4,6
- also checking swallowing and speech (check vagus and hypoglossal)
- Reflexes
- Hyper or hypo
- Bowel/Bladder Involvement
- ALL pt’s with MS have some bladder/bowel involvement
- Diagnostic Tests
- Hematology
- CBC, chemistry
- Urine
- Infections or proteins to r/o diabetes
- Cerebral spinal fluid
- Oligoclonal banding (bands of IgG bonded together)
- MRI
- Looking for plaque formation
- Visual Evoked Potential
- map out head, puts leads on it, show pics to stimulate brain
and see how they react to the pics on an EEG
- Blink reflex
- a lot of MS pt’s get a very drawn face and they lose their blink reflex
- Brainstem Auditory Evoked Potential - EEG but with auditory stimulation
- McDonald Diagnostic Criteria for MS
- Neurologic disease that results in impaired and worsening function of voluntary muscles
- Autoimmune disorder affecting nerve cells in brain and spinal cord
- The primary symptoms of MS most commonly reported are fatigue,
depression, weakness, numbness, difficulty in coordination, loss of
balance, spasticity, and pain. Cognitive changes and contractures usually
occur later in the disease
- Causes: genetic, immune-mediated attack or infection
- Myelin is destroyed → demyelination of white matter of CNS
- Brain, spinal cord, optic nerves, pyramidal tracts
- Flow of nerve impulses is disrupted
- Plaque can occur on the demyelinated axon → axons
unable to regenerate → irreversible damage
- Most commonly affected areas: optic nerve, chiasm, and tracts; cerebrum,
brainstem, cerebellum, spinal cord
- Most common course is relapsing and remitting
- Chronic and progresses in severity over time
- Mostly found in northern temperate zones (europe, NZ, southern Australia,
northern US, southern Canada)
- Characterized by exacerbations and remissions
- Exacerbation - new symptoms appear and existing ones worsen
- Remissions - symptoms decrease or disappear
- Risk factors:
- 15-50 years old is most common age of onset (67% 20-40)
- Female
- Caucasian (asians least affected)
- Etiology unknown
- Not genetically transmitted
- Smoking
- Lack of vitamin D
- Exposure to Epstein-Barr virus
- Association with interleukin-7 and 2 receptor genes
- Relapse factors:
- Viruses
- Infectious agents
- Cold climate
- Physical injury
- Emotional stress
- Anxiety, loss of job, family issues
- Pregnancy
- Puts a great strain on the body - immune & circulatory especially
- Fatigue
- Overexertion
- Temp extremes
, - Hot shower/bath
- Pathophysiology
- Sensitized T cells stay in the CNS when they shouldn't → they
promote the infiltration of other agents that damage the
immune system → destroyed myelin + oligodendroglial cells
that produce the myelin
- Plaque appears on the demyelinated axon, which further
interrupts the transmission of impulses
- Demyelinated fibers
- Decreased nerve conduction
- Decreased nerve activity
- Initial myelin recovery
- Myelin destruction with disease progression
- Sclerotic plaque formation
- Research
- Environmental
- Virology
- Genetics
- No genetic link identified
- Immunology
- T-cell suppressor levels
- Activated T cells have the capability to open the blood brain
barrier to immune-cell trafficking. Once inside the CNS,
activated T cells secrete inflammatory cytokines that aid in
the destruction of myelin
- The balance between T helper cells 1 and 2 likely determines
the extent of disease
- B-cell response
- B cells secrete myelin-specific antibodies that may
contribute to MS pathogenesis by promoting phagocytosis
of myelin and lysis of oligodendrocytes by complement
fixation
- Types of MS
- Relapsing-Remitting - 85% of pt’s
- w/each relapse, there is usually complete recovery but
w/each relapse, residual deficits remain and accumulate over
time
- Relapse could occur every couple months or years or whenever.
Differs pt to pt
- Primary-progressive - 15%
- Causes debilitating symptoms w/o remission
- Disabling symptoms steadily increase with rare plateaus and
temporary minor improvement
- Can result in quadriparesis, cognitive dysfunction, visual loss,
brainstem syndromes
, - Secondary-progressive
- Most pt’s with RR progress to this
- Disease progression occurs with or without relapse
- Progressive-relapsing - 5%
- Relapses with continuous disabling progression b/w exacerbation
- This pop. Relapses w/ a continuous progression of the disease
process & its complications
- Signs & Symptoms
- Reflect on the location of the lesion (plaque) or lesions
- Mainly:
- Fatigue
- Weakness
- Depression
- Anxiety
- Emotional lability
- Go from flat affect to laughing at inappropriate times
- r/t meds and loss of control connections b/w cortex
and basal ganglia
- Anger
- Poor attention span & judgment
- Numbness
- Difficulty in coordination
- Loss of balance
- Ataxia or muscle weakness
- Ataxic gait
- Results from involvement of the cerebellum or basal
ganglia
- Spasticity in 90% of pts, usually in lower extremities
- Can include loss of abdominal reflexes
- Results from involvement of the main motor pathways
(pyramidal tracts) of the spinal cord
- Pain
- From lesions on sensory pathway
- Also: paresthesia, dysesthesia, proprioception loss
- CN 2, 3, 4, 6 are effected
- Visual disturbances due to lesions in optic nerves or their connections
- Blurring of vision
- Diplopia (double vision)
- Scotoma (patchy blindness)
- Total blindness
- Pain with eye movement
- Changes in peripheral vision
- Sexual dysfunction
, - Bowel dysfunction - constipation, incontinence
- Bladder dysfunction - areflexia, urgency, nocturia, incontinence
- Dysphagia & dysarthria (slurred and nasal speech)
- Assessment: Objective Data
- Motor Function
- checking for paresthesia, esp. in lower extremities
- When does it happen? What are you doing when it happens?
Intermittent or all the time?
- Strength of all muscles
- Romberg’s Sign (checks proprioception – stand up with feet
together, eyes closed; loss of balance = positive Romberg
sign)
- Sensory Function
- Cerebrum
- A&O x3? Judgement issues?
- Cerebellar Function
- Gait and balance check
- Cranial Nerves
- 2,3,4,6
- also checking swallowing and speech (check vagus and hypoglossal)
- Reflexes
- Hyper or hypo
- Bowel/Bladder Involvement
- ALL pt’s with MS have some bladder/bowel involvement
- Diagnostic Tests
- Hematology
- CBC, chemistry
- Urine
- Infections or proteins to r/o diabetes
- Cerebral spinal fluid
- Oligoclonal banding (bands of IgG bonded together)
- MRI
- Looking for plaque formation
- Visual Evoked Potential
- map out head, puts leads on it, show pics to stimulate brain
and see how they react to the pics on an EEG
- Blink reflex
- a lot of MS pt’s get a very drawn face and they lose their blink reflex
- Brainstem Auditory Evoked Potential - EEG but with auditory stimulation
- McDonald Diagnostic Criteria for MS
