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Multiple Sclerosis (Symptoms (Motor (Spasticity (More common in LE…
Multiple Sclerosis
Symptoms
Motor
Weakness
Spasticity
More common in LE (hamstrings, hip flexors, quads, hip adductors)
Fatigue
80% of pts.
Visual
diplopia, fatigue, nystagmus, eye pain, blurring, discongugate gaze, blindness, scotoma
Balance and Coordination
ataxia, incoordination, dysmetria, dexterity
Pain 50%
Acute
trigeminal neuralgia, dural sensitization, dysesthesias
Chronic
Dysesthesias, spasms/cramps, musculoskeletal pain/dysfunction
Gait and Mobility
foot drop, vaulting, hip hike, trunk lean, circumduction
Sensory
Speech and Swallowing
25-40%, dysarthria, dysphonia, dysphagia
Depression
Cognition
50%, High level function (learn/remember, plan, problem solve, focus, maintain, shift attention), understand/use language, perceive environment, math
Emotion
Clinical depression, mood swings, irritability, uncontrollable laughing/crying
Sexual Dysfunction
Fatigue, spasticity, depression, self-esteem, mood. No change in fertility
Bladder
80% of pts. hesitancy, incontinence, nighttime urination
Bowel
constipation, incontinence, diarrhea
Dizziness and Vertigo
central or peripheral
Risk Factors
Exposure to virus or bacteria?
Geographic location further from equator for for first 15+ years of life
Genetics (general population: 1 in 750, close relative: 1 in 40, 80% don't have relatives affected)
Vitamin D deficiency
women 2-3x more likely than men
whites of northern European ancestry
smoking
Pathophysiology
immune mitigated disease
T-Lymphocytes attack myelin (oligodendrocytes (CNS) and schwann calls (PNS)) and also cause collateral damage to the axon via inflammation
Genetic and Environmental factors
most diagnosed 20-50 years old
lifespan = 95% normal
Major Subtypes
Primary-Progressive (10%)
slow worsening with no relapses or remissions
Secondary-Progressive (50% w/i 10 years)
R&R -> worsens steadily with flair-ups and recoveries
Relapsing-Remitting (85%)
attacks followed by full or partial recovery. no disease progression
Progressive-Relapsing (5%)
worsens steadily with flair-ups and no remission
Pseudoexacerbations
Temporary worsening of symptoms that resolve w/i 24 hours
Triggers: heat, exercise, stress
Medical Management
Medications
Anti-spasticity medications (baclofen, tizanidine, diazepam, dantrolene, botox)
"Ampyra" - dalfampridine: potassium channel blocker (improves walking speed)
CORTICOSTEROIDS (sensation, vision
intravenous methylprednisolone (vision)
Provigil (promotes wakefulness)
Vestibular Suppressants (Meclizine, Scopolmine)
Symmetrel (anti-influenza -> fatigue)
Anticonvulsant (gabapentin, lyrica) - acute pain
Antidepressants (amitriptyline), SSRIs (cymbalta)
OTC pain relievers
Disease modifying drugs (interferons, other immunomodulating agents)
Diagnosis
1) Evidence of damage to 2+ areas of CNS 2) damage occurring 1+ months apart 3) rule out all other diagnoses
MRI, EMG, spinal fluid analysis, medical history, neuro exam/tests
PT Management
Exam
Sensation
Pain
Affect and Psychosocial Function
Visual Acuity
Cognition
CN integrity
Fatigue
Krupp Fatigue Severity Scale
Temperature sensitivity
Muscle Performance
Motor Function
ROM
Posture
Balance, Gait, Locomotion
Skin Integrity
Aerobic Capacity and Endurance
Functional Status
FIM
Environment
MS Specific Measures
EDSS for pts. with PS
The Minimum Record of Disability (MDR)
MS Functional Composite (MSFC)
MS Quality of Life -54 (MSQOL-54)
MS quality of Life Inventory (MSQLI)
Functional Exam of MS (FAMS)
MS Impact Scale (MSIS-29)
Interventions
Fatigue
identify contributing factors, energy conservation, assistive devices, regular exercise, task modification, sleep hygiene, heat management
Spasticity
daily stretching
Exercise
Strength and Conditioning
proximal muscles
Aerobic Conditioning
mild-moderate
Flexibility
Coordination and Balance
vestibular rehab (central -> habituation, Peripheral -> adaptive/habituation)
ataxia
weight bearing, PNF, Frenkel's Exercises, aquatic therapy, Wii, Weighted Aids
Pain
posture correction, emphasize function, education, self-management
Locomotion
assistive devices and braces, shoes, environment modification
Sensory deficits and skin
skin checks, uptraining other systems
Functional Training
Speech and Swallowing
Cognitive Training
Education
Bladder
fluid management, medication, intermittent or continual catheterization
Psycho-social
steps of grieving, referrals, education, stress management, relaxation