MULTIPLE SCLEROSIS
MS is a chronic, progressive demyelinating disease of the CNS characterised by an inflammatory process - causing widespread degeneration of the CNS - gradually resulting in severe neurological deficit
triggers of MS
Infection
Vaccination e.g. epsine bar
pregnancy
trauma e.g. whiplash
emotional stress
Environmental factors
Viral factors
genetic factors 1.5% chance
Deficiencies in diet - vitamin D
Pathology of MS
Disruption of the blood brain barrier - cells that prevent inflammatory cells going into brain
Leakage of inflammatory cells - attack brain cells
Destruction of oligodendrocytes and myelin sheath - axons in CNS
Disruption of nerve signals, rate of conduction of nerves is slowed down
Plaques form throughout the CNS (anywhere)
'Sclerosis' means 'scaring' and 'multiple' relates to the sites of the scarring, which can occur in different places throughout the brain and spinal cord
Types of MS
Silent/ benign
Relapsing-remitting
Secondary progressive
Primary progressive
Initial Symptoms
Limb Weakness 40% - start tripping over often
Optic neuritis 22% - change in vision - inflammation of optic nerve
Parasthaesia 21% - sensory depesit
Diplopia 12% - double vision
Vertigo 5% - feeling movement when there is no movement
Micturition problems 5% - unable to control bladder
Diagnosis
Clinical history - diagnosis of exclusion
Lumbar puncture to test CSF - identify antibodies - oligoclonal bands
Nerve conduction tests e.g. auditory evolved potentials (PNF problem or CNF problem)
MRI scan - start to see plaques on MRI scan
MS relapse
Clinical event usually seen in MS
Must last at least 24 hours
Objective findings needed - symptoms alone don't count
The event cannot be a temporary worsening die to fever or infection (UTI) - pseudo attack
To be a distinct (new) attack - onset of clinical event needs to be at least 30 days after previous attack
a single paroxysmal episode (tonic spasm) does not count as a relapse but several over 24 hours or more does equal an attack
Treatment
IV Methyl Prednisolone 1 g/day for 3/7 (steroid)
Oral Methyl Prednisolone 500mg/day or 10/7 with Ranitidine 150mg bd for 10/7
do not five low prolonged steroid Rx
need Rx early (days to first 4weeks - exclude an infection
Plasmaphoresis - take out problematic plasma + antibodies + reintroduce healthy plasma
Can have immune system whipped out + replaced - v. expensive + not available on NHS
Medial treatment for symptoms
Anti-spasticity agents and relaxant - baclofen (common but centralising), tizanadine, Clonazepam, medicinal Canabis (called Satibex only if everything else fails first)
Neuropathic pain - Gabapentin, Pregabalin, Amitriptyline, Carbamazepine) needs specific medication
Antidepressants, Analgesia (pain relief)
Bladder problems - anticholinergic drugs - Regurin, Desmopressin - nocturia, Pelvic floor exercise, intermittent catheterisation
Diet - linoleic acid, fish oils, vitamin D
Hyperbaric oxygen - helps recovery from relapse
Prognosis
Highly variable, difficult to predict
Earlier age at diagnosis favours slower onset of progression - more rapid after age 40
only 50% still walking unaided 15 years after diagnosis
Health related quality of life is average 30% lower than age matched population
Suicide risk 7.5x national average
Wide variation on impact of lifespan - common causes of death are chronic bed sores, urogenital sepsis and aspiration or bacterial pneumonia
Outcome measures
Stage and severity of disease - expanded disability status scale
Function/ participation - impact of MS in daily life - MSIS-29
Activities - Impact of MS on walking - MSWS-12
Impairments / activates e.g. balance, functional reach test
Symptoms/treatment technique
Sensory Loss - Compensatory Strategies, Functional Activity Practice
Dizziness and Poor Balance - Balance exercises, Gait re-education
Visual Problems
Fatigue - Fatigue management
Decreased Intellectual Function
Spasticity and hyperreflexia - Specific stretches
Sphincter disturbance and sexual dysfunction - Education + specific strengthening exercises
Weakness - Specific strengthening exercises
Psychiatric, psychological disturbances
Ataxia and poor coordination