Multiple Sclerosis (MS) Overview

• Multiple Sclerosis (MS) involves multiple scar and plaque formations in the Central Nervous System (brain and spinal cord).
• Sclerosis refers to the hardening process that occurs in MS.
• It is a rare condition affecting 30 out of 100,000 people.
• MS is more common among women aged 20-40 and among Caucasians.
• MS was first described in 1868 by Jean-Martin Charcot.
• MS is an immune-mediated, chronic, progressive, degenerative disease.
• The condition shows periods of remission and exacerbation.
• MS involves randomly scattered patches of demyelination in the brainstem, cerebrum, cerebellum, and spinal cord.
• Demyelination leads to impaired transmission of nerve impulses.
• Twice as many women are diagnosed with MS compared to men.
• The exact cause of MS remains unknown.
• Viral infections combined with autoimmunity may contribute to MS.
• Epstein-Barr virus (EBV), hepatitis, and Herpes Zoster are possible infections leading to MS.

Theories: Predisposing Factors

• Genetics indicates a specific cluster (haplotype-DNA variation).
• Infections might contribute to the onsent and exacerbation of MS
• Environmental factors, particularly geographic location, play a role.
• Severe stress and smoking are considered predisposing factors.
• Intake of aspartame may be related to developing MS.

Pathophysiology

• Sensitized T&B lymphocytes cross the blood-brain barrier (BBB).
• In MS, sensitized T cells remain in the central nervous system (CNS).
• T cells recognize myelin as foreign.
• Inflammatory processes are triggered.
• The body attacks the myelin as if it were an invading virus.
• Plaques and demyelinated axons occur.
• Axons begin to degenerate.
• MS results in permanent and irreversible damage.

Types & Courses

• Relapsing-Remitting MS is characterized by acute attacks with full recovery or residual deficit.
• Primary Progressive MS is a disease showing progression of disability from onset without plateaus.
• Secondary Progressive MS begins with an initial RR course, progressing at a variable rate, with occasional relapses and minor remissions.
• Progressive-Relapsing MS shows progression from onset with clear acute relapses with or without recovery.

Clinical Manifestations

• During exacerbations, new symptoms appear and existing ones worsen.
• During remissions, symptoms decrease or disappear.
• Signs and symptoms are varied, reflecting the location of lesions or combinations of lesions.

Primary Symptoms

• Fatigue and weakness.
• Depression.
• Numbness.
• Difficulty in coordination, loss of balance, and pain.
• Visual disturbances are caused by the demyelination of cranial nerve II.
• Visual disturbances include blurring of vision, diplopia, and patchy blindness-scotoma
• Visual disturbances may even include total blindness
• Heat and Depression
• Anemia and Deconditioning (weakness)

Sensory Manifestations

• Pain
• Paresthesias
• Dysesthesias
• Spasticity of the extremities
• Behavioral and emotional lability, euphoria, and depression.
• Uhthoff Sign is worsening of vision caused by hot temperature, often the first sign of MS.
• Increased temperature slows or blocks nerve transmission.
• Lhermitte's Sign is an electric shock-like sensation radiating down the spine to the legs and arms when the neck is moved.
• Triggers for Uhthoff's phenomenon include hot and humid weather, saunas or hot tubs, hot showers or baths, fever, hormonal fluctuations, direct sunlight, using a hairdryer and exercise.
• Cognitive changes include memory loss and decreased concentration.

Impaired Cerebellar Function

• Scanning speech, such as "Walking is good exercise" sounding like "Walk (pause) ing is good ex (pause) er (pause) cise."
• Intention tremors occur, not when sedentary
• Nystagmus
• Ataxia
• Dysarthria (poor speech articulation)
• Bladder, bowel, and sexual dysfunctions may also be present.

Diagnostic Findings

• MRI reveals scattered patches of scar/plaque (>5mm) in the CNS.
• Cerebrospinal fluid studies show protein electrophoresis with IGs separated from CSF, indicating (+) oligoclonal bands.
• CT scans can be ran as well
• EEG can be helpful as well

Medical Management

• There is no known cure for MS.
• Treatment goals include attempting to return function after an attack.
• Treatments try to prevent new attacks, prevent disability, and delay the progression of the disease.

Pharmacologic Therapy: Disease-Modifying Therapies and Immunosuppressants

• Corticosteroids such as prednisone (Deltasone, Liquid Pred, Orasone, Prednicen-M) and methylprednisolone (Medrol, Depo-Medrol) can be prescribed.
• Corticosteroids work by down regulating or inhibiting inflammatory factors
• Interferons have the ability to regulate the immune system and protect against intruders, including viruses.
• Interferons are useful in managing MS, examples Beta 1a: rebig; beta 1b: betaseron (SQ).
• Glatiramer Acetate (Copaxone) increases suppressor T cells, administered SQ daily.
• Baclofen (Lioresal, a GABA agonist) is used for spasticity.
• Benzodiazepines (Valium), Tizanidine (Zanaflex), and dantrolene (Dantrium) are useful for spasticity

Symptom management

• Fatigue is managed with amantadine (Symmetrel), pemoline (Cylert), or fluoxetine (Prozac).
• Ataxia is managed using beta-adrenergic blockers (Inderal), antiseizure agents (Neurontin), and benzodiazepines (Klonopin).
• Bowel and Bladder problems
• Anticholinergics (probanthine; oxybutynin) are used for incontinence/frequency.
• Cholinergics (Bethanechol; Neostigmine) address retention.
• Pain can be addressed with gabapentin, carbamazepine, and amitriptyline.

Nursing Diagnoses

• Impaired physical mobility related to weakness, muscle paresis, and spasticity.
• Risk for injury related to sensory and visual impairment.
• Impaired urinary and bowel elimination.
• Disturbed thought process related to cerebral dysfunction.
• Potential for sexual dysfunction related to lesions or psychological reactions.

Nursing Interventions

• Promote physical mobility with exercises such as walking.
• Use assistive devices like canes, crutches, or walkers.
• Minimize spasticity and contractures with warm packs, daily exercises, stretch-hold-relax routines, swimming, and stationary bicycling.
• Allow enough time to do activities; avoid strenuous exercise; take frequent short rest periods.
• Help Prevent Injury by teaching gait training on how to walk with feet apart and use weighted bracelets or wrist cuffs for coordination.
• Enhancing bladder and bowel control is achieved by heeding the sensation of needing to void immediately.

More Interventions

• Maintain a voiding time schedule.
• Use adequate fluids and dietary fiber and use bowel training programs to help with bladder and bowel control.
• Enhancing communication and managing swallowing difficulties requires speech therapy.
• Have a suction apparatus available and take extra precautions to ensure proper positioning while feeding.
• Improving sensory and cognitive function
• For vision, use an eye patch or a covered eyeglass, prism glasses (for diplopia), and free talking books.
• cognition and emotional health should be managed by providing emotional support.
• Help setting meaningful and realistic goals and provide structured daily routines
• Promoting sexual functioning through collaboration among the patient, family, and health care provider.
• Sharing and communication of feelings and planning for sexual activity using alternative methods of sexual expression is helpful for all patients

Complications

• Immobility
• Blindness