Multiple Sclerosis Presentation PDF 2024

Multiple Sclerosis Troy Seely PT, BScPT, MScPT, DPT, FCAPT Health Conditions and Disease in Rehabilitation RS 3060A © Troy Seely, 2024  OUTLINE 1. Provide a general overview of what Multiple Sclerosis (MS)...

Multiple Sclerosis Troy Seely PT, BScPT, MScPT, DPT, FCAPT Health Conditions and Disease in Rehabilitation RS 3060A © Troy Seely, 2024  OUTLINE 1. Provide a general overview of what Multiple Sclerosis (MS) is. 2. Review the epidemiology and pathophysiology. 3. Consider the course of the disease. 4. What are the main symptoms of MS ? 5. Consider the effect that MS may have on a person’s life. © Troy Seely, 2024  Overview : What is Multiple Sclerosis? It is an Autoimmune disease of the central nervous system (CNS). The name is descriptive of the sclerotic plaques disseminated throughout the CNS that is a hallmark of the disease. MS attacks myelin, causing inflammation and damage (selective demyelination) and gliosis. Myelin is _______________ Insulator for nerves If damage to myelin is slight, nerve impulses travel with minor interruptions. However, if damage is substantial and if scar tissue replaces the myelin, nerve impulses may be completely disrupted, and the nerve fibres themselves can be damaged. © Troy Seely, 2024 Overview : What is Multiple Sclerosis? © Troy Seely, 2024 Demyelinated Nerve © Troy Seely, 2024  Multiple Sclerosis: Epidemiology This country has highest rate of MS in the world? ________Canada Prevalence: 1 of every 340 Canadians (over 100,000 in Canada) Occurs in __________________ Diagnosed most often in younger adults aged 15-40 yrs Older and younger people are also diagnosed MS is 3 times as likely to occur in women as in men and is more common in people of northern European background. Similar to many other autoimmune diseases, MS is more common in woman. Genetic link 3% for a sibling, 5% for a fraternal co-twin and 25% for an identical twin When one parent is affected, a child has a fivefold higher risk of developing MS © Troy Seely, 2024 MS Around the World © Troy Seely, 2024  Multiple Sclerosis: Etiology What causes MS? Unknown… The best current evidence suggests multiple factors contribute: Genetics Coexisting autoimmune disorders ( examples include __________, Psoriatic Arth. IBS ___________, Rheumatoid Arth. _______________) Biological factors links to infections Where MS occurs more frequently the farther people live from the equator it is suggested there is a possible connection between the condition and __________ deficiency. Vitamin D © Troy Seely, 2024  Multiple Sclerosis: Etiology(Research) The link to infections (Harvard T.H. Chan School of Public Health published in Science on January 13, 2022). Epstein-Barr virus (EBV) may be leading cause of multiple sclerosis “This is the first study providing compelling evidence of causality…suggests that most MS cases could be prevented by stopping EBV infection” EBV is a herpes virus that can cause infectious mononucleosis and establishes a latent, lifelong infection of the host. Establishing a causal relationship between the virus and the disease has been 95% of adults difficult because EBV infects approximately_____________. MS is a relatively rare disease, and the onset of MS symptoms was found to begin about ten years after EBV infection. © Troy Seely, 2024  Multiple Sclerosis: Etiology(Research) The researchers conducted a study among more than 10 million young adults on active duty in the U.S. military and identified 955 who were diagnosed with MS during their period of service. In review of collected biennially serum, risk of MS increased 32-fold after infection with EBV but was unchanged after infection with other viruses. The delay between EBV infection and the onset of MS may be partially due the disease's symptoms being undetected during the earliest stages…. ….. and partially due to the evolving relationship between EBV and the host's immune system, which is repeatedly stimulated whenever the latent virus reactivates. EBV vaccine or targeting the virus with EBV-specific antiviral drugs could ultimately prevent or cure MS? © Troy Seely, 2024  MS Pathophysiology The pathologic conditions that occur in MS include inflammation, demyelination, and axon loss. MS is primarily a T-cell –mediated inflammatory disorder with overproduction of proinflammatory cytokines. It is thought that initially pre-existing T cells are activated outside the CNS by foreign microbes or self-proteins. Activated T cells cross the blood-brain barrier, and the activated T cells secrete cytokines that stimulate microglial cells , recruit additional inflammatory cells, and induce antibody production. “Microglial cell?” A specialised population of macrophages that are found in the central nervous system (CNS). They remove damaged neurons and infections and are important for maintaining the health of the CNS. © Troy Seely, 2024  MS Pathophysiology (cont’d) Inflammatory process begins, in turn affecting nerve fibres: Inflammation can be cyclical (this may explain why the disease comes and goes over time). With repeat attacks, anti-inflammatory processes become less effective. Oligodendrocytes are a nonneural component of the CNS that is directly related to the cell body or axon, and they produce myelin. In early stages of MS, can produce remyelination. As the disease progresses, oligodendrocytes are affected and lose ability to produce myelin. These demyelinated areas progress to undergo “gliosis”. © Troy Seely, 2024 MS Pathophysiology (cont’d) Gliosis is a process; it leads to scaring in the central nervous system involving the production of a dense fibrous network of neuroglia (supporting cells) in areas of damage. These are termed “glial scars” also known as plaques. It is a prominent feature of MS and can be noted on MRI. © Troy Seely, 2024  MS Pathophysiology (cont’d) Gliosis leads to glial scars (plaques): This is when the axon becomes interrupted and undergoes neurodegeneration. Main cause of permanent neurological disability. Progresses to the point of brain atrophy, which is evident in early MS (again, seen on MRI) and is progressive. Note: if the CNS is affected by MS, it is not the only section compromised. © Troy Seely, 2024 MS Effect on Muscles Early on in the course: Myelin sheaths become demyelinated, slowing nerve transmission and causing fatigue. Later on in the course: With severe disruption, there becomes conduction blocks and disruption of function. © Troy Seely, 2024 MS Disease Course Two ends of disease continuum Benign MS at one end: Fully functional in all neuro systems for 15 years after onset 20% of all MS cases. Less than ____ Malignant (Marburg Disease) at other end: Relatively rare disease Rapid onset and continual progression to significant morbidity/death. Severity of MS cannot be predicted at time of diagnosis © Troy Seely, 2024 Disease Course (cont’d) 4 major disease courses: each type can have symptoms ranging from mild to severe, however identifying the different types of MS can help predict the course of the disease and the patient's response to treatment. 1. Relapsing-remitting MS (RRMS): ______ 85% of patients Discrete attacks (relapses) and periods of worsening of symptoms Relapses are followed by remissions No disease progression in remission. Partial or complete abatement of signs and symptoms. © Troy Seely, 2024 Disease Course (cont’d) 2. Secondary-progressive MS (SPMS): Secondary-progressive multiple sclerosis (SP-MS) is a form of MS that follows relapsing-remitting MS. The majority of people diagnosed with RR-MS will eventually transition to having SP-MS. This type of MS presents with a relapsing-remitting course followed by progression to steady and irreversible disability with or without occasional attacks. About half of people with RRMS start to get SPMS after 10-20 years. © Troy Seely, 2024  MS Disease Course © Troy Seely, 2024 Disease Course (cont’d) 3. Primary-progressive MS (PPMS) Rare form – only _____ 10% of cases Nearly continuous worsening of disease (ie. There may be occasional plateaus) from onset without distinct attacks. 4. Progressive-relapsing MS (PRMS) Rare form – _____ 5% of cases Progressive disease course and steady deterioration but with distinct attacks Clinicians need to be aware that the disease course can change. Watch for changes in signs and symptoms for severity, frequency and impact on function. © Troy Seely, 2024 Disease Course (cont’d) © Troy Seely, 2024 Exacerbations Pseudoexacerbations cause increases in MS symptoms but only for less than _____ 24 hours. If you get sick, have greater chance of an exacerbation Viral or bacterial infections and diseases of major organ systems are related to increased exacerbations. Major stressors in life (divorce, death, losing a job, trauma) cause exacerbations. © Troy Seely, 2024 Symptoms The onset of symptoms can occur over a course of minutes or hours. It is possible, but less frequent, to have symptoms occur over weeks or months Early symptoms typically include minor visual problems (double vision) and paresthesias (pins and needles) progressing to numbness, weakness and fatigability © Troy Seely, 2024  Anterior & Lateral Spinothalamic Pathways: Primary Somatosensory Cortex Posterior Column Pathway: © Troy Seely, 2024  Symptoms (cont’d): Sensation Sensory Limited areas of ‘diminished’ sensation. ‘Altered’ sensation more common including paresthesias or numbness of face, body or extremities. Also get disturbances of position sense and impairments of vibration sense. © Troy Seely, 2024  Symptoms (cont’d): Sensation Pain ~80% of all patients with MS have pain (clinically significant in ~____) 50% Can be acute paroxysmal or chronic Described as intense, sharp, shooting, electric shock-like and burning Trigeminal neuralgia (tic douloureux) comes from demyelination of the sensory portion of the trigeminal nerve (innervates face, cheek and jaw). Lhermitte’s Sign indicates damage to the posterior column in spinal cord. Flexion of the neck causes electric shock-like pain down the spine and into lower extremities © Troy Seely, 2024  Symptoms (cont’d): Sensation Paroxysmal limb pain shows as burning, aching pain; mainly affecting the lower extremities. Most common type of pain in MS; worse at night and after exercise. Can also happen with temperature elevations. Hyperalgesia/allodynia __________________________ Hypersensitivity to pain / normal touch = painful Light touch or light pressure elicits a severe pain reaction. Neuropathic pain comes from demyelinating lesions in spinothalamic tracts or in the sensory roots. More common in MS patients with minimum disability Burning pain similar to that from disk herniation © Troy Seely, 2024  Symptoms (cont’d): Vision Visual 80% of patients Occur in ~_____ Altered visual acuity is main problem; blindness is rare Optic Neuritis (inflammation of optic nerve) occurs commonly and causes icepick- like pain behind the eye; get blurring or graying of vision or blindness in one eye Vision improves within 4-12 weeks Neuritis rarely affects both eyes Nystagmus occurs commonly from lesions affecting the cerebellum or central vestibular pathways. Get involuntary cyclical movements of the eyeball (when look to the side) or vertically (when patient moves their head). Diplopia (double vision) Muscles of eye are not well-coordinated © Troy Seely, 2024 Motor Axons Cross to Opposite Side of Spinal Cord Lateral Corticospinal Pathway: Anterior Corticospinal Pathway. © Troy Seely, 2024  Symptoms (cont’d): Weakness Motor Patients with corticospinal lesions get upper motor neuron (UMN) syndrome Paresis, spasticity, brisk tendon reflexes, involuntary flexor and extensor spasms, clonus, Babinski’s sign, exaggerated cutaneous reflexes and loss of precise autonomic control Weakness Patients with UMN syndrome have movements that are weak, stiff and slow Caused by loss of orderly recruitment and reduced firing rates Muscle weakness secondary to inactivity varies from mild paresis to total paralysis of involved extremities © Troy Seely, 2024  Symptoms (cont’d): Spasticity Spasticity Occurs in ~75% of all MS cases Ranges from mild to severe (duration, number of relapses, worsening of symptoms) Mainly occurs in LE, can also happen in UE Causes pain, disabling contractures, abnormal posturing, problems with skin integrity, and falls Exacerbated by fatigue, stress, overheating (fever, environmental), infections, or noxious stimuli (e.g. pain, bladder, bowel, renal, skin lesions/injury) © Troy Seely, 2024  Symptoms (cont’d): Fatigue Fatigue Comes on with no warning and worsens during the day Causes tiredness, exhaustion, weakness, problems with concentration, mental dullness Daily event: Affects 75-95% of patients with MS May be the most troubling symptom in 50-60% of people with MS Not related to severity of MS – those with mild MS report fatigue as well as those with severe MS Aggravating factors: physical exertion, exposure to heat and humidity, disturbed or reduced sleep, depression, low self-esteem, mood disorders, and medical conditions © Troy Seely, 2024 Symptoms (cont’d): Coordination/Balance Coordination and Balance Demyelinating lesions in cerebellum and cerebellar tracts produce cerebellar symptoms. Problems include: Ataxia: uncoordinated movements, mainly of trunk and LE. Postural tremor: shaking oscillatory movements when in sitting or standing. Intention tremor: involuntary rhythmic shaking movement when attempting a purposeful movement (writing, hygiene, eating, walking, speaking clearly). Tremors made worse by stress, excitement and anxiety Hypotonia: weak muscles Lesions affecting the cerebellum or central vestibular pathways can produce vestibular dysfunction Symptoms of dizziness, disequilibrium, vertigo, and nausea Symptoms made worse by movements of the head or eyes © Troy Seely, 2024  Symptoms (cont’d): Gait/Mobility Gait and Mobility 50% of patients with RRMS will require some form of assistance with _______ walking during the first 15 years Ataxic gait problems include staggering, uneven steps, poor foot placement, uncoordinated limb movements, and frequent loss of balance Gait and balance impairments increase the risk of falls and fall injury Half of all patients with MS report problems with falls What other factors in MS effect balance and movement? __________, sensation __________, vision ___________, spasticity __________ fatigue © Troy Seely, 2024  Symptoms (cont’d): Speech/Swallowing Speech and Swallowing Affects about 40% of patients with MS Dysarthria: slurred or poorly articulated speech with low volume, unnatural emphasis and slow rate Dysphonia: change in vocal quality (harshness, hoarseness, breathiness, hypernasal sounds) Dysphagia: difficulty in swallowing (inability to swallow, spitting or coughing during or after eating, problems chewing, maintaining a lip seal) Aspiration pneumonia can be a serious affect of swallowing disorder © Troy Seely, 2024  Symptoms (cont’d): Cognitive Cognitive ________% 40-70% of patients with MS have cognitive issues; only 10% have problems severe enough to affect daily activities. Cognitive issues are related to where the specific lesions are, rather than the severity or course of MS and the disability status. Affect short-term memory, attention and concentration, information processing, executive functions (abstract reasoning, problem solving, planning and sequencing), visuospatial functions, and verbal fluency. Significant mental deterioration is rare; it does occur in rapidly progressing MS or in patients with large cerebral lesions. © Troy Seely, 2024  Symptoms (cont’d)n: Mental Health Depression ~50% of patients with MS will have a major depressive episode Produces feelings of hopelessness or despair, diminished interest, changes in appetite, significant weight gain/loss, insomnia/hypersomnia, lethargy, worthlessness, fatigue, decreased concentration, recurrent thoughts of suicide/death. Patients with MS face problems with the ambiguity of their health status, unpredictable disease course, unpredictable future status and loss of effective functioning, emotional distress. © Troy Seely, 2024  Symptoms (cont’d): Mental Health Emotional (affective symptoms) Affect a smaller number (about 10% of those with MS) Emotional incontinence (pseudobulbal affect – PBA) has sudden and unpredictable episodes of crying, laughing or other emotional displays. Euphoria produces exaggerated feelings of well-being or a sense of optimism incongruent with the patient’s health status. Bipolar affective disorders includes alternating periods of depression and mania. Linked with more advanced disease and greater intellectual impairment. © Troy Seely, 2024  Symptoms (cont’d): Bladder Bladder 80% of patients with MS Affects ~_____% Includes spastic bladder (failure to store), flaccid, big bladder (failure to empty) or a dyssynergic bladder (problems between coordination of bladder contraction and sphincter relaxation). Symptoms include urinary urgency, urinary frequency, hesitancy in starting urination, nocturia, dribbling and incontinence. Two other points relevance: Severity of bladder problems is linked to severity of other neurological symptoms. Risk of recurrent urinary tract infections and kidney damage from frequent UTIs. © Troy Seely, 2024  Symptoms (cont’d):Bowel Bowel Constipation is most common complaint. Related to where MS occurs (gastrocolic reflex). Can be influenced by inactivity, lack of fluid intake, poor diet and bowel habits, depression and medication side effects. © Troy Seely, 2024  Symptoms (cont’d):Sexual Function Sexual Issues very common in MS (~90% of men, ~70% of women) Women: changes in sensation, vaginal dryness, trouble reaching orgasm and loss of libido Men: impotence, decreased sensation, difficulty or inability to ejaculate, loss of libido Sexual activity is also affected by appearance of other symptoms like spasticity, uncontrollable spasms, pain, weakness and fatigue, bladder/bowel incontinence, loss of functional mobility and changes in self-image. © Troy Seely, 2024  Disease-modifying Therapies (DMT) DMTs are drugs that impact the underlying MS by targeting some aspect of the inflammatory process of MS and can reduce the frequency and severity of relapses. DMTs can also reduce the number of new lesions in the brain and spinal cord as seen on MRI, and slow down the accumulation of disability Used for treatment in individuals with RRMS and SPMS, with relapses. Unfortunately, no DMT has yet been approved to treat PPMS — the type of MS that shows steady progression at onset Taken on a long-term basis, these medications are the best defense currently available to slow the natural course of MS © Troy Seely, 2024  Disease-modifying Therapies (DMT) The base cost of disease-modifying therapies for MS varies widely and typically falls in the range of ______________ $ 20-40,000 per year. The total cost of the medication will dependent on: the treatment selected the dosage provincial drug program pricing pharmacy or clinic costs and dispensing fees © Troy Seely, 2024 Summary MS is most common in _________ Canada The cause is Unknown MS affects the myelin sheaths over nerves (autoimmune process) Disease has several courses that can change without warning 85% have RRMS MS has an extensive list of symptoms, which can overlap to influence multiple activities of function. © Troy Seely, 2024