• Multiple Sclerosis

What is MS?

Multiple sclerosis is a recurrent, chronic autoimmune disorder that affects the CNS. The disease is associated with destruction of axons and myelin sheaths.

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A Major Health Problem

  • The most common cause of progressive neurological disability in young adults (20 – 50 years).

Classification

Relapsing-remitting:

Accounts for more than 80% of the initial diagnosis MS.

Secondary-progressive

Primary-progressive

Progressive-relapsing

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Who gets Multiple Sclerosis?

  • Peak age 15 to 45
  • Women to men: 2.5 : 1
  • More common among Caucasians
  • Genetic Predisposition
    • HLA-DR2 (DRB1*1501)
  • Environmental Factors
    • Microbial Agents (EBV)
    • Vitamin D/Sunshine
    • Cigarette Smoking

Clinical Features

Clinical History consistent/suspicious for MS

  • Weakness
  • Sensory Complains
  • Visual Symptoms
  • Imbalance
  • Urinary Frequency
  • Heat Intolerance or Uhthoff’s phenomenon
  • Pain
  • Fatigue
  • Spasticity
  • Cognitive Deficits
  • Sexual Dysfunction

Examination

  • Mental Status
  • Fundus abnormalities, APD, INO
  • Motor-Gait abnormalities
  • Sensory Deficits
  • Abnormal Reflexes

You could have a normal exam between relapses especially early in the disease

Multipe Sclerosis Clinical Features
Early-Signs-of-Multiple-Sclerosis

What is Relapse?

  • Multiple Sclerosis lasting for at least 24/48 hours after a stable period of at least 30 days.
  • An established MS patient complaining of symptoms getting worse over a period of months is a sign of disease progression and not a relapse
  • Symptoms getting worse due to concurrent infections are not a relapse.
  • Symptoms getting worse with heat, fatigue which get better with cooling or rest is not a relapse.

Investigation

  • Magnetic Resonance Imaging: Brain and Spinal Cord MRI
  • Spinal Fluid
  • Blood Work
  • Evoked Potentials
    • A type of electrodiagnostic medicine
    • Look for damage to the myelin sheath in the visual (VEP), hearing (AABR), and touch perception systems (SSEP)
    • Not as sensitive as MRI or spinal fluid
Multiple Sclerosis MRI

Diagnosis

  • Based on clinical signs and symptoms combined with diagnostic testing.
  • Definitive diagnosis of MS requires evidence of demyelinating disease consisting of
    • at least two attacks
    • disseminated over time and space.

Treatment

Medication for Acute Relapses

  • Usually treated with high dose IV steroids
  • Severe relapses refractory to corticosteroids are treated with plasma exchange or IVIG.

Long Term Treatment (Disease-Modifying Therapies)

  • More effective in preventing new lesion formation than repairing old lesions.
  • These therapies include interferon β-1b (Extavia, Betaseron,), interferon β-1a (Avonex, Rebif), fingolimod (Gilenya), glatiramer acetate (Copaxone), teriflunomide (Aubagio), mitoxantrone, natalizumab, dalfampridine (Ampyra), and dimethyl fumarate (Tecfidera)

 Management of MS symptoms/Rehabilitation

  • Gait impairment
    • Non-pharmacologic
      • Exercise training
      • Physical Therapy
      • Assistive Devices
        • Cane/walkers
        • Ankle-foot or hip orthosis
        • Functional electrical stimulation (FES) for foot drop
    • Pharmacologic
      • Factors contributing to gait impairment (e.g. pain/spasticity)
      • Dalfampridine (AMPYRA): a potassium channel blocker
  • Fatigue: Most reported symptom, most commonly interfere with ADLS, one of the top reasons for quitting work
    • Non pharmacological
      • Treat depression
      • Treat co-morbid conditions (infections, anemia, thyroid disease)
      • Regulate sleep (treat pain, spasms, etc.)
      • Limiting alcohol intake
      • Consider wheel chairs
      • Temperature control
      • Improve physical conditions (PT, exercise, yoga)
      • OT referral for energy conservation strategies
    • Pharmacological
      • Methylphenidate
      • Amantadine
      • Modafinil
  • Spasticity
    • Exercise, Physical Therapy
    • Oral Agents: Baclofen, Tizanidine, Benzodiazepines
    • Intra-thecal Baclofen pump
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Recent Studies Show

Opening a new door to Multiple Sclerosis management (Details)