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.
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
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
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
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
- Non-pharmacologic
- 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
- Non pharmacological
- Spasticity
- Exercise, Physical Therapy
- Oral Agents: Baclofen, Tizanidine, Benzodiazepines
- Intra-thecal Baclofen pump
Recent Studies Show
Opening a new door to Multiple Sclerosis management (Details)