Neuro Stuff: Exam 3 and Beyond

What is the pathology of MS?

- inflammation and T cell dysregulation

- blood brain barrier disruption allows T cells into the CNS

- inflammatory cells become involved, which damage myelin, oligodendrocytes, and other structures

T/F: there are multiple inflammatory cells involved in MS?

- true

- microglia, macrophages, B cells

what is present in acute demyelination? (3)

- myelin breakdown products

- edema

- chemotaxis of lymphocytes

can myelin be restored?

- sometimes

what is sclerosis? what is the mechanism of formation?

- glial scar or plaque

- microglial cells migrate to the lesion and phagocytize the debris, producing fibrils that result in the scars and plaque

T/F: MS can cause axonal damage?

true

T/F: lesions are symmetrical?

true

T/F: lesions are scattered in gray matter?

- false

- white matter

where are MS lesions usually located? (5)

- cerebrum

- cerebellar peduncles

- brainstem

- corticospinal

- dorsal spinal cord

what is an exacerbation?

- relapse, flare-up, attack

- new or worsening of old symptoms lasting for more than 24 hours and taking place at least 30 days after a similar event

what age is incidence of MS peaking at?

30

who is more likely to get MS - males or females?

- females 3:1 males

what might contribute to there being statistics showing increase in MS in areas inhabited by people of northern europe ancestry?

- limited data from elsewhere in the world

where is MS more common geographically?

- europe

- US

- canada

- new zealand

- australia

T/F: incidence of MS increases with increased distance north or south of the equator?

true

is MS more common in temperate or tropical climates?

- temperate

- vit D supplementation is important

what is the exact etiology of MS?

unknown

is there genetic susceptibility to MS?

- yes

- relative of someone with MS = 3% or 1/40

- identical twins = 25%

- fraternal twins = 4%

what does it mean for MS to be a complex genetic disease?

- has over 200 alleles that have been discovered to contribute small risk effects

what are infections that can initiate the development of MS?

- Epstein-Barr virus

- infections that start in the gut and spread to CNS

what are environmental exposures that can influence development of MS? (5)

- smoking

- lack of sunlight

- diet

- changes in the gut microbiome

- obesity

what are the 4 common areas of the CNS that are affected by MS?

- optic nerve

- cerebellar peduncles

- periventricular white matter

- spinal cord

how is MS diagnosed?

- clinical presentation and reliable pt history of symptoms

- 2 separate exacerbation episodes with 2 separate lesions on MRI

T/F: MS is a clinical diagnosis based on lesions disseminated in space and time?

true

is there a single test for MS?

no

are evoked potentials increased or decreased with MS?

decreased NCV

is CSF increased or decreased when lumbar punctures are done to look for MS?

- increased CSF concentrations of gamma globulin and protein levels

can an MS diagnosis be made on MRI alone?

no

what is the best diagnostic criteria for MS?

2024 McDonald criteria

what is the goal with diagnosing MS?

- diagnose as soon as possible after an initial neurologic attack and initiate MS therapy ASAP

does early MS therapy delay onset of MS?

- yes for clinically isolated syndrome (CIS)

does early MS therapy reduce MS clinical attacks?

- yes and reduces long term disability in MS

what is radiologically isolated syndrome (RIS)?

- lesions on MRI but no MS like symptoms

McDonald criteria vocab: DIT

dissemination in time

McDonald criteria vocab: DIS

dissemination in space

McDonald criteria vocab: CIS

clinically isolated syndrome

what do visual evoked potentials (VEP) show?

speed of visual response

what does a CSF analysis look at? (3)

- increased WBC

- high protein levels (oligoclonal blands)

- IgG

what is the importance of an MRI with gadolinium?

- distinguishes new plaques from old

what is the importance of magnetization transfer imaging (MTI)?

- detect demyelinated tissues and damaged nerves

- can see them before they can be seen on an MRI

what is the importance of diffusion-tensor imaging (DTI)?

- allows for production of 3D images of size and location of demyelinated areas

what is prodrome?

- an early set of signs or symptoms that indicate the onset of a disease before more typical symptoms develop

what are characteristics of the prodrome periods with MS?

- may last several years

- is associated with neurodegeneration

what are common symptoms of MS? (6)

- numbness or tingling

- electric shock sensations (especially when flexing neck)

- trouble walking

- weakness/fatigue

- visual deficits

- dizziness / vertigo

what is Lhermitte sign?

- electric shock sensations that occur when bending the neck forward

what are the visual deficits associated with MS? (5)

- complete vision loss

- diplopia

- blurred vision

- scotoma (dark spot on visual field)

- optic neuritis

what is the most common MS symptom?

- fatigue (overwhelming sense of tiredness)

what is the uhthoff phenomenon?

- transient worsening of neurological symptoms when the body becomes overheated in hot weather, exercise, sauna, fever, or hot tubs

what are the 4 types of MS?

- relapsing-remitting

- primary progressive

- secondary progressive

- progressing relapsing (DONT FOCUS ON)

what is the most common type of MS?

- relapsing-remitting (RR)

- 70-80%

what is relapsing-remitting MS?

- new or recurrent neurological symptoms that are consistent with MS

- symptoms last 24-48H

- symptoms develop over days to weeks

what is primary progressive MS?

- 15-20% of patients

- gradual deterioration from onset

- no remission

what is secondary progressive MS?

- begins as relapsing-remitting, but then develops into progressive

- marked by a more gradual neurological decline

- relapses CAN occur, but are not mandatory

what is progressive relapsing MS?

- gradual deterioration with superimposed relapses

- eliminated category

what does it mean for progressive relapsing MS to be an eliminated category?

- is now classified as PPMS

definition of relapse?

- new and recurrent MS symptoms lasting more than 25 hours (generally longer)

- unrelated to another etiology

T/F: small increases in body temperature can worsen MS symptoms? would these be considered a relapse?

- true but are no relapses, instead they're pseudo-relapses

what are disease modifying therapies?

- used early in the course of active relapsing MS to prevent relapses, new lesions, and worsening disabilities

T/F: disease modifying therapies can have severe adverse reactions?

true, careful monitoring is required

do newer DMTs have better short or long term outcomes than older DMTs?

- better short term outcomes

T/F: DMTs can reduce relapses up to 30%?

true

what is used for acute relapses?

corticosteroids

what are ABC drugs?

- DMTs

- avonex

- betaseron

- copaxone

is there a cure for MS?

no

what is the average survival of MS?

- 35 years after onset

- 5-10 years shorter than general population

does death occur from MS itself?

no

what are the characteristics of having a better prognosis for MS? (5)

- younger age of onset

- female

- only 1 symptom during first year

- acute onset of initial symptoms with rapid AND COMPLETE remission

- brief length of most recent exacerbation

what is the core outcome measure?

- made by academy of neuro PT

- standard for any neurologic condition

- reminder: always have the core!!

what is the kurtzke expanded disability status scale (EDSS)

- used by researches and neurologists

- classification of disease burden for MS

- 0 = normal

- 10 = death due to MS

what is the 12-item MS walking scale?

- total out of 60

- higher score = greater impact on walking (more impairments)

what are nonpharm approaches to managing MS fatigue? are they effective?

- exercise

- cog therapy

- more effects on reducing impact of fatigue than medications

is time to fatigue in MS an indicator of level of physical impairment/disability?

no

what is an important educational point for MS?

- activity or task modification is important to lessen fatigue

why do you need to keep temperature in mind with MS?

- increasing heat can increase fatigue and symptoms

what is an activity diary?

- patients can record and track their symptoms and daily activities

- FVS

> rate fatigue

> state value or importance of activity

> satisfaction with activity performance (1-10)

when is PT indicated for MS?

- throughout to maximize functional capacity and quality of life

- requires a thorough neuro eval

will PT alter MS progression?

- can't alter the progression but can treat current symptoms and help the patient maintain highest level of function

should therapy pools be used for patients with MS?

no because they're often heated

what is a con to using cooling vests?

- they tend to be heavy

what are the 3 goals of treatment for MS?

- preventative interventions

- compensatory interventions

- maintenance therapy

what are preventative interventions?

- minimizing potential complications, impairments, activity limitations, or disabilities

what are compensatory interventions?

- modifying the task, activity, or environment

what is maintenance therapy?

- series of occasional clinical, education, and administrative services designed to maintain the patients current level of function

- typically in lateral stages of diagnosis

what is the fatigue scale for motor and cognitive functions? what ICF level?

- body function

- 20-item self report measure evaluating motor and cognitive fatigue

what is MFIS? what ICF level?

- activity/participation

- 21-item self report measure evaluating motor, cognitive, and psychological impacts of fatigue

what is trunk impairment scale? what ICF level?

- body function/activity

- measure examining the motor function of the trunk in sitting

what is 12-item MS walking scale? what ICF level?

- activity

- 12-item self report evaluating impact of MS on walking ability

Is there evidence that supports physical therapy to improve activity and participation?

yes

when is it safe for patients with RRMS to exercise?

- when the exacerbation is done/when remission is evident

what is the exercise recommendation for MS?

- 150 min/week of exercise and/or 150min/week of lifestyle physical activity

what is a consideration for types of materials you might use for a session with an MS patient?

- may have tactile or proprioception difficulties

- may want to use cable column in place of dumbbells

should patients with MS exercise to fatigue?

- no

- exercising to point of fatigue is contraindicated and can worsen symptoms

how should exercise sessions be scheduled?

- on alternate days and during optimal times (mornings)

what is the function of the basal ganglia?

- responsible for voluntary movements

- regulation of autonomic movement, posture, muscle tone, and control of motor responses

what diseases are associated with the basal ganglia? (6)

- parkinsons

- huntingtons

- tourettes

- ADD

- OCD

- addictions

T/F: basal ganglia decides if a movement should happen or not?

true

what is a direct basal ganglia pathway?

- when activated, movement occurs

what is an indirect basal ganglia pathway?

- when activated, movement is prevented (allows us to stay still at rest)

- overactivated with parkinsons

what neurotransmitter is associated with the basal ganglia?

dopamine

what does dopamine do?

- helps initiate movement

- activates direct pathways

- affects mood, motivation, cognition