Demyelinating Disease: Multiple Sclerosis

What is MS?

a demyelinating disease that impacts the white matter in the brain and spinal cord

- plaque!

immune response where the ____ and ____ are destroyed typically in a selective pattern

myelin ; axon

______ can occur after a flare up, but not always the case

remyelination

what is the etiology of MS?

no clear etiology

- could be related to genetics along with environmental factors

what gender is more at risk?

women

- 2.5x more likely

what region of the US is at higher risk?

northeastern

- vitamin B deficiency

what ages are more at risk?

between 20-40 years old

if you have what disease prior to a MS diagnosis puts you more at risk?

epstein barr virus (mono)

what nationality is more at risk?

caucasian particularly from northern european descent

what are other comorbidities that put you at higher risk?

smoking, obesity, prior autoimmune disease

6 early sxs of MS =

• Optic Neuritis

- Sensation changes: numbness/tingling, pain

- Weakness: hemi, unilateral, bilateral

- Changes to bowel and bladder

- Stiffness or spasms, pain

- Change in cognition (slowed, impaired)

5 possible other symptoms of MS =

- emotional changes (depression, anxiety)

- fatigue

- MS hug (dysthesia)

- vertigo/dizziness

- ambulation dysfunction

what are 4 less common symptoms of MS?

- Breathing issues

- Hearing loss

- Seizures

- Swallowing/Speech Issues

what are the 4 types of MS?

- relapsing remitting

- primary progressive

- secondary progressive

- clinically isolated syndrome

What is relapsing-remitting MS?

unpredictable attacks which may or may not leave permanent deficits followed by periods of remission

What is secondary progressive MS?

initial relapsing-remitting MS that suddenly begins to have decline without periods of remission

What is primary progressive MS?

A gradual decline with no periods of remission

- older population

What is clinically isolated syndrome MS?

1st episode of inflammatory demyelination in CNS --> can become MS is progressed

what is the gold standard for diagnosing MS?

MRI with and without contrast

what is the T1 weighted without contrast MRI?

dark spots showing permanent nerve damage

what is the T1 weighted with contrast MRI?

white/bright spots showing active inflammation

what is the T2 weighted MRI?

overall disease burden, total amount of lesions - old and new

MS is often diagnosed by ____ ____ due to most prevalent symptoms

rule out

what is the neurofilament light chain biomarker?

diagnostic blood test every couple of months that shows if you had any flare ups in the last 6 months

what is the purpose of blood tests during diagnosing of MS?

to manage immune responses to treatment but do NOT help with actual diagnosis only rule out

a ___ ____ is done to determine high immunoglobin levels and infections

lumbar puncture

3 types of disease modifying treatments =

oral, injectable, infused

what are examples of oral DMTs?

- Cladribine (Mavenclad®)

- Dimethyl fumarate (Tecfidera®)

- Diroximel fumerate (Vumerity®),

- Fingolimod (Gilenya®, Tascenso ODT®)

- Monomethyl fumarate (Bafiertam )

- Ozanimod (Zeposia®)

- Ponesimod (Ponvory )

- Siponimod (Mayzent®)

- Teriflunomide (Aubagio®)

what are examples of injectable DMTs?

- Glatiramer acetate (Copaxone®, glatiramer acetate injection, Glatopa®)

- Interferon beta-1a (Avonex®,Betaseron®, Extavia®, Rebif®)

- Peginterferon beta-1a (Plegridy®)

- Ofatumumab (Kesimpta®)

what are examples of infused DMTs?

- lemtuzumab (Lemtrada®)

- Mitoxantrone (Novantrone®)

- Natalizumab (Tysabri®),

- Natalizumab-sztn (Tyruko®)

- Ocrelizumab (Ocrevus®)

- Ublituximab-xiiy (Briumvi )

what is the only infused DMT for primary progressive MS?

ocrelizumab (ocrevus)

what are 4 other medications that can be used for MS?

- baclogen

- IVIG

- corticosteroids

- PLEX

why is IVIG used with MS?

used for improving immune response by boosting immune system and fighting infections

with MS, there could also be medications for what 4 other symptoms?

sexual dysfunction, sleep disturbances, pain management, etc.

what types of diet should you be on with MS?

- Anti-inflammatory Diet such as the Mediterranean Diet

- Low-fat diet

- Omega-3 and omega-6 fatty acids

- Herbs/supplements such as garlic, ginger, ginseng, etc.

what body mind therapy may be useful in someone with MS?

acupunture, massage, tai chi, yoga

what 5 outcome measures in the acute care setting can be used on people with MS?

- 12-item MS walking Scale

- Berg Balance

- MS impact scale

- Timed 25 foot walk

- TUG with Cognitive and Manual

what 7 outcome measures in the IPR setting can be used on someone with MS?

- 12-item MS walking Scale

- Berg Balance

- MS impact scale

- 6-Minute Walk test

- MS Quality of Life

- TUG with Cognitive and Manual

- Dizziness Handicap Inventory*

why would someone with MS be in the acute care setting?

newly diagnosed or acute flare-ups

how can we assess new current level of function in someone with MS?

- MMT testing

- Sensation testing

- Coordination testing (toe taps, finger to thumb, etc.)

in acute care, we should always be assessing their ____

mobility

- ambulation, stair navigation, bed mobility, transfers

what are the discharge recommendations for someone with MS?

- home - OP vs HH

- SAR/SNF

- IRF (BEST ONE)

- DME

what are 3 options of follow up treatment in acute care for MS?

- Progressing mobility

- Trialing home set up

- Family/care giver education

in IPR/SAR, we must determine _____ ____ since acute care stay

functional change

- increase in strength or sensation?

how can we assess someone with MSs mobility in IPR/SAR?

- IRF: QI scores

- Home set up training, community training, work training, etc.

what is the discharge planning in an IPR/SAR for someone with MS?

- home - OP vs HH (hopefully here)

- IRF or SAR

- DME

what is the treatment focus in an IPR/SAR for someone with MS?

- Return to PLOF or "New normal"

- Caregiver/family training

what are the treatment considerations for outpatient PT for someone with MS?

- Long term care and improvements

- Continued progression of function or return to baseline

- Care giver training

in outpatient PT for someone with MS, we may do manual therapy, including what 2 techniques?

- Stiffness/Spasticity

- PNF techniques

in outpatient, we want to progress towards a plan for someone with MS to become _______ with HEP

independent

outpatient timeline is typically _____ term and more _____ than other PT options for someone with MS

long ; recurrent

what are 4 overarching treatment considerations for someone with MS?

- fatigue

- temperature of patient and environment where exercise is being completed

- treatment schedule

- combination of aerobic and strength training

what do we need to think about when it comes to treatment schedule?

- What type of treatment are they on

- If infusions, when was their last infusion

- Side affects from treatments

how can we combine aerobic and strength training?

- Aquatic therapy

- Balance training

- Dual task training

what is MS fatigue?

Reported as a feeling of tired/exhaustion that does not go away

what are the causes of MS fatigue?

- inflammation

- nervous system impact

- symptoms of MS: sleep problems such as apnea or insomnia, spasm, pain, anxiety/depression

what is the 2 hours rule during exercise for someone with MS?

2 hour rest period after if in an active stage of inflammation

regardless of treatment, MS may lead to what?

a life of disability

if left untreated, 30% of people will have significant disability in __-___ years

20-25

older research will show MS may decrease ____ ____ , but newer research is showing that is no longer true

life expectancy

worsening of symptoms can lead to what 4 things?

- Cognitive changes/memory loss

- Needing an AD for mobility

- Sexual dysfunction

- Change in bowel/bladder function

what is the expanded disability status scale?

a 0-10 outcome measure that tracks the progression of MS based on "functional systems" on a scale that physicians and research will use

photo of the EDSS =

_____ MS had increased disability and impaired mobility compared to ____ MS

mod/severe ; mild

mod/severe had decreased _____ ____ , increased need for a WC< and increased perceived ____ ____

social interaction ; physical impact

97% of people in the _____ group were independent without an AD in 10 years

mild