MULTIPLE

SCLEROSIS
Presenter : Ms. Manju Sebastian
Moderator: Ms. Rachel Andrews

Multiple Sclerosis
A chronic, progressive neurologic
disease characterized by
scattered demyelination of nerve
fibers in the brain and spinal
cord.

Multiple Sclerosis
Most common disabling condition in
young adults
Most common demyelinating disorder
Progresses to disability in majority of
cases
Unpredictable course & variety of
signs and symptoms; sometimes
mistaken for psychiatric disorder

MS- Incidence
Peak onset 20-40 years of age
70% between ages 21-40
Rarely prior to age 10 or after age 60
F > M (approx. 2:1)
White > non-white (2:1)

Risk factors
Autoimmune process
Viral infection
Allergic reactions to infection
Familial tendencies.
Cool, temperature climates.

Etiology
Autoimmune
T-cells activate against myelin

Viral
Specific viral protein not yet identified
Suspected molecular mimicry
Roseola (HHV6) associated with
demyelination in MS patients
Viral infections known to provoke
relapses

Pathological Hallmarks
Described in late 1800s by Dr. Charcot
Inflammation and demyelination
Plaques occur anywhere in the CNS
Most frequent: optic nerve, brainstem,
cerebellum, spinal cord

Axon sparing within the plaques

Structure Of Plaques
Outer layers of myelin sheath
separate
Degenerative changes in myelin
Infiltration with macrophages
Preservation of axons

Normal Conduction

Abnormal Conduction

Results Of Demyelination
Conduction block at site of lesion
Slower conduction time along affected
nerve
Increased subjective feeling of fatigue
secondary to compensation for
neurologic deficits

Initial Symptoms
Double vision / blurred vision
Numbness
Heat intolerance
Motor weakness
Fatigue
Problems with bladder control
Facial Palsy

Signs and Symptoms.

Instability while walking
Poor coordination
Dizziness
Tremors
Spasticity of extremities
**All symptoms can be precipitated by heat**

Signs and Symptoms

Slurred speech
Difficulty in chewing and swallowing
Mental changes
cognitive dysfunction
Fecal or urinary incontinence or
retention.
Impotence

Classification
Benign Multiple Sclerosis
Mild infrequent sensory exacerbations
with full recovery.

Relapsing Remitting Multiple Sclerosis

Episodes of exacerbations and remissions
during which not all symptoms resolve
completely.

Classification
Secondary Chronic Progressive
Relapses become more severe while
remissions are less complete, shorter in
duration, and eventually non-existent. The
course of MS becomes steadily
progressive.
Primary Progressive
No relapse. Disease begins with a slow
progression of neurologic deficits.

Diagnostic tests
CSF Analysis
Magnetic resonance imaging
Computed tomography Scan
Positron Emission Tomography
Evoked Potential Studies
EEG

CSF
Increased immunoglobulin
concentration
Elevated IgG index
Oligoclonal bands
Elevated protein

Evoked Potentials
VER (visual evoked response)75%
abnormal
BAER (brainstem auditory evoked
response)30% abnormal
SSER (somatosensory evoked
response) 80% abnormal

MRI- Cerebellum

MRI- Spine

MRI- Spine

MRI- Optic Nerve

MRI- Cerebral
Hemisphere

MRI- Cerebral
Hemisphere

Differential Diagnosis

Encephalomyelitis
CNS Vasculitis
Lyme Disease
Lupus Erythematosus
Spastic Paraparesis
Behet Syndrome
Vitamin B-12 Deficiency and Syphilis
Hereditary Degenerative Disorders

Standard Therapy
Treatment of Relapses
Prevention of Relapses
Treatment of Chronic Progression

Treatment
Drugs
Corticosteroids
Methyl Prednisolone

Immunosuppressive drugs
Azathioprine (Imuran)
Cyclophosphamide (Cytoxan)
Methotrexate

Intravenous Immunoglobulin G
Oral Myelin

Prevention of exacerbations

Interferon-1a (Avonex)

Interferon-1b (Betaseron)

Symptomatic Therapy
FATIGUE
Frequent rest periods
Cool showers / baths
Amantadine
Pemoline (CNS stimulant)
Fluoxetine

Symptomatic Therapy
VERTIGO
** Can last for hours to days **
Low dose Dizepam
Promethazine
If associated with nausea/vomiting
Metoclopramide.

Symptomatic Therapy
Spasticity
* Very painful; most common in
extensor muscles of lower limbs*
Baclofen
Dantrolene
Tizanidine
Valium especially useful at night
Physical therapy with stretching exercises

Symptomatic Therapy
Psychological Problems
* suicide rate for MS patients is 7.5 times that
of the general population *

TCAs (especially Amitriptyline)

Psychological counseling.

Symptomatic Therapy
Urinary Dysfunction
Anticholinergics (oxybutynin)
Baclofen
Intermittent self-catheterization
Chronic indwelling catheter
Acidifying agents & antibiotics

Symptomatic Therapy
Pain
Carbamazepine
Phenytoin
Gabapentin (Neurontin)
Tricyclic antidepressants

Treatment - General
Considerations
Exercise
Physical Therapy
Nutrition
Pregnancy and Motherhood
Treatment of Infections and Elevated
Temperatures

Nursing management
Altered urinary elimination
Constipation
Activity intolerance
Impaired Physical mobility
Risk for self care deficit
Self esteem disturbance
Knowledge deficit regarding home
care.

Long Term Care

Physical therapy
Occupational
therapy
Rehabilitation
Bowel and bladder
training
Speech therapy

Long Term Care

Nutritional counseling
Counseling including sexual
counseling.
Bed rest during acute exacerbation.
Assistive devices: braces, walkers,
wheelchairs, splints.

Complications
Respiratory failure
Pneumonia
Neurologic deficits: paralysis.
UTI
Sexual dysfunction
Contractures

Factors that influence prognosis

Females
Low rate of relapses per year
Complete recovery from the first attack
Long interval between first and second attack
Low disability at 2 to 5 years from the disease
onset

Factors that influence prognosis

Symptoms predominantly from afferent
systems (i.e.,. sensory symptoms)
Younger age of onset
Later cerebellar involvement
Involvement of only one CNS system at the
time of onset