Multiple Sclerosis

Lynn E. Lawrence, CPOT, ABOC, COA, OSC

http://www.nationalmssociety.org/What-is-MS/MS-FAQ-s

Overview

• Multiple Sclerosis defined• Disease signs and

symptoms• Clinic presentations• Testing

What is MS?

• MS can cause many symptoms, including blurred vision, loss of balance, poor coordination, slurred speech, tremors, numbness, extreme fatigue, problems with memory and concentration, paralysis, and blindness and more. These problems may come and go or persist and worsen over time. Most people are diagnosed between the ages of 20 and 50, although individuals as young as 2 and as old as 75 have developed it.

Defined

• Multiple – can affect more than one area of the body at the same time

• Sclerosis – abnormal hardening of body tissues. In this case mainly focuses on connective and nerve tissue (myelin)

More…

Sclerosis• [sklĕ-ro´sis] an INDURATION or HARDENING,

especially of a part from inflammation, or in disease of the interstitial substance. The term is used chiefly for such a hardening of the nervous system due to hyperplasia of the connective tissue or for hardening of the blood vessels. Called also induration. adj., adjsclerot´ic.

Who Gets MS• Anyone may develop MS but there are some patterns.

More than two to three times as many women as men develop MS and this gender difference has been increasing over the past 50 years. Studies suggest that genetic risk factors increase the risk of developing MS, but there is no evidence that MS is directly inherited. Environmental factors, such as low Vitamin D and cigarette smoking have also been shown to increase the risk of MS. MS occurs in most ethnic groups, including African-Americans, Asians and Hispanics/Latinos, but is most common in Caucasians of northern European ancestry.

Facts• Affects over 2.5 million

• Affects women twice as often as men

• Family hx is a major risk factor (previous slide)

• Despite being discovered in 1868, the cause of MS largely remains a mystery. Researchers know the nerve damage is caused by inflammation, but the cause of the inflammation is still unknown (NIH, 2011).

Expert:

• With multiple sclerosis, patients can find it difficult to see. In fact, blurry vision is the first sign of MS in about 20% of patients, one expert says.

Defined

• Multiple sclerosis (MS) is a devastating disorder that affects the nerves in the brain and spinal cord. In multiple sclerosis, myelin, which normally both surrounds and protects nerves, is damaged or lost. In severe forms of MS oligodendrocyte cells, which produce myelin, are destroyed.

Defined

• sclerosis /scle·ro·sis/ (-ro´sis) an induration or hardening, especially from inflammation and in diseases of the interstitial substance; applied chiefly to such hardening of the nervous system or to hardening of the blood vessels.

• sclerosis [sklirō′sis] Etymology: Gk, skleros, harda condition characterized by hardening of tissue resulting from any of several causes, including inflammation, the deposit of mineral salts, and infiltration of connective tissue fibers.

Defined• Multiple sclerosis can cause a variety of symptoms:

changes in sensation (hypoesthesia), muscle weakness, abnormal muscle spasms, or difficulty moving; difficulties with coordination and balance; problems in speech (dysarthria) or swallowing (dysphagia), visual problems (nystagmus, optic neuritis, phosphenes or diplopia), fatigue and acute or chronic pain syndromes, bladder and boweldifficulties, cognitive impairment, or emotional symptomatology (mainly major depression). The main clinical measure in progression of the disability and severity of the symptoms is the Expanded Disability Status Scale or EDSS.[1]

Mylenation

• Definition: Myelination is the process by which a fatty layer, called myelin, accumulates around nerve cells (neurons). Myelin particularly forms around the long shaft, or axon, of neurons. Myelination enables nerve cells to transmit information faster and allows for more complex brain processes. Thus, the process is vitally important to healthy central nervous system functioning

Damage

• The damage MS causes to the protective nerve coating, myelin, can interfere with the signals nerves send between the central nervous system (CNS) and the body. Depending on where the damage occurs, you may experience a variety of symptoms.

• Symptoms vary in severity. Some may be long-lasting while others come and go. Since no two people have the same experience with MS, your symptoms may be different from someone else's. While some patients experience problems with disability, there are other symptoms that can occur.

Patient Dx

• Without this sensitive CSF technique, researchers had struggled to observe problems in gray matter. As a result, MS patients typically are not diagnosed until they display often-debilitating symptoms relating to myelin loss

Types of Multiple Sclerosis

• Relapse – Remitting (RR) MS

• Primary Progressive (PP) MS

• Secondary Progressive (SP) MS

• Progressive Relapsing (PR) MS

Difficulty in Diagnosing

• Exacerbations and Remission = Flares up and then goes away

Types of MS

• Relapsing remitting multiple sclerosis (RRMS)Approximately 85% of people with multiple sclerosis are diagnosed with relapsing-remitting MS (RRMS)

• In relapsing MS, people have clearly defined periods—which your health care professional may refer to as relapses, exacerbations or attacks—when MS symptoms worsen or new ones appear.

• These relapses are followed by a long or short period of remission when symptoms partially or completely go away.

Types of MS

• Secondary-progressive MS (SPMS)Another type of multiple sclerosis is secondary-

progressive MS (SPMS). Some people, following an initial period with relapsing MS, may develop a secondary-progressive course in which symptoms and disability get progressively worse. Relapses and periods of remission are less common.

Vision Problems• Vision problems are a common symptom of multiple

sclerosis (MS) because of the effects the disease has on the central nervous system (CNS). The process of demyelination, or the loss of myelin (the substance that surrounds the nerves), which is the underlying cause of MS, is what impedes many of the normal functions of the nervous system. As a result, in some people with MS, their vision may deteriorate.

Expanded Disability Status Scale

• The Kurtzke Expanded Disability Status Scale(EDSS) is a method of quantifying disability in multiple sclerosis.[1] The scale has been developed by John F. Kurtzke.

• The EDSS quantifies disability in eight Functional Systems (FS) and allows neurologists to assign a Functional System Score (FSS) in each of these.

EDSS rated systems

• pyramidal• cerebellar• brainstem• sensory• bowel and bladder• visual• cerebral• other

Remember

• This disease usually displays multiple signs and has a combination of ailments

Other Signs• Not everyone with MS will have the same

symptoms. During “attacks,” different symptoms can manifest themselves. Along with the symptoms mentioned on the previous slides, MS can also cause:

• hearing loss• seizures• uncontrollable shaking• breathing problems• slurred speech• trouble swallowing

Not Normally Fatal

• In general, MS is not considered a fatal disease, and most people with MS have a normal or near-normal life expectancy. In fairly rare cases, complications of MS can shorten life – though many complications are preventable or manageable. Very rare instances of MS that progress rapidly from disease onset can be fatal.

Usual Onset

• People with multiple sclerosis (MS) tend to have their first symptoms between the ages of 20 and 40. Usually the symptoms get better, but then come back. Some may come and go, while others linger

Difficult Dx• Diagnosing MS is rarely as simple as

a yes or no. It can take months, even years, and it's possible that you may feel perfectly fine during much of that time.

• Symptoms are unique to every individual patient

• There is no single test for MS

Do People Become Paralyzed?

• No. Moreover, the majority of people with MS do not become severely disabled. Two-thirds of people who have MS remain able to walk, though many will need an aid, such as a cane or crutches, and some will use a scooter or wheelchair because of fatigue, weakness, balance problems, or to assist with conserving energy.

Why are nerves important?• The central nervous system transports critical

signal information throughout the body

• How many cranial nerves do you have?

MS ReactionsThe initial attacks are often transient, mild (or asymptomatic), and self-limited. They often do not prompt a health care visit and sometimes are only identified in retrospect once the diagnosis has been made after further attacks. The most common initial symptoms reported are: changes in sensation in the arms, legs or face (33%), complete or partial vision loss (optic neuritis) (20%), weakness (13%), double vision (7%), unsteadiness when walking (5%), and balance problems (3%); but many rare initial symptoms have been reported such as aphasia or psychosis.[2][3] Fifteen percent of individuals have multiple symptoms when they first seek medical attention.[4]

Bodily Effects

• Major Depression• Unstable Moods• Cognitive Impairment• Fatigue• Physical Impairment• Weakness• Dysarthria (speech

disorder)• Pain

Patient Presentations• Moods• Dysarthria ('dys' meaning

abnormal or difficult; 'arthr' meaning articulating) is a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system[

• Weakness and mobility issues

Vision

• Vision is an early warning sign for MS

• Pain when moving eyes left to right

Proper Clinic Testing

• Visual testing• Pupil Testing• Muscle testing• Color Vision Testing• Test speed is critical

Early Symptoms of MS• Diminished brain function• Blurred or double vision• Thinking problems• Clumsiness or a lack of

coordination• Loss of balance• Fatigue and Numbness• Tingling• Weakness in an arm or leg.• No two people have exactly

the same symptoms of MS.• Swallowing issues

Common Ocular Manifestations

• Ophthalmoplegia• Nystagmus• Optic Neuritis• Phosphenes• Diplopia

Temporary Blindness

• During severe MS episodes or symptom outbreaks, temporary blindness may occur. In these cases, this increased severity can result in temporary blindness caused by acute inflammation of the optic nerve. Generally though, this is a transitory state that abates with the passage of time.

Ophthalmoplegia• Internuclear ophthalmoplegia is a

disorder of conjugate lateral gaze. The affected eye shows impairment of adduction. The partner eye diverges from the affected eye during abduction, producing diplopia; during extreme abduction, compensatory nystagmus can be seen in the partner eye. Diplopia means double vision while nystagmus is involuntary eye movement characterized by alternating smooth pursuit in one direction and a saccadic movementin the other direction.

Nystagmus• the medical term used to describe a condition in which

the eye rhythmically wobbles or oscillates involuntarily, often impairing vision. The term nystagmus originated from the Greek word "nystagmos" which described how a person would nod after having too much to drink or when excessively tired.

• Nystagmus often results from the instability or impairment of the system responsible for controlling eye movements and, therefore, the eye or usually both eyes are unable to maintain a steady fixation. Nystagmus that begins in infancy is called congenital or early-onset nystagmus and is usually inherited. When the condition develops after infancy (usually later than six months) or occurs later in life, it is called acquired nystagmus

Nystagmus: Alternate Name

• Due to the involuntary movement of the eye, it is often called "Dancing Eyes".[3][a]

Pathological Nystagmus

• Pathologic nystagmus[edit]• Pathologic nystagmus is characterized by a

biphasic ocular oscillation alternating a slow eye movement, or smooth pursuit, in one direction and a fast eye movement, or saccadic movement, in the other direction. The velocity of the slow phase eye velocity (SPEV) and the fast phase eye velocity (FPEV) are related to each other and can be considered as a measurement of the efficiency of the system stimulus/response.[8]

Physiological Nystagmus• Physiological nystagmus is a form of involuntary eye movement

that is part of the vestibulo-ocular reflex (VOR), characterized by alternating smooth pursuit in one direction and saccadic movement in the other direction.

• The direction of nystagmus is defined by the direction of its quick phase (e.g. a right-beating nystagmus is characterized by a rightward-moving quick phase, and a left-beating nystagmusby a leftward-moving quick phase). The oscillations may occur in the vertical,[11] horizontal or torsional planes, or in any combination. The resulting nystagmus is often named as a gross description of the movement, e.g. downbeat nystagmus, upbeat nystagmus, seesaw nystagmus, periodic alternating nystagmus.

• These descriptive names can be misleading however, as many were assigned historically, solely on the basis of subjective clinical examination, which is not sufficient to determine the eyes' true trajectory.

Nystagmus

• The primary symptom of nystagmus is involuntary eye movement. Usually the movement is side-to-side (horizontal nystagmus), but it can also be up and down (vertical nystagmus) or circular (rotary nystagmus). The movement can vary between slow and fast, and it usually involves both eyes.

Nystagmus Classifications• Congenital nystagmus is present at birth. With this condition, your eyes move

together as they oscillate (swing like a pendulum). Most other types of infantile nystagmus are also classified as forms of strabismus, which means the eyes don't necessarily work together at all times.

• Manifest nystagmus is present at all times, whereas latent nystagmus occurs when one eye is covered.

• Manifest-latent nystagmus is continually present, but worsens when one eye is covered.

• Acquired nystagmus can be caused by a disease (multiple sclerosis, brain tumor, diabetic neuropathy), an accident (head injury), or a neurological problem (side effect of a medication). Hyperventilation, a flashing light in front of one eye, nicotine and even vibrations have been known to cause nystagmusin rare cases. Some acquired nystagmuses can be treated with medications or surgeries.

• Optokinetic – eye related – Botox or Baclofen maybe an option to relax muscles

• Vestibular – Inner ear related – decongestants may aid in clearing this up

Nystagmus Cont…

• In some cases, acquired nystagmus may be a symptom of a life-threatening condition that should be immediately evaluated in an emergency setting. Seek immediate medical care (call 911) if you, or someone you are with, have any of these life-threatening symptoms including:– Confusion or loss of consciousness for even a brief

moment– Fainting, change in level of consciousness, or lethargy– Garbled or slurred speech or inability to speak– Loss of vision or vision changes– Severe headache– Sudden numbness or weakness

Optic Neuritis

• Optic neuritis— An inflammation of the optic nerve that can cause sudden loss of vision, usually in one eye; blurred vision and eye pain. It is the most common MS-related vision problem. Approximately half of people with MS will have at least one episode of optic neuritis. Frequently, it is the first symptom of MS. Optic neuritis may result in blurring or graying of vision, or rarely, blindness in one eye. A dark spot may also occur in the center of the visual field.

Optic Neuritis

• Up to 50% of patients with MS will develop an episode of optic neuritis and 20% of the time optic neuritis is the presenting sign of MS. The presence of demyelinating white matter lesions on brain MRIs at the time of presentation for optic neuritis is the strongest predictor in developing clinical diagnosis of MS. Almost half of the patients with optic neuritis have white matter lesions consistent with multiple sclerosis.

Optic Neuritis Cont…• Individuals experience rapid onset of pain in one eye followed

by blurry vision in part or all its visual field. Flashes of light (phosphenes) may also be present.[50] Inflammation of the optic nerve causes loss of vision most usually by the swelling and destruction of the myelin sheath covering the optic nerve.

• The blurred vision usually resolves within 10 weeks but individuals are often left with less vivid color vision, especially red, in the affected eye.[citation needed]

• A systemic intravenous treatment with corticosteroids may quicken the healing of the optic nerve, prevent complete loss of vision and delay the onset of other symptoms.[citation needed]

Testing for Optic Neuritis

• One quick test to rule out optic neuritis is a monocular color vision test

• MRI

Phosphenes• A phosphene is a phenomenon characterized by the

experience of seeing light without light actually entering the eye. The word phosphene comes from the Greek words phos (light) and phainein (to show).[1] Phosphenes are flashes of light, often associated with optic neuritis, induced by movement or sound.[2][3]

• Phosphenes can be directly induced by mechanical, electrical, or magnetic stimulation of the retina or visual cortex as well as by random firing of cells in the visual system. Phosphenes have also been reported by meditators[4] (commonly called nimitta); people who go for long periods without visual stimulation (also known as the prisoner's cinema); or those who are using psychedelic drugs.

Referral Sources

• Ophthalmology• Neuro-ophthalmology• Neurology

http://www.nationalmssociety.org/What-is-MS/MS-FAQ-s

Questions?• What is multiple sclerosis?• Who gets MS?• How many people have MS?• What are the typical symptoms of MS?• What causes the symptoms?• Is MS fatal?• Does MS always cause paralysis?• Is MS contagious or inherited?• Can MS be cured?• What medications and treatments are available?• Why is MS so difficult to diagnose?

National MS Society

• Our MS Navigators help identify solutions and provide access to the resources you are looking for. Call 1-800-344-4867 or contact us online.

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