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Understanding, Diagnosing, and Classifying MS

Tricia Pagnotta, MSN, ARNP,CNRN, MSCNThe MS Center of Greater Orlando

Maitland, FLApril 2013

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What is Multiple Sclerosis (MS)?

• Chronic Lifelong Disease of the Central Nervous System (CNS).

• CNS is the Brain, Spinal Cord, and Optic Nerves.

• Damage of the myelin, covering of the nerve, causing multiple scars, sclerosis.

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What is MS?• Nerve cell is called an Axon: I like to use the analogy of

the axons as electric wires and the myelin as the protective rubber coating, or insulation, around those wires, breaks in insulation lead to communication breakdown

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What is MS?Inflammation Neuro-Degeneration

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What is MS?

• Neurological deficits in MS result from acute inflammatory demyelination and axonal degeneration

• Effects may be silent due to compensating processes of the CNS

Trapp BD, et al. Neuroscientist. 1999;5:48-57, with permission from Lippincott Williams & Wilkins.

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Diagnosing MS

• No one test diagnoses MS• History and Examination are key• Testing builds case for or against• Great care and an open mind are necessary to

confirm this complex disease

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Diagnosing MS

• History: Common symptoms– Visual disturbances (eye pain, blurred vision, graying of

vision, loss of vision, double vision)– Numbness/tingling– Weakness– Imbalance or gait abnormality– Fatigue– Bowel or Bladder problems

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Diagnosing MS

• History: Relapses– New or Recurrent Symptoms– Persist for at least 24 hours and sometimes

worsen over 48 hours.– Separated by 1 month.– Unexplained by other factors (illness,

fatigue, heat).

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Diagnosing MS: Testing

• Examination• MRI brain• MRI Cervical Spine• MRI Thoracic Spine• Evoked Potentials

– Vision– Somatosensory– Brainstem

• LP for CSF

• Laboratory Testing– Infections

• Lyme, Syphilis, HIV

– Inflammatory diseases• Lupus, Sjogren’s, RA

– Cancers– Metabolic

• Thyroid• Vitamin B12

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Classifying MS

M GS OAdapted from Weinshenker, et al. Brain. 1989;112:133-146.

Relapsing-remittingPrimary-progressive

Disease Type at Diagnosis

Disease Type at 11-15 Years After Diagnosis (Among Those With RRMS at Diagnosis)

Natural History Over Time

Secondary-progressive

Relapsing-remitting

42%

58%

15%

85%

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QUESTIONS ??

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Symptom Management

in MS

Tricia Pagnotta, MSN, ARNP,CNRN, MSCNThe MS Center of Greater Orlando

Maitland, FLApril 2013

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The Symptom Chain of MS

• Visual Symptoms• Weakness• Fatigue• Depression

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Visual Changes

Optic neuritis Decreased visual

acuity Double vision Blurred vision Involuntary movements

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Optic Neuritis

Inflammation of the optic nerve Usually affect one eye Loss of vision can evolve over hours or days Color vision affected: red or green Eye pain Pupil defects

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Optic Neuritis Management

To quicken the healing process IV steroids Acthar

Vision usually returns gradually in 2-4 weeks

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Vision Care

Annual ophthalmology appointments Routine follow-up appointments with

neurology Discuss visual problems with HCP Disease modifying treatments Treatment with steroids or Acthar when

needed Visual aids as prescribed

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Weakness in MS• Brain and Spinal Cord nerves

have difficulty sending of electrical impulses to muscles

• Spinal cord lesions have highest risk of causing weakness.

• Location, Location, Location Monopoly: Mediterranean Avenue versus Boardwalk

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Primary Weakness• Weakness caused by Multiple Sclerosis• Repetitive movements of muscles to the point of fatigue

does not increase strength, increases weakness

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Primary Weakness

• Acute– Relapse

• Hemiparesis• Quadrapresis

• Chronic– Spasticity– Gait abnormalities

Broken light fixture: Changing the light bulb when the fuse is the problem will only cause frustration.

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Secondary Weakness

Fatigue- poor repetition

• Deconditioning/sedentary lifestyle- Atrophy

• Nutrition• Rest• Chronic Pain• Medications• Anxiety• Depression

Asthenia-feeling of weakness

• Hypothyroidism• Anemia• Illness• Diabetes• Heart Disease

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Conquering weakness Collaborative Effort With Rehabilitation Team

• Exercise• Strengthening• Coordination• Stretching

• Assistive Devices • Medications

• Ampyra• Baclofen/Zanaflex

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Crayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18.

Fatigue in MS

The most common disabling symptom of MS May appear early in the disease Occurs without warning Precipitated/accentuated by heat, humidity, cold Can generate/worsen other MS symptoms Prevents sustained physical functioning Becomes difficult to work productively

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Krupp LB. CNS Drugs. 2003;17(4):225-234.

Clinical Characteristics Overwhelming sense

of sleepiness Constant sense of tiredness Lack of energy Feeling of exhaustion Not necessarily related to level of

disability May affect motor function May affect cognitive function Not fully understood

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Multiple sclerosisPrimary MS fatigue

Secondary MS fatigue pain

Normal fatigue

Sleep disordersPrimary

Secondary

Physical healthComorbid conditions

Fatigue is identified as a

significant problem

EnvironmentPhysical

SocialCultural

Psychologic healthAnxietyStress

Depression

Multiple Sclerosis Council. Fatigue in Multiple Sclerosis: Evidence-based Management Strategies for Fatigue in Multiple Sclerosis. 1998.

Potential Causes and Effects

M GS OSchapiro RT, Schneider DM. In: Multiple Sclerosis in Clinical Practice. 1999.

Multiple Sclerosis Council. Fatigue in Multiple Sclerosis: Evidence-based Management Strategies for Fatigue in Multiple Sclerosis. 1998.

Fatigue Management: Collaborative Effort With Rehabilitation Team

Address secondary causes Metabolic: B12, folate, hormonal Sleeplessness, bladder dysfunction Medications Depression

Medications: stimulants, wakefulness drugs, antidepressants Non-pharmacologic modalities

Cooling techniques: cooling vest/consumption of cool beverages Aerobic exercise: prevents deconditioning OT/PT: learn energy-conservation techniques/work

simplification Timed rest periods (appropriate rest-to-activity ratio) Stress management techniques Exercise and relaxation

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1. Sadovnick AD, et al. Neurology. 1996;46(3):628-632.2. Feinstein A. Can J Psychiatry. 2004;49(3):157-163.3. Bashir K, Whitaker JN. Handbook of Multiple Sclerosis. 2002.4. Sadovnick AD, et al. Neurology. 1991;41(8):1193-1196.

Depression in Multiple Sclerosis

The most common mood disorder in patients with MS: lifetime occurrence approx 50% of patients

Depression may lead to altered quality of life and loss of self-esteem3

Assessment of depression by HCP is essential

M GS OSiegert RJ, Abernethy DA. J Neurol Neurosurg Psychiatry. 2005;76(4):469-475.

The National Multiple Sclerosis Society. http://www.nationalmssociety.org/download.aspx?id=53. Accessed April 9, 2009.

Clinical Characteristics Feeling sad or empty Irritable or crying

most of the day Loss of energy Loss of interest or pleasure in

most activities Significant change in appetite and

weight Unusual sleep behavior Decreased sex drive Suicidal thoughts

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Bashir K, et al. Handbook of Multiple Sclerosis. 2002.

Comprehensive Management

Identify risk factors Combine counseling and antidepressants Wellness focus (exercise, healthy living) Follow up appointments with HCP Be alert for suicidal thoughts or recurring

depression

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QUESTIONS ??