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When is it MS and When is it Something Else?
Jodie K. Haselkorn, MD, MPHJodie K. Haselkorn, MD, MPHDirector, MS Center of Excellence WestDirector, MS Center of Excellence West
Veterans Health AdministrationVeterans Health Administration
www.va.gov/mswww.va.gov/ms
Associate Director, RehabNetWestAssociate Director, RehabNetWest
University of WashingtonUniversity of Washington
Rehabilitation Medicine, Epidemiology, Medical History & BioethicsRehabilitation Medicine, Epidemiology, Medical History & Bioethics
Is it MS or Something ElseNMSS November 2004 2
MS Center of Excellence West
Jodie Haselkorn, MD, MPHJodie Haselkorn, MD, MPH Dennis Bourdette, MDDennis Bourdette, MD James Bowen, MDJames Bowen, MD Drew Blazey, AODrew Blazey, AO Gordon Campbell, RN, NPGordon Campbell, RN, NP David Gruenweld, MDDavid Gruenweld, MD John Dryden, MDJohn Dryden, MD Michael Hatzakis, Jr., MDMichael Hatzakis, Jr., MD Mark Haselkorn, PhDMark Haselkorn, PhD
Charles Lai, MSCharles Lai, MS Steve Leipertz, PhDSteve Leipertz, PhD Amy Poel, MPHAmy Poel, MPH Chuck Maynard, PhDChuck Maynard, PhD Marsha Tarvor, PhDMarsha Tarvor, PhD Aaron Turner, PhDAaron Turner, PhD Tara Stablein, MSWTara Stablein, MSW Lynne Walker, CRRNLynne Walker, CRRN Rhonda Williams, PhDRhonda Williams, PhD Ruth Whitham, MDRuth Whitham, MD
Is it MS or Something ElseNMSS November 2004 3
• Seattle
• Portland• Baltimore
Is it MS or Something ElseNMSS November 2004 4
Overview
Is it MS?Is it MS? Is it something else?Is it something else? Good PreventionGood Prevention Advocating for yourself and your Advocating for yourself and your
significant otherssignificant others
Is it MS or Something ElseNMSS November 2004 5
Is it MS or is it something else? Providers, people with MS, and Caregivers all Providers, people with MS, and Caregivers all
struggle with this issuestruggle with this issue Associated with feelings that includeAssociated with feelings that include
StressStress FearFear AnxietyAnxiety HelplessnessHelplessness FrustrationFrustration AngerAnger Decreased Self-EfficacyDecreased Self-Efficacy
Is it MS or Something ElseNMSS November 2004 6
Is it MS or is it something else? Maladaptive use of the health care Maladaptive use of the health care
system:system: non-participation non-participation constant health utilizationconstant health utilization
Is it MS or Something ElseNMSS November 2004 7
Is it MS?
MS definedMS defined Diagnostic Criteria for MSDiagnostic Criteria for MS Sometimes other conditions mimic MSSometimes other conditions mimic MS Definition of a RelapseDefinition of a Relapse Secondary Impairments Associated with Secondary Impairments Associated with
MSMS
Is it MS or Something ElseNMSS November 2004 8
Multiple Sclerosis Criteria
Objective clinical evidence of Objective clinical evidence of neurological lesions in time and in neurological lesions in time and in spacespace
Radiological and laboratory evidenceRadiological and laboratory evidence MRIMRI CSFCSF VEPVEP
No Better ExplanationNo Better Explanation
Is it MS or Something ElseNMSS November 2004 9
MRI Evidence of MS
Three of these:Three of these: One gadolinium-enhancing lesion orOne gadolinium-enhancing lesion or
>> 9 T2 hyper intense lesions 9 T2 hyper intense lesions >> 1 infratentorial lesion 1 infratentorial lesion >> 1 juxtacortical lesion 1 juxtacortical lesion >> 3 paraventricular lesions 3 paraventricular lesions
Is it MS or Something ElseNMSS November 2004 10
Multiple Sclerosis: Is it something else Many individuals seen in MS Centers Many individuals seen in MS Centers
diagnosed with MS don’t have the diagnosed with MS don’t have the disease, but have something elsedisease, but have something else
Is it MS or Something ElseNMSS November 2004 11
Multiple Sclerosis Mimics
Acute Disseminated Encephalomyelitis Acute Disseminated Encephalomyelitis (ADEM)(ADEM)
CerebritisCerebritis Cervical MyelopathyCervical Myelopathy Complicated MigraineComplicated Migraine DiabetesDiabetes
Is it MS or Something ElseNMSS November 2004 12
Multiple Sclerosis Mimics
Guillian BarraeGuillian Barrae Hereditary Spastic ParaparesisHereditary Spastic Paraparesis Lyme DiseaseLyme Disease Neromyelitis Optica (Devic’s)Neromyelitis Optica (Devic’s) NeurosyphilisNeurosyphilis Paraneoplastic SyndromesParaneoplastic Syndromes Polyarteritis nodosaPolyarteritis nodosa PolymyositisPolymyositis
Is it MS or Something ElseNMSS November 2004 13
Multiple Sclerosis Mimics
Progressive Multifocal LeukoencephalopathyProgressive Multifocal Leukoencephalopathy SarcoidosisSarcoidosis Sjogren SyndromeSjogren Syndrome Spinocerebellar SyndromeSpinocerebellar Syndrome StrokeStroke Sub-Acute Sclerosing PanencephalitisSub-Acute Sclerosing Panencephalitis TumorsTumors
Is it MS or Something ElseNMSS November 2004 14
Exacerbation, Relapse, Attack, and Flare Defined:Defined:
A sudden change in neurological function A sudden change in neurological function (worsening of symptoms or the (worsening of symptoms or the appearance of new symptoms) lasting at appearance of new symptoms) lasting at least 24 hoursleast 24 hours
Separated from the last exacerbation by Separated from the last exacerbation by one monthone month
Unexplained by other changes such as an Unexplained by other changes such as an infectioninfection
Is it MS or Something ElseNMSS November 2004 15
Pseudoexacerbation
Temporary aggravation of MS Temporary aggravation of MS symptoms that have been experienced symptoms that have been experienced before NOT associated with before NOT associated with inflammationinflammation HeatHeat FeverFever InfectionInfection
Is it MS or Something ElseNMSS November 2004 16
Secondary Impairments Associated with MS
FatigueFatigue A subjective lack A subjective lack
of physical or of physical or mental energy mental energy perceived by the perceived by the individual or individual or caregiver to caregiver to interfere with interfere with usual and desired usual and desired activities.activities.
Is it MS or Something ElseNMSS November 2004 17
Fatigue: MS or Something Else Make sure your provider:Make sure your provider:
Takes a good historyTakes a good history Does a physical examinationDoes a physical examination Performs lab work including Performs lab work including
hematocrit and thyroid stimulating hematocrit and thyroid stimulating hormone (TSH)hormone (TSH)
Is it MS or Something ElseNMSS November 2004 18
Fatigue – Something Else
Poor sleepPoor sleep Excessive caffeineExcessive caffeine Over-useOver-use AnemiaAnemia HypothyroidismHypothyroidism DepressionDepression Medication EffectsMedication Effects
Is it MS or Something ElseNMSS November 2004 19
Depression – MS related
30-60% of individuals with MS report a 30-60% of individuals with MS report a major depressive episode. major depressive episode. InflammatoryInflammatory
Coronary Artery DiseaseCoronary Artery DiseaseInflammatory Bowel DiseaseInflammatory Bowel DiseaseRheumatoid arthritis Rheumatoid arthritis
AdjustmentAdjustment
Is it MS or Something ElseNMSS November 2004 20
Depression – Is it something else?
Major Depressive Major Depressive Episode not Episode not associated with MSassociated with MS
Medication EffectsMedication Effects
Is it MS or Something ElseNMSS November 2004 21
Spasticity – MS related
Increased resistance of muscle to rapid Increased resistance of muscle to rapid stretchstretch Baseline spasticityBaseline spasticity Changes withChanges with
Exacerbation or progressionExacerbation or progressionDMTsDMTs
Is it MS or Something ElseNMSS November 2004 22
Spasticity – Is it signaling something else? InfectionInfection Increased temperatureIncreased temperature MensesMenses Tight clothingTight clothing Skin ulcerSkin ulcer Renal or bladder stonesRenal or bladder stones Temperature extremesTemperature extremes StressStress FractureFracture
Is it MS or Something ElseNMSS November 2004 23
Urinary Dysfunction – MS Related Failure to storeFailure to store
FrequencyFrequency UrgencyUrgency NocturiaNocturia IncontinenceIncontinence
HesitancyHesitancy
Is it MS or Something ElseNMSS November 2004 24
Urinary Dysfunction Basic Workup
HistoryHistory Physical Physical
ExaminationExamination UrinalysisUrinalysis Post void residualPost void residual
Is it MS or Something ElseNMSS November 2004 25
Urinary Dysfunction – Not MS
Urinary Tract InfectionUrinary Tract Infection Prostate Disorders in MenProstate Disorders in Men Stress Incontinence in WomenStress Incontinence in Women Bladder or Kidney StonesBladder or Kidney Stones Bladder, Kidney, Ureteral CancerBladder, Kidney, Ureteral Cancer
Is it MS or Something ElseNMSS November 2004 26
Bowel Function – MS Related
Demyelination interferes with the Demyelination interferes with the signals from the brain and spinal cord to signals from the brain and spinal cord to empty the bowelempty the bowel Decreased activityDecreased activity FatigueFatigue Weakness/Spasticity of the Weakness/Spasticity of the
Abdominal Muscles and Pelvic FloorAbdominal Muscles and Pelvic Floor Fluid RestrictionFluid Restriction
Is it MS or Something ElseNMSS November 2004 27
Bowel Dysfunction – Not MS
DiarrheaDiarrhea InfectionInfection Highly spiced foodsHighly spiced foods Lactose IntoleranceLactose Intolerance Irritable bowel SyndromeIrritable bowel Syndrome Colonic tumorsColonic tumors
Is it MS or Something ElseNMSS November 2004 28
Bowel Dysfunction– Not MS
ConstipationConstipation Poor water intakePoor water intake Poor dietPoor diet InactivityInactivity Calcium Calcium
supplementssupplements AntacidsAntacids Antidepressants, Antidepressants,
diuretics, opioidsdiuretics, opioids HabitHabit
Is it MS or Something ElseNMSS November 2004 29
Sensory Impairments – MS related NumbnessNumbness Pins and needlesPins and needles PainPain Banding, girdlingBanding, girdling
Is it MS or Something ElseNMSS November 2004 30
Pain Associated with MS
Trigeminal NeuralgiaTrigeminal Neuralgia Lhermitte’s SignLhermitte’s Sign DysesthesiasDysesthesias
Is it MS or Something ElseNMSS November 2004 31
Pain Associated with Secondary Impairments due to MS
Spasticity – pulling, cramping of Spasticity – pulling, cramping of musclesmuscles
Restricted Range of Motion – Muscle Restricted Range of Motion – Muscle pain and referred joint painpain and referred joint pain
Is it MS or Something ElseNMSS November 2004 32
Pain – Not MS related
Nerve entrapmentsNerve entrapments Cervical Cervical
radiculopathyradiculopathy Lumbar Lumbar
radiculopathyradiculopathy Peripheral Nerve Peripheral Nerve
EntrapmentsEntrapments• Carpal TunnelCarpal Tunnel
Is it MS or Something ElseNMSS November 2004 33
Pain – Not MS related
Musculoskeletal “wear and tear”Musculoskeletal “wear and tear”Rotator cuff disorderRotator cuff disorderOsteoarthritisOsteoarthritis
• ShouldersShoulders• HandsHands• HipsHips• KneesKnees• NeckNeck• Low BackLow Back
Is it MS or Something ElseNMSS November 2004 34
Pain (continued)
Referred PainReferred Pain Soft TissueSoft Tissue
Trigger pointsTrigger pointsOverused musclesOverused musclesFibrotic musclesFibrotic muscles
Retroperitoneal StructuresRetroperitoneal StructuresAortaAortaPancreasPancreasKidneysKidneysUterusUterus
Is it MS or Something ElseNMSS November 2004 35
Headaches
Headaches can be associated with MSHeadaches can be associated with MS
Is it MS or Something ElseNMSS November 2004 36
Headaches – Not MS
Tension headachesTension headaches Cervical segmental Cervical segmental
dysfunctiondysfunction Migraine headachesMigraine headaches Cluster headachesCluster headaches Space occupying Space occupying
lesions such as lesions such as tumorstumors
Is it MS or Something ElseNMSS November 2004 37
Facial Pain– Not MS
Dental problemsDental problems Temporomandibular joint painTemporomandibular joint pain
Is it MS or Something ElseNMSS November 2004 38
Pain – Not MS related
Musculoskeletal “wear and tear”Musculoskeletal “wear and tear”Rotator cuff disorderRotator cuff disorderOsteoarthritisOsteoarthritis
• ShouldersShoulders• HandsHands• HipsHips• KneesKnees• NeckNeck• Low BackLow Back
Is it MS or Something ElseNMSS November 2004 39
Sexual Function — MS Effects Decreased or absent sex driveDecreased or absent sex drive Changed genital sensationsChanged genital sensations
NumbnessNumbness PainPain HypersensitivityHypersensitivity
Is it MS or Something ElseNMSS November 2004 40
Sexual Function — MS Effects
Decreased vaginal toneDecreased vaginal tone Difficulty getting or maintaining an Difficulty getting or maintaining an
erectionerection Decreased vaginal lubrication and Decreased vaginal lubrication and
clitoral engorgementclitoral engorgement Difficulty or inability to ejaculateDifficulty or inability to ejaculate Decreased frequency/intensity of Decreased frequency/intensity of
orgasmsorgasms
Is it MS or Something ElseNMSS November 2004 41
Sexual Function – Secondary Effects Loss of desireLoss of desire
FatigueFatigue AnxietyAnxiety DepressionDepression
Sensory Sensory ImpairmentsImpairments PainPain Loss of sensationLoss of sensation
Is it MS or Something ElseNMSS November 2004 42
Sexual Function – Secondary Effects Fear associated with bladder or bowel Fear associated with bladder or bowel
accidentsaccidents Cognitive ImpairmentsCognitive Impairments Spasticity and Weakness Interfering Spasticity and Weakness Interfering
with positioningwith positioning Medication EffectsMedication Effects
Is it MS or Something ElseNMSS November 2004 43
Sexual Function – Tertiary Effects Grief, demoralization, anxiety, depression Grief, demoralization, anxiety, depression
and fearsand fears Changed social and family rolesChanged social and family roles Changed body imageChanged body image StressStress TimeTime Cultural values and expectationsCultural values and expectations Others…..Others…..
Is it MS or Something ElseNMSS November 2004 44
Sexual Dysfunction – Non MS
Causes of sexual difficulties includeCauses of sexual difficulties include Medication side effectsMedication side effects MoodMood Vascular ProblemsVascular Problems Other neurological problems such as Other neurological problems such as
diabetesdiabetes
Is it MS or Something ElseNMSS November 2004 45
Cognitive Functions Associated with MS Decreased attention, concentration, Decreased attention, concentration,
needing more time to store new facts, needing more time to store new facts, needing a cue to recall recently stored needing a cue to recall recently stored factsfacts
Is it MS or Something ElseNMSS November 2004 46
Cognitive Dysfunction – Not MS MedicationsMedications DementiasDementias
Is it MS or Something ElseNMSS November 2004 47
Hearing
Changes in hearing due to MS have Changes in hearing due to MS have been reported, but they are rare. been reported, but they are rare. Hearing changes should be evaluated Hearing changes should be evaluated for some other cause.for some other cause.
Is it MS or Something ElseNMSS November 2004 48
Dizziness
Dizziness is a Dizziness is a common complaint common complaint of people with MSof people with MS
Is it MS or Something ElseNMSS November 2004 49
Dizziness – Not MS
Other causes of dizziness include:Other causes of dizziness include: DehydrationDehydration MedicationsMedications Middle Ear ProblemsMiddle Ear Problems Benign Tumors of the Acoustic NerveBenign Tumors of the Acoustic Nerve
Is it MS or Something ElseNMSS November 2004 50
Is it something else?
General Prevention StrategiesGeneral Prevention Strategies Advocating for yourself and your Advocating for yourself and your
significant othersignificant other
Is it MS or Something ElseNMSS November 2004 51
Is it something else?
Good Prevention StrategiesGood Prevention Strategies ImmunizationsImmunizations Preventative MedicationsPreventative Medications Good Self CareGood Self Care Screening TestsScreening Tests
Is it MS or Something ElseNMSS November 2004 52
Immunizations
Influenza– Yearly after the age of 50 Influenza– Yearly after the age of 50 yrs. or sooner if at high riskyrs. or sooner if at high risk NOT Nasal SprayNOT Nasal Spray
Tetanus Diphtheria - Every 10 yearsTetanus Diphtheria - Every 10 years Pneumonia – Once at age 65 years or Pneumonia – Once at age 65 years or
sooner if pulmonary impairment or other sooner if pulmonary impairment or other immunosupressionimmunosupression
Hepatitis BHepatitis B
Is it MS or Something ElseNMSS November 2004 53
Preventative Medications
Aspirin – After age 40 to prevent heart Aspirin – After age 40 to prevent heart disease; younger than age 40 if high disease; younger than age 40 if high blood pressure, high cholesterol, blood pressure, high cholesterol, diabetes, or smokingdiabetes, or smoking
Is it MS or Something ElseNMSS November 2004 54
Other Self-Management Health Factors Stop smokingStop smoking Eat a healthy variety of foodsEat a healthy variety of foods Limit intake of saturated fatLimit intake of saturated fat Limit alcoholLimit alcohol Get moderate exerciseGet moderate exercise
Is it MS or Something ElseNMSS November 2004 55
Screening Tests
CholesterolCholesterol Every 5 years Every 5 years >>35 years35 years At age 20 if smoking, have diabetes, At age 20 if smoking, have diabetes,
or family history of heart diseaseor family history of heart disease
Is it MS or Something ElseNMSS November 2004 56
Screening Tests
Colorectal CancerColorectal Cancer Regular screening Regular screening >> 50 years 50 years
DepressionDepression Greater than two weeks “sad, blue, Greater than two weeks “sad, blue,
hopeless, little interest or pleasure in doing hopeless, little interest or pleasure in doing things”things”
DiabetesDiabetes If Hypertensive or HypercholesterolemiaIf Hypertensive or Hypercholesterolemia
Is it MS or Something ElseNMSS November 2004 57
Screening Tests Sexually Transmitted DiseaseSexually Transmitted Disease
Discuss with your provider if you should be Discuss with your provider if you should be screened screened
Prostate CancerProstate Cancer Yearly PSA or DRE Yearly PSA or DRE >> 40/50 without a 40/50 without a
personal history of cancer or family history personal history of cancer or family history of prostate cancerof prostate cancer
Breast CancerBreast Cancer Yearly mammograms Yearly mammograms >> 40 years 40 years
Is it MS or Something ElseNMSS November 2004 58
Screening Examinations
Yearly Pap and Gynecological Yearly Pap and Gynecological Examination for WomenExamination for Women
Every 6 month dental prophylaxisEvery 6 month dental prophylaxis
Is it MS or Something ElseNMSS November 2004 59
Self Screening Examinations
BreastBreast TestesTestes SkinSkin
Is it MS or Something ElseNMSS November 2004 60
Advocating for yourself or your significant other
Establish a relationship with your Establish a relationship with your provider teamprovider teamAsk about new symptomsAsk about new symptomsWrite down symptoms, signs or Write down symptoms, signs or concerns to review before a visitconcerns to review before a visit Educate yourselfEducate yourself Develop a support groupDevelop a support group