Multiple Sclerosis (MS)

Overview

Multiple Sclerosis (MS) is a chronic progressive, non contagious, degenerative disease of the CNS characterized by demyelinization of neurons.

The Human Nervous System

Areas affected by MS Brain Spinal cord Optic nerves

Pathologic triad CNS inflammation Demyelination Gliosis (scarring)

History of Multiple Sclerosis

The earliest description of MS was recorded in Holland on August 4, 142. But the history of the disease really begins in the 19th century with the first clear illustrations and clinical description of the disease beginning to appear in 1838.

The first actual case was diagnosed in 1849. It was Dr. Jean-Martin Charcot who is credited for giving the first signs and symptoms of Multiple Sclerosis.

Multiple Sclerosis - Epidemiology Worldwide occurrence:1.1 – 2.5 million

cases Female: male ratio = 2:1 In Canada an estimated that 55,000-

75,000 people have multiple sclerosis Affects nearly 500,000 individuals in the

US Occurs most frequently between ages

25 - 35

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Factors Contributing for MS

Genetic Factors Gender: Women are 2 to 3 times more likely to get the

disease. Family history of MS: A family history increases the

risk Race: MS appears more in Caucasians than in other

groups Environmental factors Latitude: As you increase latitude, mainly

above and below 40° latitude. MS is more common. It is five times more likely in temperate and cooler climate regions.

World Distribution of MS

Factors Contributing for MS

Environmental factors Socioeconomic status: Least common in rural and

lower class. Migration: The age at which you may move may also

be an important factor. “If you move before the age of 15, your risk is likely to that of the people in the country you move to. If you move after the age of 15, your risk stays fixed at that of the country

you grew up in”.

Factors Contributing for MS

Environmental factors Infection: “They believe MS is a delayed reaction to a viral

infection contracted during childhood by a genetically susceptible person” (O’Connor 13). The viral infections may include shingles, chicken pox, measles, or certain herpes. An idea they also have concerns the age at which you get the infection. The older you are the higher the risk for MS.

***Remember that in warm countries, children contract viruses at a younger age.

Not Everyone with a Genetic Risk Will Develop MS – Why?

Risk is modified by Environmental factors Sunlight Diet (e.g., vitamin D) Other lifetime experiences

(infections?)

Multiple Sclerosis - Causes The exact cause of multiple sclerosis is

not clear MS patients, have a higher number of

immune cells which suggests there might be an immune response; this is suspected to be due to a virus or genetic defect

Other causes are environmental and hereditary

How Does it work?

Demyelination of Nerve Fibers in MS

The destruction of the myelin sheath leads to impaired communication between nerve cells

Positive conduction abnormalities generations of spontaneous ectopic impulses and abnormal “crosstalk” between demyelinated axons Negative conduction abnormalitiesslowed axonal conduction, variable conduction blocks occur in the presence of high- but not -low frequency volleys of impulse.

Mode of Action The immune system attacks axons,

causing destruction of the myelin sheath resulting in a Conduction Block which leads to permanent loss of function.

MS is an Immune-Mediated Disease

BBB=blood-brain barrier; APC=antigen-presenting cell.Adapted from Miller et al. Continuum: Multiple Sclerosis (Part A). 1999;5:7.

Pathophysiology Autoimmune response results in damage and loss of

fibers.

Nerves can regain myelin, but the process is not fast enough to avoid the deterioration that occurs

Astrocytes form scars where myelin formerly existed

Inflammation, loss of myelin of nerve fibers, and the scarring that follows result in reduced transmission of nerve signals within the CNS.

Type of symptoms and severity vary widely due to the location of the scar tissue and the extent of demyelination

Pathophysiology of MS Click

Multiple Sclerosis Signs and Symptoms Vision impairment Lhermitte‘s sign-

momentary paresthesia

Difficulty in walking

Weakness and exhaustion

Memory loss Depression Urinary and bowel

problems + Babinski’s

reflex

Nursing Diagnosis

1. Pain chronic r/t stimulations of free nerve ending 2 to destructions of myelinated axons.

2. Impaired sensory perception r/t nonsynaptic

transmission of demyelinated axons. 3. Fatigue r/t decrease energy production4. Paralysis r/t conduction block of

demyelinated axons.

Nursing Diagnosis

5. Low self Esteem r/t change in brain structure/function.

6. Ineffective coping r/t multiple life changes.

7. Risk for care givers role train r/t severity of the

care receiver, duration of care giving required

8. Deficient knowledge regarding condition, prognosis, complications, treatment and need r/t unfamiliarity of information resources.

Cont.. Nursing Diagnosis

Multiple Sclerosis - Types

There are 4 major types of MS Relapsing-remitting MS (RR-MS) Primary-progressive MS (PP-MS) Progressive-relapsing MS (PR-MS) Secondary-progressive MS (SP-MS)

Multiple Sclerosis - TypesRelapsing-remitting MS (RR-MS) More than 80% Defined clinical exacerbation of

neurological symptoms Followed by complete or incomplete

remission during which the person fully or partially recovers from the deficits acquired during relapse

Multiple Sclerosis - Types Primary-progressive MS (PP-MS) 10 to 20% Gradual progression of the disease No overlapping relapses and

remissions

Multiple Sclerosis - Types

Progressive-relapsing MS (PR-MS) Rare Initially presenting as PP-MS, however

during the course of the disease the individuals develop true neurologic exacerbations

Steady progression of clinical neurological damage with superimposed relapses and remissions.

Multiple Sclerosis - TypesSecondary Progressive MS (SP-MS) SP-MS is characterized by a steady

progression of neurological damage with or without superimposed relapses and minor remissions

Individuals with SP-MS will have experienced a period of RR-MS, which may have lasted from 2 to 40 years

Any super-imposed relapses and remissions fade over time

How Is MS Diagnosed? At least two episodes of symptoms

Occur at different point in time Result from involvement of different

areas of the central nervous system Absence of other treatable causes

for the symptoms Results of neurological testing

DIAGNOSTIC WORKUP

Radiologic studies It is diagnosed by neurological

examination and brain MRI scans Signs of two separate attacks

with demyelination of CNS supports the diagnosis.

Is a noninvasive diagnostic

scanning technique in which the client is placed in a magnetic field. MRI provides a better contrast between normal and abnormal tissue than the CT scan. For visualization of the brain, spine, limbs, and joints, heart, blood vessels, abdomen and pelvis.

 

Magnetic Resonance Imaging (MRI)

Brain Atrophy (Shrinkage) in Untreated MS

Images acquired over the course of 7 years from a single person

with untreated MS Brain atrophy is seen as the enlargement of

the ventricle and sulcal spaces. In untreated MS, by year 2, up to

6% of brain volume can be lost.2

Assessment of the Appearance of MS Lesions Over time

Time lapse = 1 year

Serum and CSF Analysis Blood tests Lumbar Puncture (spinal tap) - If MS is present, persistent

elevated of CSF protein IgG (oligoclonal antibody) bands can be seen in spinal fluid which is an additional confirmatory test.

Symptom Management – Examples

Pain control Management of impaired bladder

and bowel function Anti-spasmodic drugs Treatment of fatigue Splinting for contractures Counseling

The end..

References All About MS @  http://www.mult-sclerosis.org/ Multiple Sclerosis Society @  http://www.mssociety.org.uk/ The National Multiple Sclerosis Society @ http://www.nationalmssociety.org/ All About MS @  http://www.mult-sclerosis.org/ Multiple Sclerosis Society @  http://www.mssociety.org.uk/ The National Multiple Sclerosis Society @ http://www.nationalmssociety.org Resource Link for the MS Foundation (MS Facts) @ http://www.msfacts.org/ Barnes, David. Multiple Sclerosis Questions and Answers, Merit Publishing International,

Florida, 2000 O’Connor, Dr. Paul. Multiple Sclerosis The Facts You Need, Firefly Books Inc., New York, 1999.   Christopher Bourque, Diagnostic Issues Ref :“DEMYELINATING DISEASE MULTIPLE SCLEROSIS”ELLEN MARDER MD PHD, 8/4/2005 Multiple Sclerosis: Hope Through Research, 06 April

2003http://intelihealth.com/IH/ihtIH/WSIHW000/8320/21151/195415.html?d=dmtcontent>, www.jama.com on February 14, 2009