Multiple Sclerosis

MRI in MS

detects lesions in CNS may indicate demyelination

Drug Alert: β-Interferon

• Rotate injection sites with each dose. • Assess for depression and suicidal ideation. • Teach patient to wear sunscreen and protective clothing when exposed to sun. • Tell the patient that flu-like symptoms are common after starting therapy.

Etiology MS

Cause of MS remains unknown. We think MS develops in a genetically susceptible person after an environmental exposure, such as an infection. The disease has hereditary prevalence with common genetic factors in families with more than 1 affected member increasing the risk of developing the disease. Possible precipitating factors include -infection -smoking -physical injury -emotional stress -excessive fatigue -pregnancy -poor state of health.

Pharmacological interventions for MS: 1st line therapy

Immunomodulators- 1st line Relapsing MS- Tx with 1 or more of following drugs: Interferon beta (Avonex, Betaseron or Rebif); immunomodulator that ↓ # & severity of exacerbations, ↓ size of brain lesions SE- flu like symptoms, depression -Glatiramer acetate (Copaxone)- relapsing-remitting MS; SE- transient chest pain & sinus tachycardia -Teriflunomide (Aubagio)-Anti-inflammatory properties as well

Pharmacological interventions for MS: 2nd line therapy

Immunosuppressants- 2nd line Secondary progressive, progressive relapsing, worsening relapsing-remitting MS: •Mitoxantrone (Novantrone): antineoplastic; long-term causes heart failure & life-threatening dysrhythmias •Dimethyl fumarate- (Tecfidera)-leukopenia, anaphylactoid reactions ( Since these drugs decrease immune system, what should you teach your pt? infection prevention and no live vaccine's after tx)

Non pharmacological therapies for MS

Includes both physical and speech therapy. Exercise decreases spasticity, increases coordination, and retrains unaffected muscles to act for impaired ones. An especially beneficial type of physical therapy is water exercise Surgeries are often reserved for patients with unmanageable symptoms and that are unresponsive to drug therapy (e.g., neurectomy, rhizotomy, cordotomy), dorsal-column electrical stimulation, or intrathecal baclofen (Lioresal).

Who is at risk for MS?

MS affects women 2 to 3 times more often than men. MS is more prevalent in temperate climates (between 45 and 65 degrees of latitude), such as those found in the northern United States, Canada, and Europe. Higher incidence of MS in whites Onset of MS usually around the age of 30 through 50. The later the diagnoses the more progressive the disease tends to be. In its earlier stages it is often misdiagnosed.

Pathophysiology of MS

MS is marked by 3 processes: -chronic inflammation, -demyelination, -gliosis in the CNS The primary condition is an autoimmune process driven by activated T cells. An unknown trigger in a genetically susceptible person may start this process. The activated T cells in the systemic circulation go to the CNS and disrupt the blood-brain barrier. This may be the first event in the development of MS. Subsequent antigen-antibody reaction within the CNS activates the inflammatory response and leads to axon demyelination. Attacks on the myelin sheaths of the neurons in the brain and spinal cord first cause damage to the myelin sheath. The nerve fiber is not affected. Transmission of nerve impulses still occurs, but it is slowed. The patient may have a noticeable impairment of function (e.g., weakness). However, myelin can still regenerate. When it does, symptoms disappear. At that point, the patient has a remission. As inflammation continues, nearby oligodendrocytes are affected. Myelin loses the ability to regenerate. Eventually damage occurs to the underlying axon. Nerve impulse transmission is disrupted, and nerve function is lost permanently. As inflammation subsides, glial scar tissue replaces damaged tissue. This leads to the formation of hard, rigid plaques . These plaques are found throughout the white matter of the CNS. Picture description: Pathogenesis of multiple sclerosis A, Normal nerve cell with myelin sheath. B, Normal axon. C, Myelin breakdown. D, Myelin totally disrupted; axon not functioning.

Major types of MS

Relapsing-remitting MS • Clearly defined attacks of worsening neurologic function (relapses) with partial or complete recovery (remission). • 85% of people first diagnosed with this type of MS. Primary progressive MS • Steadily worsening neurologic function from the beginning with minor improvements but no distinct relapses or remissions. • 10% of people first diagnosed with this type of MS. Secondary progressive MS • A relapsing-remitting initial course, followed by progression with or without occasional relapses, minor remissions, and plateaus. • New treatments may slow progression. • Most people initially diagnosed with relapsing-remitting MS eventually transition to this type. Progressive-relapsing MS • Progressive disease from onset, with clear acute relapses, with or without full recovery. Periods between relapses are characterized by continuing progression. • 5% of people with MS.

Nursing considerations for patients with MS

The focus of nursing interventions at this phase is to prevent complications of immobility. These include respiratory and UTIs and pressure injuries. Bladder control is a major problem for many pt's with MS. Focus on complications that can arise from this. Falls can arise as a result of CNS deficits so fall prevention needs to be implemented.

Lhermittes's sign

also referred to barber chair phenomenon an electric shock-like sensation that occurs on flexion of the neck. This sensation radiates down the spine, often into the legs, arms, and sometimes to the trunk.

Multiple Sclerosis (MS)

is a chronic, progressive, degenerative Autoimmune disease of the central nervous system (CNS). characterized by disseminated demyelination of nerve fibers of the brain and spinal cord that is presented with episodes of neurologic dysfunction (exacerbation) followed by recovery (remission). Exacerbations become more frequent as disease progresses. The inflammatory response resulting in random or patchy areas of plaque in the white matter of the CNS is very definitive of MS.

Uhthoff's phenomenon

worsening of neurologic symptoms in multiple sclerosis and other neurological, demyelinating conditions when the body gets overheated from hot weather, exercise, fever, or saunas and hot tubs.

Pharmacological interventions for MS: Acute exacerbations

• Methylprednisolone (Solu-Medrol) IV -reduces edema and inflammatory responses, then oral Prednisone •Plasmapheresis or IV immunoglobulin G -may be used short term if no improvement with steroids. This medication focuses on improving symptoms right away and is very important to teach the patient about tapering off of the medication when they go to discontinue it.

Pharmacological interventions for MS: Other therapies

•Antispasmodic drugs: Baclofen, Dantrolene (Dantrium) •Anticholinergics for bladder dysfunction (detrusor hyperreflexia): Oxybutynin (Ditropan); ↓ urge incontinence •Neurologic conduction enhancer- dalfampridine (Ampyta) -improves walking speed •Fatigue- modafinil (Provigil), fluoxetine (Prozac)

Diagnosis of MS

•There is no definitive diagnostic tests for MS. Therefore, the patient history, manifestations, and result of certain diagnostic tests are important. •Diagnosis includes: 1- Two inflammatory demyelinating lesions from 2 different locations of the CNS 2- Damage or an attack occurring at 2 separate times (usually one month or more apart) 3- All other causes ruled out •An MRI of the brain and spinal cord may show plaques, inflammation, atrophy, and tissue breakdown and destruction. •Cerebral spinal fluid (CSF) analysis may show an increase in immunoglobulin G (IgG) and the presence of oligoclonal banding

Manifestations of MS

•Visual -Nystagmus (rapid involuntary movement of the eyes) -Diplopia (double vision) -Blurred vision •Auditory -Hearing loss •Speech -Dysarthria (difficult or unclear articulation of speech) •Throat -Dysphagia (difficulty or discomfort in swallowing) •Sensation -pain -Paresthesia (numbness, tingling sensations) -Lhermitte's sign -Dizziness •Urinary -Incontinence -Frequency/retention •CNS -Fatigue (most disabling symptom) -Cognitive impairment -Depression -Unstable mood •Musculoskeletal -Weakness -Spasms -Tremors -Ataxia (decreased motor function) •Bowel -Diarrhea -Constipation •Reproductive -Erectile dysfunction -Decreased libido -Decreased sensation