PM6 Assignment

Preparation time Discussion time Demonstration time All based on cases in PM6

Multiple Sclerosis

Janet Rooney

2006

Definition

“A common idiopathic inflammatory demyelinating disease of the central nervous system (brain and spinal cord) characterised by discrete lesions (plaques) scattered throughout the CNS with symptoms resulting from impaired conduction through the demyelinated and transected axons”

(Giovannoni and Miller, 1999; Ko Ko, 1999; Schwid, 2003; Lazoff, 2005; Dangond, 2006; Multiple Sclerosis Society, 2006)

Prevalence

Most common cause of progressive neurological disability in the United Kingdom

Giovannoni and Miller, 1999

Lifetime risk = 1:400 Compston and Coles, 2002

350,000 cases in the United States, more than 2.5 million worldwide

Dangond, 2006

Prevalence

100-130/100,000 in the United Kingdom Craig et al, 2003; NICE, 2003

52-85,000 people in the United Kingdom NICE, 2003; Multiple Sclerosis Society, 2006

Incidence

25,000 persons newly diagnosed with MS in the United States, more than 1 million worldwide

Lazoff, 2005

3-7/100,000 diagnosed with MS each year in the United Kingdom

NICE, 2003

Early adulthood with a peak onset between the ages of 20 and 45

Ko Ko, 1999

Female to male ratio 2:1 Predominantly northern Europeans Familial recurrence rate of about 15%

Compston and Coles, 2002

Diagnosis

Expert panel McDonald et al, 2001

An ‘attack’ Exacerbation/relapse Episode of neurological disturbance Lasts at least 24 hours Not ‘pseudo-attack’

Diagnosis

Magnetic resonance imaging Cerebro-spinal fluid examination

Oligoclonal bands on electrophoresis Presence of an elevated IgG

Visual Evoked Potentials Slow but with well-preserved wave form

Clinical subtypes

Relapsing remitting 65-75% evolve into secondary progressive )

Dangond, 2006; Multiple Sclerosis Society, 2006

Chronic progressive Primary progressive Relapsing progressive Secondary progressive

Acute fulminant/Malignant Benign

Lazoff, 2005; Multiple Sclerosis Society, 2006

Symptoms

Primary Neurological

Secondary Consequence of immobility Consequence of impairment Consequence of Disability

Tertiary Consequence of Handicap

Pathophysiology

Giovannoni and Miller, 1999

Demyelination

MRI scan - plaques

Impact

Career and aspirations, social and family life

Muscle weakness Spasticity Altered or reduced sensation Visual loss Dysarthria/dysphagia Respiratory dysfunction

Impact

Loss of coordination/ataxia Cognitive impairment Anxiety and depression Fatigue, Heat intolerance Pain/sensory disturbance Loss of bladder and bowel control

Ko Ko, 1999; Thompson, 2001

Fatigue

75%-95% of individuals with MS experience variable degrees of fatigue

50%- 60% report fatigue as one of their worst problems

Multiple Sclerosis Council for Clinical Guidelines, 1998; Dangond, 2006

Fatigue

Contractile force 30-70% lower than controls

Reduced muscle oxidative capacity Decreased ability to activate their

muscle/failure of muscle activation A portion of the weakness in MS can be

attributed to disuse Lambert et al, 2001, Surakka et al, 2004

Spasticity

Contributes to poor hygiene Pressure sores Difficulty in sexual activity Painful spasm Contractures of limbs Can be a good thing

Urinary tract dysfunction

Causes distress, disability and handicap Urgency, frequency and incontinence

combined with poor mobility Disturbance of sleep Tissue breakdown Pressure sores Spasticity

Ko Ko, 1999

EDSS

Kurtzke Expanded Disability Status Scale

Measure of disease progression Dangond, 2006

Severity scored on a scale of 1-10 Reliable, valid but not responsive

Sharrack et al , 1999

Heat sensitivity

Uthoff’s phenomenon Conduction block through partially

demyelinated nerves increases steadily as temperature increases

Cooling demyelinated nerves can reduce conduction block

Patients in Schwid et al study reported less fatigue during cooling

Schwid, 2003

Morbidity/Mortality

Life expectancy of someone with MS is reduced on average by 6 – 11 years

Multiple Sclerosis Society, 2006

Live 25 years from diagnosis Compston and Coles, 2002

Will manage without walking aids for 15 years from diagnosis

Autonomic Disturbance

Bladder dysfunction Bowel dysfunction Sexual dysfunction Cardiovascular autonomic dysfunction Thermoregulation Sweating Pupillary function

Merkelbach et al, 2006

Neuroplasticity

Evidence of potentially adaptive cortical plasticity that increases with brain injury in patients with multiple sclerosis

Reddy et al, 2002; Reddy et al, 2000

Training dependent changes in the brain can be demonstrated using MRI scanning technology

Limited task specific reductions in activation in the brain following training in patients vs. normals

Morgen et al, 2004

Interventions for MS

Evolves and changes as disease progresses Education Therapy input

Neurorehabilitation to minimize disability and handicap and to maintain the role of each individual in the family, workplace and community

Alleviation of symptoms Drug treatment

Treatments that modify the course of the disease by changing its natural history

Ko Ko, 1999; Thompson, 2001

Which intervention

Pills and potions Steroids Beta interferon Glatiramer acetate

Group exercise Freeman and Allison, 2004

Home exercise Surakka et al, 2004

Which intervention

Bobath concept Facilitation approach

Motor relearning approach (Carr & Shepherd) Task-oriented approach

Lord et al, 1998

Which intervention

Yoga Oken et al, 2004

‘Rehabilitation’ Craig et al, 2003

Supportive technologies Cattaneo et al, 2002

Effectiveness

Depends what you mean 65% of patients made functional gains Only 18% improved neurologically Reduction in distress

Ko Ko 1999

The more the merrier Slade et al 2002

Guidelines

National Institute for Clinical Excellence (2003) Multiple Sclerosis: national clinical guideline for diagnosis and management in primary and secondary care [online] available from http://www.rcplondon.ac.uk/pubs/books/MS/MSfulldocument.pdf [accessed 16/10/2006]

Guidelines

National Institute for Clinical Excellence (2002), Multiple sclerosis – beta interferon and glatiramer acetate for the treatment of multiple sclerosis, NICE Technology Appraisal Guidance No. 51. London, National Institute for Clinical Excellence [online] available from the World Wide Web at http://www.nice.org.uk

Guidance

Multiple Sclerosis Society (2006), A guide to MS for GPs and primary care teams, London, Multiple Sclerosis Society [online] available from the World Wide Web at http://www.mssociety.org.uk/document.rm?id=1077 [accessed 16/10/2006]