Mov 470 MS lecture - Multiple Sclerosis By Amy Crawley By...

Unformatted text preview: Multiple Sclerosis By Amy Crawley By Exercise has not been shown to affect the Exercise prognosis or progression of MS but it will improve symptoms and quality of life. improve The goal of exercise is to make the quality The of life better… of Review : The Role of the Nervous System The The eventual role of the nervous system is the The control of various bodily activities: control Contraction of appropriate skeletal muscle Contraction of smooth muscle (internal Contraction organs) organs) Secretion of active chemical substances by Secretion both exocrine and endocrine glands in many parts of the body parts Figure 1 Myelinated Nerve Figure Figure 5-16 Function of the Schwann Figure cell to insulate nerve fibers. A, Wrapping of a Schwann cell membrane around a large axon to form the myelin sheath of the myelinated nerve fiber. B, Partial wrapping of the membrane and cytoplasm of a Schwann cell around multiple unmyelinated nerve fibers (shown in cross section). (A, Modified from Leeson TS, Leeson R: Histology. Synapses Synapses The synapse is the junction point from one The neuron to the next neuron Determine the directions the nervous Determine signals will spread signals Performs a selective action Memory is a function of synapses. The Memory disease of MS attacks these synapses so they cannot transmit a signal. (stored in Nerve with Myelin Nerve Sensory Receptors Sensory Activities of the nervous system are initiated by excitation Activities of sensory receptors of The experience can cause an immediate reaction or for a The memory to be stored There are multiple sensory areas where information enters There the CNS through peripheral nerves. the 99% of all sensory information is discarded by the brain as 99% irrelevant. irrelevant. Transduction of Nerve Signals Action potentials occur only at the node of Ranvier Action – The nerve impulse ‘jumps’ down the fiber from The node to node to be exposed to extracellular fluid propagating the action potential (Saltatory conduction) conduction) – This causes an increase in the velocity of the This depolarization process 5-50 fold, only the nodes depolarize requiring little metabolism to maintain concentration of ions and also allows for repolarization to occur with very little transfer of ions transfer Multiple Sclerosis Multiple Historical Perspective First described by a French neurologist, First Jean Martin Charcot, in 1868 Jean – He noted the accumulation of inflammatory He cells in a perivascular distribution within the brain and spinal cord white matter of patients with intermittent episodes of neurological dysfunction dysfunction – This led to the term sclerose en plaques disseminees, or multiple sclerosis disseminees or Historical continued… Historical In 1933 Thomas Rivers, at the Rockefeller In Institute, demonstrated an autoimmune, at times demyelinating, disease in mammals with the immunization of CNS myelin with EAE: Experimental Autoimmune EAE: Encephalomyelitis has led to the generally accepted hypothesis that multiple sclerosis is secondary to an autoimmune response to secondary self-antigens in a genetically susceptible host (typically something triggers it…such as (typically Hypothetical confirmed genetic Hypothetical Causes Genetic Propensity: only Genetic feature from the MHC on chromosome 6p21, believed to be multiple gene involvement Environmental factors: (e.g., viral Environmental infections, bacterial polysaccharides, superantigens) may expose macrophages and microglial cells to myelin antigens resulting in the activation and proliferation of T lymphocytes that destroy the myelin sheath. sheath. Pathology of Multiple Sclerosis Pathology 4 pathological categories: 1-The basis of myelin protein loss 2-The geography and extension of 2-The plaques plaques 3-The patterns of oligodendrocyte 3-The destruction destruction 4-The immunopathological evidence 4-The of complement activation of Pathology of Multiple Sclerosis Pathology Brain tissue of individuals with MS reveal Brain multiple sharply demarcated plaques in the CNS white matter with a predilection to the optic nerves and white matter tracts of the periventricular regions, brain stem, and spinal cord spinal Substantial axonal injury with axonal Substantial transections is abound through active MS lesions lesions Profile of Inflammatory Cell Profile Active lesions are characterized by Active perivascular infiltration of oligoclonal autoreactive T cells oligoclonal Lesions of MS are primarily Lesions inflammatory and demyelinating and that axonal loss may occur early in the disease course leading to the development of irreversible disability irreversible MS Facts MS Two times as prevalent in females Symptoms manifest during young adulthood but Symptoms often go undiagnosed often Incidence much higher in Caucasian pop. Higher Incidence in cooler climates (above 40 Higher degree latitude) degree Prevalence rate of about 1 in 600 This is the most common neurological disease This affecting young adults MS is unpredictable with symptoms that intensify MS (relapse) and then improve (remission). (relapse) Types of Multiple Sclerosis Types RRMS-Relapsing Remitting MS (85-90%) – Identified by episodes of acute attacks on Identified neurological functioning followed by periods without disease progression and sometimes nearly complete recovery nearly – Symptoms may develop over hours to several Symptoms days and persist for up to eight weeks and then disappearing disappearing – Early immunotherapy prevents onset of Early secondary progressive multiple sclerosis disease disease Types of Multiple Sclerosis Types SPMS-Secondary Progressive MS – Begins with a RRMS course at onset followed Begins by progression with or without relapses, remissions or plateaus remissions – Steady (continuous) and chronic increase of Steady physical symptoms and disability physical – Approximately 40% of RRMS patients develop Approximately SPMS within 10 years of initial diagnosis – Some can be diagnosed right off of the bat Types of Multiple Sclerosis Types PPMS-Primary Progressive MS (1015%) – Indicated by a gradual and worsening onset of Indicated symptoms continuously without interruption by distinct relapses distinct – Tends to occur in older individuals and males – Presents with fewer lesions on MRI and lower Presents levels of inflammatory markers levels – Lacks any form of response to immunotherapy Lacks Types of Multiple MS Sclerosis Types PRMS-Progressive Relapsing – 10% of MS patients 10% – Sometimes referred to as malignant MS Sometimes because death occurs within several months because – Characterized by absence of acute attacks, Characterized instead involves a gradual clinical decline instead – Possible to have a singular episode (ex: temp Possible loss of sight) loss – Lacks response to any form of immunotherapy **People can also have ‘singular sclerosis’ **People Symptoms of MS Symptoms Severe Fatigue Tremors Vision-Optic neuritis Balance, Coordination Balance, and Gait and Dizziness from Brain Dizziness Stem Dysfunction Stem Seizures Cognition Dysfunction Cognition (~30%) (~30%) Paresthesia (burning) Sexual Dysfunction Incontinence Weakness/clumsy Spactisity (loss of Spactisity ability of the muscles to interact.) to Exercise and Symptoms Patients should NOT exercise to fatigue, MS symptoms are exacerbated by heat, stress (mental or physical), and anxiety. 50% of patients will experience memory lapses (cognitive dysfunctions) Their muscles loss the ability to communicate or interact with each other (Spactisity). This does not mean their muscles are incapable of activity. Diagnostic Criteria Diagnostic Clinical event – Presence of neurological dysfunction evidenced by an Presence attack of symptoms attack MRI-Magnetic Resonance Imaging – findings showing 2-3 typical lesions has around a 90% findings risk of developing MS risk – Sensitive but less specific diagnosis – Beneficial in predicting future disability, disease Beneficial activity and early diagnosis activity Cerebrospinal Fluid Analysis – Increase in immunoglobulin G (IgG) in response to Increase myelin antigens myelin MRI Lesion Image MRI Two images of a 48 yr old woman with RRMS showing a ring type lesion and pressure on surrounding brain tissue. Inflammation is shown in white part of Inflammation cat scan cat FIG. 3. T1-weighted post contrast (left) and CSE T1-weighted T2-weighted (right) images of a 48-year-old woman with RR MS show a ring enhancing lesion and corresponding complex appearance on the T2 image. appearance NeuroRx. 2005 April; 2(2): 277–303. NeuroRx. Copyright © 2005, The American Society MRI Normal/MS Image: Demonstrates the actual loss of gray MRI matter that relates to physical disability, cognitive dysfunction, and brain atrophy. matter Space is shown – Brain matter is actually lost Individualized Treatment Individualized No standard recommendations for treatment 10-20% of patients with MS have no need 10-20% of treatment due to a benign course of The goal for RRMS is to reduce the The frequency and severity of relapses and postpone the onset of SPMS postpone The goal for SPMS is to prevent The progressive worsening of the disease progressive Drug Therapies Drug Corticosteroids-until recently were the only Corticosteroids-until option recommended for treatment of acute disabling attacks because they shorten the duration of symptoms duration Over the last ten years 6 new disease Over modifying drugs were approved by the FDA for treatment of MS FDA Beta-Interferons Beta-Interferons Avonex, Betaseron, Rebif – First choice of treatment for patients with First RRMS (typically are the first treatment given…you cant miss a dose..take every other day…helps keep lessions from continuing) day…helps – These drugs are immune modulators (example: These reduce T cell proliferation) reduce – Do not reverse fixed deficits – Should be considered early in the course of the Should disease disease – Differ based on dosage (of interferon beta), Differ route and frequency of administration route Glatiramer Acetate Glatiramer Copaxone – A synthetic copolymer consisting of four amino synthetic acids A:K:E:Y (some immunological similarities to myelin basic protein) similarities – Interferes with antigen specific T cell activation – Subcutaneously administered – Second choice of treatment for RRMS New Developments New A whole new range of treatment strategies whole are under investigation are Recent observations of axonal damage early in the disease course and increasing disability despite optimal anti-inflammatory treatment Emphasize the need for rigorous Emphasize investigation of neuroprotective treatment investigation Exercise Testinga >15% PredictionExercise test has Prediction from submax error in this population error Measure HR, RPE, BP, but patients with Measure MS can have a blunted HR response and a decrease in BP with exercise Preferred mode is a bike (with foot straps) Preferred or treadmill Temperature should be 72 – 76 degrees VERY IMPORTANT to ask for sensory VERY awareness during testing awareness Exercise Prescription Exercise Aerobic goal – increase or maintain current Aerobic function 30-40min sess/3 days a wk/ 60function 85% peak HR (4-6 months) Strength goal – functional fitness (do not Strength perform on endurance/aerobic days) 2-3 days/wk using large muscle groups…fxnal fitness fitness Strength and aerobic occur on different Strength days …not the same days Flexibility goal – Increase maintain ROM, Flexibility Safety Considerations It is important to anticipate accidents, monitor the room and patient movements to prevent falls They might need frequent breaks for fluid before, during and after exercise Fatigue level is your intensity guide focus on what the CAN do. NO 1RM testing for this population, use 10RM Do not have a patient perform cervical flexion (chin to chest) will cause a brief but stabbing electrical shock down their neck and spinal cord called Lhermitte’s sign. ...
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