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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- Spring '11
- Crawley
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