multiple sclerosis, causes,clinical findings, assessment and medical management

1. Jincy susan
Multiple sclerosis

2. Definition
Multiple sclerosis
Multiple sclerosis is a chronic inflammatory
demyelinating disease of the central nervous
system manifested morphologically by
inflammation, demyelination, axonal loss and
gliosis.

3. Dr.Jean Charcot charcot in 1868 who
defined the disease by its
characteristic clinical and
pathological finding paralysis and
cardinal symptoms of nystagmus,
intention tremor and scanning
speech, later termed as Charcot triad.
Cardinal features

4. Ethology
• The precise ethology is unknown. Its an autoimmune disease in which body own auto
immune attacks the CNS.
• Exposure to common viruses- Rubella, Rubeola, Canine distemper
• Genetic factors- MHC protein, encoded on the chromosome 6 that linked to antibody
production and MS.
• Epidemiological factors-Northern US, Northern europe, Southern Canada,
Scandenavian countries

5. Pathophysiology
The pathologic hallmark of multiple sclerosis (MS) is multiple focal areas of myelin loss
within the CNS called plaques or lesions.Demyelination is accompanied by variable gliosis
and inflammation and by relative axonal preservation. Lesions are disseminated throughout
the CNS but have a predilection for optic nerves, subpial spinal cord, brainstem, cerebellum
The, and juxtacortical and periventricular white matter regions. Although MS has historically
been considered a disease primarily affecting the CNS white matter, recent pathologic and
imaging studies have established that demyelinated lesions are also commonly found in the
cortical grey matter of MS patients.

7. Sensory impairment
Motor impairment
Visual impairment
Cognitive and Behavioural impairment
Bowel and Bladder impairment
Clinical manifestation

8. Sensory impairment
• Paresthesias- Pin and needle sensation
• Numbness
• Disturbance of position sense and vibration sense
• Dysesthesia- abnormal burning and aching (common in MS)
• Hyperpathia
• Trigeminal neuralgia
• Lhermitte’s sign
• Chronic pain

9. Visual impairment
• Impairment of optic nerve alter visual acuity rarely blindness
• Optic neuritis
• Scotoma - A dark spot at the centre of visual field
• Pain may present behind the eyes worsen with eye movements
• Marcus Gunn pupil
• Nystagmus and internuclear ophthalmoplegia
• Diplopia

10. Motor impairment
• Upper motor neurone syndrome due damage of corticospinal tract causes paresis,
spasticity, brisk tendon reflexes, involuntary flexor and extensor spam, clonus,
Babinski’s sign, exaggerated cutaneous reflexes and of precise autonomic control.
• Movements become slow and week due to loss of orderly recruitment and reduced
firing
• Fatigue- relatively refreshed in the morning and worsened fatigue in afternoon and
evening. Heat, humidity, stress, depression, vigorous exercise aggravate the fatigue.
Improvement has been reported with rest, sleep, moderate exercise, prayer, relaxation,
cooled water bath.

11. • Demyelinating lesion of cerebellum
and its tracts are common it leads to
Ataxia, postural tremor, ataxia during
gait, intention tremor ie gross tremor
or fine tremor
• dysmetria, dyssynergia,
dysdiadochokinesia
• Dizziness, vertigo, nausea, worsen
with eye and head movement. This
leads to a period of hyperventilation
Cerebellum and brain stem
involvement produce dysarthria,
scanning speech, dysphagia,
aspiration pneumonia can develop.
• Dysphagia leads to poor nutritional
intake and dehydration and weight
loss

12. Cognitive and behavioural dysfunction
• Deficit of memory, attention, concentration, learning , conceptional reasoning, speed of
information processing and reaction time and executive functions.
• Frontal lesion causes cognitive inflexibility, global dementia may occur in malignant
• MS. Depression is common in MS patient
• Emotional dysregulation, Euphoria, bipolar affective disorders

13. Bladder and bowel dysfunction
• Loss of volitional and synergistic control of micturition reflexes due to demyelination of
posterior and lateral spinal tracts
• Types of bladder dysfunction includes spastic, flaccid and dyssynergic bladder.
Common symptom includes urinary urgency, urinary frequency, hesitancy in starting
urination, nocturne, dribbling and incontinence. Recurrent urinary infection are
common.
• Bowel dysfunction may also occur. The CNS lesion affects gastrocolic reflex.
Constipation may occurs due to inactivity, less water intake and as the Side effect of
drug.
• Sexual dysfunction may occurs.

14. Pattern of symptoms
• Vary greatly from person to person
• Vary over time in each individual affected
• First symptoms usually in young adults
• Early symptoms are usually transient and it include problem with vision.
• Problem develop in more than one nervous system function.
• Acute symptoms followed by months or years and usually followed by month or years of
remission.

15. Exacerbating factors
• Bacterial and viral infection( cold, flu, hepatitis)
• Change in the chemical composition of blood affects normal brain and spinal cord
function.
• stress( loss of job, divorce, death)
• Uthoff’s symptom- heat worsen Ms temporary ie hot bath, hot weather, increased
internal body temperature.
• Hyperventilation also occurs as symptoms worsen.
• Dehydration, malnutrition, and sleep deprivation affects.

16. Assessment
• Cognitive assessement-MMSE
• Affective and psychosocial function
• Sensory integrity
• Visual assessment
• Pain assessment
• Cranial nerve assessment
• ROM assessment
• Postural assessment

17. • Assessment of muscle performance- MMT,isokinetic dynamometer
• Fatigue assessment- modified fatigue impact scale
• Assessment of temperature sensitivity- tympanic membrane thermometer
• Assessment of motor function
• a)corticospinal sign assessment, b)cerebellar sign, c) vestibular dysfunction
• Assessment of gait and locomotion
• Assessment of assistive devices
• Assessment of balance
• Assessment aerobic capacity and endurance

18. • Assessment of skin integrity and condition
• Functional assessment
• Environmental assessment
• General health measures
• Disease specific measures
• Expanded disability status measures
• Minimum record of disability
• Multifunctional quality of life measures.

19. Types of MS

20. Relapsing And remitting MS
The most common disease course – is characterised by clearly defined attacks of new or
increasing neurologic symptoms. These attacks also called relapses or exacerbations – are
followed by periods of partial or complete recovery (remissions). During remissions, all
symptoms may disappear, or some symptoms may continue and become permanent.However,
there is no apparent progression of the disease during the periods of remission. At different
points in time, RRMS can be further characterized as either active (with relapses or evidence of
new MRI activity) or not active, as well as worsening (a confirmed increase in disability over a
specified period of time following a relapse) or not worsening.Approximately 85
percent of people with MS are initially diagnosed with RRMS.

21. Primary progressive MS (PPMS)
It is characterized by worsening neurologic function (accumulation of disability) from the
onset of symptoms, without early relapses or remissions. PPMS can be further
characterized at different point in time as either active (with an occasional relapse or
evidence of new MRI activity) or not active, as well as with progression (evidence of
disease worsening on an objective measure of change over time, with or without relapse
or new MRI activity) or without progression.Approximately 15 percent of people with MS
are diagnosed with PPMS.

22. Secondary progressive MS (SPMS)
SPMS follows an initial relapsing-remitting course. Some people who are diagnosed
with RRMS will eventually transition to a secondary progressive course in which there
is a progressive worsening of neurologic function (accumulation of disability) over time.
SPMS can be further characterised at different points in time as either active (with
relapses and/or evidence of new MRI activity) or not active, as well as with progression
(evidence of disease worsening on an objective measure of change over time, with or
without relapses) or without progression.

23. Progressive-relapsing multiple sclerosis (PRMS)
Progressive-relapsing multiple sclerosis (PRMS) is the least common
form of the disease.The condition is characterised by a progressive
worsening of the condition from the beginning, similar to
primary-progressive multiple sclerosis (PPMS). There are occasional
relapse episodes of intensified symptoms similar to those experienced
by relapsing-remitting MS (RRMS).The progressive worsening of the
condition in PRMS is caused by nerve damage or loss, while the
relapse episodes are due to inflammation.

24. Benign MS
Benign MS is a misleading and controversial term. Some neurologists don't recognise
this as a form of MS at all. Those who meet the criteria for having benign MS tend to
disagree and report that it feels anything but benign. It's believed that if people make it
to 10 years without significant disability, they will not really progress to needing
assistance to walk and may be able to stop treatment. However, some simply disagree
with the classification and don't make treatment decisions based on a "benign"
designation.

25. Malignant MS
Malignant MS is an aggressive and rare form of MS. It's characterized by
rapidly progressive inflammation and destruction of myelin (protective covering
surrounding the nerves) and increased formation of lesions and plaque in the
brain and spine. The loss of myelin affects the brain's ability to transmit
electrochemical impulses between the nerve cells of the brain, and the spinal
cord, resulting in diminished or loss of neurological functioning and death within
in relative short time.

27. Medical History
The doctor will ask a number of questions about the symptoms that you are currently experiencing and any
that you have experienced in the past and ask about any medications you are taking and the results of any
medical tests you may have had in the past. Also be asked several questions about the medical history of
relatives, drug and alcohol use, as well as other prior health issues.

28. CSF Examination
• Cell count and protein count are normal or slightly elevated. Shows
elevated gamma globulin(IgG) more than 15% of total protein and
oligoclonal band IgG on agarose electrophoresis.Elevated myelin
basic protein or myelin proteolytic fragments in higher than normal
concentration indicates active demyelination in acute episode of
disease.

29. EVOKED POTENTIAL TEST
Three evoked potential tests can be used in evaluating MS. For all them, electrodes are applied to the scalp with
conducting gel, and placement depends on the test being performed.
Visual evoked potentials (VEPs): Visual evoked potential testing looks at your brain's response to light. It can
be particularly helpful in confirming a diagnosis of MS because it can reveal nerve damage along your optic nerve
pathways even if no associated symptoms.
Somatosensory evoked potentials (SSEP): SSEP measures the brain's response to sensation through
electrical pulses.
Brainstem auditory evoked potentials (BAEP): BAEP measures the brain's response to sound by playing
clicks, tones, or beeps into your ear through headphones.
Prolonged latencies and conduction disturbance can reveal the presence of silent lesions.

30. Magnetic Resonance Imaging
Some diagnoses of MS are made through a combination of clinical findings and evidence of
an MS lesion on an MRI.If MS is suspected, a special contrast material (gadolinium) injection
is usually administered at the time of the scan, as it reacts to areas of inflammation and will
"light up" when a lesion is active.1This indicates that demyelination is occurring now or has
occurred within the last several week,MRI is considered the best test for diagnosing MS, as
abnormal lesions appear on MRIs in more than 95 percent of people with the condition.In the
other 5 percent, MRI can lead to a false-negative.Some age-related damage or other
conditions, like a migraine or brain trauma, look like MS lesions and can produce a false-
positive.

31. Medical management of MS
• There is no treatment that prevent or cure MS. Medical management directed at the
overall disease process itself and for management of specific symptoms. Supportive
treatment are essential element of care.
• Immnuosuppressant- Initially high dose of corticosteroid are give intravenously followed
by gradual reduction of dosage for 5-6 weeks.Cyclophosphamide, azathioprine,
cyclosporin and methotrexate are also given for long term suppression of disease. Side
effects- Osteoporosis, Fluid retention,Ulcers, bleeding disorders, cataracts, risk of
infections

33. Interferon Beta
Interferon beta is considered first-line therapy for RRMS and the other forms of MS. Interferon
beta-1a is available in an intramuscular (IM) and a subcutaneous (SC) formulation, and
interferon beta-1b is available in a SC formulation. The exact mechanism of action of
interferon beta in MS is still unknown but may be related to suppression of T-helper cell
response. It is thought that reducing T-cell migration into the CNS may decrease lesion
proliferation. In published trials, interferon beta delayed the time to sustained progression in
disability, reduced the frequency of exacerbations, and decreased subclinical disease . It
adverse side effects including hypotension and DVT.

34. Medical management
• spasticity - baclofen (Lioresal), clonazepam (Klonopin), dantrolene (Dantrium), diazepam
(Valium), or tizanidine (Zanaflex)
• Tremor-hydroxyzine(Atarax,Vistaril),Clonazepam(Klonopin),Propranolol(Inderal),
• Ondansetron(Zofran), Primidon(Mysoline),Azetazolamide(Diamox)
• Bladder dysfunction-Small spastic bladder- Oxybutynin,Hyoscyamine,Tolterodine tartrate
• Flaccid bladder-crude technique,intemittent self catheterisation
• Dyssynergic bladder-Alpha blockers
• UTI-antibiotic therapy

35. • fatigue-Amantadine(symmetrel),Pemoline(Cylert),4-aminopyridine,3,4-diaminopyridine
• Constipation-laxative(metamucil), dactyl sodium sulfosuccniate
• pain-carbamazepine(tegretol),Phenytonin(dilantin),amitriptyline(elavil)
• Trigeminal neuralgia-carbamazepine,Diphenyl hydantoin
Medical management

36. STEM CELL THERAPY
There is exciting and innovative research and progress occurring related to the potential of many types of stem
cells for slowing MS disease activity and for repairing damage to the nervous system, particularly for those with
more progressive forms of the disease.
Stem cell therapy is any treatment that uses or targets stem cells, which are the types of cells that differentiate
into many different specialized cells in our bodies. Stem cells are found in both embryos and adults cells.
Many types of stem cells are being explored for their potential benefits for treating multiple sclerosis. Only when
the results of these and subsequent clinical trials are available will it be possible to determine what the optimal
cells, delivery methods, safety and actual effectiveness of these current experimental therapies might be for
people with MS.
Although cell based therapy has generated a great deal of interest and holds promise, the field is in its infancy
and much more research is needed before cell based therapies become a MS treatment option.

37. Different Types of Stem Cells
HSCs (haematopoietic stem cells) – adult stem cells that are found in bone marrow and blood. HSCs are
capable of producing all of the cells that make up the blood and the immune system.
MSCs (mesenchymal stem cells) – adult stem cells found in several places in the body, including the bone
marrow, skin and fat tissue. They produce cells which help other stem cells function properly.
NSCs (neural stem cells) – specialized stem cells responsible for repairing nerve-insulating myelin in the
brain. These can be derived from other types of stem cells such as mesenchymal cells.
hESCs (human embryonic stem cells) – stem cells derived from donated embryos. They can naturally
produce every type of cell in the body. One concern about their potential therapeutic use is that they have been
found to cause tumours.
iPSCs (induced pluripotent stem cells) -are engineered from adult cells to produce many types of cells. One
concern about their potential therapeutic use is that they have been found to cause tumours.