This document provides an overview of Multiple Sclerosis (MS), including its definition, pathophysiology, types, symptoms, diagnostic evaluation, treatment, nursing management, complications, and references. MS is a chronic demyelinating disease of the central nervous system that results in destruction of myelin sheath. It can cause a variety of symptoms such as fatigue, numbness, vision problems, and impaired mobility. Diagnosis involves MRI, lumbar puncture, and ruling out other conditions. Treatment focuses on modifying the disease course, managing symptoms, and rehabilitation. Nursing care is aimed at promoting function and minimizing complications.
2. General objective
• At the end of this session, the participant
will be able to explain about the Multiple
Sclerosis.
3. Specific objectives
At the end of this session the participant will be
able to:
• Anatomy and physiology of Nervous System
• Introduction of Multiple Sclerosis
• Definition of Multiple Sclerosis
• Incidence of Multiple Sclerosis
• Etiology and Risk factors of Multiple Sclerosis
• Pathophysiology of Multiple Sclerosis
4. Specific objectives Contd…
• Clinical Manifestations of Multiple Sclerosis
• Diagnostic Evaluation of Multiple Sclerosis
• Management of Multiple Sclerosis
• Complications
• Research Article
• References
5.
6. Terminology
• Disseminated Sclerosis: a chronic progressive nervous
disorder involving loss of myelin sheath around certain
nerve fibers.
• Encephalomyelitis disseminate: is a neurological
disorder characterized by brief but widespread attacks
of inflammation (swelling) in the brain and spinal cord
that damages myelin.
• Immune mediated disease: is a condition that results
from an abnormal immune system response. In these
diseases, the immune system mistakenly targets the
body. This creates an inflammatory response that
causes damage.
7. Terminology Contd…
• An autoimmune disease: is a condition arising from
an abnormal immune response to a normal body part.
• T- cells: A type of white blood cell. T cells are part of
the immune system and develop from stem cells in the
bone marrow. They help protect the body from
infection and may help fight cancer. Also called T
lymphocyte and thymocyte.
• B- cells: A type of white blood cell that makes
antibodies. B cells are part of the immune system and
develop from stem cells in the bone marrow. Also
called B lymphocyte
8. Terminology Contd…
• Macrophages: A type of white blood cell that
surrounds and kills microorganisms, removes dead cells,
and stimulates the action of other immune system cells
• Oligodendrocytes: A cell that forms the myelin sheath
(a layer that covers and protects nerve cells) in the brain
and spinal cord.
• Spasticity: is a condition in which there is an
abnormal increase in muscle tone or stiffness of muscle,
which might interfere with movement, speech, or be
associated with discomfort or pain.
11. Myelin
Myelin is an insulating layer, or sheath that forms
around nerves, including those in the brain and
spinal cord. It is made up of protein and fatty
substances.
• This myelin sheath allows electrical impulses to
transmit quickly and efficiently along the nerve
cells. If myelin is damaged, these impulses slow
down. This can cause diseases such as multiple
sclerosis.
12. There are two types of myelin:
• Central nervous system myelin: coats the nerve fibers
of the "white matter" in the brain and is produced by
oligodendrocytes.
• Peripheral nervous system myelin: coats the motor
neuron fibers and is produced by Schwann cells
13.
14. Introduction of MS
• MS is a chronic demyelinating disease that
affects the myelin sheath of neurons in the central
nervous system
• Multiple sclerosis occurs as a result of destruction
of myelin sheath resulting in impaired
transmission of nerve impulses.
• It is also known as "disseminated sclerosis" or
"encephalomyelitis disseminata”.
15. • Although MS is thought to be an autoimmune
disease, the specific target of the immune attack in
MS has not yet been identified. So, MS is referred
to as an immune-mediated disease.
• As part of the immune attack on the CNS, myelin
is damaged, along with the nerve fibers
themselves. The damaged myelin forms scar tissue
(sclerosis), which gives the disease its name.
• It is a disease of white matter.
Introduction of MS Contd…
19. Epidemiology (WHO 2020)
• The latest estimation of the total number of
people with multiple sclerosis was 2.8 million
globally, with a prevalence of 36 per 100,000
people. In Africa, there are 5 people per 100, 000
diagnosed with MS, compared to South East
Asia where the prevalence in 9 per 100,000, 112
per 100,000 in the America and 133 per 100,000
in Europe.
20. Epidemiology (WHO 2020) Contd…
• Most people are diagnosed between 20 to 50 yrs.
• In Nepal death rate reached 38% or 0.02% of
total death.
• Women are more affected the man (3:1).
• White people are more affected than Hispanics,
black or Asian.
• Most prevalent in colder climates of North
America and Europe.
22. Causes of MS Contd…
While the cause (etiology) of MS is still not
known, scientists believe that a combination of
several factors may be involved.
• Immunologic
• Environmental
• Infectious
• Genetic
23. Causes: Immunologic Factor
• The body’s own immune cells attack the CNS
and ultimately destroy nerve condition.
• Many different cells are involved in the
abnormal immune response. Two important
types of immune cells are T cells and B cells.
• In MS, the immune system is responsible for
the demyelination. The removal of the
protective myelin sheath of the nerve cells in
the CNS.
24. Causes: Environmental
• Variations in geography, demographics,
genetics, infectious causes and migration
patterns are being studied.
• Climate, sunlight and low vitamin D have
been investigated as influences of the
disease.
25. Causes: Infectious
• Measles, human herpes virus-6, Epstein-
Barr, and Chlamydia pneumonia.
• Initial exposure to numerous viruses,
bacteria and other microbes occurs during
childhood and since viruses are well
recognized as causes of demyelination
and inflammation.
26. Causes: Genetic
• Having a first-degree relative such as a
parent or sibling with MS increases an
individual's risk of developing the disease
• Some researchers theorize that MS develops
because a person is born with a genetic
predisposition to react to some environmental
agent that upon exposure, triggers an
autoimmune response.
27. Pathophysiology
Due to etiological factors
Activated T-cells expressed in CNS and Macrophages (B- cells)
enter the brain from peripheral circulation
Production of inflammatory cytokines and reactive O2 species
Inflammation
Then activated T-cells and B-cells cause demyelination and
destruction of oligodendrocytes
28. Pathophysiology Contd…
Formation of plaque
Causes scarring and destruction of sheath
Compensatory system starts causing subsidation of edema
and inflammation
After that some remyelination process occurs which is often
incomplete
Multiple Sclerosis
29. Types of Multiple Sclerosis
• Relapsing-Remitting MS
• Primary-Progressive MS
• Secondary-Progressive MS
• Progressive-Relapsing MS
30. 1. Relapsing-remitting MS (RR-MS)
• More than 80% of the cases
• Followed by complete or incomplete remission
during which the person full or partially recovers
from the deficits acquired during relapse
31. 2. Primary-progressive MS (PP-MS)
• 10 to 20% of individuals with MS are diagnosed
with PP-MS
• Gradual progression of the disease from its onset
• No overlapping relapses and remissions
32. 3. Progressive-relapsing MS (PR-MS)
• Steady progression of clinical neurological damage
with superimposed relapses and remissions.
33. 4. Secondary Progressive MS (SP-MS)
• SP-MS is characterized by a steady progression
of neurological damage with or without
superimposed relapses and minor remissions
38. Diagnostic evaluation
• History taking and physical examination
• No definitive test for MS
• CSF analysis for the presence of oligoclonal
banding, proteins and electrolytes.
• MRI brain and spinal cord for presence of MS plaques
• CSF Electrophoresis: presence of Immunoglobulin G
(normal protein is 15-45mg /dl) elevated 10 mg/dl )
• Evoked potentials of the optic pathways and auditory
system to assess the presence of slowed nerve
conduction
39. • MRI brain and spinal cord for presence of MS
plaques
40. Treatment
Although there is still no cure for MS,
effective strategies are available to:
• Modifying the Disease Course
• Treating exacerbations
• Managing Symptoms
• Promoting Function through Rehabilitation
43. Treating exacerbations
• Severe exacerbations are most commonly
treated with high-dose corticosteroids to
reduce the inflammation.
• Plasmapheresis (Is a blood purification
procedure used to treat several autoimmune
disease. It is also known as therapeutic
plasma exchange) is considered for 10%
who do not respond well to corticosteroids.
45. Promoting function through Rehabilitation
Besides medication, self-care techniques and the
use of assistive devices, rehabilitation includes:
• Physical Therapy
• Occupational Therapy
• Therapy for Speech and Swallowing Problems
• Cognitive Rehabilitation
• Vocational Rehabilitation
47. Assessment
• Observe motor strength, coordination and gait
• Perform cranial nerve assessment
• Evaluate elimination function
• Explore coping, effect on activity and sexual
function, emotional adjustment
• Assess patient and family coping, support
system and available resources.
48. Nursing diagnosis
• Impaired physical mobility related to muscle weakness,
spasticity and incoordination.
• Self care deficit related to intolerance to activity.
• Fatigue related to increased energy requirements to
perform activities and stress of coping
• Disturbed sensory perception related to disease process.
• Impaired urinary elimination related to neuromuscular
impairment.
• Interrupted family process related to disease process.
49. Nursing diagnosis Contd…
• Sexual dysfunction related to disease process.
• Low self esteem related to change in structure and
function.
• Powerlessness related to lifestyle of helplessness
• Risk for ineffective coping related to multiple life
changes.
• Risk for caregiver role strain related to complexity and
amount of caregiving tasks.
• Deficient knowledge related to cognitive limitation.
50. Interventions
Promoting motor function
• Perform muscle stretching and strengthening exercises.
• Apply ice packs before stretching to reduce spasticity.
• Avoid muscle fatigue and take frequent rests.
• Encourage ambulation and activity and teach patients
how to use supportive devices.
• Avoid sudden changes position which may cause falls
• Frequent position change while immobilized to avoid
pressure sores
51. Interventions Contd…
Minimizing fatigue
• Understand fatigue is an integral part of MS.
• Plan and prioritize activities
• Avoid overheating, overexertion and
infection
• Encourage energy conservation techniques
• Develop healthy lifestyle
52. Interventions Contd…
Optimizing sensory functions
• Use eye patch or frosted lens for double vision
• Encourage ophthalmic consultations
• Provide safe environment:
Orientation to environment, arrangement of
furniture, clear floor, use of all senses to
maintain awareness to environment.
53. Interventions Contd…
Maintaining urinary elimination
• Ensure adequate fluid intake to prevent
infection and stone formation
• Assess urinary retention and catheterize
for residual urine
• Set up bladder training program to reduce
incontinence
54. Interventions Contd…
Promoting sexual function
• Encourage open communication between
partners
• Discuss birth control options if appropriate
• Suggest sexual activity when patient is
most rested
• Suggest consultation with sexual therapist
to help obtain greatest sexual satisfaction.
55. Interventions Contd…
Normalizing family process
• Encourage verbalization of feelings of each family
member
• Encourage counseling and use of community resources
• Divide household duties and child care responsibilities
• Expand treatment efforts to include whole family
• Explore adaptation of some roles so patient can still
function in family unit.
56. Complications
1. Respiratory dysfunction
2. Infections: bladder, respiratory, sepsis
3. Complications with immobility
4. Speech, voice and language disorders
such as dysarthria
57. Research Article
Rising Prevalence of MS Worldwide: Insight from
the Atlas of MS
Abstract
• Background: High-quality epidemiologic data
worldwide are needed to improve our
understanding of disease risk, support health
policy to meet the diverse needs of people with
multiple sclerosis (MS) and support advocacy
efforts.
58. Research Article Contd…
• Objectives: The Atlas of MS is an open-source global
compendium of data regarding the epidemiology of
MS and the availability of resources for people with
MS reported at country, regional and global levels.
• Methods: Country representatives reported
epidemiologic data and their sources via survey
between September 2019 and March 2020, covering
prevalence and incidence in males, females, children,
and age and MS type at diagnosis. Regional analyses
and comparisons with 2013 data were conducted.
59. Research Article Contd…
• Results: A total of 2.8 million people are estimated to
live with MS worldwide (35.9 per 100,000 population).
MS prevalence has increased in every world region
since 2013 but gaps in prevalence estimates persist.
The pooled incidence rate across 75 reporting countries
is 2.1 per 100,000 persons/year, and the mean age of
diagnosis is 32 years. Females are twice as likely to live
with MS as males.
• Conclusions: The global prevalence of MS has risen
since 2013, but good surveillance data is not universal.
Action is needed by multiple stakeholders to close
knowledge gaps
60. REFERENCES
1. Sharma S., Madhavi S., Hinkle, J. L. &Cheever, K.H.
Brunner & Suddarth’s. Textbook of Medical-Surgical
nursing. 2nd ed. New Delhi: Wolters Kluwer (India) Pvt.
Ltd; 2019: 1775-1782.
2. Chugh S N. Textbook of Medical Surgical Nursing. 1st
ed. New Delhi: Avichal Publishing Company; 2013:
1141-1144.
3. Sharma M., Kalpana P., Gautam R. Essential Textbook
of Medical Surgical Nursing. 2nd ed. Ghattekulo
Rautahadevi Marga, Kathmandu: Samiksha Publication
Pvt. Ltd; 2017: 362-368.
61. REFERENCES Contd…
4. Walton C, King R, Rechtman L, Kaye W, Leray E,
Marrie RA, et al. Rising prevalence of multiple sclerosis
worldwide: Insights from the Atlas of MS, third edition.
Mult Scler. 2020 Dec;26(14):1816-1821. doi:
10.1177/1352458520970841. Epub 2020 Nov 11. PMID:
33174475; PMCID: PMC7720355.
5. https://en.wikipedia.org/wiki/Multiple_sclerosis
6. https://www.physiopedia.com/Multiple_Sclerosis_(MS)
