Medicine 5th year, 6th lecture/part one (Dr. Mohammed Tahir)
What is Multiple Sclerosis? <ul><li>It is an Auto Immune Disease which is when the body starts to destroy itself. </li></ul><ul><li>It is a life-long disease with no cure. </li></ul><ul><li>In MS, the body attacks and destroys the fatty tissue called myelin that insulates an axon/nerve, and is called demyelination. </li></ul><ul><li>If damage is severe it can also destroy the nerve/axon itself. </li></ul><ul><li>MS affects the central nervous system and inflames the white matter in the brain which creates plaques. White matter is below the top layer of our brain and spinal cord. Plaques block a signal from being passed from the body to the spinal cord and brain. </li></ul><ul><li>Currently in the US, 250,000-300,000 people have been diagnosed with MS and there are 200 new cases diagnosed every week. </li></ul>
History of Multiple Sclerosis Multiple Sclerosis, also known as MS, was given its name, multiple because of the numerous sites of demyelination and ‘sclerosis’ which means scarring. “There are accounts of probable MS dating back to the 14 th century but the history of the disease really begins in the 19 th century with the first illustrations and clear clinical description of the disease beginning to appear in 1838” (Barnes 16). It was in Holland on August 4, 1421, that the earliest descriptions were seen. Even though the previous description, the first actual case was first diagnosed in 1849. It was Jean-Martin Charcot who is credited with giving us the first signs and symptoms of Multiple Sclerosis.
What Causes MS? “ Despite extensive research, we still don’t know what causes MS” (O'Connor 8). However they have found associations and links between many factors including genetic and environmental. Genetic Environmental Sex Latitude Racial Group SES Family history Migration Infections
Genetic Factors Sex: Women are more likely to have MS than men by a 2:1 ratio. They also think that this is true because women are in general more likely to have an Auto immune Disease. Racial Group: “ Whites are more than twice as likely as other races to develop MS” ( Hope 2). Family History: In a normal population the chance of someone to exhibit the symptoms of MS is only 0.1%. Now if someone in your family has MS, the risk increases. If your parent, brothers, or sisters (your first-degree relatives) have MS your chance increases to 3%. If a second-degree relative has it, you only have a 1% chance of having MS. If both of your parents have the disease you have a risk of 20%. Other percentages are if you have a half sister/brother, identical twin, or fraternal twin your risks are as follows, 1.5%, 30%, and 3-4%. ***Remember that women have a slightly higher risk and that if one identical twins has MS it is not 100% positive that the other twin will have MS due to the environmental factors.
Environmental Factors Latitude: As you increase latitude, mainly above and below 40° latitude, MS is more common. These are temperate and cooler climates. It is five times more likely in these regions. SES: Your socioeconomic status can also affect the occurrence of MS. It is least common in the lower class and in rural residence. Migration: The age at which you may move may also be an important factor. “If you move before the age of 15, your risk is that of the people in the country you move to. If you move after the age of 15, your risk stays fixed at that of the country you grew up in” (O’Connor 15). Infection: “They believe MS is a delayed reaction to a viral infection contracted during childhood by a genetically susceptible person” (O’Connor 13). The viral infections may include shingles, chicken pox, measles, or certain herpes. An idea they also have is the age at which you get the infection. The older you are the higher the risk for MS. ***Remember that in warm countries, children contract viruses at a younger age.
What actually happens in the Immune System? “ The immune system – a complex network of specialized cells and organs – defends the body against attacks by “foreign invaders such as bacteria, viruses, fungi, and parasites” (Hope 3). It goes out looking for the invaders and kills them. In our body we have different antigens, which cause an immune response, for different invaders. When the right invader and antigen met, the antigen multiples to destroy the invader. T-cells are also important in the role of MS. They help keep the immune system in order and directly destroy the infected or damaged cell. How do these T-cells know that the cell they are attacking is an invader? Well on each of our cells there are markers that let our immune system know it is our own cell or a foreign body. Since MS is a autoimmune disease that persons body does not know the difference between self and non-self cells. Another aspect ofthe immune system that they are looking at is the blood-brain barrier (bbb). The bbb is a membrane that surround the brain and allows substances to cross from the blood to the central nervous system. Some feel that the bbb is breached and some of the immune system defense cross over and cause damage to the CNS.
Diagnosing MS <ul><li>“ The most important principle to consider when diagnosing MS is whether the person fulfils the diagnostic criteria on clinical grounds” (Barnes 29). </li></ul><ul><li>To date there is no diagnostic or blood test for MS. </li></ul><ul><li>Family physician will send you to a neurologist who goes over your symptoms and history. </li></ul><ul><li>You can be given one of four test to help the doctor see if there is damage to the spinal cord and brain. These test are only half of the diagnostic process. The tests you can take are MRI, MRS, evoked potentials, and lumbar puncture. </li></ul><ul><li>These tests may be able to rule out a viral infection that can exhibit the same symptoms as an MS attack. </li></ul><ul><li>Remember that these tests are just as important as a clinical evaluation. </li></ul>
Diagnostic categories of MS <ul><li>“ The phrase ‘multiple abnormalities in space and time’ sums up what a physician needs to find a diagnosis of MS” (O’Connor 32). </li></ul><ul><li>There are three categories of MS; Definite, Probable, and Possible MS. </li></ul><ul><li>Definite MS: “Consistent course (relapse-remitting course with at least 2 bouts separated by at least 1 month or slow or stepwise progressive course for at least 6 months) of documented neurological signs of lesions in more than one site of brain or spinal cord white matter” ( Hope 7). The age of onset is between 10 and 50 years of age. </li></ul><ul><li>Probable MS: Here the signs are not previously documented and there is one current sign of MS. There is more than one site of lesions, they have a good recovery and have a history of relapse-remitting symptoms. </li></ul><ul><li>Possible MS: There is no documented signs of MS and more than one lesion. There is also a history of one relapse-remitting symptoms. </li></ul>
Courses of MS Listed below are the different paths that MS can take. <ul><li>Relapse-remitting MS (RRMS): Here you have an attack, go into complete or partial remission, then have the symptoms return. </li></ul><ul><li>Primary-progressive MS (PPMS): Here you continually decline and have no remissions. There may be a temporary relief in symptoms. </li></ul><ul><li>A few patients have malignant MS which is where they have a quick decline which leaves them severely disabled or even lead to death. </li></ul><ul><li>Secondary-progressive MS (SPMS): This stage of MS starts with RRMS symptoms and continues on to show signs of PPMS. </li></ul><ul><li>Progressive-relapsing MS (PRMS): This is a rare form but here it takes a progressive route made worse by acute attacks. </li></ul><ul><li>20% of the people with MS have a benign form. Here they show little progression after the first attack. </li></ul>
Symptoms of MS <ul><li>Fatigue </li></ul><ul><li>Depression </li></ul><ul><li>Memory change </li></ul><ul><li>Pain </li></ul><ul><li>Spasticity </li></ul><ul><li>Vertigo </li></ul><ul><li>Tremor </li></ul><ul><li>Double Vision/Vision Loss </li></ul><ul><li>Weakness </li></ul><ul><li>Dizziness/Unsteadiness </li></ul><ul><li>Numbness/Tingling </li></ul><ul><li>Ataxia </li></ul><ul><li>Euphoria </li></ul><ul><li>Speech disturbance </li></ul><ul><li>Bladder/Bowel/Sexual dysfunction </li></ul>
Is disability inevitable? As mentioned above there are numerous different paths that MS can take you on. “ Although MS as a disease is much feared, the prognosis in general is not as poor as commonly thought” (Barnes 15). 5-20% of all patients will develop benign MS, and another 33% will have little to no disabilities allowing them to live independently while not in relapse. Only 33% of MS patients will have a severe disability.
Can I still have children? This question is important to many sufferers. This question is mainly for women though. It was once thought that women should not have children at all if she was diagnosed with MS. Actually during the mothers’ last trimester there is a 70% reduction in the relapse rate. The thought behind this process is that the mother’s immune system changes so her body does not reject the unborn child who has a different genetic makeup. Although there is a brief decrease in symptoms, within three months after the child is born, there is a similar increase in the relapse rate. Also, be aware of the medication and the effects it will have. Some drugs are not to be taken if you are going to become pregnant, are pregnant, or are nursing.
Medications used for MS <ul><li>Spasticity - Baclofen, Tizanidine, Diazepam, Dantrolene </li></ul><ul><li>Optic Neuritis - Methlyprednisolone, Oral steroids </li></ul><ul><li>Fatigue - Antidepressant, Amantadine </li></ul><ul><li>Pain - Codeine, Aspirin </li></ul><ul><li>Sexual Dysfunction - Viagra, Pravatine </li></ul><ul><li>Tremor - Isoniazid, Primidone, Propranolol </li></ul><ul><li>Disease-Modifying Drugs - Interferon beta 1a and 1b, and Glatiramer acetate </li></ul>
Disease-Modifying Drugs <ul><li>Interferon Beta 1a (Avonex and Rebif): is a protein that is a replica of human interferon. It suppress the immune system and helps to maintain the blood-brain barrier. You inject Avonex into the muscle once a week and Rebif is injected under the skin three times a week. This drug is useful to people who have definite progressive MS. One side effect of the drug is a flu like symptom. </li></ul><ul><li>Interferon Beta 1b (Betaseron): is slightly different from our own interferon. This medication does the same thing as beta 1a, but is injected just under the skin every two days. Side effects include irritation, bruising, and redness at the site of injection and the flu like symptoms. This is also given to people who have definite progressive MS. </li></ul>
Disease-Modifying Drugs (con’t) <ul><li>Glatiramer Acetate ( Copaxone): “is a small fragment of a protein that resembles a protein in myelin” ( O’Connor 106). It decrease the reoccurrence of relapse. It is injected just under the skin every day. There is no flu like symptoms but occasional redness may occur at the injection site. A few amount of people do experience brief shortness of breathe. </li></ul><ul><li>In summary all three of these drugs decrease relapses by 33%, have manageable side effect, are injected, stabilize the disease, and tend to be costly. </li></ul>
Alternative Treatments <ul><li>Acupuncture </li></ul><ul><li>Aromatherapy </li></ul><ul><li>Cannabis (Marijuana) </li></ul><ul><li>Chiropractic </li></ul><ul><li>Cold Immersion </li></ul><ul><li>Dietary Supplements </li></ul><ul><li>Herbal Medication </li></ul><ul><li>Homeotherapy </li></ul><ul><li>Injection of Venom such as snake and bee </li></ul><ul><li>Massage </li></ul><ul><li>Meditation </li></ul><ul><li>Reflexology </li></ul><ul><li>Tai Chi </li></ul><ul><li>Yoga </li></ul>