Understanding, Diagnosing, and Classifying MS Symptom Management


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Understanding, Diagnosing, and Classifying MS Symptom Management. Presented by Tricia Pagnotta, MSN, ARNP, CNRN, MSCN at the MS Views and News Education Seminar Maitland, Fl on April 2013

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Understanding, Diagnosing, and Classifying MS Symptom Management

  1. 1. M GS O
  2. 2. M GS OWhat is Multiple Sclerosis (MS)?• Chronic Lifelong Disease of the CentralNervous System (CNS).• CNS is the Brain, Spinal Cord, and OpticNerves.• Damage of the myelin, covering of the nerve,causing multiple scars, sclerosis.
  3. 3. M GS OWhat is MS?• Nerve cell is called an Axon: I like to use the analogy ofthe axons as electric wires and the myelin as the protectiverubber coating, or insulation, around those wires, breaks ininsulation lead to communication breakdown
  4. 4. M GS OWhat is MS?Inflammation Neuro-Degeneration
  5. 5. M GS OWhat is MS?• Neurological deficits in MS result from acuteinflammatory demyelination and axonal degeneration• Effects may be silent due to compensating processes ofthe CNSTrapp BD, et al. Neuroscientist. 1999;5:48-57, with permissionfrom Lippincott Williams & Wilkins.
  6. 6. M GS ODiagnosing MS• No one test diagnoses MS• History and Examination are key• Testing builds case for or against• Great care and an open mind are necessary toconfirm this complex disease
  7. 7. M GS ODiagnosing MS• History: Common symptoms– Visual disturbances (eye pain, blurred vision, graying ofvision, loss of vision, double vision)– Numbness/tingling– Weakness– Imbalance or gait abnormality– Fatigue– Bowel or Bladder problems
  8. 8. M GS ODiagnosing MS• History: Relapses– New or Recurrent Symptoms– Persist for at least 24 hours and sometimesworsen over 48 hours.– Separated by 1 month.– Unexplained by other factors (illness,fatigue, heat).
  9. 9. M GS ODiagnosing MS: Testing• Examination• MRI brain• MRI Cervical Spine• MRI Thoracic Spine• Evoked Potentials– Vision– Somatosensory– Brainstem• LP for CSF• Laboratory Testing– Infections• Lyme, Syphilis, HIV– Inflammatory diseases• Lupus, Sjogren’s, RA– Cancers– Metabolic• Thyroid• Vitamin B12
  10. 10. M GS OClassifying MS
  11. 11. M GS OAdapted from Weinshenker, et al. Brain. 1989;112:133-146.Relapsing-remittingPrimary-progressiveDisease Type atDiagnosisDisease Type at 11-15Years After Diagnosis(Among Those WithRRMS at Diagnosis)Secondary-progressiveRelapsing-remitting42%58%15%85%
  12. 12. M GS OQUESTIONS ??
  13. 13. M GS O
  14. 14. M GS OThe Symptom Chain of MS• Visual Symptoms• Weakness• Fatigue• Depression
  15. 15. M GS OVisual Changes Optic neuritis Decreased visualacuity Double vision Blurred vision Involuntarymovements
  16. 16. M GS OOptic Neuritis Inflammation of the optic nerve Usually affect one eye Loss of vision can evolve over hours or days Color vision affected: red or green Eye pain Pupil defects
  17. 17. M GS OOptic Neuritis Management To quicken the healing process IV steroids Acthar Vision usually returns graduallyin 2-4 weeks
  18. 18. M GS OVision Care Annual ophthalmology appointments Routine follow-up appointments withneurology Discuss visual problems with HCP Disease modifying treatments Treatment with steroids or Acthar whenneeded Visual aids as prescribed
  19. 19. M GS OWeakness in MS• Brain and Spinal Cord nerveshave difficulty sending ofelectrical impulses to muscles• Spinal cord lesions have highestrisk of causing weakness.• Location, Location, LocationMonopoly: MediterraneanAvenue versus Boardwalk
  20. 20. M GS OPrimary Weakness• Weakness caused by Multiple Sclerosis• Repetitive movements of muscles to the point of fatiguedoes not increase strength, increases weakness
  21. 21. M GS OPrimary Weakness• Acute– Relapse• Hemiparesis• Quadrapresis• Chronic– Spasticity– Gait abnormalitiesBroken light fixture: Changing thelight bulb when the fuse is theproblem will only cause frustration.
  22. 22. M GS OSecondary WeaknessFatigue- poor repetition• Deconditioning/sedentarylifestyle- Atrophy• Nutrition• Rest• Chronic Pain• Medications• Anxiety• DepressionAsthenia-feeling of weakness• Hypothyroidism• Anemia• Illness• Diabetes• Heart Disease
  23. 23. M GS OConquering weaknessCollaborative Effort With Rehabilitation Team• Exercise• Strengthening• Coordination• Stretching• Assistive Devices• Medications• Ampyra• Baclofen/Zanaflex
  24. 24. M GS OCrayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18.Fatigue in MS The most common disabling symptom of MS May appear early in the disease Occurs without warning Precipitated/accentuated by heat, humidity, cold Can generate/worsen other MS symptoms Prevents sustained physical functioning Becomes difficult to work productively
  25. 25. M GS OKrupp LB. CNS Drugs. 2003;17(4):225-234.Clinical Characteristics Overwhelming senseof sleepiness Constant sense of tiredness Lack of energy Feeling of exhaustion Not necessarily related to level ofdisability May affect motor function May affect cognitive function Not fully understood
  26. 26. M GS OMultiple sclerosisPrimary MS fatigueSecondary MS fatigue painNormal fatigueSleep disordersPrimarySecondaryPhysical healthComorbid conditionsFatigue isidentified as asignificantproblemEnvironmentPhysicalSocialCulturalPsychologichealthAnxietyStressDepressionMultiple Sclerosis Council. Fatigue in Multiple Sclerosis: Evidence-based Management Strategies for Fatigue in MultipleSclerosis. 1998.Potential Causes and Effects
  27. 27. M GS OSchapiro RT, Schneider DM. In: Multiple Sclerosis in Clinical Practice. 1999.Multiple Sclerosis Council. Fatigue in Multiple Sclerosis: Evidence-based Management Strategies for Fatigue in MultipleSclerosis. 1998.Fatigue Management:Collaborative Effort With Rehabilitation Team Address secondary causes Metabolic: B12, folate, hormonal Sleeplessness, bladder dysfunction Medications Depression Medications: stimulants, wakefulness drugs, antidepressants Non-pharmacologic modalities Cooling techniques: cooling vest/consumption of cool beverages Aerobic exercise: prevents deconditioning OT/PT: learn energy-conservation techniques/worksimplification Timed rest periods (appropriate rest-to-activity ratio) Stress management techniques Exercise and relaxation
  28. 28. M GS O1. Sadovnick AD, et al. Neurology. 1996;46(3):628-632.2. Feinstein A. Can J Psychiatry. 2004;49(3):157-163.3. Bashir K, Whitaker JN. Handbook of Multiple Sclerosis. 2002.4. Sadovnick AD, et al. Neurology. 1991;41(8):1193-1196.Depression in Multiple Sclerosis The most common mood disorder in patients withMS: lifetime occurrence approx 50% of patients Depression may lead to altered quality of life andloss of self-esteem3 Assessment of depression by HCP is essential
  29. 29. M GS OSiegert RJ, Abernethy DA. J Neurol Neurosurg Psychiatry. 2005;76(4):469-475.The National Multiple Sclerosis Society. http://www.nationalmssociety.org/download.aspx?id=53. Accessed April 9, 2009.Clinical Characteristics Feeling sad or empty Irritable or cryingmost of the day Loss of energy Loss of interest or pleasure inmost activities Significant change in appetite andweight Unusual sleep behavior Decreased sex drive Suicidal thoughts
  30. 30. M GS OBashir K, et al. Handbook of Multiple Sclerosis. 2002.Comprehensive Management Identify risk factors Combine counseling and antidepressants Wellness focus (exercise, healthy living) Follow up appointments with HCP Be alert for suicidal thoughts or recurringdepression
  31. 31. M GS OQUESTIONS ??
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