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  1. 1. (MS) MultipleSclerosis
  2. 2. A chronnic, progessive, demyelinating disease of the CNS. Dr. Jean Cruveilhier – french physician first used the term “Island of Sclerosis”
  3. 3. Clinical & pathological characteristics: Charcots Triad (Dr. Jean Charcot, 1868) - Intention tremor – slow feedback, overshoot - Scanning speech – pause bet. syllables
  4. 4. Nystagmus – Involuntary Movt ofeyes,fast (may be: side-side, up-down, rotary)*Termed as “sclerosis in plaques”
  5. 5. Epidemiology Ratio of 2:1, > in women Affects white population Areas of frequencies: High - N. US & Europe, S. Canada & AUS, New Zealand -rates of 30-80 /100k pop. Medium - S. US & Europe, rest of AUS -rates of 10-25 / 100k pop.
  6. 6. Low – Tropical Area,ASIA, Africa& S. America- rates <5 / 100k pop.
  7. 7. Etiology Precise theory is Unknown Widely accepted theory: autoimmune dse. Induced by viral/other infectious agents (33%). In particular, herpes V. - I (oral),II (genital),IV & chlamydial pneumonia > young adults bet. 20 – 40
  8. 8.  f/hx st – 15% (1 degree relative) 3-5 % fraternal co-twinm, but rises to 26% for identical co-twin.
  9. 9. Pathophysiology Immune response triggers the prod. Of T – lymphocytes, macrophages, and antibodies (IgG). Antigen is activated producing autoimmune cytotoxic effects w/in the CNS.
  10. 10.  BBB fails & myelin synthesized T- lymphocytes enter & attack the myelin sheath surrounding the nerves. Eventually oligodendrocytes becomes involved.
  11. 11.  Demyelinated areas eventually become filled w/ fibrous astrocytes and undergo gliosis. Axonal loss varies from 10-20% (milder forms), and as much as 80%(severe) Primarily affects white matter early, w/ lesions of gray matter in advance cases.
  12. 12. Main patterns of disease progression are recognized: RELAPSING AND REMITTING MS – lesion often occurs in diff. parts of the CNS at diff. times SECONDARY PROGRESSIVE MS – char. by initial RRMS course, followed by progression at a variable rate that may also include occasional relapses & minor remissions.
  13. 13.  PRIMARY PROGRESSIVE MS – in w/c there is little or no recovery from relapse. With a cumulative disability PROGRESSIVE – RELAPSING – char. by progressive dse. From onset but w/o clear acute relapses that may that may or may not have some recovery ; commonly seen in people who develop the dse. After 40 yrs. Of age.
  14. 14.  Benign MS - fully functl in all neurological system 15 yrs. After onset. - affects 20% of cases Malignant MS (Marburg Variant) - rare dse. Course, char. by rapid onset & almost continual progression leading to significant disability / death w/ short time after onset.
  15. 15. Exacerbating factors  Viral/bacterial infections (cold, UTI)  Dse. of major organs-hepa,asthma  Stress (major - divorce, death, minor- exhaustion,dehydration)  Pseudoexacerbation*sx/s tend to get worse with heat (eg.In the bath or during hot weather) –Uthoffs phenomenon
  16. 16. Differential Dx.Investigationsno diagnostic test but the clinical suspicionis suported by the ff. Three tests:  MRI  CSF  Evoked Potentials- visual evoked potentials (VEPs)- Somatosensory Evoked Potentials(SSEPs)- Brainstem Auditory Evoked Potentials(BAEPs)
  17. 17. Clinical manifestations/symptoms Minor visual disturbances,blurred,diplopia Paresthesias – fatigue,weakness, etc. Dyesthesia,Chronic pain Memory/Recall problems Depression/anxiety Nocturia, incontinence,urinary urgency
  18. 18.  Impotence, dec. libido Constipation, diarrhea Dysarthria, dysphonia, dysphagia dysautonomia
  19. 19. prognosis 74 % survives after 25 of onset of symtoms. Minority are still in the workforce after 10 yrs. Onset. 15 yrs. – 50% uses asst. devices 20 yrs. - 50% requires w/c
  20. 20. Prognostic Factors Symptoms Course of dse. Age-younger > 40 yrs. old Neurological findingd at 5 years MRI findings
  21. 21. Medical Mx. Dse. Modifying agents - interferons (interferon beta – 1b, inteferon beta 1a) -reduce relapse by about 30 % Glatiramer acetate & novatrone -clogs T – cell receptors. Limited lifetime dose to prevent heart problems.
  22. 22. Mx. of Relapse & symptoms Corticosteroid therapy – treat acute disease relapse,shortening duration of episodes. - 1000 mg/day, IV (3-5 days) followed by dosage of oral medication over a period of 10 days,5-6 weeks ACTH- long term supression of the immune system, alone/with steriods
  23. 23. Symptomatic treament Spasticity - diazepam Bladder Dysfunction – anticholinergic Pain - phenytoin Intention tremor – clonazepam Fatigue – amantadine hydrochloride Cognitive & emotional probs. -(donepezil [arecept])
  24. 24. Clinical manifestation of inactivity Psychosocial – anxiety/depression Neuromuscular – dec. sensory input, motor control, poor coordination Renal – inc. urinary infections, renal calculi Cardiovascular – inc. HR, thrombophlebitis, OHPN Integumentary – skin atrophy,decubiti Respiratory – inc. resp. infection Digestive – anorexia, constipation Musculoskeletal- osteoporosis, atrophy
  25. 25.  Preventive intervention includes: -Primary prevention -Secondary prevention -Tertiary prevention Compensatory inervention Maintetnance Therapy – series of occassional ,clinical, educational and admiinistrative services defined to maintain the Pxs current level of function.
  26. 26. PT examination Client/patient Hx. Tests & Measures -Cognitive / behavioral -Affective and physiologic functions -Sensation -Visual acuity -CN intergity -ROM -Mse. Performace -Fatigue ( MFIS)questionaire
  27. 27. -Temp. sensitivity-Motor functions-Posture-Balance, gait & locomotion-Aerobic capacity & endurance-Skin integrity & condition-Functional status-Environment-General Health-Disease-specific measures
  28. 28. Standardized tests & measures Expanded Disability Status Scale (EDSS) (Kurtyze, 1955) Minimum Record of Disability (MRD) (Intl. Federation of MS Soceities, 1985) Modified Fatigue Impact Scale (Fisk et. al.,1994) MS Functional Composite (MSFC) MS Quality of Life – 54 MS Quality of Life inventory (MSQLI) Functional Exam. Of the MS (FAMS) Multiple Sclerosis Impact Scale (MSIS-29)
  29. 29. Goals & outcomes Impact of pathology/pathophysiology is reduced Impact of impairment is reduced Improved ability to perform physical actions, tasks, activities Reduced disability assoc w/ chronic illness Improved health status & quality of life Enhanced px./client satisfaction
  30. 30. Diagnostic tests LP / CSF, elevated gamma globulin, CT / MRI, myelogram, EEG
  31. 31. PT Interventions Mx. of Sensory Deficits & Skin Care Mx. of Pain Exercise Training
  32. 32. strength and conditioning Prescription based on four interralated elements: -Freq. Of exercise -Intensity of exercise -Type of exercise -Time/Duration
  33. 33. Guidelines Exerise session should be alternate (non endurance).optimal time such as morning. Submaximal exercise (moderate intensities 50 – 70% MVC)well tolerated,maximal(not) Resistance training modes Circuit training Balance exercise w/ rest periods
  34. 34.  Progression Precautions Functional training activities Group exercise outcome measures
  35. 35. Cardiovascular conditioning (Guidelines for clinical exercise testing) Performance measure
  36. 36. Strengthening and Conditioning
  37. 37. CV Conditioning
  38. 38. Flexiblity Exercise PROM(daily,short Pds.) AROM(daily, short Pds.) Tai Chi (more active Px.) Goniometry – to measure outcome
  39. 39. Mx. of Fatigue Activity diary -F-atigue -V-alue -S-atisfation Energy conservation Activity pacing
  40. 40. Mx. of Spasticity Topical cold/hydrotherapy ROM -stretching 30-60s hold/rep.(5-10) HEP ES Static positioning is deleterious
  41. 41. Mx. of Coordination and Balance Deficits Exercises Functional movements Water aerobics Functional balance Movement transitions Proprioceptive loading
  42. 42. Frenkels Exercise (1889) Sensory problems Positions:lying,sitting,stand,walk Slowly w/ vision as guide
  43. 43. Examples half-lying:hip & knee flexion & extension each limb, foot flat on mat Sitting: alternate foot placing to a specified target (floor markings) Standing: up & down to a specified count Walking: sideways or forward to a specified count (floor marking)
  44. 44. Locomotor Training
  45. 45. Functional Training
  46. 46. Mx. of Speech & Swallowing
  47. 47. Cognitive Training
  48. 48. Psychosocial Issues
  49. 49. Patient & Family / Caregiver Education