MULTIPLE SCLEROSIS

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MULTIPLE SCLEROSIS A chronic, progressive neurological disease characterized by scattered demyelination of nerve fibers in the brain and spinal cord.

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Presentation Transcript

MULTIPLE SCLEROSIS : 

MULTIPLE SCLEROSIS Presenter : Ms. Manju Sebastian Moderator: Ms. Rachel Andrews

Multiple Sclerosis : 

Multiple Sclerosis A chronic, progressive neurologic disease characterized by scattered demyelination of nerve fibers in the brain and spinal cord.

Multiple Sclerosis : 

Multiple Sclerosis Most common disabling condition in young adults Most common demyelinating disorder Progresses to disability in majority of cases Unpredictable course & variety of signs and symptoms; sometimes mistaken for psychiatric disorder

MS- Incidence : 

MS- Incidence Peak onset 20-40 years of age 70% between ages 21-40 Rarely prior to age 10 or after age 60 F > M (approx. 2:1) White > non-white (2:1)

Risk factors : 

Risk factors Autoimmune process Viral infection Allergic reactions to infection Familial tendencies. Cool, temperature climates.

Etiology : 

Etiology Autoimmune T-cells activate against myelin Viral Specific viral protein not yet identified Suspected “molecular mimicry” Roseola (HHV6) associated with demyelination in MS patients Viral infections known to provoke relapses

Pathological Hallmarks : 

Pathological Hallmarks Described in late 1800s by Dr. Charcot Inflammation and demyelination Plaques occur anywhere in the CNS Most frequent: optic nerve, brainstem, cerebellum, spinal cord Axon sparing within the plaques

Structure Of Plaques : 

Structure Of Plaques Outer layers of myelin sheath separate Degenerative changes in myelin Infiltration with macrophages Preservation of axons

Normal Conduction : 

Normal Conduction

Abnormal Conduction : 

Abnormal Conduction

Results Of Demyelination : 

Results Of Demyelination Conduction block at site of lesion Slower conduction time along affected nerve Increased subjective feeling of fatigue secondary to compensation for neurologic deficits

Initial Symptoms : 

Initial Symptoms Double vision / blurred vision Numbness Heat intolerance Motor weakness Fatigue Problems with bladder control Facial Palsy

Signs and Symptoms. : 

Signs and Symptoms. Instability while walking Poor coordination Dizziness Tremors Spasticity of extremities **All symptoms can be precipitated by heat**

Signs and Symptoms : 

Signs and Symptoms Slurred speech Difficulty in chewing and swallowing Mental changes cognitive dysfunction Fecal or urinary incontinence or retention. Impotence

Cerebellar signs : 

Cerebellar signs -Incoordination (dysdiadochokinesia, problems with heel-to-shin test) -Slowing of rapid repeating movements -Ataxic gait -Scanning speech -Loss of balance

Classification : 

Classification Benign Multiple Sclerosis Mild infrequent sensory exacerbations with full recovery. Relapsing Remitting Multiple Sclerosis Episodes of exacerbations and remissions during which not all symptoms resolve completely.

Classification : 

Classification Secondary Chronic Progressive Relapses become more severe while remissions are less complete, shorter in duration, and eventually non-existent. The course of MS becomes steadily progressive. Primary Progressive No relapse. Disease begins with a slow progression of neurologic deficits.

Diagnostic tests : 

Diagnostic tests CSF Analysis Magnetic resonance imaging Computed tomography Scan Positron Emission Tomography Evoked Potential Studies EEG

CSF : 

CSF Increased immunoglobulin concentration Elevated IgG index Oligoclonal bands Elevated protein

o : 

o

Evoked Potentials : 

Evoked Potentials VER (visual evoked response)—75% abnormal BAER (brainstem auditory evoked response)—30% abnormal SSER (somatosensory evoked response) – 80% abnormal

MRI- Cerebellum : 

MRI- Cerebellum

MRI- Spine : 

MRI- Spine

MRI- Spine : 

MRI- Spine

MRI- Optic Nerve : 

MRI- Optic Nerve

MRI- Cerebral Hemisphere : 

MRI- Cerebral Hemisphere

MRI- Cerebral Hemisphere : 

MRI- Cerebral Hemisphere

Differential Diagnosis : 

Differential Diagnosis Encephalomyelitis CNS Vasculitis Lyme Disease Lupus Erythematosus Spastic Paraparesis Behçet Syndrome Vitamin B-12 Deficiency and Syphilis Hereditary Degenerative Disorders

Standard Therapy : 

Standard Therapy Treatment of Relapses Prevention of Relapses Treatment of Chronic Progression

Treatment : 

Treatment Drugs Corticosteroids Methyl Prednisolone Immunosuppressive drugs Azathioprine (Imuran) Cyclophosphamide (Cytoxan) Methotrexate Intravenous Immunoglobulin G Oral Myelin

Prevention of exacerbations : 

Prevention of exacerbations Interferonß-1a (Avonex) Interferonß-1b (Betaseron)

Symptomatic Therapy : 

Symptomatic Therapy Fatigue Vertigo Spasticity and Muscle Spasms Psychological Problems Urinary Dysfunction Sexual Problems Tremors and Incoordination Pain Cognitive Problems

Symptomatic Therapy : 

Symptomatic Therapy FATIGUE Frequent rest periods Cool showers / baths Amantadine Pemoline (CNS stimulant) Fluoxetine

Symptomatic Therapy : 

Symptomatic Therapy VERTIGO ** Can last for hours to days ** Low dose Dizepam Promethazine If associated with nausea/vomiting ? Metoclopramide.

Symptomatic Therapy : 

Symptomatic Therapy Spasticity * Very painful; most common in extensor muscles of lower limbs* Baclofen Dantrolene Tizanidine Valium ? especially useful at night Physical therapy with stretching exercises

Symptomatic Therapy : 

Symptomatic Therapy Psychological Problems * suicide rate for MS patients is 7.5 times that of the general population * TCAs (especially Amitriptyline) Psychological counseling.

Symptomatic Therapy : 

Symptomatic Therapy Urinary Dysfunction Anticholinergics (oxybutynin) Baclofen Intermittent self-catheterization Chronic indwelling catheter Acidifying agents & antibiotics

Symptomatic Therapy : 

Symptomatic Therapy Pain Carbamazepine Phenytoin Gabapentin (Neurontin) Tricyclic antidepressants

Treatment - General Considerations : 

Treatment - General Considerations Exercise Physical Therapy Nutrition Pregnancy and Motherhood Treatment of Infections and Elevated Temperatures

Nursing management : 

Nursing management Altered urinary elimination Constipation Activity intolerance Impaired Physical mobility Risk for self care deficit Self esteem disturbance Knowledge deficit regarding home care.

Long Term Care : 

Long Term Care Physical therapy Occupational therapy Rehabilitation Bowel and bladder training Speech therapy

Long Term Care : 

Long Term Care Nutritional counseling Counseling including sexual counseling. Bed rest during acute exacerbation. Assistive devices: braces, walkers, wheelchairs, splints.

Complications : 

Complications Respiratory failure Pneumonia Neurologic deficits: paralysis. UTI Sexual dysfunction Contractures

Factors that influence prognosis : 

Factors that influence prognosis Females Low rate of relapses per year Complete recovery from the first attack Long interval between first and second attack Low disability at 2 to 5 years from the disease onset

Factors that influence prognosis : 

Factors that influence prognosis Symptoms predominantly from afferent systems (i.e.,. sensory symptoms) Younger age of onset Later cerebellar involvement Involvement of only one CNS system at the time of onset

Slide 49: 

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