11
Impaired recall, information processing, attention and concentration
Cognitive impairments in MS ***
Which type of memory is LEAST affected in MS?
Long term memory ***
Side effects to which med type:
- injection site reaction, flu-like symptoms, depression, lab abnormalities (lipoatrophy with GA) (dimpling of the skin)
Injectables
Poor vaginal lubrication, decreased sensation, decreased libido
Sexual dysfunction in MS
Side effects to which med type:
GI
Oral meds
- CN 8 vestibulocochlear issue
- Secondary BPPV
- Vestibulospinal pathway issues (helps maintain upright posture)
- MS issue due to demyelination
- VOR issue (coordinates eye movements during head motion)
Dizziness
MS specific medication
- Goal: reduce relapse frequency, limit development of disability, limit MRI disease activity
- 17 DMTs (15 FDA approved)
Disease modifying therapy (DMT)
T/F: cognitive dysfunction equals disability ?
FALSE: Cognitive dysfunction does not equal disability
What are the (3) types of medication agents in MS?
1. Injectable agents (ABC meds - patient gives this daily to themselves)
2. Infusible agents (get every 6 months - 1 year)
3. Oral medications (taking daily)
Side effects to which med type:
UTI
Infusions
- 70% decrease in risk of exacerbation during pregnancy
- 70% increase 3-6 months post partum
- Cessation of meds prior to conception, during pregnancy and during breastfeeding
- Consult with neurologist during planning or as soon as pregnancy is confirmed
- Clinical trials ongoing for safety of meds during pregnancy
Pregnancy and MS
- RARE viral disease of the brain, potentially fatal oppotunistic infection of cerebral oligodendrocytes cause by reactivity of latent JC virus (John Cunningham virus). Labs include JCV testing to determine activity of the virus/presence of the virus. Presence DOES NOT mean you cannot be on certain meds, but risk/benefit is assessed and monitoring is required.
- Clinical manifestations: cognitive and behavioral disturbances, language dysfunction, hemiparesis, cortical visual deficits, seizures
- Immediate referral to ER/MD
PML - Progressive multifocal leukoencephalopathy
- Relapse
- Establishing care with a provider/initial assessment
- Mobility issues
- Training with new DME/orthotics
- Orthopedic concerns
- Establish exercise routine/wellness program
- Pelvic floor
Reasons for PT referral
What score on the expanded disability status scale is intermittent or unilateral constant assistance to walk, can still use an aide if needed
6
- "why not" med
- All types of MS, low SE profile, contraindicated in patients with renal dysfunction or seizures. Its an extended release potassium channel blocker that increase acetylcholine at the neuromuscular junction and in the CNS, "walking drug". Targets EFFORT of walking as well as speed. Needs strict adherence
- DMT adherence: 60-76% for 2-5 years; non-adherence 25-30%
- Red flags, consider: disease progression while on DMT, worsening of existing symptoms, onset of new symptoms
Ampyra "Walking drug for MS"
Outcome measures:
Rate 1-5 how they feel; great to understand what they are feeling week to week without having them have to say these feelings out loud
MSIS 29
T/F: People with MS have their own gait speed, usually 3x the amount of normal gait speed because of MS fatigue
True
Outcome measures:
Fatigue based; measure fatigue focusing on MS specific, physical, cognitive, mental fatigue activities
MFIS
Outcome measures:
25 ft walk test, 9 hole PEG test, some cognitive tests
MSFC
What score on the expanded disability status scale is fully ambulatory without an aid?
4
Outcome measures:
Sexual satisfaction, bowel/bladder, vision; comprehensive assessment
MSQOL
-12 item MS walking scale
- Modified fatigue impact scale (MFIS)
- MS impact scale (MSIS29)
- Timed 25 foot walk test = gait speed
- Other: MSFC, MSQLI
PT evaluation outcome measures specific to MS
Individual - MS specific symptoms
Task - start simple and progress
Environment - establish practice sessions to enable problem solving, provide perceptual cues and facilitate transfer of learning
- Monitor fatigue and need to "chunk" eval (might need to come back a different day taking fatigue into consideration)
- Don't forget the cognitive impact of the eval
Evaluation components
Outcome measures:
how has MS affected your ability to do these things in the past 2 weeks; quick and for ambulatory patients only
12 item MS walking scale