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

1. M G
S O

2. M G
S O
What is Multiple Sclerosis (MS)?
• Chronic Lifelong Disease of the Central
Nervous System (CNS).
• CNS is the Brain, Spinal Cord, and Optic
Nerves.
• Damage of the myelin, covering of the nerve,
causing multiple scars, sclerosis.

3. M G
S O
What is MS?
• Nerve cell is called an Axon: I like to use the analogy of
the axons as electric wires and the myelin as the protective
rubber coating, or insulation, around those wires, breaks in
insulation lead to communication breakdown

4. M G
S O
What is MS?
Inflammation Neuro-Degeneration

5. M G
S O
What is MS?
• Neurological deficits in MS result from acute
inflammatory demyelination and axonal degeneration
• Effects may be silent due to compensating processes of
the CNS
Trapp BD, et al. Neuroscientist. 1999;5:48-57, with permission
from Lippincott Williams & Wilkins.

6. M G
S O
Diagnosing 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 to
confirm this complex disease

7. M G
S O
Diagnosing MS
• History: Common symptoms
– Visual disturbances (eye pain, blurred vision, graying of
vision, loss of vision, double vision)
– Numbness/tingling
– Weakness
– Imbalance or gait abnormality
– Fatigue
– Bowel or Bladder problems

8. M G
S O
Diagnosing MS
• History: Relapses
– New or Recurrent Symptoms
– Persist for at least 24 hours and sometimes
worsen over 48 hours.
– Separated by 1 month.
– Unexplained by other factors (illness,
fatigue, heat).

9. M G
S O
Diagnosing 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. M G
S O
Classifying MS

11. M G
S OAdapted from Weinshenker, et al. Brain. 1989;112:133-146.
Relapsing-remitting
Primary-progressive
Disease Type at
Diagnosis
Disease Type at 11-15
Years After Diagnosis
(Among Those With
RRMS at Diagnosis)
Secondary-progressive
Relapsing-remitting
42%
58%
15%
85%

12. M G
S O
QUESTIONS ??

13. M G
S O

14. M G
S O
The Symptom Chain of MS
• Visual Symptoms
• Weakness
• Fatigue
• Depression

15. M G
S O
Visual Changes
 Optic neuritis
 Decreased visual
acuity
 Double vision
 Blurred vision
 Involuntary
movements

16. M G
S O
Optic 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. M G
S O
Optic Neuritis Management
 To quicken the healing process
 IV steroids
 Acthar
 Vision usually returns gradually
in 2-4 weeks

18. M G
S O
Vision Care
 Annual ophthalmology appointments
 Routine follow-up appointments with
neurology
 Discuss visual problems with HCP
 Disease modifying treatments
 Treatment with steroids or Acthar when
needed
 Visual aids as prescribed

19. M G
S O
Weakness in MS
• Brain and Spinal Cord nerves
have difficulty sending of
electrical impulses to muscles
• Spinal cord lesions have highest
risk of causing weakness.
• Location, Location, Location
Monopoly: Mediterranean
Avenue versus Boardwalk

20. M G
S O
Primary Weakness
• Weakness caused by Multiple Sclerosis
• Repetitive movements of muscles to the point of fatigue
does not increase strength, increases weakness

21. M G
S O
Primary Weakness
• Acute
– Relapse
• Hemiparesis
• Quadrapresis
• Chronic
– Spasticity
– Gait abnormalities
Broken light fixture: Changing the
light bulb when the fuse is the
problem will only cause frustration.

22. M G
S O
Secondary Weakness
Fatigue- poor repetition
• Deconditioning/sedentary
lifestyle- Atrophy
• Nutrition
• Rest
• Chronic Pain
• Medications
• Anxiety
• Depression
Asthenia-feeling of weakness
• Hypothyroidism
• Anemia
• Illness
• Diabetes
• Heart Disease

23. M G
S O
Conquering weakness
Collaborative Effort With Rehabilitation Team
• Exercise
• Strengthening
• Coordination
• Stretching
• Assistive Devices
• Medications
• Ampyra
• Baclofen/Zanaflex

24. M G
S O
Crayton 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. M G
S O
Krupp LB. CNS Drugs. 2003;17(4):225-234.
Clinical Characteristics
 Overwhelming sense
of sleepiness
 Constant sense of tiredness
 Lack of energy
 Feeling of exhaustion
 Not necessarily related to level of
disability
 May affect motor function
 May affect cognitive function
 Not fully understood

26. M G
S O
Multiple sclerosis
Primary MS fatigue
Secondary MS fatigue pain
Normal fatigue
Sleep disorders
Primary
Secondary
Physical health
Comorbid conditions
Fatigue is
identified as a
significant
problem
Environment
Physical
Social
Cultural
Psychologic
health
Anxiety
Stress
Depression
Multiple Sclerosis Council. Fatigue in Multiple Sclerosis: Evidence-based Management Strategies for Fatigue in Multiple
Sclerosis. 1998.
Potential Causes and Effects

27. M G
S 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 Multiple
Sclerosis. 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/work
simplification
 Timed rest periods (appropriate rest-to-activity ratio)
 Stress management techniques
 Exercise and relaxation

28. M G
S O
1. 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 with
MS: lifetime occurrence approx 50% of patients
 Depression may lead to altered quality of life and
loss of self-esteem3
 Assessment of depression by HCP is essential

29. M G
S 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 crying
most of the day
 Loss of energy
 Loss of interest or pleasure in
most activities
 Significant change in appetite and
weight
 Unusual sleep behavior
 Decreased sex drive
 Suicidal thoughts

30. M G
S O
Bashir 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 recurring
depression

31. M G
S O
QUESTIONS ??