Malignant (Marburg) – rapid onset, almost continual 

MULTIPLE SCLEROSIS progression

Trigeminal neuralgia (tic douloureux) –
demyelination of sensory division of trigeminal
 Autoimmune disease characterized by nerve
inflammation, selective demyelination, and  Hyperpathia – hypersensitivity to minor sensory
gliosis. stimuli
 First defined by Dr. Jean Charcot in 1868 Four major disease courses:  Headache
o Paralysis  Relapsing-remitting (RRMS) – m/c, ~85% of pts  Neuropathic pain – demyelinating lesions in
o Charcot’s Triad: o Relapses followed by remissions, lack of spinothalamic tracts/sensory roots
 Scanned speech – brainstem progression between  (+) Lhermitte’s sign – post column damage in
 Intention tremor – motor  Secondary-progressing (SPMS) – some RRMS the SC; electric shock-like pain down the spine
pathways/cerebellum may progress to SPMS upon neck flexion
 Nystagmus – nerves of the eyes o Begins with relapsing-remitting course Visual – 80% of pts
 Onset usually 20-40 y/o followed by progression to steady and  Improves c/in 4-12 wks
 W>M, 2-3:1 irreversible decline  Optic neuritis – inflammation of the optic nerve;
Etiology o Progressive axonal loss rather than new icepick-like pain behind the eye c
 3% in a sibling lesions blurring/graying of vision/blindness in one eye,
 5% in a fraternal twin  Primary-progressive (PPMS) – 10% of cases, scotoma may appear
later onset (40 y/o)  Marcus Gunn pupil – paradoxical dilation of both
 25% in an identical twin
o Nearly continuous worsening of the pupils when light is shone in affected eye
 Molecular mimicry – myelin-reactive
disease from onset  Nystagmus – cerebellum/central vestibular
lymphocytes activated by the immune system
during exposure to virus  Progressive-relapsing (PRMS) – 5% of pts pathway; involuntary cyclical movements of the
o Progressive from onset and steady eyeball
 Implicated virus
o Measles deterioration, with occasional acute  Internuclear ophthalmoplegia (INO) –
attacks demyelination of pontine medial longitudinal
o Epstein-Barr virus
Exacerbating Factors – new and recurrent MS fasciculus; lateral gaze palsy on affected side,
o Chlamydia pneumoniae
symptoms lasting > 24 hrs nystagmus of opposite abducting eye
o Canine distemper
 Overall health  Diplopia – double vision
o Human herpesvirus-6
 Viral/bacterial infections (cold, flu, UTI, sinus Motor – UMN signs (paresis, spasticity, brisk tendon
 Risk of MS may be ↑ in vit. D deficiency and
infection) reflexes, involuntary flexor and extensor spasms,
smoking
 Disease of major organ systems (hepatitis, clonus, Babinski’s sign, exaggerated cutaneous
Pathophysiology
pancreatitis, asthma attacks) reflexes, loss of precise autonomic control)
Immune Autoantige  Stress  Weakness – loss of orderly recruitment and ↓
response ns  Pseudoexacerbation – temporary worsening of firing rate modulation
MS symptoms, usually c/in 24 hrs o Asthenia and ataxia in pts c cerebellar
Gliosis Demyelinati
o Uthoff’s symptoms – adverse reaction to lesions
on
heat  Spasticity – 75% of cases
Symptoms o Certain antidepressants (SSRIs) can
Lesion Type I
Sensory exacerbate spasticity
Type II  Hypesthesia, numbness  Fatigue – 75-95% of pts; subjective lack of
 Paresthesia physical/mental energy perceived to interfere c
Type Pain – 80% of pts, 55% clinically significant usual and desired activities
III  Paroxysmal limb pain – dysesthesia common in o Results of central activation failure
Disease Course
Benign – pt remains fully functional 15 yrs p onset the LE, m/c type of pain Coordination and Balance
o Fewer than 20% of cases  Ataxia – dysmetria (undershoot/overshoot),
dyssynergia (loss of synergy),
 dysdiadochokinesia (rapid alternating  Constipation – m/c GI complaint; lesions  Antidepressants
movements) affecting control of gastrocolic reflex PT Examination
 Postural tremor during sitting/standing o Spasticity of pelvic floor muscles,  Complete musculoskeletal and neurologic
 Intention tremor – involuntary, rhythmic, inactivity assessment
shaking movements when purposeful o Bowel impaction – serious complication Exercise Training
movements are attempted Sexual – 91% of men, 72% of women  Emphasis on maintenance of general
Gait and Mobility Diagnosis conditioning
 ~50% of pts c RRMS require some form of  Dissemination of lesions in space and time  Best exercise for task is the task itself.
assistance during walking 15 yrs p diagnosis  Lab tests: MRI, EP, LP c CSF analysis Important Prognostic Signs
 Ataxic gait – staggering, uneven steps, poor o MRI is highly sensitive, 95%  Male
foot placement, uncoordinated limb o Bright spots in new lesions (preceding 6  Initial presentation over 35 y/o
movements, frequent loss of balance wks)  Motor/cerebellar dysfunction
 Scissoring gait – spasticity of the adductor o Black holes in more long-term disease  Rapid disease progression
muscles activity (gadolinium-enhanced)  Polysymptomatic onset
Speech and Swallowing  VEP is most sensitive indicator of optic nerve
 Dysarthria dysfunction Expanded Disability Status Scale for Patients with MS
 Dysphonia  Elevated immunoglobulin (IgG) in CSF
 Aspiration pneumonia – wet voice quality c Medical Management
gurgling, sounds of congestion, fever Acute Relapses
Cognitive - ~50% of pts  Corticosteroids (methylprednisolone) shorten
 Short-term memory, attention and duration of exacerbations
concentration, information processing, Spasticity
executive functions, visuospatial functions,  Oral baclofen (Lioresal)
verbal fluency  Tizanidine
 Dantrolene sodium
Depression - ~50% of pts  Diazepam
Emotional
 Carbamazepine – paroxysmal spasms
 Pseudobulbar Affect
 Botulinum toxin
 Euphoria Pain
Bladder - ~80% of lesions  Neuropathic pain – tricyclic antidepressants
 Spastic/small
 Paroxysmal pain – carbamazepine,
 Flaccid/big amitriptyline, phenytoin, diazepam, gabapentin
 Dyssynergic/conflicting – problem c  Dysesthesia – amitriptyline, imipramine,
coordination between bladder and sphincter desipramine
contraction  Trigeminal neuralgia – antiepileptic drugs
 Types of incontinence (carbamazepine)
o Urge – overactive bladder  Mild painkillers (acetaminophen, ibuprofen)
o Stress – poor bladder closure Fatigue
o Overflow – poor contraction/urethral  Amantadine, Modafinil
blockage Tremor
o Functional – medications/health  Hydroxizine, propranolol, buspirone,
problems making it hard to reach the ondansetron, primidone
bathroom  Anti-nausea drugs for dizziness and vertigo
Bowel Cognitive and Emotional Impairments