MULTIPLE SCLEROSIS INTRODUCTION Multiple sclerosis (MS) is a chronic disease of the nervous system. Multiple sclerosis causes inflammation and damage to the protective coatings in the brain and the nerves. Despite extensive research, no one knows the exact cause – or causes – of MS. There are about 400,000 Americans who have MS. Although most patients with MS have similar signs and symptoms, the progress and pattern of these differs from patient to patient. The signs and symptoms and the progress of MS can also vary in each individual. Multiple sclerosis can be very debilitating. Supportive care and medications can make MS easier to tolerate. However, because there is no cure for MS and the signs and symptoms appear and disappear randomly, the unpredictable nature of MS makes it a very hard to disease to live with. OBJECTIVES When the student has finished this module, he/she will be able to: 1. Identify the correct definition of MS. 2. Identify the basic cause of MS. 3. Identify the four probable causes of MS. 4. Identify the specific type of disease MS is thought to be. 5. Identify four common signs and symptoms of MS. 6. Identify the basic pattern of the signs and symptoms of MS. 7. Identify the most common presentation of the signs and symptoms of MS. 8. Correctly identify a drug that is commonly used for treating MS. 9. Identify three areas of care a CNA must focus on when caring for a patient with MS. 10. Identify an important enviromental concern for patients with MS. MULTIPLE SCLEROSIS AND THE NERVOUS SYSTEM The brain, the spinal cord, and the nerves make up our nervous system. The nervous system controls everything we do. It controls involuntary actions of our bodies that happen without conscious control, e.g., breathing, digestion, etc. It also controls the things that we can do consciously, such as walk, talk, think, etc. The nervous system operates by sending signals through nerve fibers (which are a bit like wires in an electrical circuit) out from the brain to the heart, muscles, etc, and it also receives signals back from the heart, muscles, etc. These signals are actually electrical impulses. In order for these signals to be transmitted effectively and quickly, the brain, spinal cord, and nerve fibers have a protective sheath called myelin. Myelin covers the parts of the nervous system that are involved in sending and receiving signals. By doing so, the myelin makes sure these electrical signals to and from the brain don’t “leak” away, acting very much like the insulation around an electrical wire. WHAT CAUSES MULTIPLE SCLEROSIS? The basic cause of MS is damage to the myelin sheaths covering of the nervous system. The name of the disease is an accurate description of the cause and what happens; there are many, many (multiple) areas of damage to the myelin (sclerosis is a medical term that means scarring). The damage and scarring come from inflammation. Learning Break: Inflammation is one of the ways the body responds to trauma, injury, or infection. Inflammation increases blood flow to the damaged/infected area and also brings antibodies and other healing blood components. However, if the process of inflammation is widespread, there can be some “collateral damage.” It is this collateral damage that is the problem in MS. The body responds to damage to the myelin sheaths y activating the process of inflammation. Inflammation when it is mild and controlled is a healing process. But when it is intense and widespread, there is harm done to the inflamed areas – in this case, the myelin sheaths. Because of the damage to the myelin, the impulses and information that travel to and from our brains do not make it through or a make it through slowly and/or erratically. Multiple sclerosis is a disease that has been exhaustively studied in the search for a cause. There are strong suspicions that MS is a disease that is caused by several factors working together. Like many diseases, MS probably begins when someone who is genetically susceptible to MS encounters a “trigger” that sets the disease in motion. The most recent research suggests that MS is caused by a combination of: Environmental factors: Cigarette smoking, prolonged exposure to the sun, and diet may be environmental causes of MS. A vitamin D deficiency could also be part of the picture. Genetic factors: Genes have been identified that may make someone more likely to develop MS. But it is also very likely that there are multiple genetic variations that would need to combine to help cause MS. Even then, it probably takes some type of environmental trigger to cause the disease. Infection: The Epstein-Barr virus is a common virus. It can cause diseases such as mononucleosis and rheumatoid arthritis. There is some evidence that the EpsteinBarr virus may be cause of MS. However, the idea that MS is caused by an infection is still controversial. Multiple sclerosis is not contagious. Autoimmune dysfunction: Some authorities believe that in MS the environment, genetics, and infection are not the actual causes of MS. Instead, they believe these factors combine to cause an autoimmune disease. The current thinking is that MS is very likely an autoimmune disease. Learning Break: The body has defenses against infection and trauma and one of these is the immune system. The immune system is made of specialized cells and blood components that attack and neutralize harmful bacteria, viruses, etc. However, at times the immune system malfunctions and starts attacking normal structures and tissues. When this happens – as in MS – it is called an autoimmune disease. Autoimmune diseases are common: certain types of arthritis, psoriasis, and Type I diabetes are all autoimmune diseases. Multiple sclerosis is most common in people aged 18 to 50. Most people get diagnosed with MS when they are in their late 20s or early 30s. It is more common in women than men by a 2:1 ratio. People of northern European ancestry are more likely to develop MS. WHAT ARE THE SIGNS AND SYMPTOMS OF MULTIPLE SCLEROSIS? There are certain signs ands symptoms that are common to everyone who has MS. However, there is also a lot of variation in what these patients experience. Some of the common signs and symptoms of MS include: Fatigue Mood swings Constipation Urinary incontinence Fecal incontinence Spasticity (Sudden and uncontrollable spasms or jerking movements) Numbness/weakness of one or more limbs Loss of vision Blurred vision or double vision Dizziness Depression Tremors Lack of coordination The most common and the ones that prevent normal functioning are fatigue, spasticity, pain, and weakness. Learning Break: The physical signs and symptoms of MS are easy to focus on as they are easily seen. But many patients with MS are troubled by depression. The suicide rate for people with MS is almost 8 times higher than that of the population without MS. One of the hallmarks of MS is that these signs and symptoms wax and wane. Another common issue is that the nature of the attacks is unpredictable. The patient may have pain and weakness in one arm, and when the next attack occurs he/she will have problems somewhere else. Learning Break: It is not clear why, but patients with MS will often feel much worse and their signs and symptoms will get worse as the temperature increases. Many patients find hot summer temperatures intolerable. The patient with MS will have good days and bad days. When he/she is having an attack, it will be very difficult for that person to function. Moving and walking can be painful and unsafe. The patient will feel tired and depressed, and their moods may be very variable. They may have difficulty seeing. There are also several different patterns of the disease in terms of how it progresses. Relapsing remitting MS: These patients have attacks of the signs and symptoms of MS, but after each attack, they return to their normal health status (relapses) or very close to it. This is the most common form of MS. Primary progressive MS: People who have primary progressive MS do not return to their normal health status between attacks. Instead, they become progressively more and more disabled. Approximately 10% of all people with MS have this form of the disease. Secondary progressive: The secondary progressive form of MS begins with the relapsing remitting form, but then these patients eventually develop progressive signs, symptoms, and disabilities. Progressive relapsing: This form of MS is very uncommon. The patient has relapses, but the disabilities get worse overtime. Most people with MS have a normal or close to normal life span. Paralysis is very uncommon. If people with MS die as a result of the disease, it is usually because they are immobile and develop an overwhelming pneumonia. However, patients with MS do often have a lot of fatigue and a lot of pain and weakness in their arms or legs. Eventually, some patients with MS are not able to walk without a lot of assistance. They will need a cane, a walker, or a motorized scooter to get around. HOW CAN MULTIPLE SCLEROSIS BE DIAGNOSED? The signs and symptoms MS are very common problems that can be caused by many different medical problems. However, because of the on/off pattern of how these signs and symptoms come and go, it is possible to be relatively certain that someone has MS. There are no blood tests that can detect MS. The physician will perform a physical exam, interview the patient, and then to confirm the diagnosis will order several types of tests. A magnetic resonance imaging (MRI) test can be useful, but some people with MS will have a normal MRI. A sample of the fluid that surrounds the spinal cord can be removed and tested in a procedure called a lumbar puncture. In some patients with MS, there will be characteristic abnormalities. But like the MRI, there are a percentage of people who have MS and will have normal spinal fluid. Finally, there is a test called a visual evoked potential test. In this exam the response of the patient’s nervous system is examined while he/she is undergoing various types of stimulation such as visual or auditory. The response will be abnormal or slow in a patient with MS. TREATMENT FOR THE PATIENT WITH MULTIPLE SCLEROSIS: THE BASICS There is no cure for MS. Most people have a normal life expectancy, but the disease can result in a lot of pain, fatigue, and severely limit what someone can and can’t do. The treatments for MS can make a big difference in helping someone cope with the disease. Treatment basically focuses on three goals: Modifying the course of the disease: There are drugs available that can modify the course of the disease. These decrease the frequency of the attacks and hopefully prolong the asymptomatic periods between the attacks. They do not cure the disease. Treat exacerbations: People who are having an exacerbation of their MS are often in a great deal of discomfort. There are medications available that can provide relief during these symptomatic periods. These medications help by affecting the basic process of MS and by relieving the signs and symptoms caused by that process. Improve function: Physical therapy, occupational therapy, and speech therapy can all help the patient with MS cope with the disabilities and lead a more normal life. Psychotherapy can also be helpful for patients who are depressed. Learning Break: Those are the three basic goals of treating someone with MS: Modify the course of the disease, treat the exacerbations, and improve function. Drug therapy is the most important medical treatment for meeting the first two goals. MODIFYING THE COURSE OF THE DISEASE AND TREATING EXACERBATIONS: DRUG THERAPY Drug therapy can make a big difference for patients with MS. Medications are used to decrease the frequency of MS attacks, they are use to decrease the severity of these attacks while they are happening, and they are used to treat some of the associated issues of an MS attack. Decreasing frequency of MS attacks: The main categories of medications that are used for this purpose are drugs that change the function of the immune system. MS is almost certainly an autoimmune disease. The most common drug used for people with MS, interferon, can suppress the activity of the immune system. It has been proven that therapy with interferon can reduce the number of symptomatic periods. They may also slow down the progression of the disease. Although there is no doubt that these drugs are very helpful, there is a lot of controversy about the best way to prescribe them. Treat exacerbations: Corticosteroids such as methylprednisolone decrease the inflammation caused by MS and these can be used during symptomatic periods. Other medications such as Prozac and other antidepressants ® can be used to treat depression, amantadine and Provigil® can be used to treat fatigue, baclofen and Valium® can be used to treat muscle spasms and pain, and Mysoline® can be used to treat tremors and difficulty walking. IMPROVING FUNCTION: OTHER THERAPIES Some of the medications listed above can improve functioning. However, there are other ways that the patient can be helped to maintain independence and a normal life. Physical therapy can help the patient with MS stay strong and flexible. It can also help spasticity and improve coordination. Occupational therapy can help the patient find strategies for managing the practical aspects of day to day life such as dressing, transportation, etc. Patients can also benefit from speech therapy. WORKING WITH A PATIENT WHO HAS MS When you are working with a patient who has MS, there are three areas of care you will need to focus on. Activity: The patient with MS can be very limited in what he/she can do. This can be because of fatigue. It can also be caused by, pain, numbness, and spasticity. You will need to work closely with the patient to determine an appropriate level of activity and how much assistance you will need to provide. Remember: Patients with MS very often cannot tolerate hot temperatures. Safety: Because of the activity limitations, the patient must be protected against falls. Make sure you avoid hot showers or baths. Skin care: Incontinence of stool or urine can cause skin breakdown. If the patient has limited mobility, the skin irritation and the inability to move normally can lead to pressure sores. Elimination: Constipation can also be a problem for the patient with MS. Encourage the patient to stay hydrated, and make sure you document the patient’s pattern of elimination. Notify your supervisor if you supect the patient is constipated. SUMMARY: IMPORTANT POINTS TO REMEMBER ABOUT MULTIPLE SCLEROSIS Multiple sclerosis is a chronic disease of the nervous system. There is no cure for MS. MS is caused by damage to the myelin sheaths of the nervous system. This damage is caused by inflammation. Because of this damage, signals to and from the nervous system are not transmitted or are transmitted slowly and erratically. Multiple sclerosis is an autoimmune disease. The signs and symptoms wax and wane, come and go. Fatigue, weakness, spasticity, and pain are the most common signs and symptoms.