Multiple Sclerosis

Definition
Multiple sclerosis is a chronic, degenerative
progressive disorder ease of the central
nervous
system
characterized
by
the
occurrence of small patches of demyelination
in the brain and spinal cord.
Demyelination refers to the destruction of
myelin, the fatty and protein material that
surrounds certain nerve fibers in the brain and
spinal cord, which results in impaired
transmission of the nerve impulses.
Types
1. Benign

Nervous system, dysfunction will

occur in different episodes, full
recovery occurs
2. Relapsing Remitting

Most common

Neurological exacerbations occur

but improvement can be seen with
either complete or partial recovery
3. Primary Progressive

Sudden
loss
of
neurological
function occurs, which may not
resolve

Leaves
severe
functional
impairments

These may actually worsen over

time

No remission follows
4. Secondary Progressive

Starts familiar to relapsing

remitting

Changes to a primary progressive

form

No remission follows

Anatomy and Physiology

Nervous System
Is the master and communicating system of
the body. Every thought, action and emotion reflects its
activity.
Its
signaling
device
or
means
of
communicating with body cells is electrical impulses,
which are rapid and specific and causes almost
immediate responses.
Three functions:
1. Monitor changes inside and outside the body

Changes are called as stimuli

Gathered information is called as

sensory input
2. Processes and interprets sensory input

Integration making decision about

what should be done at the moment
3. Effects a response by muscle or gland
activation
Structural Classification
1. Central Nervous System
Consists of the brain and the spinal
cord, which occupies the dorsal body
cavity
Acts as the integrating and command
centers of the nervous system
Interpret sensory information and issue
instructions based on past/present
experiences
2. Peripheral Nervous System
Spinal nerves (carry impulses to and
from the spinal cord) and cranial

nerves (carry impulses to and from the

brain)
Links all body parts of the body by
carrying impulses from the sensory
receptors to the CNS and from the CNS
to the glands and muscles

Functional Classification
1. Sensory or Afferent Division
Nerve fibers that convey the impulses
to the CNS from sensory receptors from
the body
Sensory fibers
o Somatic sensory fibers skin,
skeletal muscles and joints
o Visceral sensory fibers visceral
organs
2. Motor or Efferent Division
Carry impulses from the CNS to
effector organs, muscles and glands
Two subdivisions
o Somatic Nervous System - allows to
consciously and voluntarily control
the skeletal muscles
o Parasympathetic Nervous System
automatic or involuntary
Sympathetic
Parasympathetic
Nervous Tissue: Structure and Function
1. Neuroglia (Supporting Cells)
Support, insulate and protect the
delicate neurons
Not able to transmit nerve impulses
Never lose the ability to divide
Astrocytes
o Forms a living barrier between
capillaries and neurons and play a
role in making exchanges between
the two
o Control the chemical environment
in the brain by picking up excess
ions
and
recapturing
neurotransmitters
-

Microglia
o Dispose debris, including dead
brain cells and bacteria
Ependymal
o Lines the cavities of the brain
and spinal cord
o Helps to circulate the CSF that
fills those cavities and forms a
protective cushion
Oligodendrocytes
o Wrap the flat extensions tightly
around
the
nerve
fibers,
producing
fatty
insulating
coverings called as the myelin
sheaths
Schwann Cells
o Form
the
myelin
sheaths
around nerve fibers found in
the PNS
Satellite Cells
o Protective and cushioning cells
2. Neurons

Axon
-

Transmits messages from one part of

the body to the another
*Axons transmit nerve impulses away
from the cell body. When these
impulses reach the axon terminals,
they
stimulate
the
release
of
neurotransmitters into the extracellular
space.
Cell body
o Metabolic center of the neuron
o Contains the usual organelles
Neurofibril
o Intermediate filaments that are
important in maintaining cell
shape
Processes or fibers
o Convey incoming messages
toward the cell body
Dendrites
o Generate nerve impulses and
conduct them away from the
cell body
Axons
o Each neuron has only one axon
o Arises from the axon hillock
Axon terminals
o Contain the chemicals called as
neurotransmitters
Terminal
Separated from the next neuron by a
tiny gap called synaptic cleft
Such a functional junction is called as
synapse
Very close, but never actually touch
other neuron
Covered with a white, fatty material
called as myelin
o Protects and insulates the
fibers
and
increases
the
transmission rate of the nerve
impulses
Axons outside the CNS are myelinated
by
Schwann
cells,
specialized
supporting that wrap themselves
tightly around the axon
After the wrapping process, a tight coil
of
wrapped
membranes,
myelin
sheaths, encloses the axons
Since the myelin sheath is formed by
many Schwann Cells, it has gaps or
indentations called as the Nodes of
Ranvier

Neurons
Myelinated fibers are also found in the central
nervous
system,
however,
it
is
oligodendrocytes that for the CNS myelin
sheaths
Although the myelin sheaths formed by the
oligodendrocytes and those formed by the
Schwann cells are similar, the CNS sheaths
lacks a neurilemma
o Neurilemma remains intact when a
peripheral nerve fiber is damaged
o Plays an important role in fiber
regeneration

Etiology

M More common in women

Women produce more protein called as

S1PR2 which controls the permeability
of the blood brain barrier

Hormones may also play a significant

role of the susceptibility to MS

U Usually occurs between ages 20 to 40

years old

L later reaction ta viral infection

T Trauma

I Infection (viral)

The virus Epstein Barr is the most

consistently linked to MS, a virus that
causes mononucleosis

P Pregnant

Symptoms decrease during pregnancy

and increase after delivery

Disabling effects makes it difficult for

the mother to carry pregnancy

Increases likelihood for falls

Worsen fatigue

Increases risk for infection

L Loss of energy

E Emotional stress
Symptomatology

MS course assume different patterns

A Ataxia or impaired coordination of

movements

Due to involvement of the cerebellum

or basal ganglia

M Muscle spasticity and muscle weakness

Due to involvement of the main motor

pathways of the spinal cord

U Unusual reflexes (positive Babinski)

L Loss of energy (fatigue) COMMON

SYMPTOM

T Tremors

T Two visions (diplopia) EARLIEST SIGN

Due to lesions in the optic nerves or

their connections

I Incontinence in urinary and bowel

Secondary complications of MS

P Paresthesia and pain

Due to disruption of the sensory axons

L Less perception to pain, touch and

temperature

E Emotional changes (apathy, euphoria)

D Depression

Due to frontal or parietal lobe

involvement

Medical Management
a. Laboratory Tests

MRI
Test
that
produces
clear
pictures of the human body
without the use of x rays
Uses large magnets, radio
waves and a computer to
produce images

To visualize small plaques and

to evaluate the course of the
disease and effect of the
treatment
Spinal Tap or Lumbar Puncture
A procedure used to remove
and test CSF to diagnose brain
and spinal cord disorders
including multiple sclerosis
CSF studies help define the
extent of the disease process
and monitor changes
Evoked Potential Tests
Tests
that
measure
the
electrical activity of the brain
caused by light, sound and
touch
Detects problems along the
cranial and spinal nerves

b. Medications

Corticosteroids
(prednisone
and
methylprednisolone) and ACTH
o Used as anti inflammatory
agents that may improve nerve
conduction

Immunosuppressive
agents
like
cyclosporine and glatiramer acetate
Reduce the rate at which the
disease
progresses
and
decrease the frequency and
severity of exacerbations
Interferons beta 1b (Betaseron and
Avonex)
o Used in relapsing remitting
MS and significantly reduces
the area of demyelination in
the brain tissue
Baclofen
o An antispasmodic agent, choice
for spasticity
Beta
adrenergic
blockers,
anticonvulsants, and benzodiazepines
o Used to treat ataxia
Ascorbic acid
o To
acidify
urine,
making
bacterial growth less likely
o

c.

Treatments and Surgery

No cure is available, supportive care
should be maintained
Maximum support to client and family
is usually needed
Safety precautions
Promoting physical mobility
Preventing injury
Enhancing bladder and bowel control
Managing speech and swallowing
difficulties
Improving
sensory
and
cognitive
function
Improving self care abilities
Promoting sexual functioning

Identify personal strengths and accept

support
through
the
nursing
relationship

Determine risk for client inflicting self

harm

Maintain environment with low levels of

stimuli
Impaired home maintenance management
related to physical, psychological and social
limits
imposed
by
MS
potential for sexual dysfunction related to
spinal cord involvement or psychological
reactions to conditions

Determine information needed to be

taught and learned

Determine type of equipment needed,

considering availability,
cost and
durability

Determine type of assistance needed

Discuss implications of caring for a

chronically ill family member

Allow patient to share thoughts and

feelings

Refer to community agencies as

indicated
Impaired speech and swallowing related to
cranial nerve involvement
Altered thought processes related to cerebral
dysfunction

Nursing Diagnosis and Interventions

1. Impaired physical mobility related to weakness,
muscle paresis, spasticity

Perform passive ROM on affected limbs

Safety precautions at all times

Encourage
ambulation
for
short,
frequent walks, with assistance if
unsteady

Teach proper ways to use ambulatory

devices like crutches, walkers and
wheelchair
2. Risk for injury related to sensory and visual
impairment

Orient to surroundings

Supervise patient during first few

nights/days to assess safety

Encourage to ask assistance at all

times

Keep bed at lowest level during night

Teach proper ways to use ambulatory

devices like crutches, walkers and
wheelchair

Provide nonslip handgrips, railings

along hallways and bathrooms

Remove protruding objects

Safety precautions at all times

3. Altered urinary and bowel elimination related
to spinal cord dysfunction

Administer medications

Bladder training

Catheterization

Increase oral fluid intake

4. Ineffective individual coping

Verbalize feelings related to emotional

state

Identify
coping
patterns
and
consequences of the behavior that
results

5.

6.
7.

Prognosis
Prognosis for people with MS is encouraging.
Studies show that majority of MS patient will
experience a normal (or almost normal) life span.
People with MS tend to die from many of the same
conditions that people without MS die form, like cancer
and heart disease.
Prognosis for longevity is good except in cases
of sever MS. Symptoms cause pain, discomfort and
inconvenience, even though patients will never
become severely disabled. Some patient will need
crutches or cane to remain ambulatory, however.

Pathophysiology
Destruction of myelin nerve axons causes a temporary, repetitive or sustained interruption in conduction of
nerve impulses that causes symptoms of MS
Plaque formation occurs throughout white matter of the CNS, which also affects nerve impulses, disorder
affects optic nerves, cervical spinal cord, and the thoracic and lumbar spine
Inflammation occurs around the plaques as well as normal tissue
o Astrocytes (gliosis) appear in lesions and scar tissue forms, replacing axons and leading to permanent
disability
o The tem gliosis leads to the term sclerosis which means scarring
Immune response
o Helper T cells re elevated in the CSF at onset of disease
o T suppressor cells are decreased in serum before and during a exacerbation of illness
o Immunocompetent cells are present within plaques
o Antibody production is evident intrathecally
Overproduction of the
protein Interleukin 12

Oxidative mitochondrial
damage

Transformation of CD4+
autoreactive T cells

Alteration of
mitochondrial proteins

Inflammatory Th1 and

Progressive tissue

Triggers inflammation
and lesion formation

Diplopia or
double vision

Lesion in the white

matter of the brain
Beta cells
migrate to the

Formation of
myelin
reactive

Muscle spasticity
Muscle weakness
Tremors

Paresthesia
Less perception to
touch and temperature
Emotional changes

Blood Brain Barrier

WBC and

Leukocytes

Leukocyte and
lymphocyte infiltration in

T lymphocyte
proliferation

Inflammation and
demyelination of
oligodendrocytes

Increased Blood
Brain Barrier
permeability

Scarring of neural tissue

or sclerosis

Altered energy metabolism

Fatigue

Slower impulses and

degeneration

Brain tissue scarring

Irreversible brain tissue

Ataxia
Depression