1 When is it MS and When is it Something Else? Jodie K. Haselkorn, MD, MPH Director, MS Center of...

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When is it MS and When is it Something Else?

Jodie K. Haselkorn, MD, MPHJodie K. Haselkorn, MD, MPHDirector, MS Center of Excellence WestDirector, MS Center of Excellence West

Veterans Health AdministrationVeterans Health Administration

www.va.gov/mswww.va.gov/ms

Associate Director, RehabNetWestAssociate Director, RehabNetWest

University of WashingtonUniversity of Washington

Rehabilitation Medicine, Epidemiology, Medical History & BioethicsRehabilitation Medicine, Epidemiology, Medical History & Bioethics

Is it MS or Something ElseNMSS November 2004 2

MS Center of Excellence West

Jodie Haselkorn, MD, MPHJodie Haselkorn, MD, MPH Dennis Bourdette, MDDennis Bourdette, MD James Bowen, MDJames Bowen, MD Drew Blazey, AODrew Blazey, AO Gordon Campbell, RN, NPGordon Campbell, RN, NP David Gruenweld, MDDavid Gruenweld, MD John Dryden, MDJohn Dryden, MD Michael Hatzakis, Jr., MDMichael Hatzakis, Jr., MD Mark Haselkorn, PhDMark Haselkorn, PhD

Charles Lai, MSCharles Lai, MS Steve Leipertz, PhDSteve Leipertz, PhD Amy Poel, MPHAmy Poel, MPH Chuck Maynard, PhDChuck Maynard, PhD Marsha Tarvor, PhDMarsha Tarvor, PhD Aaron Turner, PhDAaron Turner, PhD Tara Stablein, MSWTara Stablein, MSW Lynne Walker, CRRNLynne Walker, CRRN Rhonda Williams, PhDRhonda Williams, PhD Ruth Whitham, MDRuth Whitham, MD


• Seattle

• Portland• Baltimore


Overview

Is it MS?Is it MS? Is it something else?Is it something else? Good PreventionGood Prevention Advocating for yourself and your Advocating for yourself and your

significant otherssignificant others


Is it MS or is it something else? Providers, people with MS, and Caregivers all Providers, people with MS, and Caregivers all

struggle with this issuestruggle with this issue Associated with feelings that includeAssociated with feelings that include

StressStress FearFear AnxietyAnxiety HelplessnessHelplessness FrustrationFrustration AngerAnger Decreased Self-EfficacyDecreased Self-Efficacy


Is it MS or is it something else? Maladaptive use of the health care Maladaptive use of the health care

system:system: non-participation non-participation constant health utilizationconstant health utilization


Is it MS?

MS definedMS defined Diagnostic Criteria for MSDiagnostic Criteria for MS Sometimes other conditions mimic MSSometimes other conditions mimic MS Definition of a RelapseDefinition of a Relapse Secondary Impairments Associated with Secondary Impairments Associated with

MSMS


Multiple Sclerosis Criteria

Objective clinical evidence of Objective clinical evidence of neurological lesions in time and in neurological lesions in time and in spacespace

Radiological and laboratory evidenceRadiological and laboratory evidence MRIMRI CSFCSF VEPVEP

No Better ExplanationNo Better Explanation


MRI Evidence of MS

Three of these:Three of these: One gadolinium-enhancing lesion orOne gadolinium-enhancing lesion or

>> 9 T2 hyper intense lesions 9 T2 hyper intense lesions >> 1 infratentorial lesion 1 infratentorial lesion >> 1 juxtacortical lesion 1 juxtacortical lesion >> 3 paraventricular lesions 3 paraventricular lesions


Multiple Sclerosis: Is it something else Many individuals seen in MS Centers Many individuals seen in MS Centers

diagnosed with MS don’t have the diagnosed with MS don’t have the disease, but have something elsedisease, but have something else


Multiple Sclerosis Mimics

Acute Disseminated Encephalomyelitis Acute Disseminated Encephalomyelitis (ADEM)(ADEM)

CerebritisCerebritis Cervical MyelopathyCervical Myelopathy Complicated MigraineComplicated Migraine DiabetesDiabetes



Guillian BarraeGuillian Barrae Hereditary Spastic ParaparesisHereditary Spastic Paraparesis Lyme DiseaseLyme Disease Neromyelitis Optica (Devic’s)Neromyelitis Optica (Devic’s) NeurosyphilisNeurosyphilis Paraneoplastic SyndromesParaneoplastic Syndromes Polyarteritis nodosaPolyarteritis nodosa PolymyositisPolymyositis



Progressive Multifocal LeukoencephalopathyProgressive Multifocal Leukoencephalopathy SarcoidosisSarcoidosis Sjogren SyndromeSjogren Syndrome Spinocerebellar SyndromeSpinocerebellar Syndrome StrokeStroke Sub-Acute Sclerosing PanencephalitisSub-Acute Sclerosing Panencephalitis TumorsTumors


Exacerbation, Relapse, Attack, and Flare Defined:Defined:

A sudden change in neurological function A sudden change in neurological function (worsening of symptoms or the (worsening of symptoms or the appearance of new symptoms) lasting at appearance of new symptoms) lasting at least 24 hoursleast 24 hours

Separated from the last exacerbation by Separated from the last exacerbation by one monthone month

Unexplained by other changes such as an Unexplained by other changes such as an infectioninfection


Pseudoexacerbation

Temporary aggravation of MS Temporary aggravation of MS symptoms that have been experienced symptoms that have been experienced before NOT associated with before NOT associated with inflammationinflammation HeatHeat FeverFever InfectionInfection


Secondary Impairments Associated with MS

FatigueFatigue A subjective lack A subjective lack

of physical or of physical or mental energy mental energy perceived by the perceived by the individual or individual or caregiver to caregiver to interfere with interfere with usual and desired usual and desired activities.activities.


Fatigue: MS or Something Else Make sure your provider:Make sure your provider:

Takes a good historyTakes a good history Does a physical examinationDoes a physical examination Performs lab work including Performs lab work including

hematocrit and thyroid stimulating hematocrit and thyroid stimulating hormone (TSH)hormone (TSH)


Fatigue – Something Else

Poor sleepPoor sleep Excessive caffeineExcessive caffeine Over-useOver-use AnemiaAnemia HypothyroidismHypothyroidism DepressionDepression Medication EffectsMedication Effects


Depression – MS related

30-60% of individuals with MS report a 30-60% of individuals with MS report a major depressive episode. major depressive episode. InflammatoryInflammatory

Coronary Artery DiseaseCoronary Artery DiseaseInflammatory Bowel DiseaseInflammatory Bowel DiseaseRheumatoid arthritis Rheumatoid arthritis

AdjustmentAdjustment


Depression – Is it something else?

Major Depressive Major Depressive Episode not Episode not associated with MSassociated with MS

Medication EffectsMedication Effects


Spasticity – MS related

Increased resistance of muscle to rapid Increased resistance of muscle to rapid stretchstretch Baseline spasticityBaseline spasticity Changes withChanges with

Exacerbation or progressionExacerbation or progressionDMTsDMTs


Spasticity – Is it signaling something else? InfectionInfection Increased temperatureIncreased temperature MensesMenses Tight clothingTight clothing Skin ulcerSkin ulcer Renal or bladder stonesRenal or bladder stones Temperature extremesTemperature extremes StressStress FractureFracture


Urinary Dysfunction – MS Related Failure to storeFailure to store

FrequencyFrequency UrgencyUrgency NocturiaNocturia IncontinenceIncontinence

HesitancyHesitancy


Urinary Dysfunction Basic Workup

HistoryHistory Physical Physical

ExaminationExamination UrinalysisUrinalysis Post void residualPost void residual


Urinary Dysfunction – Not MS

Urinary Tract InfectionUrinary Tract Infection Prostate Disorders in MenProstate Disorders in Men Stress Incontinence in WomenStress Incontinence in Women Bladder or Kidney StonesBladder or Kidney Stones Bladder, Kidney, Ureteral CancerBladder, Kidney, Ureteral Cancer


Bowel Function – MS Related

Demyelination interferes with the Demyelination interferes with the signals from the brain and spinal cord to signals from the brain and spinal cord to empty the bowelempty the bowel Decreased activityDecreased activity FatigueFatigue Weakness/Spasticity of the Weakness/Spasticity of the

Abdominal Muscles and Pelvic FloorAbdominal Muscles and Pelvic Floor Fluid RestrictionFluid Restriction


Bowel Dysfunction – Not MS

DiarrheaDiarrhea InfectionInfection Highly spiced foodsHighly spiced foods Lactose IntoleranceLactose Intolerance Irritable bowel SyndromeIrritable bowel Syndrome Colonic tumorsColonic tumors


Bowel Dysfunction– Not MS

ConstipationConstipation Poor water intakePoor water intake Poor dietPoor diet InactivityInactivity Calcium Calcium

supplementssupplements AntacidsAntacids Antidepressants, Antidepressants,

diuretics, opioidsdiuretics, opioids HabitHabit


Sensory Impairments – MS related NumbnessNumbness Pins and needlesPins and needles PainPain Banding, girdlingBanding, girdling


Pain Associated with MS

Trigeminal NeuralgiaTrigeminal Neuralgia Lhermitte’s SignLhermitte’s Sign DysesthesiasDysesthesias


Pain Associated with Secondary Impairments due to MS

Spasticity – pulling, cramping of Spasticity – pulling, cramping of musclesmuscles

Restricted Range of Motion – Muscle Restricted Range of Motion – Muscle pain and referred joint painpain and referred joint pain


Pain – Not MS related

Nerve entrapmentsNerve entrapments Cervical Cervical

radiculopathyradiculopathy Lumbar Lumbar

radiculopathyradiculopathy Peripheral Nerve Peripheral Nerve

EntrapmentsEntrapments• Carpal TunnelCarpal Tunnel



Musculoskeletal “wear and tear”Musculoskeletal “wear and tear”Rotator cuff disorderRotator cuff disorderOsteoarthritisOsteoarthritis

• ShouldersShoulders• HandsHands• HipsHips• KneesKnees• NeckNeck• Low BackLow Back


Pain (continued)

Referred PainReferred Pain Soft TissueSoft Tissue

Trigger pointsTrigger pointsOverused musclesOverused musclesFibrotic musclesFibrotic muscles

Retroperitoneal StructuresRetroperitoneal StructuresAortaAortaPancreasPancreasKidneysKidneysUterusUterus


Headaches

Headaches can be associated with MSHeadaches can be associated with MS


Headaches – Not MS

Tension headachesTension headaches Cervical segmental Cervical segmental

dysfunctiondysfunction Migraine headachesMigraine headaches Cluster headachesCluster headaches Space occupying Space occupying

lesions such as lesions such as tumorstumors


Facial Pain– Not MS

Dental problemsDental problems Temporomandibular joint painTemporomandibular joint pain



Musculoskeletal “wear and tear”Musculoskeletal “wear and tear”Rotator cuff disorderRotator cuff disorderOsteoarthritisOsteoarthritis

• ShouldersShoulders• HandsHands• HipsHips• KneesKnees• NeckNeck• Low BackLow Back


Sexual Function — MS Effects Decreased or absent sex driveDecreased or absent sex drive Changed genital sensationsChanged genital sensations

NumbnessNumbness PainPain HypersensitivityHypersensitivity


Sexual Function — MS Effects

Decreased vaginal toneDecreased vaginal tone Difficulty getting or maintaining an Difficulty getting or maintaining an

erectionerection Decreased vaginal lubrication and Decreased vaginal lubrication and

clitoral engorgementclitoral engorgement Difficulty or inability to ejaculateDifficulty or inability to ejaculate Decreased frequency/intensity of Decreased frequency/intensity of

orgasmsorgasms


Sexual Function – Secondary Effects Loss of desireLoss of desire

FatigueFatigue AnxietyAnxiety DepressionDepression

Sensory Sensory ImpairmentsImpairments PainPain Loss of sensationLoss of sensation


Sexual Function – Secondary Effects Fear associated with bladder or bowel Fear associated with bladder or bowel

accidentsaccidents Cognitive ImpairmentsCognitive Impairments Spasticity and Weakness Interfering Spasticity and Weakness Interfering

with positioningwith positioning Medication EffectsMedication Effects


Sexual Function – Tertiary Effects Grief, demoralization, anxiety, depression Grief, demoralization, anxiety, depression

and fearsand fears Changed social and family rolesChanged social and family roles Changed body imageChanged body image StressStress TimeTime Cultural values and expectationsCultural values and expectations Others…..Others…..


Sexual Dysfunction – Non MS

Causes of sexual difficulties includeCauses of sexual difficulties include Medication side effectsMedication side effects MoodMood Vascular ProblemsVascular Problems Other neurological problems such as Other neurological problems such as

diabetesdiabetes


Cognitive Functions Associated with MS Decreased attention, concentration, Decreased attention, concentration,

needing more time to store new facts, needing more time to store new facts, needing a cue to recall recently stored needing a cue to recall recently stored factsfacts


Cognitive Dysfunction – Not MS MedicationsMedications DementiasDementias


Hearing

Changes in hearing due to MS have Changes in hearing due to MS have been reported, but they are rare. been reported, but they are rare. Hearing changes should be evaluated Hearing changes should be evaluated for some other cause.for some other cause.


Dizziness

Dizziness is a Dizziness is a common complaint common complaint of people with MSof people with MS


Dizziness – Not MS

Other causes of dizziness include:Other causes of dizziness include: DehydrationDehydration MedicationsMedications Middle Ear ProblemsMiddle Ear Problems Benign Tumors of the Acoustic NerveBenign Tumors of the Acoustic Nerve


Is it something else?

General Prevention StrategiesGeneral Prevention Strategies Advocating for yourself and your Advocating for yourself and your

significant othersignificant other


Is it something else?

Good Prevention StrategiesGood Prevention Strategies ImmunizationsImmunizations Preventative MedicationsPreventative Medications Good Self CareGood Self Care Screening TestsScreening Tests


Immunizations

Influenza– Yearly after the age of 50 Influenza– Yearly after the age of 50 yrs. or sooner if at high riskyrs. or sooner if at high risk NOT Nasal SprayNOT Nasal Spray

Tetanus Diphtheria - Every 10 yearsTetanus Diphtheria - Every 10 years Pneumonia – Once at age 65 years or Pneumonia – Once at age 65 years or

sooner if pulmonary impairment or other sooner if pulmonary impairment or other immunosupressionimmunosupression

Hepatitis BHepatitis B


Preventative Medications

Aspirin – After age 40 to prevent heart Aspirin – After age 40 to prevent heart disease; younger than age 40 if high disease; younger than age 40 if high blood pressure, high cholesterol, blood pressure, high cholesterol, diabetes, or smokingdiabetes, or smoking


Other Self-Management Health Factors Stop smokingStop smoking Eat a healthy variety of foodsEat a healthy variety of foods Limit intake of saturated fatLimit intake of saturated fat Limit alcoholLimit alcohol Get moderate exerciseGet moderate exercise


Screening Tests

CholesterolCholesterol Every 5 years Every 5 years >>35 years35 years At age 20 if smoking, have diabetes, At age 20 if smoking, have diabetes,

or family history of heart diseaseor family history of heart disease


Screening Tests

Colorectal CancerColorectal Cancer Regular screening Regular screening >> 50 years 50 years

DepressionDepression Greater than two weeks “sad, blue, Greater than two weeks “sad, blue,

hopeless, little interest or pleasure in doing hopeless, little interest or pleasure in doing things”things”

DiabetesDiabetes If Hypertensive or HypercholesterolemiaIf Hypertensive or Hypercholesterolemia


Screening Tests Sexually Transmitted DiseaseSexually Transmitted Disease

Discuss with your provider if you should be Discuss with your provider if you should be screened screened

Prostate CancerProstate Cancer Yearly PSA or DRE Yearly PSA or DRE >> 40/50 without a 40/50 without a

personal history of cancer or family history personal history of cancer or family history of prostate cancerof prostate cancer

Breast CancerBreast Cancer Yearly mammograms Yearly mammograms >> 40 years 40 years


Screening Examinations

Yearly Pap and Gynecological Yearly Pap and Gynecological Examination for WomenExamination for Women

Every 6 month dental prophylaxisEvery 6 month dental prophylaxis


Self Screening Examinations

BreastBreast TestesTestes SkinSkin


Advocating for yourself or your significant other

Establish a relationship with your Establish a relationship with your provider teamprovider teamAsk about new symptomsAsk about new symptomsWrite down symptoms, signs or Write down symptoms, signs or concerns to review before a visitconcerns to review before a visit Educate yourselfEducate yourself Develop a support groupDevelop a support group

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