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When is it MS and When is it Something Else?

When is it MS and When is it Something Else?. Jodie K. Haselkorn, MD, MPH Director, MS Center of Excellence West Veterans Health Administration www.va.gov/ms Associate Director, RehabNetWest University of Washington Rehabilitation Medicine, Epidemiology, Medical History & Bioethics.

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When is it MS and When is it Something Else?

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  1. When is it MS and When is it Something Else? Jodie K. Haselkorn, MD, MPH Director, MS Center of Excellence West Veterans Health Administration www.va.gov/ms Associate Director, RehabNetWest University of Washington Rehabilitation Medicine, Epidemiology, Medical History & Bioethics

  2. Jodie Haselkorn, MD, MPH Dennis Bourdette, MD James Bowen, MD Drew Blazey, AO Gordon Campbell, RN, NP David Gruenweld, MD John Dryden, MD Michael Hatzakis, Jr., MD Mark Haselkorn, PhD Charles Lai, MS Steve Leipertz, PhD Amy Poel, MPH Chuck Maynard, PhD Marsha Tarvor, PhD Aaron Turner, PhD Tara Stablein, MSW Lynne Walker, CRRN Rhonda Williams, PhD Ruth Whitham, MD MS Center of Excellence West Is it MS or Something Else NMSS November 2004

  3. Seattle • Baltimore • Portland Is it MS or Something Else NMSS November 2004

  4. Overview • Is it MS? • Is it something else? • Good Prevention • Advocating for yourself and your significant others Is it MS or Something Else NMSS November 2004

  5. Is it MS or is it something else? • Providers, people with MS, and Caregivers all struggle with this issue • Associated with feelings that include • Stress • Fear • Anxiety • Helplessness • Frustration • Anger • Decreased Self-Efficacy Is it MS or Something Else NMSS November 2004

  6. Is it MS or is it something else? • Maladaptive use of the health care system: • non-participation • constant health utilization Is it MS or Something Else NMSS November 2004

  7. Is it MS? • MS defined • Diagnostic Criteria for MS • Sometimes other conditions mimic MS • Definition of a Relapse • Secondary Impairments Associated with MS Is it MS or Something Else NMSS November 2004

  8. Multiple Sclerosis Criteria • Objective clinical evidence of neurological lesions in time and in space • Radiological and laboratory evidence • MRI • CSF • VEP • No Better Explanation Is it MS or Something Else NMSS November 2004

  9. MRI Evidence of MS • Three of these: • One gadolinium-enhancing lesion or > 9 T2 hyper intense lesions • > 1 infratentorial lesion • > 1 juxtacortical lesion • > 3 paraventricular lesions Is it MS or Something Else NMSS November 2004

  10. Multiple Sclerosis: Is it something else • Many individuals seen in MS Centers diagnosed with MS don’t have the disease, but have something else Is it MS or Something Else NMSS November 2004

  11. Multiple Sclerosis Mimics • Acute Disseminated Encephalomyelitis (ADEM) • Cerebritis • Cervical Myelopathy • Complicated Migraine • Diabetes Is it MS or Something Else NMSS November 2004

  12. Multiple Sclerosis Mimics • Guillian Barrae • Hereditary Spastic Paraparesis • Lyme Disease • Neromyelitis Optica (Devic’s) • Neurosyphilis • Paraneoplastic Syndromes • Polyarteritis nodosa • Polymyositis Is it MS or Something Else NMSS November 2004

  13. Multiple Sclerosis Mimics • Progressive Multifocal Leukoencephalopathy • Sarcoidosis • Sjogren Syndrome • Spinocerebellar Syndrome • Stroke • Sub-Acute Sclerosing Panencephalitis • Tumors Is it MS or Something Else NMSS November 2004

  14. Exacerbation, Relapse, Attack, and Flare • Defined: • A sudden change in neurological function (worsening of symptoms or the appearance of new symptoms) lasting at least 24 hours • Separated from the last exacerbation by one month • Unexplained by other changes such as an infection Is it MS or Something Else NMSS November 2004

  15. Pseudoexacerbation • Temporary aggravation of MS symptoms that have been experienced before NOT associated with inflammation • Heat • Fever • Infection Is it MS or Something Else NMSS November 2004

  16. Secondary Impairments Associated with MS • Fatigue • A subjective lack of physical or mental energy perceived by the individual or caregiver to interfere with usual and desired activities. Is it MS or Something Else NMSS November 2004

  17. Fatigue: MS or Something Else • Make sure your provider: • Takes a good history • Does a physical examination • Performs lab work including hematocrit and thyroid stimulating hormone (TSH) Is it MS or Something Else NMSS November 2004

  18. Fatigue – Something Else • Poor sleep • Excessive caffeine • Over-use • Anemia • Hypothyroidism • Depression • Medication Effects Is it MS or Something Else NMSS November 2004

  19. Depression – MS related • 30-60% of individuals with MS report a major depressive episode. • Inflammatory • Coronary Artery Disease • Inflammatory Bowel Disease • Rheumatoid arthritis • Adjustment Is it MS or Something Else NMSS November 2004

  20. Depression – Is it something else? • Major Depressive Episode not associated with MS • Medication Effects Is it MS or Something Else NMSS November 2004

  21. Spasticity – MS related • Increased resistance of muscle to rapid stretch • Baseline spasticity • Changes with • Exacerbation or progression • DMTs Is it MS or Something Else NMSS November 2004

  22. Spasticity – Is it signaling something else? • Infection • Increased temperature • Menses • Tight clothing • Skin ulcer • Renal or bladder stones • Temperature extremes • Stress • Fracture Is it MS or Something Else NMSS November 2004

  23. Urinary Dysfunction – MS Related • Failure to store • Frequency • Urgency • Nocturia • Incontinence • Hesitancy Is it MS or Something Else NMSS November 2004

  24. Urinary Dysfunction Basic Workup • History • Physical Examination • Urinalysis • Post void residual Is it MS or Something Else NMSS November 2004

  25. Urinary Dysfunction – Not MS • Urinary Tract Infection • Prostate Disorders in Men • Stress Incontinence in Women • Bladder or Kidney Stones • Bladder, Kidney, Ureteral Cancer Is it MS or Something Else NMSS November 2004

  26. Bowel Function – MS Related • Demyelination interferes with the signals from the brain and spinal cord to empty the bowel • Decreased activity • Fatigue • Weakness/Spasticity of the Abdominal Muscles and Pelvic Floor • Fluid Restriction Is it MS or Something Else NMSS November 2004

  27. Bowel Dysfunction – Not MS • Diarrhea • Infection • Highly spiced foods • Lactose Intolerance • Irritable bowel Syndrome • Colonic tumors Is it MS or Something Else NMSS November 2004

  28. Bowel Dysfunction– Not MS • Constipation • Poor water intake • Poor diet • Inactivity • Calcium supplements • Antacids • Antidepressants, diuretics, opioids • Habit Is it MS or Something Else NMSS November 2004

  29. Sensory Impairments – MS related • Numbness • Pins and needles • Pain • Banding, girdling Is it MS or Something Else NMSS November 2004

  30. Pain Associated with MS • Trigeminal Neuralgia • Lhermitte’s Sign • Dysesthesias Is it MS or Something Else NMSS November 2004

  31. Pain Associated with Secondary Impairments due to MS • Spasticity – pulling, cramping of muscles • Restricted Range of Motion – Muscle pain and referred joint pain Is it MS or Something Else NMSS November 2004

  32. Pain – Not MS related Nerve entrapments • Cervical radiculopathy • Lumbar radiculopathy • Peripheral Nerve Entrapments • Carpal Tunnel Is it MS or Something Else NMSS November 2004

  33. Pain – Not MS related • Musculoskeletal “wear and tear” • Rotator cuff disorder • Osteoarthritis • Shoulders • Hands • Hips • Knees • Neck • Low Back Is it MS or Something Else NMSS November 2004

  34. Pain (continued) • Referred Pain • Soft Tissue • Trigger points • Overused muscles • Fibrotic muscles • Retroperitoneal Structures • Aorta • Pancreas • Kidneys • Uterus Is it MS or Something Else NMSS November 2004

  35. Headaches • Headaches can be associated with MS Is it MS or Something Else NMSS November 2004

  36. Headaches – Not MS • Tension headaches • Cervical segmental dysfunction • Migraine headaches • Cluster headaches • Space occupying lesions such as tumors Is it MS or Something Else NMSS November 2004

  37. Facial Pain– Not MS • Dental problems • Temporomandibular joint pain Is it MS or Something Else NMSS November 2004

  38. Pain – Not MS related • Musculoskeletal “wear and tear” • Rotator cuff disorder • Osteoarthritis • Shoulders • Hands • Hips • Knees • Neck • Low Back Is it MS or Something Else NMSS November 2004

  39. Sexual Function — MS Effects • Decreased or absent sex drive • Changed genital sensations • Numbness • Pain • Hypersensitivity Is it MS or Something Else NMSS November 2004

  40. Sexual Function — MS Effects • Decreased vaginal tone • Difficulty getting or maintaining an erection • Decreased vaginal lubrication and clitoral engorgement • Difficulty or inability to ejaculate • Decreased frequency/intensity of orgasms Is it MS or Something Else NMSS November 2004

  41. Sexual Function – Secondary Effects • Loss of desire • Fatigue • Anxiety • Depression • Sensory Impairments • Pain • Loss of sensation Is it MS or Something Else NMSS November 2004

  42. Sexual Function – Secondary Effects • Fear associated with bladder or bowel accidents • Cognitive Impairments • Spasticity and Weakness Interfering with positioning • Medication Effects Is it MS or Something Else NMSS November 2004

  43. Sexual Function – Tertiary Effects • Grief, demoralization, anxiety, depression and fears • Changed social and family roles • Changed body image • Stress • Time • Cultural values and expectations • Others….. Is it MS or Something Else NMSS November 2004

  44. Sexual Dysfunction – Non MS • Causes of sexual difficulties include • Medication side effects • Mood • Vascular Problems • Other neurological problems such as diabetes Is it MS or Something Else NMSS November 2004

  45. Cognitive Functions Associated with MS • Decreased attention, concentration, needing more time to store new facts, needing a cue to recall recently stored facts Is it MS or Something Else NMSS November 2004

  46. Cognitive Dysfunction – Not MS • Medications • Dementias Is it MS or Something Else NMSS November 2004

  47. Hearing • Changes in hearing due to MS have been reported, but they are rare. Hearing changes should be evaluated for some other cause. Is it MS or Something Else NMSS November 2004

  48. Dizziness • Dizziness is a common complaint of people with MS Is it MS or Something Else NMSS November 2004

  49. Dizziness – Not MS • Other causes of dizziness include: • Dehydration • Medications • Middle Ear Problems • Benign Tumors of the Acoustic Nerve Is it MS or Something Else NMSS November 2004

  50. Is it something else? • General Prevention Strategies • Advocating for yourself and your significant other Is it MS or Something Else NMSS November 2004

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