Multiple Sclerosis

Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central
nervous system).

In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and
causes communication problems between your brain and the rest of your body. Eventually, the
disease can cause the nerves themselves to deteriorate or become permanently damaged.

Signs and symptoms of MS vary widely and depend on the amount of nerve damage and which
nerves are affected. Some people with severe MS may lose the ability to walk independently or
at all, while others may experience long periods of remission without any new symptoms.

There's no cure for multiple sclerosis. However, treatments can help speed recovery from attacks,
modify the course of the disease and manage symptoms.

Symptoms

Multiple sclerosis signs and symptoms may differ greatly from person to person and over the
course of the disease depending on the location of affected nerve fibers. They may include:

 Numbness or weakness in one or more limbs that typically occurs on one side of your body
at a time, or the legs and trunk

 Partial or complete loss of vision, usually in one eye at a time, often with pain during eye
movement

 Prolonged double vision

 Tingling or pain in parts of your body

 Electric-shock sensations that occur with certain neck movements, especially bending the
neck forward (Lhermitte sign)

 Tremor, lack of coordination or unsteady gait

 Slurred speech

 Fatigue

 Dizziness
  Problems with bowel and bladder function

Diagnosis

 Blood tests, to help rule out other diseases with symptoms similar to MS. Tests to check
for specific biomarkers associated with MS are currently under development and may also
aid in diagnosing the disease.

 Lumbar puncture (spinal tap), in which a small sample of fluid is removed from your
spinal canal for laboratory analysis. This sample can show abnormalities in antibodies that
are associated with MS. Spinal tap can also help rule out infections and other conditions
with symptoms similar to MS.

 MRI, which can reveal areas of MS (lesions) on your brain and spinal cord. You may
receive an intravenous injection of a contrast material to highlight lesions that indicate your
disease is in an active phase.

 Evoked potential tests, which record the electrical signals produced by your nervous
system in response to stimuli. An evoked potential test may use visual stimuli or electrical
stimuli, in which you watch a moving visual pattern, or short electrical impulses are
applied to nerves in your legs or arms. Electrodes measure how quickly the information
travels down your nerve pathways.

In most people with relapsing-remitting MS, the diagnosis is fairly straightforward and based on
a pattern of symptoms consistent with the disease and confirmed by brain imaging scans, such as
MRI.

Diagnosing MS can be more difficult in persons with unusual symptoms or progressive disease.
In these cases, further testing with spinal fluid analysis, evoked potentials and additional imaging
may be needed.

Treatment

There is no cure for multiple sclerosis. Treatment typically focuses on speeding recovery from
attacks, slowing the progression of the disease and managing MS symptoms. Some people have
such mild symptoms that no treatment is necessary.

Treatments for MS attacks

  Corticosteroids, such as oral prednisone and intravenous methylprednisolone, are
prescribed to reduce nerve inflammation. Side effects may include insomnia, increased
blood pressure, mood swings and fluid retention.

Indication: Corticosteroids (cortisone-like medicines) are used to provide relief for inflamed
areas of the body. They lessen swelling, redness, itching, and allergic reactions. They are
often used as part of the treatment for a number of different diseases, such
as severe allergies or skin problems, asthma, or arthritis.

Nursing consideration:

 Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is
removed and separated from your blood cells. The blood cells are then mixed with a
protein solution (albumin) and put back into your body. Plasma exchange may be used if
your symptoms are new, severe and haven't responded to steroids.

Treatments to modify progression

For primary-progressive MS, ocrelizumab (Ocrevus) is the only FDA-approved disease-

modifying therapy. It slows worsening of disability in people with this type of MS.

For relapsing-remitting MS, several disease-modifying therapies are available.

Much of the immune response associated with MS occurs in the early stages of the disease.
Aggressive treatment with these medications as early as possible can lower the relapse rate and
slow the formation of new lesions.

Many of the disease-modifying therapies used to treat MS carry significant health risks.
Selecting the right therapy for you will depend on careful consideration of many factors,
including duration and severity of disease, effectiveness of previous MS treatments, other health
issues, cost, and child-bearing status.

Treatment options for relapsing-remitting MS include:

 Beta interferons. These medications are among the most commonly prescribed
medications to treat MS. They are injected under the skin or into muscle and can reduce the
frequency and severity of relapses.
 Side effects of beta interferons may include flu-like symptoms and injection-site reactions.

You'll need blood tests to monitor your liver enzymes because liver damage is a possible
side effect of interferon use. People taking interferons may develop neutralizing antibodies
that can reduce drug effectiveness.

 Ocrelizumab (Ocrevus). This humanized immunoglobulin antibody medication is the only

DMT approved by the FDA to treat both the relapse-remitting and primary progressive
forms of MS. Clinical trials showed it reduced relapse rate in relapsing disease and slowed
worsening of disability in both forms of the disease.

Ocrevus is given via an intravenous infusion by a medical professional. Side effects may
infusion-related reactions including irritation at the injection site, low blood pressure, fever,
and nausea among others. Ocrevus may also increase the risk of some types of cancer,
particularly breast cancer.

 Glatiramer acetate (Copaxone). This medication may help block your immune system's
attack on myelin and must be injected beneath the skin. Side effects may include skin
irritation at the injection site.

 Dimethyl fumarate (Tecfidera). This twice-daily oral medication can reduce relapses.
Side effects may include flushing, diarrhea, nausea and lowered white blood cell count.

 Fingolimod (Gilenya). This once-daily oral medication reduces relapse rate.

You'll need to have your heart rate monitored for six hours after the first dose because your
heartbeat may be slowed. Other side effects include headache, high blood pressure and
blurred vision.

 Teriflunomide (Aubagio). This once-daily medication can reduce relapse rate.

Teriflunomide can cause liver damage, hair loss and other side effects. It is harmful to a
developing fetus and should not be used by women who may become pregnant and are not
using appropriate contraception, or their male partner.

 Natalizumab (Tysabri). This medication is designed to block the movement of potentially

damaging immune cells from your bloodstream to your brain and spinal cord. It may be
considered a first line treatment for some people with severe MS or as a second line
treatment in others. This medication increases the risk of a viral infection of the brain
called progressive multifocal leukoencephalopathy in some people.
  Alemtuzumab (Lemtrada). This drug helps reduce relapses of MS by targeting a protein
on the surface of immune cells and depleting white blood cells. This effect can limit
potential nerve damage caused by the white blood cells, but it also increases the risk of
infections and autoimmune disorders.

Treatment with alemtuzumab involves five consecutive days of drug infusions followed by
another three days of infusions a year later. Infusion reactions are common with
alemtuzumab. The drug is only available from registered providers, and people treated with
the drug must be registered in a special drug safety monitoring program.

 Mitoxantrone. This immunosuppressant drug can be harmful to the heart and is associated
with development of blood cancers. As a result, its use in treating MS is extremely limited.
Mitoxantrone is usually used only to treat severe, advanced MS.

Treatments for MS signs and symptoms

 Physical therapy. A physical or occupational therapist can teach you stretching and
strengthening exercises and show you how to use devices to make it easier to perform daily
tasks.

Physical therapy along with the use of a mobility aid when necessary can also help manage
leg weakness and other gait problems often associated with MS.

 Muscle relaxants. You may experience painful or uncontrollable muscle stiffness or

spasms, particularly in your legs. Muscle relaxants such as baclofen (Lioresal) and
tizanidine (Zanaflex) may help.

 Medications to reduce fatigue.

 Other medications. Medications also may be prescribed for depression, pain, sexual
dysfunction, and bladder or bowel control problems that are associated with MS.

Myasthenia Gravis

Myasthenia Gravis is characterized by weakness and rapid fatigue of any of the muscles under
your voluntary control.

Myasthenia gravis is caused by a breakdown in the normal communication between nerves and
muscles.
There is no cure for myasthenia gravis, but treatment can help relieve signs and symptoms, such
as weakness of arm or leg muscles, double vision, drooping eyelids, and difficulties with speech,
chewing, swallowing and breathing.

Though myasthenia gravis can affect people of any age, it's more common in women younger
than 40 and in men older than 60.

Symptoms
Muscle weakness caused by myasthenia gravis worsens as the affected muscle is used
repeatedly. Because symptoms usually improve with rest, your muscle weakness may come and
go. However, myasthenia gravis symptoms tend to progress over time, usually reaching their
worst within a few years after the onset of the disease.

Although myasthenia gravis can affect any of the muscles that you control voluntarily, certain
muscle groups are more commonly affected than others.

Eye muscles

In more than half the people who develop myasthenia gravis, their first signs and symptoms
involve eye problems, such as:

Drooping of one or both eyelids (ptosis).

Double vision (diplopia), which may be horizontal or vertical, and improves or resolves when
one eye is closed.

Face and throat muscles

In about 15 percent of people with myasthenia gravis, the first symptoms involve face and throat
muscles, which can cause:

Altered speaking. Your speech may sound very soft or nasal, depending upon which muscles
have been affected.

Difficulty swallowing. You may choke very easily, which makes it difficult to eat, drink or take
pills. In some cases, liquids you're trying to swallow may come out your nose.

Problems chewing. The muscles used for chewing may wear out halfway through a meal,
particularly if you've been eating something hard to chew, such as steak.

Limited facial expressions. Your family members may comment that you've "lost your smile" if
the muscles that control your facial expressions have been affected.

Neck and limb muscles

Myasthenia gravis can cause weakness in your neck, arms and legs, but this usually happens
along with muscle weakness in other parts of your body, such as your eyes, face or throat.

The disorder usually affects arms more often than legs. However, if it affects your legs, you may
waddle when you walk. If your neck is weak, it may be hard to hold up your head.

Diagnosis

To diagnose your condition, your doctor will review your symptoms and your medical history
and conduct a physical examination. Your doctor may conduct several tests, including:

Neurological examination

Your doctor may check your neurological health by testing your:

 Reflexes

 Muscle strength

 Muscle tone

 Senses of touch and sight

 Coordination

 Balance

The key sign that points to the possibility of myasthenia gravis is muscle weakness that improves
with rest. Tests to help confirm the diagnosis may include:

Edrophonium test

Injection of the chemical edrophonium chloride (Tensilon) may result in a sudden, although
temporary, improvement in your muscle strength. This is an indication that you may have
myasthenia gravis.
Edrophonium chloride blocks an enzyme that breaks down acetylcholine, the chemical that
transmits signals from your nerve endings to your muscle receptor sites.

Ice pack test

If you have a droopy eyelid, your doctor may conduct an ice pack test. In this test, a doctor
places a bag filled with ice on your eyelid. After two minutes, your doctor removes the bag and
analyzes your droopy eyelid for signs of improvement. Doctors may conduct this test instead of
the edrophonium test.

Blood analysis

A blood test may reveal the presence of abnormal antibodies that disrupt the receptor sites where
nerve impulses signal your muscles to move.

Repetitive nerve stimulation

In this nerve conduction study, doctors attach electrodes to your skin over the muscles to be
tested. Doctors send small pulses of electricity through the electrodes to measure the nerve's
ability to send a signal to your muscle.

To diagnose myasthenia gravis, doctors will test the nerve many times to see if its ability to send
signals worsens with fatigue.

Single-fiber electromyography (EMG)

Electromyography (EMG) measures the electrical activity traveling between your brain and your
muscle. It involves inserting a fine wire electrode through your skin and into a muscle to test a
single muscle fiber.

Imaging scans

Your doctor may order a CT scan or an MRI to check if there's a tumor or other abnormality in
your thymus.
Pulmonary function tests

Your doctor may perform pulmonary function tests to evaluate whether your condition is
affecting your breathing.

Treatment
Doctors use a variety of treatments, alone or in combination, to relieve symptoms of myasthenia
gravis.

Medications

 Cholinesterase inhibitors. Medications such as pyridostigmine (Mestinon) enhance

communication between nerves and muscles. These medications don't cure the underlying
condition, but they may improve muscle contraction and muscle strength.

Possible side effects may include gastrointestinal upset, nausea, and excessive salivation
and sweating.

 Corticosteroids. Corticosteroids such as prednisone inhibit the immune system, limiting

antibody production.

Prolonged use of corticosteroids, however, can lead to serious side effects, such as bone
thinning, weight gain, diabetes and increased risk of some infections.

 Immunosuppressants. Your doctor may also prescribe other medications that alter your
immune system, such as azathioprine (Imuran), mycophenolate mofetil (CellCept),
cyclosporine (Sandimmune, Neoral), methotrexate (Trexall) or tacrolimus (Prograf).

Side effects of immunosuppressants can be serious and may include nausea, vomiting,
gastrointestinal upset, increased risk of infection, liver damage and kidney damage.
Intravenous therapy

 Plasmapheresis (plaz-muh-fuh-REE-sis). This procedure uses a filtering process similar

to dialysis. Your blood is routed through a machine that removes the antibodies that block
transmission of signals from your nerve endings to your muscles' receptor sites. However,
the beneficial effects usually last only a few weeks.

After repeated treatments, it may be difficult for doctors to gain access to your vein. They
may need to implant a long, flexible tube (catheter) into your chest to conduct the
procedure.
 Other risks associated with plasmapheresis include a drop in blood pressure, bleeding, heart
rhythm problems or muscle cramps. Some people may also develop an allergic reaction to
the solutions used to replace the plasma.

 Intravenous immunoglobulin (IVIg). This therapy provides your body with normal
antibodies, which alters your immune system response.

IVIg has a lower risk of side effects than do plasmapheresis and immune-suppressing
therapy. However, it may take about a week to start working, and the benefits usually last
no more than three to six weeks.

Side effects, which usually are mild, may include chills, dizziness, headaches and fluid
retention.

 Monoclonal antibody. Rituximab (Rituxan) is an intravenous medication that is used in

some cases of myasthenia gravis. This drug depletes certain white blood cells, altering the
immune system and improving myasthenia gravis.

Rituximab is usually given in infusions at an infusion center or done in a hospital on an

outpatient basis. Repeat infusions are often done over a few weeks. Occasionally the
infusions are repeated months later.
Surgery

About 15 percent of the people with myasthenia gravis have a tumor in their thymus gland, a
gland under the breastbone that is involved with the immune system. If you have a tumor, called
a thymoma, doctors will conduct surgery to remove your thymus gland (thymectomy).

If you don't have a tumor in the thymus gland, surgery to remove the thymus gland may improve
your myasthenia gravis symptoms. It may eliminate your symptoms, and you may be able to stop
taking medications for your condition. However, you may not notice the benefits of a
thymectomy for several years, if at all.

A thymectomy may be performed as an open surgery or as a minimally invasive surgery.

In an open surgery, your surgeon splits the central breast bone (sternum) to open your chest and
remove your thymus gland.

Surgeons may perform minimally invasive surgery to remove the thymus gland, which uses
smaller incisions. Minimally invasive thymectomy may include:
  Video-assisted thymectomy. In one form of this surgery, surgeons make a small incision
in your neck and use a long thin camera (video endoscope) and small instruments to
visualize and remove the thymus gland through your neck.

Alternatively, surgeons may make a few small incisions in the side of your chest. Doctors
use a video scope and small instruments to conduct the procedure and remove the thymus
gland through these incisions.

 Robot-assisted thymectomy. In a robot-assisted thymectomy, surgeons make several

small incisions in the side of your chest. Surgeons conduct the procedure to remove the
thymus gland using a robotic system, which includes a camera arm and mechanical arms.

Guillain-Barre syndrome
Guillain-Barre is a rare disorder in which your body's immune system attacks your nerves.
Weakness and tingling in your extremities are usually the first symptoms.

These sensations can quickly spread, eventually paralyzing your whole body. In its most severe
form Guillain-Barre syndrome is a medical emergency. Most people with the condition must be
hospitalized to receive treatment.

The exact cause of Guillain-Barre syndrome is unknown. But it is often preceded by an

infectious illness such as a respiratory infection or the stomach flu.

There's no known cure for Guillain-Barre syndrome, but several treatments can ease symptoms
and reduce the duration of the illness. Most people recover from Guillain-Barre syndrome,
though some may experience lingering effects from it, such as weakness, numbness or fatigue.

Symptoms

Guillain-Barre syndrome often begins with tingling and weakness starting in your feet and legs
and spreading to your upper body and arms. In about half of people with the disorder, symptoms
begin in the arms or face. As Guillain-Barre syndrome progresses, muscle weakness can evolve
into paralysis.

Signs and symptoms of Guillain-Barre syndrome may include:

  Prickling, pins and needles sensations in your fingers, toes, ankles or wrists

 Weakness in your legs that spreads to your upper body

 Unsteady walking or inability to walk or climb stairs

 Difficulty with eye or facial movements, including speaking, chewing or swallowing

 Severe pain that may feel achy or cramplike and may be worse at night

 Difficulty with bladder control or bowel function

 Rapid heart rate

 Low or high blood pressure

 Difficulty breathing

People with Guillain-Barre syndrome usually experience their most significant weakness within
two to four weeks after symptoms begin.

Types

Once thought to be a single disorder, Guillain-Barre syndrome is now known to occur in several
forms. The main types are:

 Acute inflammatory demyelinating polyradiculoneuropathy (AIDP), the most common

form in the U.S. The most common sign of AIDP is muscle weakness that starts in the
lower part of your body and spreads upward.

 Miller Fisher syndrome (MFS), in which paralysis starts in the eyes. MFS is also
associated with unsteady gait. MFS occurs in about 5 percent of people with Guillain-Barre
syndrome in the U.S. but is more common in Asia.

 Acute motor axonal neuropathy (AMAN) and acute motor-sensory axonal neuropathy
(AMSAN) are less common in the U.S. But AMAN and AMSAN are more frequent in
China, Japan and Mexico.

Diagnosis

Guillain-Barre syndrome can be difficult to diagnose in its earliest stages. Its signs and
symptoms are similar to those of other neurological disorders and may vary from person to
person.
Your doctor is likely to start with a medical history and thorough physical examination.

Your doctor may then recommend:

 Spinal tap (lumbar puncture). A small amount of fluid is withdrawn from the spinal
canal in your lower back. The fluid is tested for a type of change that commonly occurs in
people who have Guillain-Barre syndrome.

 Electromyography. Thin-needle electrodes are inserted into the muscles your doctor wants
to study. The electrodes measure nerve activity in the muscles.

 Nerve conduction studies. Electrodes are taped to the skin above your nerves. A small
shock is passed through the nerve to measure the speed of nerve signals.

Treatment

There's no cure for Guillain-Barre syndrome. But two types of treatments can speed recovery and
reduce the severity of the illness:

 Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is
removed and separated from your blood cells. The blood cells are then put back into your
body, which manufactures more plasma to make up for what was removed. Plasmapheresis
may work by ridding plasma of certain antibodies that contribute to the immune system's
attack on the peripheral nerves.

 Immunoglobulin therapy. Immunoglobulin containing healthy antibodies from blood

donors is given through a vein (intravenously). High doses of immunoglobulin can block
the damaging antibodies that may contribute to Guillain-Barre syndrome.

These treatments are equally effective. Mixing them or administering one after the other is no
more effective than using either method alone.

You also are likely to be given medication to:

 Relieve pain, which can be severe

 Prevent blood clots, which can develop while you're immobile

People with Guillain-Barre syndrome need physical help and therapy before and during
recovery. Your care may include:
 Movement of your arms and legs by caregivers before recovery, to help keep your muscles
flexible and strong

 Physical therapy during recovery to help you cope with fatigue and regain strength and
proper movement

 Training with adaptive devices, such as a wheelchair or braces, to give you mobility and
self-care skills