Tuesday, 28 July 2015

What's in a Name

Dear All

Thank you for voting for the Survey...What's in a name. 

If you haven't done it sign up to MS Register in the UK,
NARCOMS in North America.
I will post the paper when it is accepted but

Your choice preference was remarkably similar in all Surveys 
However, this is not what Scientists/Clinicians use.

Evolution of the blog

Is it time to change the blog? To let it evolve? #MSBlog #MSResearch

"First the internet, and then the web, has transformed society and how we interact with each other. I would argue that the greatest benefit to mankind has been its effect on the democratisation of knowledge and the easy access to knowledge via efficient search engines. Gone are the paternalistic days when neurologists knew it all and the patient (yes, the patient rather than the MSer, or person with MS) knew very little."

"One thing I have learnt from this blog is that there are no real boundaries between people with MS, their families, healthcare professionals, researchers, politicians and other people with an interest in MS, when it comes to access to knowledge. I frequently learn things I don't know from comments made by you the reader. Therefore, we are proposing changing our byline to the following:

A blog for people interested in multiple sclerosis
"Interpreting good, bad and other MS news"

Why the proposed change? We run a MS Preceptorship, or teaching course, for trainee healthcare professionals (HCPs) with an interest in MS. As part of this course we want to extend the teaching online. We could do this via a separate website requiring online registration, but feel this would be wrong. You have already expressed a desire to be able to learn about MS in existing teaching portals that are restricted to HCPs only. We want to challenge the status quo. We also feel that you would benefit greatly from reading the case studies and learning about the thought processes and complexities behind clinical decision making and management. Hopefully, the case studies will generate lively debates, to illustrate that medicine remains an art and is not a science."
"In short this site is evolving into a multi-dimensional site for HCPs as well. In reality, this has happened already. I rarely attend a meeting without hearing from HCPs how useful they find some aspects of the blog and how they use it as a resource for information. In fact we are proud of this. We also don't want to force change that you don't want. Therefore we are asking you to vote on the proposed change."


I promised to post on spasticity in MS a while back. Hope you find this post useful...

Firstly, here is the wikepedia version [click].

And now mine - as clinicians when we say there's spasticity in an arm/leg we mean that there's increased resistance to movement of the arm/leg at the level of it's joint. For example, this is the knee joint for the lower leg, or the hip for the upper leg.

This happens due to increased muscle tone (termed a high tone/hypertonus) and varies with the speed of movement at the joint. This is opposed to rigidity which is present throughout the range of movement, and is seen in conditions such as Parkinson's disease.
Spasticity can be mild with simply a catch on bending and extending the leg at the knee joint or severe where the leg may remain in a flexed posture even at rest and lead to contractures (permanent shortening of the muscle) and painful spasms. Spinal cord lesions as opposed to brain lesions tend to have more spasticity than brain lesions.

Spasticity often does not occur in isolation and is commonly seen together with:
  • Abnormal reflex transmission with increased gain on reflexes
  • Clonus (muscle spasm with repeated, rhythmic contractions - on flexing a muscle or simply on movement) 
  • Painful muscle spasms (which are sudden involuntary [i.e. happen without any planned intention] movements involving multiple muscles in response to movement or touch)
  • Dystonia (tonic muscle overactivity without triggers due to an inability of the nerve innervating the muscle to stop firing after voluntary movement or reflex activity)
  • Co-contraction (inappropriate activation of the opposing muscles during voluntary movement leading to loss of dexterity and slowed movements)

Cross-section through the spinal cord (ascending and descending tracts to and from the brain).

In the spinal cord for sometime the wildly held belief was that spasiticity was caused by damage to the corticospinal tract (all of these pathways except the medial reticulospinal tract and vestibulospinal tract are held under INHIBITORY control by the brain), but it is now understood that other motor tracts may also play a role:
  • The lateral reticulospinal tract which is adjacent to the corticospinal tract (see diagram above) may be involved in MS where lesions have a predilection for the lateral surface of spinal cord. This pathway has an inhibitory effect on stretch reflexes. 
  • The medial reticulospinal tract and vestibulospinal tract (see diagram above) which have excitatory effects on extensor muscle tone.
The over activity of the spinal neurones leads to involuntary activation of muscles.

Whereas lesions affecting the brain leads to increased excitation of the spinal pathways and a lowering of the threshold (i.e. easily triggered) to respond to stimuli such as stretch.

There are certain things which worsen spasticity:
  • skin ulcers, ingrown toenails, skin infections
  • constipation, UTIs, kidney stones, and pain 
  • improper seating, ill fitting orthotics
  • rapid withdrawal of anti-spasticity medication
  • other- deep vein thrombosis/DVT, injuries, stress

Pharmacological medications commonly used include Baclofen (GABAergic drug which relieves spasms) often in combination with Tizandine (centrally acting alpha2-noradrengic drug) as their mechanism of action is complimetary. Gabapentin is also a useful anti-spasmodic but limited by its sedative side effects, the latter also occurs with Baclofen. Botox is useful when individual muscles are involved. When oral anti-spasticity medications are of limited use, intrathecal Baclofen which delivers Baclofen into the spinal space may be used. Rarely, drastic measures are taken for painful immobile spastic legs with reflex spasms using intrathecal phenol or alcohol which causes irreversible nerve damage. Other measures include relief of pain and discomfort, improvement in posture, stretch exercises, facilitation of sitting, standing and walking, and prevention of complications such as contractures and pressure sores. Contractures which are not severe can be corrected using sequential casting (see below).

Stretch exercises (left) and manual sequential casts (right)