Saturday, 26 July 2014

Clinic Speak: MS, DVT and pulmonary embolus

Are you aware that MS is associated with a high risk of DVTs and pulmonary embolus? #ClinicSpeak #MSBlog #MSResearch

"The Swedish register study below confirms that MS is associated with a high-risk of deep vein thrombosis (DVT); typically a clot in the veins of the lower limbs or abdomen. This is not surprising as we already know that immobility, dehydration and intermittent steroid use, which are common in MSers, are know risk factors for DVT and pulmonary embolism or PE (blood clot that has come away from its original site and lodged in the lungs)."

"Only a month ago a husband of one of my patients with SPMS phoned to say that his wife had died suddenly of a pulmonary embolus (PE). He was surprised that they hadn't been warned about this risk. It made me realise that maybe we should have a system in place to inform all of our patients of the risk of DVT & PE and give then generic advice on how to prevent, or at least reduce the chances, of this potentially fatal complication of MS from happening."

"To try and lower your risk and help prevent DVT, take these steps:
  1. Maintain an active lifestyle with regular exercise - daily, if possible. Walking, swimming and cycling, activities that activate the muscles in the calf, that pump the blood to the heart, are appropriate activities.
  2. Try and maintain a healthy weight - obesity increases your risks of DVT and PE.
  3. If you smoke, stop. Smoking is another risk factor for thrombosis. 
  4. Report any family or personal history of blood-clotting problems to your MS team.
  5. Discuss alternatives to birth control pills, or hormone-replacement therapy, with your MS team or GP; these therapies increase your chances of having a DVT.
  6. Making sure you don't get dehydrated; this is something MSers do, in particular those who have troubling bladder problems." 
"If you need surgery, you may need specific measures to help prevent DVT; for example having the surgery under local, rather than general, anesthetic, taking an anticoagulant, wearing a calf device on your legs during surgery to compress your legs and keep blood flowing through your veins, wearing elastic compression stockings, elevating the foot of your bed, becoming mobile ASAP after surgery, taking analgesics to make it easier to move around, doing regular leg exercises such as leg lifts and gentle foot and ankle exercises."

"If you have to travel or sit still for long periods of time your risk of DVT increases. The following may help reduce this risk: wearing compression stockings, avoiding wearing short, tight socks, avoid crossing your legs for long periods, drinking plenty of fluids and avoid dehydrating fluids, such as alcohol, if possible get up and walk around every hour or do regular leg exercises such as leg lifts and gentle foot and ankle exercises. Some guidelines recommend taking a low dose of aspirin (150mg) before travelling, in particular on long-haul flights, but this advice is controversial."

"It is important that if you have any symptoms suggestive of a DVT or PE you should seek urgent medical attention. Some cases of DVT may be asymptomatic, however, possible symptoms include:
  1. pain, swelling and tenderness in one of your legs (usually the calf)
  2. a heavy ache in the affected area
  3. warm skin in the area of the clot
  4. redness of your skin, particularly at the back of your leg below the knee
DVT typically affects one leg, but it can rarely affect both legs simultaneously. The leg pain associated with a DVT may be made worse by bending your foot upward towards your knee. If DVT is not treated, a PE may occur. If you have a PE, you may experience more serious symptoms, such as:
  1. breathlessness, which may develop gradually or come on very suddenly
  2. chest pain, which is typically made worse when you breathe in
  3. sudden collapse
Both DVT and PE are serious conditions that require urgent investigation and treatment."

"As DVT is a new topic on this blog, I would appreciate it if you could take a few seconds to complete this survey."

Epub: Roshanisefat et al. Multiple sclerosis clinical course and cardiovascular disease risk - Swedish cohort study. Eur J Neurol. 2014 Jul 17.

BACKGROUND AND PURPOSE: Cardiovascular disease (CVD) risk amongst MSers appears raised, but few studies have examined CVD risk amongst an unselected MSer group. MS course may be relevant for CVD risk. Our aim was to assess CVD risk and variation by course in MSers.

METHODS: The Multiple Sclerosis Register identified 7667 MSers who received an MS diagnosis between 1964 and 2005. They were matched by age, period, region and sex with 76 045 members of the general population without MS using Swedish registers. Poisson regression compared the two cohorts to estimate the relative risk for CVD, overall, as well as grouped and individual CVD diagnoses.

RESULTS: MSers had an increased adjusted relative risk (with 95% confidence intervals; number of MS cohort events) for CVD of 1.31 (1.22-1.41; n = 847), with some variation by course: relapsing-remitting 1.38 (1.17-1.62; n = 168); secondary progressive 1.30 (1.18-1.53; n = 405) and primary progressive 1.15 (0.93-1.41; n = 108). The association for the relapsing-remitting course was not significant after excluding the first year of follow-up. Overall incidence rates per 1000 person-years for CVD are 11.8 (11.06-12.66) for the MS cohort and 8.8 (8.60-9.05) for the non-MS cohort. The most pronounced association was for deep vein thrombosis: relapsing-remitting 2.16 (1.21-3.87; n = 14), secondary progressive 3.41 (2.45-4.75; n = 52) and primary progressive 3.57 (1.95-6.56; n = 15). MS was associated with ischaemic stroke but largely during the first year of follow-up. MS was associated with a decreased relative risk for angina pectoris and atrial fibrillation.

CONCLUSIONS: There is a significantly increased relative risk for CVD in MS, particularly for venous thromboembolic disorders in progressive MS, suggesting immobility as a possible factor. An increased frequency of ischaemic stroke in MS is most probably due to surveillance bias resulting from diagnostic investigations for MS. There is no increased relative risk for ischaemic heart disease in MS and atrial fibrillation appears to be less common than amongst the general population.

Playing piano can help manual dexterity

Gatti R, Tettamanti A, Lambiase S, Rossi P, Comola M. Improving Hand Functional Use in Subjects with Multiple Sclerosis Using a Musical Keyboard: A Randomized Controlled Trial. Physiother Res Int. 2014 Jul . doi: 10.1002/pri.1600. [Epub ahead of print]

BACKGROUND AND PURPOSE: Playing an instrument implies neuroplasticity in different cerebral regions. This phenomenon has been described in subjects with stroke, suggesting that it could play a role in hand rehabilitation. The aim of this study is to analyse the effectiveness of playing a musical keyboard in improving hand function in subjects with multiple sclerosis.
METHODS: Nineteen hospitalized subjects were randomized in two groups: nine played a turned-on musical keyboard by sequences of fingers movements (audio feedback present) and 10 performed the same exercises on a turned-off musical keyboard (audio feedback absent). Training duration was half an hour per day for 15 days. Primary outcome was the perceived hand functional use measured by ABILHAND Questionnaire. Secondary outcomes were hand dexterity, measured by Nine-Hole Peg Test, and hand strength, measured by Jamar and Pinch dynamometers. Two-way analysis of variance was used for data analysis.
RESULTS: The interaction time × group was significant (p = 0.003) for ABILHAND Questionnaire in favour of experimental group (mean between-group difference 0.99 logit [IC95%: 0.44; 1.54]). The two groups showed a significant time effect for all outcomes except for Jamar measure.
DISCUSSION: Playing a musical keyboard seems a valid method to train the functional use of hands in subjects with multiple sclerosis

ABILHAND (click) is a measure of manual ability for adults with upper limb impairments. The scale measures a person's ability to manage daily activities that require the use of the upper limbs, whatever the strategies involved.

Jamar dynanoneger measures grip strength this wasn't affected

Pinch dynamometers measure pinch

In this study practising on a piano can help manual dexterity, maybe try a grip master but not as much fun. Turn on the sound and it becomes less of a chore


Khare M, Singh A, Zamboni P.Prospect of brain-machine interface in motor disabilities: the future support for multiple sclerosis patient to improve quality of life. Ann Med Health Sci Res. 2014;4(3):305-12. doi: 10.4103/2141-9248.133447.

Multiple sclerosis (MS) is an autoimmune neurological disorder, which has impacted health related quality of life (HRQoL) more intensively than any other neurological disorder. The approaches to improve the health standard in MS patient are still a subject of primary importance in medical practice and seek a lot of experimental exploration. The present review briefly explains the anomaly in neuron anatomy and dysfunction in signal transmission arising in the context with the chronic cerebrospinal venous insufficiency (CCSVI), a recent hypothesis related with MS pathophysiology. Subsequently, it insights brain-machine interface (BMI) as an alternative approach to improve the HRQoL of MS subjects. Information sources were searched from peer-reviewed data bases (Medline, BioMed Central, PubMed) and grey-literature databases for data published in 2000 or later. We also did systemic search in edited books, articles in seminar papers, reports extracted from newspapers and scientific magazines, articles accessed from internet; mostly using PubMed, Google search engine and Wikipedia. Out of approximately 178, 240 research articles obtained using selected keywords, those articles were included in the present study which addresses the latest definitions of HRQol and latest scientific and ethical developments in the research of MS and BMI. The article presented a brief survey of CCSVI mediated MS and BMI-approach as a treatment to serve the patients suffering from disabilities as a result of MS, followed by successful precedence of BMI approach. Apart from these, the major findings of selected research articles including the development of parameters to define HRQoL, types and development of BMIs and its role in interconnecting brain with actuators, along with CCSVI being a possible cause of MS have formed the foundations to conclude the findings of the present review article. We propose a perspective BMI approach and promises it holds for future research to improve HRQoL in MS patients. In addition, we propose that brain-computer interfaces will be the core of new treatment modalities in the future for MS disabilities.