Dr. Barbara Willekens

MS Nurse Pro Module 1

Understanding MS

Many questions…..

• What is MS?

• How did I get MS?

• What type of MS do I have?

• Can MS be cured?

• Is it inheritable?

• Can I grow old with MS?

• How will my disease evolve?

Etcetera………

Overview of Module 1

• Demographics• Epidemiology

• Definition and classification

• Clinical course

• Contributing factors

• Understanding the causes of MS • Basic anatomy

• Basic immunology

• Pathophysiology

• Relating pathophysiology to MS symptoms

Demographics

> 2,500,000 MS patients

Europe:Incidence rate4/100.000/jaar

Age at onset 20-50 years

Average age at onset is 30 years

Gender

But……M=F in in PPMS

Sexhormonesmodulateimmune responses

Race

• Caucasians more than other races• Vikings and Goths?

• African-Americans more aggressive disease course and greaterdisability

• Rare in Maltese, Innuits, Laps, Siberians, Hungarian Gypsies andCentral Asians

Latitude

Moving before the age of 15 gives the person the risk of the region moved to

Survival

• Not entirely clear

• Probably decreased life expectancy (-7-14 years)

• Dependent of type of MS

• 50% of patients die of directlyMS related causes

• Improving with time

Classification and clinical course

The Old versus the New

MS types

Genetic susceptibility

MS = NOT inherited

Risk increased to 20% when both parents have MS

20% of the patients has a positive family history

Twin studies

What drives twin discordance?

Genome of a pair of monozygotic twins

DNA sequencingDNA methylation IdenticalGene expression

Environment = key driver of twin discordance

Up to 75% of MS cases must be due to non-geneticfactors

MS Risk in families

Vitamine D

• Birth month: spring > fall• Recent study:

50 babies born in May vs. November: 20% increase of risk in May-babies

• Higher T cells and lower vitamin D levels

• T cells more anti-inflammatory and regulated

Smoking

• Increases the risk of developing MS (40-80%)

• Passive smoking in children!

• Increases the risk of RRMS SPMS

• Disability, lesionload, atrophy

Stress

• May trigger relapses

• Significant increase in relapses in patients living in a war zone

• Stress reduction programme reduces enhancing lesions on MRI

• Bidirectional relationship between endocrine system and immune system

Viral infections

• Viral triggers?• Difficult to investigate

• Might increase risk of developing MS

• EBV, HZV, HSV, HHV-6, Paramyxovirus,…

• Relapse after infection?

Understanding the causes of MS

What’s in a name?

• Multiplum sklerosis = multiple hardenings

Central nervous system

Neuron

Blood-brain barrier

Spinal cord

The immune system

Humoral vs Cellular

Auto-immunity simplified….

Immune dysregulation in MS

Progressive multiple sclerosis

MS plaque

1. Inflammation ~ relapse

2. Neurodegeneration/axonal loss ~ progression

Inflammation vs. Degeneration

• RRMS Inflammation vs. Degeneration

• SPMS Inflammation vs. Degeneration

• PPMS Inflammation vs. Degeneration

Relating pathophysiology to MS symptoms

Disruption of conduction

Heat sensitivity

60-80% of patients

Uhthoff’s phenomenon

Positive symptoms

• Hyperexcitability of demyelinated axons

• Ephaptic crosstalk between demyelinated axons

• L’Hermitte

• Trigeminal neuralgia

• Paresthesia/tingling

• Phosphenes

• Pain

Cortical lesions ~ cognitive dysfunction