A little ditty about MS and an accordion finish

Today I worked again with Ms. E who has multiple sclerosis (MS), though I'm not sure which type she has.  For those who are not familiar, MS is a disease of demyelination within the central nervous system.  In simpler terms, most nerves are covered in myelin, a succession of fatty insulating blobs that allow electrical impulses to travel faster along said nerve.  The exact origin of MS is unknown, though it is postulated to be an autoimmune disease where the body "attacks" itself and removes this insulation layer (demyelination), but only within nerves inside the spinal cord and/or in the brain.  There is no pattern to what areas of the spinal cord and/or brain are affected in the way that Parkinson's is always a disorder of the extrapyramidal system (the substantia nigra portion of basal ganglia).  Symptoms thus occur according to the nerves that are involved.  These "lesions" can progress slowly over time so that more and more nerves are affected, they could be affected in bursts of lesion development called exacerbations that are intermixed with remission, or they could develop one lesion and rarely be affected by it in the future.  All depends on what type you have and what areas are affected.

What happens when nerves are demyelinated?  The electrical impulse does not travel the way it is supposed to.  If a motor nerve is involved there could be weakness or paralysis of a muscle.  If sensory is involved, there could be paresthesia (abnormal and/or painful sensation) or anesthesia (absence of sensation).  Why are lesions limited to the central nervous system?  Good question.  If it is known, it is above my level of knowledge.  But one big common theme with MS is fatigue.  The absence of myelin means electrical impulses travel slower, but this is heightened with increased body temperature regardless of whether this is due to hot weather or due to raised body heat from exercise.  Activity must then be modified so that the patient does not hit that level of effort that may trigger their fatigue.  Otherwise you will see those muscles progressively weaken until they seem paralyzed minutes later.  With rest this improves, and this does not preclude them from exercise in general -- on the contrary, preventing disuse atrophy is one of the best ways to prepare a patient with MS for any exacerbation of their disease.

So back to Ms. E.  Her MS at this point has developed into paralysis of both lower extremities, a very weak trunk, and partial use of her arms with the right more functional than the left.  Paralysis in the case of a central nervous system disease means that signals still reach muscles, but they are not normal.  School prepared us for all the motoric involvement with patients, such as with Ms. E.  But we never really discussed the sensory involvement aside from stating that "it can be quite painful."  Okay, bub, that sure helps me out.

Turns out that Ms. E has specific sensory involvement that can be pinpointed in a way I had not expected.  Different types of sensation travel by their own types of nerves grouped together in the spinal cord.  Light touch (think of a tickle from a cotton ball), proprioception (knowing where your body is in space) and vibration all travel through the dorsal column/medial lemniscus.  Separately, crude touch (a hand grabbing your arm), pain and temperature travel through the spinothalamic tract.  It is her dorsal column which is affected, and you can easily tell the difference.  Any light touch, such as a gentle hand resting on her knee while waiting for the aides to get set up for a multi-person transfer, is incredibly painful.  However if you go for it and grab her knee like you would a bat, using crude touch, then everything is fine.  Similarly she has no idea where her legs are in space, and thus will fuss over whether her leg is straight or whether her foot is fully supported on the footrest of the tilt table when everything is already set in a very fine position.  Vibration, well, I'm pretty sure that this is not testable due to the pain associated with light touch.  And she definitely feels pain and temperature differences, which are in the spinothalamic tract.

This type of differential involvement was taught to us assuming we'd need it for our spinal cord patients.  I have 5 spinal cord patients, and I haven't needed to differentiate any of this with them, likely because I'm in an outpatient clinic instead of rehab, but whatever.  But to get to see this in any patient is incredibly interesting.  Realizing what I was looking at was one of those "aha!" moments where you see for the first time the anatomy play out just like the textbooks say it could.  It is rarely so clean cut and distinct as with Ms. E's case.  Yet another moment of maintaining a facade of professionalism while inside I'm jumping up and down like a 5 year old screaming "WHOA!  Did you SEE THAT?  Duuuuude...."  And, yea, I'm that much of a nerd and that classy deep down inside....

How do accordions fit in with this?  Well, they don't.  This morning's run was pleasantly supplied a mental soundtrack by Beirut's song "Nantes."  Thought y'all might enjoy too.  Again, a better quality video may be seen by following the link to the original YouTube video.

 
Lastly, I leave you with Sadie's first experience with a laser.  I imagine that a kitteh rave would look something like this.  You can also see Merus's flapper attack here.