MULTIPLE SCLEROSIS CERTIFIED SPECIALIST EXAM WITH CORRECT
RATIONALES
Relapse cRemitting cMultiple cSclerosis c(RRMS) c- cCORRECT cANS✔✔Periods cof cacute cworsening cof cneurologic cfunction, cwith
csome cdegree cof crecovery. cThere cis co cprogression cin cbetween. cAbout c85% cindividuals care cdx cwith cRRMS cinitially
How coften ccan cremissions coccur cin cRRMS? c- cCORRECT cANS✔✔Remissions ccan cbe cmonths cto cyears cwith cno cnew csigns
cof cdisease cactivity. cDeficits csuffered cduring cattacks cor cexacerbation cmay ctotally cresolve cor cresult cin congoing cdeficits.
Secondary cProgressive c(SPMS) c- cCORRECT cANS✔✔Following can cinitial crelapse cremitting ccourse, cthe cdisease ctransitions cin
cmany cpeople cto ca csteadily cprogressive cform cwith cincreased closs cof cfunction. cOF cthe c85% cwho cstart cwith cRRMS, cmore
cthan c50% cwill cdevelop cSPMA cwithin c10 cyears cand c90% cwithin c25 cyears.
Primary cProgressive cMultiple cSclerosis c(PPMS) c- cCORRECT cANS✔✔Continuing cworsening cof cdisease cfrom conset, cwithout
cdistinct crelapses. cApproximately c10% cof cpeople care cdx cwith cPPMS.
Progressive-Relapsing cMultiple cSclerosis c(PPMS) c- cCORRECT cANS✔✔Progressive cneurologic cdecline cwith coccasional cacute
crelapses. cAbout c5% cof cpeople cappear cto chave cPRMS cat cdiagnosis.
Benign cMS c- cCORRECT cANS✔✔Patients cwho chave crare cattacks cand care cminimally cdisables c20 cyears cafter cbeing cdiagnose
cwith cMS. cAbout c10% cof cMS cpatients cexperience ca c"benign ccourse" cof cMS.
Radiologically cIsolated cSyndrome c(RIS) c- cCORRECT cANS✔✔Radiologically cisolated csyndrome c(RIS) cis canother cearly
cindicator cof cdemyelination cbut cwith cno csymptoms. cRIS cis cusually cdetected cincidentally cin chealthy cpeople cwho chave can cMRI
cthat cshows ctypical cMS clesions. cThese cpeople cmay cremain casymptomatic c(have cno csymptoms), cor cgo con cto cdevelop cCIS cor
cMS. cTherefore, cRIS cmay crepresent cthe cearliest cindicator cof cMS cbefore csymptoms cappear.
Clinically cIsolated cSyndrome c(CIS) c- cCORRECT cANS✔✔A cterm cthat cdescribes ca cfirst cclinical cepisode cwith cfeatures
csuggestive cof cmultiple csclerosis. cUsually coccurs cin cyoung cadults cand caffects coptic cnerves, cbrainstem, cor cthe cspinal ccord.
cThey cusually crecover cfrom ctheir cpresenting cepisode. cIt cis coften cthe cfirst cmanifestation cof cMS.
Advanced cDisease c- cCORRECT cANS✔✔
Pediatric cMS c- cCORRECT cANS✔✔5% cof call cpatients cwith cMS cdevelop cthe cdisease cbefore cage cof c18, c1% cbefore cthe cage
cof c10 cyears. cData csuggests cIFN cBeta cand cglatiramer cacetate care csafe, ceffective, cand cwell ctolerated cI cthe cpediatric
cpopulation.
10 cyear coutlook cfor cindividuals cwith cMS
(How cmany cutilize ca ccane cto cambulate? cWhat cpercentage crequire ca cwheelchair? cHow cman cconvert cto csecondary
cprogressive cphase cof cthe cdisease? c- cCORRECT cANS✔✔1/2 cof cpatients cuse ca ccane cto cambulate
15% crequire ca cwheelchair
Approximately c1/2 cof cpatients cconvert cto cSPMS
Multiple cSclerosis cDefinition c- cCORRECT cANS✔✔The cmost ccommon cimmune-mediated cinflammatory cdemyelinating cdisease
cof cthe ccentral cnervous csystem c(CNS) c- cthe cbrain, cspinal ccord, cand coptic cnerves- cand cis ca cleading ccause cof cdisability cin
cyoung cadults. cIt cis cthought cthat cthe cimmune csystem cattacks ctheCNS.
Myelin c- cCORRECT cANS✔✔Coating cthat csurrounds cthe cnerve cfibers
Axons c- cCORRECT cANS✔✔Carry cimpulses caway cfrom cthe ccell cbody
Nerve cFibers
How cdoes cMS cget cits cname? c- cCORRECT cANS✔✔Damaged cmyelin c(demyelination) cforms cscar ctissue c(sclerosis) cin
cmultiple csites cin cthe cCNS.
, Immune csystem cand chow cit crelated cto ccause cof cMS c- cCORRECT cANS✔✔It cmay cbe cthe cresult cof cabnormal cimmune
cresponse cto csome cinfectious cor cenvironmental ctrigger cin ca cgenetically csusceptible cindividual.
The cpathologic cprocess cin cMS cbegins cin cMS cbeginning cwith cthe cactivation cof c__________in cthe cperiphery cafter cthey care
cpresented cwith ca cpossible cvirus. c- cCORRECT cANS✔✔CD4+ cT ccells
What ccombination cof ccells cproduce can cinflammatory cresponse cand csubsequent cmyelin cdamage cthrough cmultiple
cmechanisms. c- cCORRECT cANS✔✔Activated cCD4+ cT cCells calong cwith cB cCells, cmacrophages, cand cCD c8+ cT ccells cinteract
cto cproduce can cinflammatory cresponse.
innate cimmunity c- cCORRECT cANS✔✔Immune cresponse cto ccertain cpathogens, cwhich coccurs cin call chealthy cindividuals cand
cdoes cnot crequire cprior cexposure cto cthe cpathogen. cImmediate cdestruction cof csome cpathogen cby cphagocytic ccells csuch cas
cmacrophage cand cneutrophils.
adaptive cimmunity c- cCORRECT cANS✔✔Antibodies cthat care cproduced cto cpathogens cserve cas can cimmunologic cmemory.
cCompromised cprimarily cof clympthocytic cB ccells, cwhich cproduce cthe cantibodies cthat cattach cto cspecific cantigens cand cT ccells.
Risks cof cthe cimmune csystem c- cCORRECT cANS✔✔Discomfort cand ccollateral cdamage cresulting cfrom cinflammation. cDamage
cto cself cresulting cfrom chypersensitivity cor cautoimmunity.
The cimmune cmechanisms cthought cto ccontribute cto cthe cdevelopment cof cMS c(6 csteps) c- cCORRECT cANS✔✔1. cTH1 ccells care
cstimulated/activated cin cthe cperiphery cby cpresentation cwith cantigens c(possibly cby ca cvirus). c
2. cOnce cactivate cthese ccells crapidly cincrease cin cnumbers cand crelease ccytokines cand cmetalloproteinases cthat cbreak cdown
cand cextracellular cmatrix cof cthe cblood cbrain cbarrier. c
3. cOnce cin cthe cCNS, cTH2 ccells care cpresented cwith cmyelin cprotein cthat cis csimilar cto cthe cantigen cpresented cin cthe cperiphery.
c
4. cThe creactivated cT ccells calong cwith cB ccells, cmacrophages, cand cCD8+ ct ccells cinteract cto cproduce can cinflammatory
cresponse cresulting cin cmyelin cdamage. c
5. cCells cinteract cto cproduce can cinflammatory cresponse cdirected cat ccomponents cof cthe cCNS.
6. cInflammation cleads cto cdemyelination cas cwell cas caxonal cdegeneration cfollowed cby cchronic cneurodegeneration.
Gadolinium cenhancement con cMRI cis cseen cin... c- cCORRECT cANS✔✔early cstates cof cthe cmost cdemyelinating clesions cin
cpatients cwith cRRMS cand cSPMS. cInflammation cin cconjunction cwith cblood cbrain cbarrier cdisruption cis cwhat ccauses cthis
cappearance.
What ctypes cof clevels care cfound cin ccerebral cspinal cfluid cin cpatients cwith cMS? c- cCORRECT cANS✔✔Increased coligoclonal
cIgM cand cIgG clevels care cfound cin cthe ccerebrospinal cfluid cof cpatients cwith cMS.
Ratio cfor cwoman cprevalence c- cCORRECT cANS✔✔MS cis cmore ccommon cin cMS c3:1 cratio, cbut cif cmen cget cit cthey ctend cto
cobtain cmore cprogressive, ceven cmalignant cclinical ccourse.
Laboratory cTesting cand cMS cDx c- cCORRECT cANS✔✔There cis cno cdefinitive cblood ctest cfor cMS. cBlood ctests ccan crule cout
cother cconditions cthat ccause csymptoms csimilar cto cthose cof cMS c(Lyme cdisease, ca cgroup cof cdiseases cknown cas ccollagen-
vascular cdiseases, ccertain crare chereditary cdisorders, cand cADIS).
Lumbar cPuncture cand cMS cdx c- cCORRECT cANS✔✔Analysis cof cthe ccerebrospinal cfluid c(CSF) ctaken cby cspinal ctap, cdetects
cthe clevels cof ccertain cimmune csystem cproteins cand cthe cpresence cof coligoclonal cbands. cThese cbands cindicate can cimmune
cresponse cwithin cthe cCNS, cand care cfound cin cabout c90-95% cof cpeople cwith cMS. cThey ccan calso cbe cpresent cin cother
cdiseases.
optic cneuritis c- cCORRECT cANS✔✔Unilateral cvisual closs, corbital cpain, cafferent cpupillary cdefect, cretrobublar cor cmild cdisc
cswelling, cvisual closs cdoes cnot cprogress cbeyond ctwo cweeks.
Brainstem c- cCORRECT cANS✔✔Internuclear copthalmoplegia, c6th cnerve cpalsy, cnultifocal csigns c(facial csensory closs, cvertigo,
chearing closs, cataxia, cdysarthria)
Optic cNeuritis cand cNormal cBrain cMRI c- cCORRECT cANS✔✔20% crisk cof cconversion cto cclinically cdefinite cMS
Optic cNeuritis cand cAbnormal cBrain cMRI c- cCORRECT cANS✔✔Equal cto cor cless cthan c2 clesions cconsistent cwith cdemyelination
c= c80-90% crisk cof cconversion cto cclinically cdefinite cMS, cdepending con cCIS cpresentation.
Risk cfactors cof cMS c- cCORRECT cANS✔✔1. cClinically csilent cMRI clesions
2. cCSF coligoclonal cbands
3. cWeak cor cuncertain crisk cfactors csuch cas cvitamin cD cdeficiency, cEpstein cbarr cvirus cinfection, csmoking, cHLA cgenes, cand
cmisc. cimmunological cabnormalities.
Musculoskeletal cPain c(preventative c/rehabilitation/pharmacologic) c- cCORRECT cANS✔✔Preventative: cBone canti-resorptive
ctherapies, cstop csmoking, ccalcium cand cvitamin cD csupplements
PT: cassessment, cmanagement cfor csafety, cgait, cpositioning, cmobility caids
Frequent cposition cchanges cand cuse cof cproper csupport
Medications: cAcetaminophen cand cnon-steroidal canti-inflammatories c(lowest ceffective cdose)
RATIONALES
Relapse cRemitting cMultiple cSclerosis c(RRMS) c- cCORRECT cANS✔✔Periods cof cacute cworsening cof cneurologic cfunction, cwith
csome cdegree cof crecovery. cThere cis co cprogression cin cbetween. cAbout c85% cindividuals care cdx cwith cRRMS cinitially
How coften ccan cremissions coccur cin cRRMS? c- cCORRECT cANS✔✔Remissions ccan cbe cmonths cto cyears cwith cno cnew csigns
cof cdisease cactivity. cDeficits csuffered cduring cattacks cor cexacerbation cmay ctotally cresolve cor cresult cin congoing cdeficits.
Secondary cProgressive c(SPMS) c- cCORRECT cANS✔✔Following can cinitial crelapse cremitting ccourse, cthe cdisease ctransitions cin
cmany cpeople cto ca csteadily cprogressive cform cwith cincreased closs cof cfunction. cOF cthe c85% cwho cstart cwith cRRMS, cmore
cthan c50% cwill cdevelop cSPMA cwithin c10 cyears cand c90% cwithin c25 cyears.
Primary cProgressive cMultiple cSclerosis c(PPMS) c- cCORRECT cANS✔✔Continuing cworsening cof cdisease cfrom conset, cwithout
cdistinct crelapses. cApproximately c10% cof cpeople care cdx cwith cPPMS.
Progressive-Relapsing cMultiple cSclerosis c(PPMS) c- cCORRECT cANS✔✔Progressive cneurologic cdecline cwith coccasional cacute
crelapses. cAbout c5% cof cpeople cappear cto chave cPRMS cat cdiagnosis.
Benign cMS c- cCORRECT cANS✔✔Patients cwho chave crare cattacks cand care cminimally cdisables c20 cyears cafter cbeing cdiagnose
cwith cMS. cAbout c10% cof cMS cpatients cexperience ca c"benign ccourse" cof cMS.
Radiologically cIsolated cSyndrome c(RIS) c- cCORRECT cANS✔✔Radiologically cisolated csyndrome c(RIS) cis canother cearly
cindicator cof cdemyelination cbut cwith cno csymptoms. cRIS cis cusually cdetected cincidentally cin chealthy cpeople cwho chave can cMRI
cthat cshows ctypical cMS clesions. cThese cpeople cmay cremain casymptomatic c(have cno csymptoms), cor cgo con cto cdevelop cCIS cor
cMS. cTherefore, cRIS cmay crepresent cthe cearliest cindicator cof cMS cbefore csymptoms cappear.
Clinically cIsolated cSyndrome c(CIS) c- cCORRECT cANS✔✔A cterm cthat cdescribes ca cfirst cclinical cepisode cwith cfeatures
csuggestive cof cmultiple csclerosis. cUsually coccurs cin cyoung cadults cand caffects coptic cnerves, cbrainstem, cor cthe cspinal ccord.
cThey cusually crecover cfrom ctheir cpresenting cepisode. cIt cis coften cthe cfirst cmanifestation cof cMS.
Advanced cDisease c- cCORRECT cANS✔✔
Pediatric cMS c- cCORRECT cANS✔✔5% cof call cpatients cwith cMS cdevelop cthe cdisease cbefore cage cof c18, c1% cbefore cthe cage
cof c10 cyears. cData csuggests cIFN cBeta cand cglatiramer cacetate care csafe, ceffective, cand cwell ctolerated cI cthe cpediatric
cpopulation.
10 cyear coutlook cfor cindividuals cwith cMS
(How cmany cutilize ca ccane cto cambulate? cWhat cpercentage crequire ca cwheelchair? cHow cman cconvert cto csecondary
cprogressive cphase cof cthe cdisease? c- cCORRECT cANS✔✔1/2 cof cpatients cuse ca ccane cto cambulate
15% crequire ca cwheelchair
Approximately c1/2 cof cpatients cconvert cto cSPMS
Multiple cSclerosis cDefinition c- cCORRECT cANS✔✔The cmost ccommon cimmune-mediated cinflammatory cdemyelinating cdisease
cof cthe ccentral cnervous csystem c(CNS) c- cthe cbrain, cspinal ccord, cand coptic cnerves- cand cis ca cleading ccause cof cdisability cin
cyoung cadults. cIt cis cthought cthat cthe cimmune csystem cattacks ctheCNS.
Myelin c- cCORRECT cANS✔✔Coating cthat csurrounds cthe cnerve cfibers
Axons c- cCORRECT cANS✔✔Carry cimpulses caway cfrom cthe ccell cbody
Nerve cFibers
How cdoes cMS cget cits cname? c- cCORRECT cANS✔✔Damaged cmyelin c(demyelination) cforms cscar ctissue c(sclerosis) cin
cmultiple csites cin cthe cCNS.
, Immune csystem cand chow cit crelated cto ccause cof cMS c- cCORRECT cANS✔✔It cmay cbe cthe cresult cof cabnormal cimmune
cresponse cto csome cinfectious cor cenvironmental ctrigger cin ca cgenetically csusceptible cindividual.
The cpathologic cprocess cin cMS cbegins cin cMS cbeginning cwith cthe cactivation cof c__________in cthe cperiphery cafter cthey care
cpresented cwith ca cpossible cvirus. c- cCORRECT cANS✔✔CD4+ cT ccells
What ccombination cof ccells cproduce can cinflammatory cresponse cand csubsequent cmyelin cdamage cthrough cmultiple
cmechanisms. c- cCORRECT cANS✔✔Activated cCD4+ cT cCells calong cwith cB cCells, cmacrophages, cand cCD c8+ cT ccells cinteract
cto cproduce can cinflammatory cresponse.
innate cimmunity c- cCORRECT cANS✔✔Immune cresponse cto ccertain cpathogens, cwhich coccurs cin call chealthy cindividuals cand
cdoes cnot crequire cprior cexposure cto cthe cpathogen. cImmediate cdestruction cof csome cpathogen cby cphagocytic ccells csuch cas
cmacrophage cand cneutrophils.
adaptive cimmunity c- cCORRECT cANS✔✔Antibodies cthat care cproduced cto cpathogens cserve cas can cimmunologic cmemory.
cCompromised cprimarily cof clympthocytic cB ccells, cwhich cproduce cthe cantibodies cthat cattach cto cspecific cantigens cand cT ccells.
Risks cof cthe cimmune csystem c- cCORRECT cANS✔✔Discomfort cand ccollateral cdamage cresulting cfrom cinflammation. cDamage
cto cself cresulting cfrom chypersensitivity cor cautoimmunity.
The cimmune cmechanisms cthought cto ccontribute cto cthe cdevelopment cof cMS c(6 csteps) c- cCORRECT cANS✔✔1. cTH1 ccells care
cstimulated/activated cin cthe cperiphery cby cpresentation cwith cantigens c(possibly cby ca cvirus). c
2. cOnce cactivate cthese ccells crapidly cincrease cin cnumbers cand crelease ccytokines cand cmetalloproteinases cthat cbreak cdown
cand cextracellular cmatrix cof cthe cblood cbrain cbarrier. c
3. cOnce cin cthe cCNS, cTH2 ccells care cpresented cwith cmyelin cprotein cthat cis csimilar cto cthe cantigen cpresented cin cthe cperiphery.
c
4. cThe creactivated cT ccells calong cwith cB ccells, cmacrophages, cand cCD8+ ct ccells cinteract cto cproduce can cinflammatory
cresponse cresulting cin cmyelin cdamage. c
5. cCells cinteract cto cproduce can cinflammatory cresponse cdirected cat ccomponents cof cthe cCNS.
6. cInflammation cleads cto cdemyelination cas cwell cas caxonal cdegeneration cfollowed cby cchronic cneurodegeneration.
Gadolinium cenhancement con cMRI cis cseen cin... c- cCORRECT cANS✔✔early cstates cof cthe cmost cdemyelinating clesions cin
cpatients cwith cRRMS cand cSPMS. cInflammation cin cconjunction cwith cblood cbrain cbarrier cdisruption cis cwhat ccauses cthis
cappearance.
What ctypes cof clevels care cfound cin ccerebral cspinal cfluid cin cpatients cwith cMS? c- cCORRECT cANS✔✔Increased coligoclonal
cIgM cand cIgG clevels care cfound cin cthe ccerebrospinal cfluid cof cpatients cwith cMS.
Ratio cfor cwoman cprevalence c- cCORRECT cANS✔✔MS cis cmore ccommon cin cMS c3:1 cratio, cbut cif cmen cget cit cthey ctend cto
cobtain cmore cprogressive, ceven cmalignant cclinical ccourse.
Laboratory cTesting cand cMS cDx c- cCORRECT cANS✔✔There cis cno cdefinitive cblood ctest cfor cMS. cBlood ctests ccan crule cout
cother cconditions cthat ccause csymptoms csimilar cto cthose cof cMS c(Lyme cdisease, ca cgroup cof cdiseases cknown cas ccollagen-
vascular cdiseases, ccertain crare chereditary cdisorders, cand cADIS).
Lumbar cPuncture cand cMS cdx c- cCORRECT cANS✔✔Analysis cof cthe ccerebrospinal cfluid c(CSF) ctaken cby cspinal ctap, cdetects
cthe clevels cof ccertain cimmune csystem cproteins cand cthe cpresence cof coligoclonal cbands. cThese cbands cindicate can cimmune
cresponse cwithin cthe cCNS, cand care cfound cin cabout c90-95% cof cpeople cwith cMS. cThey ccan calso cbe cpresent cin cother
cdiseases.
optic cneuritis c- cCORRECT cANS✔✔Unilateral cvisual closs, corbital cpain, cafferent cpupillary cdefect, cretrobublar cor cmild cdisc
cswelling, cvisual closs cdoes cnot cprogress cbeyond ctwo cweeks.
Brainstem c- cCORRECT cANS✔✔Internuclear copthalmoplegia, c6th cnerve cpalsy, cnultifocal csigns c(facial csensory closs, cvertigo,
chearing closs, cataxia, cdysarthria)
Optic cNeuritis cand cNormal cBrain cMRI c- cCORRECT cANS✔✔20% crisk cof cconversion cto cclinically cdefinite cMS
Optic cNeuritis cand cAbnormal cBrain cMRI c- cCORRECT cANS✔✔Equal cto cor cless cthan c2 clesions cconsistent cwith cdemyelination
c= c80-90% crisk cof cconversion cto cclinically cdefinite cMS, cdepending con cCIS cpresentation.
Risk cfactors cof cMS c- cCORRECT cANS✔✔1. cClinically csilent cMRI clesions
2. cCSF coligoclonal cbands
3. cWeak cor cuncertain crisk cfactors csuch cas cvitamin cD cdeficiency, cEpstein cbarr cvirus cinfection, csmoking, cHLA cgenes, cand
cmisc. cimmunological cabnormalities.
Musculoskeletal cPain c(preventative c/rehabilitation/pharmacologic) c- cCORRECT cANS✔✔Preventative: cBone canti-resorptive
ctherapies, cstop csmoking, ccalcium cand cvitamin cD csupplements
PT: cassessment, cmanagement cfor csafety, cgait, cpositioning, cmobility caids
Frequent cposition cchanges cand cuse cof cproper csupport
Medications: cAcetaminophen cand cnon-steroidal canti-inflammatories c(lowest ceffective cdose)
