Symptomatic Treatment in Multiple Sclerosis
Multiple sclerosis affects many parts of the central nervous system, and may cause many and varied symptoms. The common symptoms include fatigue, mobility difficulty, anxiety, depression, spasticity, bladder and bowel disturbance, cognitive impairment, pain, numbness, heat sensitivity, spasticity or stiffness, tremor, difficulty with speech and swallowing, and visual disturbance. In general, most symptoms respond to simple non-pharmacological measures. Medications are sometimes helpful. Proactive management by a multi-disciplinary team which includes neurologists, MS nurses, physiotherapist, rehabilitation specialists, pain specialists, gastroenterologists, urologists, occupational therapists, continence nurses, dieticians, speech therapists and others is often needed.
Fatigue Fatigue is one of the commonest symptoms in multiple sclerosis, affecting up to 80% of people with MS, either during the early or latter phase of the disease, and is probably one of the most disabling symptoms. Fatigue may also be the first symptom of depression. The basis of fatigue in multiple sclerosis is not well understood. Fatigue may be managed by scheduling appropriate breaks during work. Graduated exercise programmes, cardiovascular conditioning and cognitive behavioural therapy are helpful measures. Medications used to treat fatigue include amantadine, acetyl-L-carnitine, Fampridine, aspirin and modafinil.
Spasticity Spasticity is a significant source of discomfort and disability, and may affect people with mild or severe MS. Spasticity may be produced by or exacerbated by infections, pressure sores, ingrown nails, fracture, cellulitis, and medications such as selective serotonin reuptake inhibitors used to treat depression, and beta interferon. Management strategies include regular stretching exercises and physiotherapy. Medications used to treat spasticity include baclofen, benzodiazepines, dantrolene and botulinum toxin. Sometimes surgery may be necessary.
Bladder problems Bladder problems occur in about 70% of people with MS, usually with loss of sensation, lack of control, and not being able to delay bladder emptying. Bladder problems may lead to urinary tract infection. Medications used to treat pain, tingling, spasticity and other MS symptoms may worsen bladder problems. Pelvic floor exercises and double voiding are useful strategies. Medications such as oxybutynin, tolterodine and solifenacin may be helpful if the residual urine volume after voiding is less than 100 ml; otherwise, urinary catheterization may be necessary. Sometimes a catheter inserted through the lower abdomen to drain residual urine (suprapubic catheter) may be useful in people who cannot catheterize themselves.
Bowel problems Constipation is a common problem among people with MS. Sometimes this is complicated by overflow diarrhoea and bacterial overgrowth in the gastrointestinal system. Medications used to treat pain and depression may aggravate bowel problems. Regular high fibre diet and adequate hydration are important. If the problem does not respond to these measures, laxatives and enemas may be needed. Rarely, colostomy is performed for intractable incontinence causing profound social and physical impairment.
Pain, acute and chronic Pain is an uncommon symptoms in MS. Causes of acute pain include trigeminal neuralgia, paroxysmal tonic spasm, neuropathic pain syndrome, inflammatory pain and migraine. Sometimes these pains may become chronic. Trigeminal neuralgia is short lasting, sharp, severe, shooting pain in the face. Paroxysmal tonic spasm is painful spasm that spreads from one part of the limb to another, often lasting minutes, and may occur many times in a day. Neuropathic pain syndrome usually affects the legs but may affect any part of the body and is usually burning or sharp, and may be associated with skin sensitivity. Acute inflammation from an MS relapse may be painful; inflammation in the optic nerve causes eye pain, and inflammation in the spinal cord may cause severe painful tightness in the limbs or torso. For unclear reasons, migraine is more common in people with MS. Non-pharmacological management such as psychological therapies, acupuncture, transcutaneous nerve stimulation (TENS) may be helpful in some patients. Long term use of strong painkillers such as opioids (codeine, Targin, Tramadol, morphine) and nonsteroidal anti-inflammatory drugs are best avoided because of potential side effects. Neuropathic medications such as pregabalin, amitriptyline, gabapentin, carbamazepine, ketamine and some anti-depressants are better for long term pain control. Surgery may be necessary if the pain is otherwise not controlled.
Gait disturbance Gait and walking disturbance affects up to 80% of people with MS within 10-15 years of diagnosis, though this may be delayed by the use of disease modifying therapy. Walking difficulty may be compounded by spasticity, loss of balance, visual disturbance and pain. A multidisciplinary approach is particularly important in the management of gait disturbance, particularly including a physiotherapist. Gait analysis may be necessary before an exercise regime is prescribed. Regular exercises are important and helpful to improve muscle strength, spasticity and balance. Various walking aids are often effective in restoring mobility and in the prevention of fall. Medications, both to improve walking (Fampridine) and to treat spasticity and other complications may be useful in some.
Anxiety and Depression About 1 in 3 people with MS suffers from depression, and half as many anxiety. People with MS are at risk of chronic depression that does not improve with time, unlike other people suffering from depression. Both depression and anxiety have a profound impact on physical, cognitive and emotional functioning of people with MS, and impact how well they cope with the disease and its complications. Some medications, such as beta interferon, may worsen depression. The help of psychologists and psychiatrists is invaluable in the management of depression and anxiety. Psychotherapy and medications are used to treat these problems.