Symptom Management in MS
Nancy Fontneau MD
Department of Neurology
Disclosures
I have nothing to disclose
I will discuss off label use of some
Overview
Management of Symptoms in MS
makes quality of life better for our
patients.
Problems vary from patient to
patient and time to time.
Anticipatory patient education helps
Topics
Weakness and Spasticity
Fatigue
Urinary Dysfunction and
Incontinence
Bowel Dysfunction
Sexual Dysfunction
Weakness and Mobility
Usually legs worse than arms
Mobility dysfunction in > 70% of patients
General conditioning as well as specific
exercise of weakened muscles helps
Rest periods and avoidance of
overheating is needed
Adaptive aids for walking and ADLs may
help patients maintain independence
Fatigue
Common in MS patients
May occur when little energy used
Often worse following activity or at
end of day
May bring out deficits not present
when refreshed (foot drop, blurry
vision, etc)
Limits social and occupational
Managing Fatigue
Educate re energy conservation
techniques and equipment
Optimize nocturnal sleep. Plan rest
periods before important activities
Avoid hot environments
Medications
Stimulants (methylphenydate, amphetamines) Provigil
Antidepressants (especially activating ones) Amantadine
Spasticity
It is velocity dependent muscle over
activity that results from injury to nerves
in the brain and spinal cord. It is one of
the most common problems in MS.
It can have symptoms of stiffness,
inability to move one muscle
independently of another, and spasms
(may be painful).
Can limit walking, transfers, sitting,
Not all spasticity is Bad!
When patients are weak, spasticity
may allow weight bearing for
transfers or even walking.
Spasms can help move a patient to
What makes spasticity worse?
An MS attack may make spasticity worse
(or may lessen it if there is “shock” or
increased weakness).
An infection (like a UTI or the flu)
Constipation, full bladder, menstrual
periods
Pain
Skin sores
Extremes of heat or cold
Help your patient get to know what
makes their spasticity worse. Its
individual.
Managing Spasticity
Partnership between patient and MD
How physicians can help….
Prescribe medications
Prescribe PT, OT, braces, splints
Recommend nerve blocks or other treatments Make sure there are no contractures or
decubiti
What patients can do…..
Know their triggers—avoid them if possible Do stretching program faithfully
Take medications as instructed
Medications for Spasticity—1
Dose must be slowly increased for
each patient to optimize good
effects and reduce side effects.
Most are 3-4 times/d.
All have similar side effects—
drowsiness, weakness when too
much is given. Some cause dry
mouth or low blood pressure.
Some forms can be used together.
Most should not be stopped
suddenly!!!! Please warn your
patients.
Medications for Spasticity--2
Baclofen (Lioresal®) agonist at spinal cord GABA
receptor. It can be given orally or directly into the spinal space with an implanted pump. This route reduces drowsiness, but works much better for leg than arm spasticity.
Tizanidine (Zanaflex®), an alpha blocker, works
centrally to relax muscles.
Diazepam (Valium®) works in the entire nervous
system to relax muscles, at GABA receptors. It also decreases anxiety and promotes sleep.
Patients may withdraw with quick discontinuation. Clonazepam (Klonopin®) is similar.
Medications for Spasticity—3
Dantrolene (Dantrium®) works directly on the Ca
channels in muscles. Side effects on liver, so LFTs needed to monitor.
BOTOX® or other botulinum toxins (Myobloc®,
Dysport®) is injected into muscles when spasticity is focal.
Phenol or Alcohol Nerve blocks may be used when
the motor nerves can be isolated, to weaken spastic muscles. They last longer then BOTOX. Best for adductors of hips (obturator nerve).
Pain treatment, when appropriate, can also
Surgery for Spasticity
Surgery is needed to place the
Intrathecal Baclofen Pump
Tendonotomy--Surgery to cut or
lengthen tendons, can restore
mobility to a joint.
Rhizotomy—Surgery to cut nerve
roots in the spinal cord to relax
muscles nearby.
Stretches
Should be
individualized to
patient need
Help
maintain/regain
joint range of
motion and avoid
contractures.
Should be done
daily, with other
treatments
Physical and Occupational Therapy
Physical Therapy—Teach positioning
to reduce spasticity, stretching and
strength home exercise programs,
use of heat or ice, massage, splints
or braces.
Occupational Therapy—Teach
adaptive equipment to maximize
independence, positioning and
seating in wheelchair, upper
Bracing and Splints
Braces work to support joints, reduce
injury, assist weakened muscles.
Splinting supports joints to prevent or
reduce contractures.
Patients need to wear them!!
Cosmetics and fit are important, as well as
function
May need larger shoe. Should remove
innersole from shoe with brace. Look for shoe with big toe box and flat sole (walking shoe or cross trainer, not running style)
Choice of Braces
Toe off AFO—
for foot drop, little spasticity or inversion
Solid ankle AFO—
For foot drop (MRC 2-3 Tib Ant), knee
hyperextension or buckling, poor endurance, poor proprioception, mild spasticity
Articulated ankle AFO
For more natural movement at ankle, allows
driving or squatting in brace, allows adjustment of dorsiflexion
Double metal upright AFO—
Walk Aide
Functional
Electrical
Stimulation to
Peroneal nerve for
foot drop
Urinary Dysfunction
Almost all MS patients will develop
Two main types—
Urge incontinence—patient has insufficient
time to get to toilet before voiding reflex begins.
Detrusor-sphincter dyssynergia—patient gets
urge but cannot initiate, or initiation slow and voiding incomplete.
UTI and decubiti and falls can result from
UI
Urinary Dysfunction--2
Normal voiding reflex contracts
detrusor at same time that
sphincters (internal and external)
relax
Parasympathetics Pee and
Sympathetics Squeeze and Store.
Up to 8 voids/day and 2/night is
normal. Nocturia may contribute to
fatigue in MS
Medications For Urinary Dysfunction
To increase storage:
Anticholinergics (propantheline, hyoscyamine,
solifenacin, fesoterodine, darifenacin)
Smooth muscle relaxers (oxybutynin,
flavoxate, dicyclomine)
Tricyclic antidepressants (imipramine, doxepin) Treat spasticity
To improve sphincter opening:
Alpha blockers (terazosin, prazosin, clonidine) Tamsulosin
Other options for urinary problems
Catheters
Self intermittent catheterization (or by helper) Indwelling Foley
Surgical solutions
Suprapubic catheter Urinary diversion
Sphincterotomy (with condom cath for men)
DDAVP if nocturia prevents sleep
Absorptive pads, timed voiding
Bowel Dysfunction
Presents in a majority of MS patients at
some point.
Most commonly constipation—MS rarely
causes hyperactive bowels or rectal
sensory loss leading to incontinence.
Most patients should be able to achieve
continence with good management.
Important for skin integrity but most
important for social interactions
Constipation also leads to bladder
Bowel Dysfunction-2
Mechanisms:
Diminished bowel motility from SC lesion Overall diminished mobility worsens
constipation, especially if patient cannot use commode for elimination. Abdominal muscle weakness makes defecation more difficult.
Poor dietary habits (low fiber)
Poor fluid intake (to reduce bladder accidents) Side effects of medications (particularly
anticholinergics for bladder and antidepressants)
Bowel Management
Goals—regular elimination pattern with good
evacuation and no stool oozing
Methods
Adequate fluid and fiber intake (dietary fiber, psyllium, methylcellulose, polycarbophil)
Softeners and fiber help hold more water in stool
Laxatives—osmotic (lactulose, MOM, Mag Citrate, PEG) Laxatives—stimulant (Senna, bisacodyl)
Time toileting for 20-30 minutes after meal—uses gastrocolic reflex to help peristalsis.
Suppositories, Enemeez®, digital stimulation may start reflex defecation.
Allow sufficient uninterrupted time for elimination
Sexual dysfunction in MS
Frequent, and often associated with bladder and
bowel problems.
Both sexes experience low libido, decreased
genital sensation, alteration of experience of orgasm and fatigue from MS
Men have difficulty with getting or maintaining
erection and with ejaculation.
Women have difficulty with arousal and
lubrication
Non-genital physical and psychological imitations
may also affect ability to engage in sexual activity.
Sexual Dysfunction—first steps
Open a discussion, give permission
to talk, normalize the experience for
the patient
RELAX yourself--try to speak with
both partners together
Get the history—find out the
problems and whether the partners
need information
Sexuality--Specific Suggestions
Timing—when fatigue is minimal, bowels and bladder
evacuated (if an issue)
Positioning for comfort and physical abilities Water soluble lubricant
Dealing with catheters
Dealing with erectile dysfunction
Medications (Sildenafil, Tadalafil, Vardenafil, alprostadil) Vacuum pump
Penile protheses (surgical)
Dealing with arousal problems
vibrators, direct genital stimulation by mouth or hand
Give permission to experiment Fertility
Paroxysmal Symptoms
Painful spasms (usually flexor)—
Carbamazepine, gabapentin, PTN
Trigeminal Neuralgia—
