Managing symptoms in MS – Ernie Butler

Case study 37 yo single mother comes to see me. 12 years of MS She reports extreme fatigue. She can’t get off to sleep because of painful leg muscle spasms. A burning pain in both legs is also worse at night. She rises at least 2-3 times per night to urinate, with daytime urgency and occasional incontinence. On further questioning she reports feelings of worthlessness, irritability and tearfulness.

How can I help? What are her problems? How can you help her?

What are her problems? Depression Nerve pain Muscle spasms Fatigue Bladder problems

Depression in MS One of your most important functions as a neurologist in MS management is to ask your patient about how they are feeling, particularly ask about mood. Depression is frequently present in MS and occurs more often than in most other chronic neurological disorders. 50% lifetime prevalence of depression following a diagnosis of MS, in contrast to 11.6% for the general Australian population. Treat depression with antidepressants, GP mental health plan, psychology or psychiatry

Pain in MS Paroxysmal v chronic pain Neuropathic leg pain from MS was shown to be prevalent in 26% of patients. Other causes of pain include trigeminal neuralgia. Out of all causes of chronic pain, nerve pain is considered the most debilitating Treatment includes various medications, ketamine, behavioural strategies, sometimes surgery. I have no experience using medical cannabis but Sativex is available

Spasticity and spasms in MS Spasticity is common, can sometimes be disabling, and can sometimes be useful. Non-drug treatment: exercise, passive and active stretching Drugs: Oral agents: baclofen, clonidine, diazepam, dantrium Cannabinoids [e.g Sativex nasal spray is TGA approved] Botulinum Toxin Intrathecal baclofen

Fatigue in MS Fatigue is perhaps the commonest of MS symptoms: it is multifactorial: Sleep disorder e.g. insomnia, restless legs Pain Depression Work factors Medication No other factor than MS Off-label medications: e.g. modafanil The hospital-based MS treatments can reduce fatigue. e.g. Tysabri.

Mobility in MS Phoebe will discuss this

Employment in MS Is your patient able to continue in their role Physically able? Cognitively able? Fatigue Consider OT assessment Consider reducing hours, particularly later in the day; perhaps a day off mid-week MS employment support services [MS Australia]

MS bladder Bladder storage and/or emptying problems Investigation: urine test, kidney blood test, bladder utrasound, urodynamic study Management Prevention and early treatment of urinary infection Difficulty emptying: might need a catheter Can’t store urine: medications Botox injection into the bladder wall for severe cases Continence clinic Referral to a urologist sometimes

Management and prevention of infections Influenza vaccination for all. An inactivated vaccine, so safe to use with MS immunotherapy. Pneumococcal vaccine for some. Better management of urinary problems. The more active MS immunotherapies can potentially predispose to various infections.

Sexual dysfunction in MS A problem often not volunteered by people Most men with MS have this symptom Psychological & physical causes Medications used include: Viagra, Cialis, Levitra

Impaired cognition in MS Cognitive impairment is present in some people with MS. Problems most often appear in attention, information processing, word-finding, long-term memory, visuo- spatial perception and executive function. Can be assessed by a neuropsychologist. The trick as a neurologist is to prevent this problem with early and effective MS therapy.

How can you help our case example? Antidepressant medication and psychiatric/psychological evaluation. Probe the cause for her fatigue and manage Manage muscle spasticity and spasms with exercise, muscle stretching and baclofen Arrange physiotherapy review and intervention Depending on bladder investigations consider Ditropan at night or other agents Treat pain with drugs +/- pain team assessment NDIS