1. Managing symptoms in MS – Ernie Butler

2. 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.

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

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

5. 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

6. 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

7. 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

8. 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.

9. Mobility in MS
Phoebe will discuss this

10. 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]

11. 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

12. 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.

13. 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

14. 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.

15. 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