Symptomatic Therapy of MS
Dr. Martin Landolt was senior physician at the Neurological Clinic of the Kanton Hospital in Aarau for many years and opened his own neurological practice in Basel in April 2000.
People with MS are frequently tired. What do you advise patients to do about this?
Chronic fatigue is in fact a frequent complaint made by people with MS and it can come about in all stages of the disease. Such fatigue can have various different causes and is frequently the outcome of several factors acting at the same time, for instance decreased physical strength as well as depression. Then we also have actual chronic fatigue in its more narrow context (Chronic Fatigue Syndrome). In this case the patient suffers from a kind of paralysing fatigue which can occur in different kinds of diseases but is fairly typical for MS.
The treatment of fatigue does not aim at the cause of the symptom. If depression is the primary cause, this should be treated directly. In the case of chronic fatigue in the narrower context, behaviour changes in daily life should first of all be attempted. For instance it would be advisable to interrupt activity with regular pauses and rest breaks. An exercise program with regular muscle training without overstraining is also often a favourable approach. Drug therapy is often unsatisfactory. There are studies with positive results from administering 3.4-diaminopyridine 1 and Pemoline,2 drugs which are not available in Switzerland due to their adverse reactions. Amantadine or the serotonin-reuptake inhibitors can be used, in general with moderate success3. The first truly positive results among people with MS were reported with modafinil, a drug used to treat excessive sleepiness (narcolepsy).3 The drug is not approved for use in every country. Generally, restraint is practised in the prescription of psychostimulants.
What is spasticity?
Spasticity is an increase in muscle stiffness which occurs as an involuntary reflex action of the body. Such stiffness is manifested when rapid movements are made, and are a consequence of damage to the motor nerve tracks in the brain and/or spinal cord. Since the muscles can cramp up in the process, spasticity is frequently also accompanied by pain.
How does one treat spasticity? Aside from drug treatment, are there any alternative methods?
The treatment depends on the degree of spasticity. The most frequent used and successful medications are baclofen and Sirdalud® (generic). They have a central effect, i.e. directly on the nerve cells in the brain and spinal cord. At the beginning of therapy, patients able to walk must take care to observe a gradual increase in the dosage. Otherwise they face the danger of increased fatigue or knees giving way while walking due to the decrease in muscle stiffness. A recent development is the increasing report of the antispastic effect of cannabis drugs. Studies are underway, but I don’t have any experience with this approach. If the spasticity can be clearly localised and is not widespread, botulin toxin injections into the affected muscles can be helpful. The effect generally lasts for about 3 months, after which fresh injections are needed.
A non-drug method for relaxing the musculature and restoring movement involves physiotherapy with all its possibilities (warm/cold, therapeutic gymnastics, etc.). Since, in the case of spasticity, the normal involuntary motion sequences are disturbed, coordinatory exercises are also important (physiotherapy, hippotherapy). Regular periods of standing up counteracts contractures and osteoporosis and reduces the risk of leg venous thrombosis.
What is a baclofen pump and in when is such a pump advisable?
A baclofen pump provides a continual administration of the antispastic drug directly into the spinal cord via a pump system with a reservoir inserted under the skin. The advantage is that higher concentrations of the active ingredient can reach the desired location at once, i.e. at the spinal cord, practically without any systemic adverse reactions. The prerequisite is that there is spasticity in the legs caused by focal disorders in the spinal cord which has not responded even to heavy dosages of medication. A baclofen pump is only suitable for a certain group of patients. Such people should be in a stable condition. The entire explanation and insertion of the pump takes a lot of time and must be done in the hospital. The risk of complications is considerable, but if the indications are favourable and the pump functions properly, good success can be achieved in certain cases.
What do you advise MS patients with depression?
Depression is extremely frequent among people with MS, although no more so than among people with other chronic debilitating diseases resulting in permanent impairment where therapeutic options are limited. The question always arises whether the depression is a reaction to the disease (reactive depression) or its own symptom complex which developed either before or after the development of MS. Reactive depression is most likely the more common.
Treatment depend on the severity of the depression. Older antidepressant drugs often have undesirable adverse reactions such as increased fatigue or bladder disorders, especially for people with MS. This is less the case with the newer drugs. The natural product St. John's Wort is often used. Psychotherapeutic and social medicine measures are also frequently necessary. It goes without saying that a positive family environment is of great importance. As well as many other services and helpful advice, the MS Society offers counselling for persons with MS and their families.
Bladder disorders can result in enormous social restrictions for the sufferer. What kinds of bladder disorders occur with MS?
Bladder disorders are the consequence of damage to the relevant centres and pathways in the brain and spinal cord caused by MS lesions. The most frequent of these is the inability to store urine for long periods of time. The person suddenly feels a strong urge to urinate and must immediately seek out a toilet or else suffer the undesired consequence of incontinence (wetting). The disorder can also mean an inability to urinate at will, which in the worst case makes it necessary to empty the bladder with a catheter.
How does one treat bladder disorders? Are there preventive measures one can take, such as pelvic floor training?
In bladder disorders, first of all a bladder infection must be ruled out or treated if necessary. The bladder disorder most frequently seen among people with MS, urge incontinence (urgent desire to urinate), can be treated with medication and with bladder training. Such training involves the attempt to consciously prolong the intervals between passing water, and the patient keeps a log of this activity. In mild cases a change in drinking habits can be of help, e.g. reducing the amount of liquids taken in the evening, no coffee or alcohol. There is a large selection of possible medications. However, if the bladder disorder cannot be mastered with medication and the residual urine is too large, a catheter must be regularly employed to avoid further complications, or even a permanent catheter inserted. Although this is a drastic measure, it allows many affected persons the possibility of a socially less restrictive way of life.
In contrast to bladder training, pelvic floor training in cases of so-called stress incontinence can be helpful. This form of incontinence generally occurs frequently in older women. They pass a little urine in certain situations, such as when coughing. Pelvic floor training is a voluntary training of the pelvic floor muscles to improve control of passing urine.
What do you advise people with MS to do if they suffer sexual disorders?
Sexual performance functions to a certain degree as a part of involuntary nervous system, i.e. as a reflex. These reflexes can be damaged by the disease. Sensation disorders in the genital region can also impair the normal sexual functions. As with bladder disorders, sexual dysfunction is frequent among people with MS, but both patient and doctor often do not discuss them. As a rule, the disorder among people with MS is directly related to the manifestation of the disease itself, and not only psychological, although psychological factors can certainly play a role in coping with the disease.
For men with potency problems, nowadays sildenafil (Viagra®) has been successfully used, although larger-scale studies on its special efficacy in MS have still not been undertaken. To use this medication safely, it is important that the patient not suffer from any heart disease and is not taking certain medications such as nitrates. The advantage is in its availability in pill form. Injections into the penis prior to sexual intercourse or mechanical devices such as pump systems are another possibility, but a good deal more awkward to use. Certain complaints on the part of women with MS concerning unpleasant genital sensations cannot be specifically treated.
References
1 Sheean GL, Murray NM et al. An open-labelled clinical and electrophysiological study of 3,4 diaminopyridine in the treatment of fatigue in multiple sclerosis. Brain 1998;121(5):967-975.
2 Brañas P, Jordan R et al. Treatments for fatigue in multiple sclerosis: a rapid and systematic review. Health Technology Assessment; 4(27):1-61.
3 Rammohan KW, Rosenberg JH et al. Efficacy and safety of modafinil (Provigil®) for the treatment of fatigue in multiple sclerosis: A two centre phase 2 study. Journal of Neurology, Neurosurgery, and Psychiatry 2002;72:179-183.
