The Treatment of Multiple Sclerosis

There is no cure for Multiple Sclerosis, some drugs appear to be effective, in some cases, in slowing down the frequency of relapses and reducing their severity. These disease modifying drugs, beta interferon and glatiramer acetate, are available on the NHS under the Risk Sharing Scheme (whereby the government pays the manufacturers a reduced amount if the drugs turn out to be less effective than claimed.)

Criteria for the treatment of multiple sclerosis with beta-interferon and glatiramer acetate.

The Association of British Neurologists guidance states that:"All eligible patients should be ambulant and have a diagnosis of MS established by the McDonald criteria with relapsing onset.They will normally be aged 18 or more years, although treatment at a younger age may be warranted in some circumstances".

For those with relapsing remitting MS there should be one or more of:

• Two clinically significant relapses in the last two years;
• One disabling relapse in the past year;
• Active MRI scan containing new or gadolinium enhancing lesions that have developed in the last year;
• Can walk for 100 meteres without assistance.

For those with secondary progressive MS the medication should only be given to those who are relapsing and where the relapses are the predominant cause of increasing disability. The other criteria is that people should be able to walk unassisted for at least 10 metres.

These drugs will not be given to those with primary progressive MS.

Treatment with Corticosteroids.

The NICE guidance on MS states that: "Any individual who experiences an acute episode (including optic neuritis) sufficient to cause distressing symptoms or an increased limitation on activities should be offered a course of high-dose corticosteroids".

The guidance goes on to say that people should only be given corticosteroids if the have been informed of and fully understand the risks involved in taking corticosteroids and that frequent or prolonged use of cosrticosteroids should be avoided.

Treating the effects of MS.

Fatigue

Fatigue is one of the commonest and most frustrating symptoms associated with MS. Fatigue is associated with depression and disability and doctors should consider whether fatigue is a significant problem for the patient.

If fatigue is found to be dirsupting a person's life then:

• A full review of the person's medication should be undertaken to see if any medicine with sedating effects can be replaced or removed;
• Consideration should be given as to whether the patient is depressed- if depression is identified than this should be treated in the normal way;
• Other factors that may cause fatigue (chronic pain, poor nutrition and disturbed sleep) should be identified and dealt with;
• The person should be given general advice on how to manage fatigue, this should include encouragement to undertake aerobic exercise and on energy conservation.

Bladder Problems

Urinary inconctinence is a common feature of MS but one that rarely comes to light because patients tend to be embarrassed about discussing it. The NICE guidance makes a range of recommendations for addressing bladder problems:

• Each professional in contact with a person with MS should consider whether the person has any problems controlling bladder function. Problems may include frequency or urgency of micturition, sleep disturbance from nocturia (awaking with need to empty bladder), difficulty in passing urine or incontinence of urine;
• Any person with MS who has bladder symptoms should: have their post-micturition residual bladder volume measured using a simple measure such as ultra-sonography of the bladder, be assessed for the presence of a urinary tract infection clinically and, if necessary, using an appropriate dipstick for nitrites and leucocyte esterase. Treatment should be provided, if necessary;
• Urgency or urge incontinence sufficient to be bothersome or cause incontinence should be treated in the first instance using advice on changes to clothing and/or toilet arrangements (for example, provision of a commode downstairs), intermittent self-catheterisation if there is a high residual volume, and the person is able and willing, anticholinergic medicines such as – oxybutynin, or tolterodine D checking for an increased post-voiding residual volume if symptoms recur;
• Any person who has nocturia should be offered desmopressin (100–400µg orally or 10–40µg intranasally) at night, to control the symptom;
• Any person who wishes to control urinary frequency during the day (for example, when travelling), and who has failed with other measures, should be offered desmopressin (100–400µg orally or 10–40µg intranasally) but desmopressin should never be used more than once in 24 hours;
• Any person with MS who, despite treatment, has incontinence more than once a week should be referred to a specialist continence service for further assessment and advice, be considered for a course of pelvic floor exercises, preceded by a course of electrical stimulation of the pelvic floor muscles (if such a course is available);
• Any person with MS who experiences persistent incontinence should be offered a convene drain (for men) or pads (for women);
• Any person who has continued bladder symptoms despite pharmacological and other treatments should be considered for intermittent self-catheterisation taught by a suitably trained specialist, or for longer-term urethral catheterisation as a means of control, with suprapubic catheterisation being considered especially when active sexual function is still wanted.

Urinary tract infections

One of the major causes of urinary tract infections in people with MS is the use of long-term indwelling catheters. The NICE guidance says that for people with MS the use of such catheters should only be considered after all other options have been tried and that their use should be reviewed regularly to ascertain if less invasive procedures may be used.

The guidance also recommends that people who have had three or more episodes of urinary tract infection in a year should be assessed by a continence specialist for residual urine and other risk factors and offered appropriate treatment and advice.

Bowel Problems

For people with MS bowel problems can be caused by:

• reduced gut mobility as a result of increasing immobility;
• the side effects of drugs used to treat various impairments;
• the impairment of the neurological control of the bowels.

The main problem is constipation although a sizeable group report problems with continence.

NICE makes the following recommendations for addressing bowel problems:

• Each professional in contact with a person with MS should consider whether the person has any problems controlling bowel function. Potential problems include urgency, difficulty, pain, constipation or incontinence;
• Any person with MS who has apparent constipation (pain on or difficulty with defecation, bowels open less than twice a week) should be offered advice on fluid intake and dietary changes that might help, and then be considered for oral laxatives;
• Any person with faecal incontinence should be assessed for constipation with overflow, possibly exacerbated by laxative use;
• If a person with MS has apparent constipation (pain on or difficulty with defecation, bowels open less than twice a week) despite treatment with oral laxatives he or she should be considered for the routine use of suppositories or enemas.

Weakness

"Weakness" is the most common symptom for people with MS. It is however important to know whay exactly is being referred to when a patient describes a feeling of weakness as this phenomena can often have many different causes.

People with motor weakness should receive advice on exercises and techniques to maximise strength and endurance appropriate to their circumstances. People with motor weakness should also be taught techniques and given equipment "appropriate to their circumstances".

Spasms, Stiffness and Spasticity

Spasticity is characterised by increased stiffness and a slowness in limb movement, the development of certain postures, an association weakness of voluntary muscle power and sometimes painful spasms of limbs.

Muscles that are affected by spasticity may suddenly start to jerk in an uncontrolled way. Some people with MS experience different kinds of spasm:

• flexor spasms which cause a limb to bend towards the body;
• extensor spasms which cause the limb to shoot out away from the body;
• adductor spasms which can cause the legs to come together making it difficult to separate the thighs.

The Nice guidance on MS recommends that all MS pateients with who have persistent spaticity and/or spasms should be seen by a neurophysiotherapist who will undertake an assessment and provide advice on physical techniques such as passive muscle stretching in order to reduce spasticity and to prevent development of contractures (The shortening of soft tissues around a joint that limits range of movement at that joint.)

The guidance states that pharmacological treatments should only be tried if the patient's spasticity or spasms are causing pain or distress.

Initial pharmaclogical treatment should be with baclofen of gabopentin. If treatment with these is unsuccesful or causes intolerable side effects then the following may be tried:

• tizanidine;
• diazepam;
• donazepam; or
• dantrolene.

Patients who continue to have troublesome and unresponsive spasms and spasticity should be seen by a specialist team with specific expertise in the assessment and management of spasticity. The team should consider using one or more of the following approaches:

• Standing and weight bearing through legs;
• splints;
• serial casting;
• special or customised seating, such as tilt-in-space chairs;
• intrathecal balcofen;
• phenol injections to motor points or intrathecally.

Contracture

A contracture is a shortening in the soft tissues that surround a joint that limits the passive and active range of movement of that joint. Because of the postural distortions that occur, contracture presents enormous problems to carers with regard to positioning, seating, dressing and feeding.

The NICE guidance recommends that people who are deemed to be at risk of contractures should be given advice and instruction in preventative measures such as regular passive stretching of the joint at risk together with appropriate positioning of limbs at rest. Those who have developed a contracture may be treated by means of serial plaster casts and/or the use of standing frames with removable splints, these strategies are usually combined with local botulinum toxin injection and surgery (when necessary).

Ataxia and Tremor

Ataxia is a condition charcterised by uncoordinated voluntary movement which is due to disturbed function in the brain. It is difficult to distinguish ataxia from tremor which is any regular or rhythmic alternating movement affecting a joint or group of joints.

The NICE guidance indicates that people with severe and intractable problems with tremor/ataxia should by assessed for surgery, once a full explanation has been given with regard to the major risks and possible benefits.

Sensory Losses

Feelings of tingling and numbness are common in people with MS. Numbness in the hands can make fine dextrous activities impossible and people may drop things and injure themselves. Although there is no treatment for these sensory losses, people experiencing these problems should still be given advice on techniques and equipment to lessen their limitations and on ensuring their personal safety.

Visual Problems

Most people with MS who experience problems with their sight have abnormalities in the control of eye movements. The NICE guidance makes the point that visual problems in people with MS are often overlooked.

Nystagmus is a condition characterised by involuntary eye movements with smooth movement in one direction and jerky movements in the opposite. The guidance indicates that this condition should be treated with oral gabapentin.

For other kinds of visual impairment people who are still experiencing difficulties despite using suitables glasses should be assessed in a specialist opthalmology clinic.

Pain

For people with MS, pain is often a significant factor. There are two main types of pain:

• Neuropathic pain which is pain arising from areas of demyelination in the brain. Trigeminal neuralgia is the best known of these.
• Musculoskeletal pain which arises from reduced movement and/or abnormal posture.

The NICE guidance on MS makes the following recommendations with regard to musculoskeletal pain:

• Every person with MS who has musculoskeletal pain secondary to reduced or abnormal movement should be assessed by specialist therapists to see whether exercise, passive movement, better seating or other procedures might be of benefit;
• If non-pharmacological means are proving unsuccessful in managing the musculoskeletal pain (arising from reduced movement and/or abnormal posture), the individual should be offered appropriate analgesic medicines;
• Any person with MS who has continuing unresolved secondary musculoskeletal pain, should be considered for transcutaneous nerve stimulation or antidepressant medication;
• Treatments that should not be used routinely for musculoskeletal pain include ultrasound, low-grade laser treatment, and anticonvulsant medicines.
• Cognitive behavioural and imagery treatment methods should be considered in a person with MS who has musculoskeletal pain only if the person has sufficiently well preserved cognition to participate actively.

The guidance makes the following recommendations with regards to neuropathic pain:

• Neuropathic pain, characterised by its sharp and often shooting nature, and any painful hypersensitivity, should be treated using anticonvulsants such as carbamazepine or gabapentin, or using antidepressants such as amitriptyline.
• If the neuropathic pain remains uncontrolled after initial treatments have been tried, the individual should be referred to a specialist pain service.

Cognitive Loss

Approximately half of people with MS experience some form of cognitive loss (impaired memory, concentration or thinking). Cognitive loss affects most aspects of an individuals life, from performing straightforward domestic tasks to giving consent to treatment. Other impairments such as disinhibition may have an adverse effect on social interaction and communication.

There is no succesful treatment for cognitive loss, the NICE guidance suggests that people with cognitive problems should have their medication reviewed to ensure that the problems are not caused by drugs taken for other symptoms and that they should be assessed for depression. The guidance also calls for a formal cognitive assessment coupled with specialist advice on the implications of the results.

Depression

Depression is a common complaint in people with MS. Depression was found in 36% of one MS sample. All professionals should be aware of depression and all MS healthcare teams should be able to identify and treat it appropriately. In those patients who are depressed, a list of contributory factors should be drawn up. Antidepressants and pschological treatments such as cognitive behaviour therapy may be used as part of an overall programme of depression management.

Anxiety

The NICE guidance states that anxiety is "probably the commonest emotional impairment associated with MS". The precise cause of anxiety is not known but it can significantly increase dependency and distress. The following recommendations are made for responding to MS patients with anxiety:

• Any person with MS whose function or happiness is being adversely affected by anxiety should be offered specialist assessment and management.
• In people with MS with marked anxiety, psychologically-based treatment should be offered.
• Pharmacological treatment of anxiety should be through using antidepressants or benzodiazepines. The Committee on Safety of Medicines (CSM) guidelines on the use of benzodiazepines (reproduced in the British National Formulary) should be used.

Swallowing Difficulties

Some people with MS will experience some problems with swallowing which can result in choking or the transmission of liquid and food to the lungs instead of the stomach. Food particles in the lungs can cause chest infecti0ons and even death. Understandably, the NICE guidance calls for early detection before problems arise. The guidance lists a number of progressive steps in response to swallowing problems:

• Advice from a specialist speech and language therapist on swallowing techniques, adapting food consistencies and dietary intake;
• adjustments to or provision of seating that will increase ease and safety of swallowing and feeding;
• chest physiotherapy;
• short-term use of naso-gastric tube;
• PEG feeding;

If a PEG tube is to be fitted, it should be inserted by a suitable specialist. Family members and carers should be given full training in the use of the feeding system prior to the patient being discharged from hospital.

Speech Difficulties

Slurred speech is a problem for some people with MS. For most patients this is a mild problem, for others it can be so severe as to limit or prevent communication altogether.

Each person for whom speaking is difficult should be seen by a speech and language therapist who should undertake and assessment and provide advice. For those with severe speaking difficulties, consideration should be given to teaching non-verbal means of communictation.

Pressure Ulcers

Pressure ulcers are a major problem for people with MS because of their limited mobility, poor sensory functioning, reduced cognitive function and undernutrition. The NICE guidance with regard to pressure ulcers says "prevention must be a priority yet they continue to occur with monotonous regularity".

With regard to prevention the guidance says that every MS patient who uses a wheelchair should be assessed for their risk of developing a pressure ulcer and offered appropriate advice.

Patients who use a wheelchair daily should subject to regular clinical assessment - from this an action plan should be drawn up including:

• optimisation of nutritional status;
• provision of suitable equipment;
• documentation of agreed manual handling techniques.

For every person with MS considered to be at risk on their bed:

• an appropriate specialist mattress should be provided wherever they are lying down;
• regular turning should not be depended upon as a policy for preventing pressure ulcers;
• the skin areas at risk should be inspected to ensure adequate protection is being provided.

The guidance recommends that if a pressure ulcer occurs, it should be considered an adverse event worthy of investigation and advice should be sought from a specialist service and that any person with MS who develops a pressure ulcer should be nursed on a low-loss mattress.

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