Symptom Management in MS. Nancy Fontneau MD Department of Neurology University of Massachusetts

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1 Symptom Management in MS Nancy Fontneau MD Department of Neurology University of Massachusetts

2 Disclosures I have nothing to disclose I will discuss off label use of some medications.

3 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 getting patients to report difficulties

4 Topics Weakness and Spasticity Fatigue Urinary Dysfunction and Incontinence Bowel Dysfunction Sexual Dysfunction

5 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 Medications--Ampyra (dalfampridine)

6 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 function

7 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 Pemoline

8 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, hygiene, sex. Contributes to MS fatigue.

9 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 unload ischemic skin.

10 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.

11 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 Relaxation and Massage sometimes help

12 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.

13 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.

14 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 decrease spasticity.

15 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.

16 Intrathecal Pump

17 Stretches Should be individualized to patient need Help maintain/regain joint range of motion and avoid contractures. Should be done daily, with other treatments

18 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 extremity exercises and splinting.

19 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)

20 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 Better if there is severe edema

21 Ankle Foot Orthoses

22 Walk Aide Functional Electrical Stimulation to Peroneal nerve for foot drop

23 Ankle splints

24 Wrist Splints

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26 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 History may not be enough for Diagnosis

27 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

28 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 To close sphincter better: imipramine

29 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

30 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 dysfunction!!

31 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)

32 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 minutes after meal uses gastrocolic reflex to help peristalsis. Suppositories, Enemeez, digital stimulation may start reflex defecation. Allow sufficient uninterrupted time for elimination Digital disimpaction (by self or helper) or enema if needed

33 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.

34 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 Give specific suggestions..

35 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

36 Paroxysmal Symptoms Painful spasms (usually flexor) Carbamazepine, gabapentin, PTN Trigeminal Neuralgia Carbamazepine, PTN, Baclofen, Gabapentin, Amitryptiline

37 Adaptive Devices save Energy

38 Questions?