Lectures: Treatment Options - Symptomatic Therapy
Spasticity and Muscle Spasms
Tremors and Incoordination
Fatique is a very common problem in patients with MS. The subjective feeling of fatigue increases as the day progresses, or as the patient attempts to exercise. Along with the subjective feeling of fatigue a patient may notice objective decrease of neurologic status and level of functioning toward the end of the day. A number of patients with fatigue may have problems with sleep, and even if they get enough sleep they still report not feeling rested in the morning. Sometimes an underlying depression is a real cause of fatigue. In those cases treatment of depression also will help with fatigue. Fatigue may be managed sometimes by adjusting the daily activities with emphasis on one or two brief naps during the day and moderate exercise. Cool showers and baths may help to rejuvenate the patient. If these are not helpful, then medications can be tried to fight fatigue. Amantadine is helpful in about 40% of patients with fatigue. Its mechanism of action is not clear. Other medications include Pemoline and Fluoxetine. Pemoline is a CNS stimulant and should be used with caution. Fluoxetine (Prozac) is an antidepressant medication which also is sometimes helpful to increase energy. Other antidepressants and psychotherapy may also be utilized.
Vertigo is not uncommon in patients with MS and can be an extremely frustrating and disabling problem. Vertigo can present itself as sudden "spells" or it can last for hours or days at a time. It may at times be associated with oscillopsia - an illusory movement of the environment in which stationary objects appear to move back and forth or from side to side. Oscillopsia may be associated with severe nystagmus. Medications that may be helpful in patients with vertigo include Meclizine, low-dose Diasepam and Promethazine hydrochloride. Oscillopsia may respond to Clonazepam or Baclofen. Vertigo associated with nausea and vomiting may respond to Metoclopramide.
Spasticity and Muscle Spasms
Spasticity and muscle spasms can be quite a painful problem for patients with MS. It occurs most frequently in extensor muscles of the lower limbs. Primary treatment of spasticity includes physical therapy with stretching exercises in combination with medications. Baclofen is a medication of choice for spasticity with unknown mechanism of action. It is quite helpful for most patients with spasticity, but doses need to be adjusted individually for each patient. Side effects of Baclofen include muscle weakness, and more seldom - drowsiness, confusion and nausea. Muscle weakness may sometimes be a limiting factor for using the medication. Diazepam is another good medication for spasticity and can be used in combination with Baclofen in patients who do not tolerate very high doses of Baclofen alone. Diazepam is particularly helpful in controlling spasticity in flexor and extensor muscles at night. Tizanidine is a new antispasmodic awaiting final FDA approval at this time. Baclofen pump - a subcutaneous reservoir of the medication with programmed dose levels - can be used for treatment of patients with intractable spasticity. This method of administration can be advantageous, because the lower doses can be delivered directly into the spinal cord resulting in decreased side effects. Anticonvulsant medications are sometimes tried for the treatment of spasticity. Spastic dysarthria is sometimes seen in patients with MS. It is usually accompanied with other lower brain stem symptoms, i.e.,. difficulty with breath control, etc. Baclofen sometimes is helpful in this condition.
The most common psychological problems in patients with MS are severe mood swings, affecting their marital and social relationships and work. Tricyclic antidepressants, i.e.,. Amitriptyline can be used to treat this problem. Depression is also quite common in MS and need to be treated promptly. Treatments may include tricyclic and non tricyclic antidepressants as well as psychological counseling. This problem can be serious resulting in the suicide rate in MS patients that is 7.5 times higher than in general in the population.
Urinary dysfunction is a very common concern for MS patients. The most frequently seen problem is a spastic (small hyperactive) bladder. Patients complain of urgency, increased frequency of urination and incontinence. These symptoms respond to anticholinergic drugs such as Oxybutynin or Propantheline. Sometimes Baclofen or Amytriptyline can be used to control this problem. A different problem is detrusor-external sphincter dyssynergia, when the bladder attempts to empty through the closed urethra. Symptoms include urgency and hesitancy of urination, increased frequency of urination with feeling of incomplete emptying of the bladder. The treatment commonly used is a combination of anticholinergic drugs and intermittent self catheterization (2 - 4 times per day) about which the patient is educated. Flaccid bladder is less frequently seen in MS. Problems may include hesitancy of urination, double voiding, a feeling of incomplete emptying and dribbling incontinence. This problem may result in urinary retention with subsequent infections and even hydronephrosis. A schedule of intermittent self-catheterization should be discussed with the patient and is usually helpful in preventing the above mentioned problems. If UTIs develop they should be treated with antibiotics as thoroughly as possible. High doses of Vitamin C are helpful in preventing UTI, as well as other acidifying agents i.e.,. hippuric acid. Patients who develop major bladder problems and are not responding to noninvasive therapy may require a chronic indwelling catheter or urinary diversion.
Sexual problems are common in both men and women with MS. For females, treatment of muscle spasms and pain relieving medications may allow intercourse with less pain. For males, multi disciplinary approach toward erectile dysfunction needs to be undertaken. Sometimes, -2-adrenergic receptor agonist, Papaverine or Phentolamine injections maybe helpful.
Tremor and Incoordination
Tremor and Incoordination can be a significant problem for many MS patients. This problem is frequently non-responsive to medications, but Clonazepam, Propronalol, Diazepam or Primidone can be tried. Clonazepam is reported by some to be the most helpful of the medications available now.
Pain is in fact more common in MS patients than was expected. Much of the pain syndromes relate to muscular-skeletal abnormalities in MS patients. This pain is often secondary to the disease process, resulting from poor posture due to loss of muscle strength in lower extremities, overuse of upper extremities in wheelchair-bound patients, etc. The primary MS pain is often dysesthetic, most commonly in lower extremities, but can be felt in any location. This pain can be controlled with Carbamazepine, Phentoin, or tricyclic antidepressants. A new class of medications is now being tried in clinics for pain in MS. One new anticonvulsant medication that seems to be somewhat helpful is Gabapentin (Neurontin).
Cognitive dysfunction is sometimes seen in MS patients. They tend to be associated with a loss of retrieval rather than a loss of memory. These difficulties can contribute to increased disability, social problems and coping abilities. Patients with cognitive dysfunctions have larger number of lesions in cerebral hemispheres, especially in the frontal lobes. Patients with cognitive problems need to undergo detailed neuropsychiatric evaluation to be advised on rehabilitation techniques and occupational therapy.