Overwhelming fatigue is one of the most common symptoms affecting persons with MS. The clinician should rule out other conditions that can cause fatigue such as medication effects, metabolic imbalances, infection, anemia, hypothyroidism, vitamin B12 deficiency, or depression (Saguil et al., 2014). The extra energy required to overcome spasticity, deconditioning of muscles, and weakness can cause fatigue. Nocturia, pain, and sleep apnea may cause inadequate sleep and daytime fatigue. Occupational therapists can teach the patient how to conserve energy when performing tasks. Altering medication schedules to allow for an uninterrupted sleep regimen is important. Exercise therapy can also counteract fatigue. According to a meta-analysis by Heine et al. (2015), of 2,250 patients, prescribed exercise interventions including endurance training and muscle strengthening effectively counteracted fatigue. Exercise was not found to do harm nor trigger relapse in the subjects with MS. To counteract fatigue, stimulant medications such as amantadine, modafinil, and methylphenidate can be used (Newsome et al., 2016).
Sensory disturbances that consist of feelings of numbness, tingling, burning, and heaviness in the extremities are common in patients with MS. Sensory losses can hinder independent activities and affect the safety of the individual. Occupational therapists can demonstrate ways for the patient to carry on activities of daily living with the sensory losses with assistive devices and task modification strategies. According to Newsome et al. (2017), burning and numbness sensations may be treated with gabapentin, pregabalin, carbamazepine, topiramate, or oxcarbazepine. Serotonin-norepinephrine receptor inhibitors and tricyclic antidepressants have also been effective.
Spasticity and stiffness are common problems for patients, particularly during MS exacerbations. These commonly affect the hamstrings, quadriceps, and gastrocnemius muscles (Frohman et al., 2011). Stretching exercises, relaxation techniques, orthotic devices, and pain management can be helpful. Also the clinician should understand that individuals with MS suffer from heat sensitivity. This heat sensitivity is known as Uhthoff sign, which is demonstrated as a worsening of symptoms when the patient is overheated. Cooling methods such as cool showers, ice packs, cold towels, cold beverages, fans, and air conditioning of the environment can counteract this phenomenon (Frohman et al., 2013).
Medications such as baclofen, tizanidine, and gabapentin are often prescribed, but may not be effective (Newsome et al., 2017). Adding cannabidiol oromucosal spray to the regimen has been effective for moderate-to-severely resistant MS spasticity (Vermersch & Trojano, 2016). Intramuscular botulinum toxin has also been effective in reducing spasticity (Safarpour et al., 2017).
Gait and Balance Difficulty
Aerobic exercises, stretching, and core strengthening are important for the individual with MS. Physical therapists can assess the patient's limitations and ability to develop an exercise regimen that enhances balance and coordination. Additionally, there are numerous ambulation assistive devices that can be used. Physical therapy should include ambulation on uneven surfaces and inclines, ambulation up and down curbs, the ability to cross the street with head scanning and gait velocity, ambulation in the community with an assistive device, and community mobility with a wheelchair or scooter (Ontaneda et al., 2015).
Studies show that dalfampridine, an orally administered potassium channel blocker, can help patients with walking impairment. Filli et al. (2017) found that patients with MS demonstrated improvements in walking speed, endurance, and self-perceived ambulatory function after long-term use (2 years) of the drug (Goodman et al., 2009). Hippotherapy (horseback riding) was also found to be a beneficial physical therapy treatment strategy in MS patients to improve balance, functional gait, and enhance sensory processing cues for postural control (Lindroth et al., 2015).
Patients with MS may have symptoms of neurogenic bladder that include urgency, frequency, incomplete emptying, hesitancy, nocturia, incontinence, urinary tract infection, and dysuria. The patient may have inability to retain urine or to void. The patient should avoid bladder irritants such as caffeine, aspartame, and smoking. Fluids should be discontinued 2 to 3 hours before bedtime. Kegel exercises to increase pelvic floor muscle strength can be taught. Protective pads, panty liners, and insertion of a vaginal pessary device can be used. Botox injections into the bladder detrusor muscle and a surgical sling procedure that can support the urethra and enhance the integrity of the bladder are also possible (Frohman et al., 2011 ; Safarpour et al., 2017). There are numerous medications available that can enhance bladder retention (Table 3). Anticholinergics/antimuscarinic medications such as oxybutynin, tolterodine, solifenacin succinate, and darifenacin can be used to enhance retention of urine. Alpha-adrenergic blockers tamsulosin and doxazosin can be used to enhance urinary flow. Timed voiding to empty bladder every 2 hours during the day can be helpful. Intermittent catheterization, indwelling catheterization, and external bladder stimulators can also be used (Newsome et al., 2017).
The clinician should assess the patient's bowel function, stool frequency and consistency, straining or pain with defecation, fiber in the diet, fluid intake, and activities. Although MS causes neurologic impairment of the bowel, medication side effects can also cause bowel dysfunction. Common symptoms of bowel dysfunction in MS include constipation, fecal incontinence, and irritable bowel syndrome (Dibley et al., 2017 ; Frohman et al., 2011). Constipation, the most common complaint, can be treated with fiber supplements, stool softeners, or increased fluid intake. Osmotic laxatives such as polyethylene glycol (Miralax) are preferred over stimulant laxatives. Suppositories and digital manual stimulation can be used. Regular exercise, if possible, is recommended. Medications such as lubiprostone can be used off label (National Multiple Sclerosis Society, 2011).
Pain occurs in more than half of people with MS (O'Connor et al., 2008). Primary pain is directly related to MS pathology (i.e., neuropathic pain) and includes dysesthesia and paresthesia, trigeminal neuralgia, and paroxysmal cord phenomena. This pain can be treated with certain anticonvulsant or antidepressant medications; however, narcotics have a limited effect. According to Newsome et al. (2017), commonly used medications include gabapentin, pregabalin, tricyclic antidepressants such as amitriptyline, and serotonin-norepinephrine receptor inhibitors such as venlafaxine and duloxetine. Other medications that can decrease pain in some patients include carbamazepine, clonazepam, baclofen, misoprostol, tramadol, topiramate, tizanidine, and phenytoin. Physical therapy, exercise, transcutaneous electrical neurostimulation (TENS), hydrotherapy, and cooling are recommended. Additionally, studies show cannabinoids are effective as adjunctive treatment to control pain in MS (Andreae et al., 2015). Patients also use alternative medicine therapies such as yoga, meditation, massage, acupuncture, guided imagery, breathing, and relaxation techniques (Claflin et al., 2018).
Optic neuritis is one of the most common manifestations of MS (Kale, 2016). This may cause visual acuity loss, a “blind spot” in the center of vision, decreased color distinction, reduced light perception, and pain. Diplopia, nystagmus, and eye movement abnormalities due to cranial nerve palsies are also common in MS. The primary strategy for treatment of acute-onset oculomotor syndromes is high-dose corticosteroids. For diplopia, an ophthalmologist should be consulted and lenses containing prisms can be prescribed (Costello, 2016).
In MS, dysphagia occurs because of weakened esophageal muscles that can lead to choking and aspiration pneumonia. Aspiration pneumonia is a leading cause of death in MS (Tassorelli et al., 2008). Clinicians should always assess the gag reflex before feeding a patient with MS. Individuals with liquid dysphagia may complain of coughing or choking while eating, whereas those with solid food dysphagia may complain of food “sticking” in the throat or chest. Other features include dysphonia, “wet” voice/phonation, coughing, or gastroesophageal reflux (GERD) (Poorjavad et al., 2010). Patients with hypersalivation may benefit from anticholinergic medications and/or botulinum toxin injections. Proton pump inhibitors are used to treat symptoms of GERD. A speech pathologist should be consulted for a swallowing assessment and rehabilitative recommendations. In some cases, a nasogastric or percutaneous endoscopic gastrostomy tube may be temporarily or permanently required to maintain optimal nutritional and fluid intake, decrease the risk of choking, and increase survival (Bell & Brammer, 2017).
Dysarthria and Dysphonia
Dysarthria and dysphonia are the most commonly observed speech-related disorders in the MS population (Renauld et al., 2016). Dysarthria is a collection of motor speech disorders caused by weakness, slowness, and/or lack of coordination of the muscles utilized for speech. Dysphonia is a disorder of voice, often seen with dysarthria, and affects respiration, phonation, articulation, pitch, speech rate, stress, prosody, intelligibility, loudness, and vocal quality. Consultation with a speech pathologist for evaluation and rehabilitative strategies is necessary. Speech techniques can be taught that augment voice and voice amplifiers can be used. Although not usually needed, augmentative strategies with communication boards and computerized devices may be used.
Depression is the most common mood disorder for people with MS; it is underdiagnosed and undertreated. It affects over half of all patients with MS and is a contributor to diminished quality of life (Mohr et al., 2007). Depression affects motivation, limits physical abilities, and decreases overall health. Treatment with selective serotonin receptor inhibitors and venlafaxine ER have been shown to work for treatment of depression in older adults with MS (National Multiple Sclerosis Society, 2011). Improvement in depressive symptoms may take up to 12 weeks and patients should be advised to remain on the medication for at least 3 months to experience a benefit. Follow-up telephone calls can encourage the patient to give the medication time to take effect and increase adherence.
Problems with memory and cognition affect 40% to 70% of persons with MS and are more common as patients age (National Multiple Sclerosis Society, 2011). Word retrieval difficulties, delayed verbal recall, and impaired executive functioning are most common. Executive functioning include such activities as balancing a check book, paying bills, and understanding complex directions. Cognitive impairment can cause loss of ability to engage in social activities and maintain relationships. Patients should be encouraged to remain as physically and mentally active as possible to maintain cognitive health. According to Newsome et al. (2017), attention-enhancing medications (modafinil, armodafinil, and amphetamine stimulants) may be effective in improving cognition. All other patient medications should be evaluated for possible cognitive side effects and changed if they are a source. Comorbid illnesses other than MS should be assessed for and treated. Pain, depression, and fatigue should be particularly treated because these disorders can cause or mimic cognitive difficulties.
MS is a chronic neurologic disease and the most common cause of nontraumatic disability in young adults in the United States. It strikes adults in the prime of life and gradually affects neurologic function. It can diminish physical and mental function, affect relationships, employment, financial capacity, and independence. MS patients live with a variety of symptoms such as fatigue, spasticity, pain, visual impairment, dysphagia, cognitive dysfunction, depression, bowel and bladder dysfunction. Neurologic symptoms fluctuate in a pattern of remissions and exacerbations for the majority of those with MS. A multidisciplinary treatment approach is essential. There are a wide number of medications that can be used for disease exacerbation, disease modification, and symptom management. Treating the disease at an early stage within the first 5 years of clinical symptom onset is optimal. Monitoring lesion progression on MRI is essential throughout the disease. Home healthcare providers can use a variety of assessment tools to evaluate disease progression, teach the patient and family how to live with the disorder, and monitor the patient for medication effectiveness and side effects.
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