Symptoms and Treatment

TREATMENT OPTIONS

Before deciding on an MS treatment, you should fully explore your options with your doctor. He or she can recommend the best MS treatment for you.

Since not all MS treatments have the same effect on the underlying disease, it is important to choose an MS treatment that is proven to slow the progression of physical disability AND reduce flare-ups (relapses).

There are a number of medicines available to help manage multiple sclerosis. They fall into two basic categories:

SYMPTOMATIC
Medicines that treat multiple sclerosis symptoms (symptomatic treatment), such as corticosteroids

IMMODULATORS/DMT’s
Medicines that treat the underlying disease (immomodulators /disease modifying therapies (DMT’s), such as interferon, glatiramer acetate and nataluzumab

Please note that there are other treatments available internationally.

Corticosteroids
Corticosteroids, substances related to the hormones produced by the adrenal glands, have long been used as a major method of treatment to shorten the periods of relapse in MS. Corticosteroids are known for their ability to combat inflammation. Although they do not have any affect on the progression of MS, they do reduce the length of relapse. “Time to recovery is gained.”

Corticosteroids can be administered in a variety of ways. Usually an intravenous drip is used (the medication goes into the bloodstream directly) to administer the corticosteroid known as methylprednisolone. Generally the treatment lasts for three to five days.

Corticosteroids used for a long time (i.e. for months at a stretch) could cause side effects. The effect produced by corticosteroids is best seen during an MS relapse that has occurred suddenly – within a few days. Their effect on symptoms affecting the reduction of muscle power or on symptoms affecting the eye is often better in cases of symptoms affecting the sense of touch or balance.
Not every MS relapse is treated with corticosteroids. Mild relapses are often left to themselves: the patient rests and waits until things improve with time.

In addition to rest and the use of corticosteroids, some recent discoveries have proved to be able to prevent a relapse from occurring or to reduce the severity of the relapse. These substances are dealt with briefly below.

Interferons
There are 5 disease modifying treatments available in South Africa

1. IM Ifnb-1a x1 per week administered intramuscularly once a week
2. Interferon beta 1b administered subcutaneously every other day
3. Glatiramer acetate administered subcutaneously every day
4. Interferon beta 1a administered subcutaneously three times a week
5. Natalizumab administered by infusion every 28 days

Your neurologist will decide which treatment is best for you.

Alternative therapies
You will find that concerned family and friends may often tell you about a new, alternative treatment for MS, known as ‘complementary medicine’. The effectiveness of alternative therapies is often based on conjecture and has not been studied professionally in scientific studies. It can be regarded as a supplement to conventional therapy. However, MS cannot be cured by conventional therapy so this may be a reason to feel that you need to consider other approaches. The feeling that you are doing something yourself about your situation can often give great satisfaction. Or your beliefs may encourage you to seek other forms of treatment, but please discuss it with your doctor before embarking on a “new” therapy.

Remember, MS is often “dormant” (or in remission) and many times patients consider themselves cured by the alternative therapy, while in fact they are in a remission phase of the illness.

Nutrition and MS
There are theories that nutrition is important in MS. Naturally, the food you eat every day should be appropriate – enough vitamins, fresh vegetables, sufficient calcium, not too many unhealthy fats and so on. Some people regard certain diets supplemented with polyunsaturated animal fats (fish oil) or vegetable oils (evening primrose oil – Oenotherabiennis) as being helpful.

The same is also said of a gluten-free diet (gluten is found in grains). There is also a theory that a diet that largely excludes coffee, tea and cocoa can help.

However, with MS, though the myelin may heal enough to alleviate symptoms, scars and lesions are often left behind indicating where the damage was done. These scars can build up and themselves interfere with the electrical impulses travelling across the central nervous system (CNS). In addition, in places where the myelin does not heal, the axon itself can become damaged.Many MS symptoms may suddenly appear, last a few weeks, and then clear up completely. The reason for this is that damaged myelin can often heal itself. (See section on remyelinisation)

When working with your doctor to choose the best multiple sclerosis treatment, consider IM Ifnb-1a x1 per week, the only once-weekly MS treatment that delays progression of disability and reduces the number of flare-ups.

MS symptoms can be very varied. Some problems occur often and some are seldom seen. Some MS symptoms are seen more often early in the course of disease, while others show up later as the disease progresses. The course of illness is different for each person. Even when there are no symptoms, there is progression of damage to the CNS over time. That’s why it is important to begin MS treatment as soon as possible after receiving a diagnosis.

Symptom Specific treatment and/or suggestions to help you cope better
Fatigue
Many people with multiple sclerosis experience fatigue or tiredness. But since fatigue can be a sign of so many other diseases, it is not often immediately identified as being caused by MS. Fatigue occurs in both relapsing multiple sclerosis and in the more progressive types of the disease. It can often last for a few months during which time your energy is used up every day with just a little exertion.Exhaustion, not just physical but also mental, can have the same temporary worsening effect on your condition. When you have MS there are days when it is difficult to make any effort at all – and this varies from day to day and it also varies from person to person.
A simple approach here – depending on how you feel – is to rest and try not to do too much in any one day or change your daily programme.Sometimes amantadine is prescribed for MS patients. This is a substance used for certain types of Parkinson’s disease and used to prevent flu.Another drug prescribed is 4-aminopyridine, but it has disadvantages compared with amantadine because it carries a greater risk of annoying side-effect such as dizziness, tingling in the fingers or a slight feeling of nausea. The side-effects often disappear after 4-aminopyridine has been taken for some time.
Temperature
It is well known that temperature has an effect on MS. Some PwMS have problems with heat – sitting in the sun, in the sauna, or swimming in warm water. Increases in body temperature (fever associated with flu, for instance) can have the same effect. If you are exposed to heat for too long you can become tired or lose muscle strength in you arms and legs.By way of contrast, some MS patients have difficulty with cold.
A few hours of rest in a cool atmosphere or taking a cool bath can help here.Once you know what you are sensitive to; you will be better able to avoid any conditions that cause you problems.
Optic neuritis
This is an inflammation of the optic nerve, the nerve that controls the eye. Over a period of days, you may develop blurred vision. Sometimes you may feel pain behind your eye, which increases when you turn your eye. After initial symptoms, there is gradual improvement, sometimes after several weeks. But recovery is not always complete.During periods of stress, fatigue or fever, the blurred vision in the eye may return. This does not necessarily mean that the MS is active again. Rather, it may be the result of permanent disability that has accumulated over time.
Wait for the relapse to pass or your doctor may prescribe costicosteroid treatment.
Lhermitte’s sign
This is an electrical shock-like sensation that goes down the spine and into the legs when you bend your neck forward.
Speak to your neurologist and/or wait for the episode to pass. Your doctor may also prescribe costicosteroid treatment.
Change in sense of touch
The vast nervous system includes many sensory nerve fibres dedicated to helping you be aware of your environment. They provide the sense of touch in your fingers, and your ability to feel cold or heat on all parts of your body. When these fibres are damaged through MS, your sense of touch may be replaced by feelings of numbness or tingling.Parts of your body may feel burning or cold, even though there is no heat or chill present.Symptoms can be temporary (flare-ups or relapses) or more progressive, and can occur in various parts of the body. This could be just one part of an arm or leg, in the whole lower half of the body, say below the navel, or in a collection of numb patches occurring randomly all over the body.Sometimes, PwMS describe the change as “Walking on cotton-wool”.
No medication works really successfully against symptoms of numbness but over-sensitivity can be reduced somewhat with the use of drugs usually prescribed for epilepsy. When used in MS they are prescribed at a lower dosage. Among these medications are carbamazepine and amitriptyline.
Loss of muscle strength in arms and legs
The nervous system contains large numbers of nerve fibres that control movement – what we call motor function. Often, MS is active on the nerve fibres that control muscle movement. Many people with multiple sclerosis lose muscular strength in the arms and legs as the disease progresses.The loss can range from reduced dexterity (the fingers no longer work so well) to paralysis of an arm or leg.Loss of muscular strength occurs not only in the form of flare-ups or relapses but also as a gradual (progressive) process without recovery. Gradual loss of strength occurs more frequently in the legs than in the arms.
As with any muscle strength loss exercise, walking and medication will help.Depending on the severity, you may need to rely on a cane, crutches or even a wheelchair to get around.
Pain and spasticity
MS can be accompanied by various kinds of pain. Damage to the sensory tracts in the spinal cord can result in burning pain in the arms and legs.MS can often result in damage to the nerves of the face, a painful condition known as “trigeminal neuralgia.”If MS has impaired your ability to walk, the extra strain in the muscles of your back and legs can become painful. MS can also cause extra tension in the muscles of your arms and legs: this is known as “spasticity” and can also be painful. Temperature has a role to play here: when it is hot the symptoms may get worse.Some people experience a band-like tightness around their trunk or legs.
When you are clearly suffering from spasticity you can opt for medication to fight the symptoms. Some examples of these drugs are: baclofen, tizanidine, dantrolene.In general, these drugs are all prescribed at a low dosage in the beginning. Later, depending on the symptoms and the effect produced by the drugs, the dosage can be raised. However it must be raised gradually, otherwise you achieve the opposite of what you are trying to do: the muscles become too slack. If muscle slackness does occur it can be easily corrected by taking a lower dose of the medication.Botulinum toxin is a muscle-relaxing medication used to decrease spasticity related to multiple sclerosis and other neurological conditions.Physiotherapy can also provide relief from spasticity: keep your legs moving with the use of special electrically driven equipment or have a massage.
Balance/coordination problems (Ataxia)
The part of the brain known as the cerebellum controls and corrects all our movements. Damage from MS can result in poor balance or coordination.You may also experience difficulty in grasping small objects which is often accompanied by tremor – leading to problems in writing clearly, or keeping a steady hand.When walking across a room, you may find yourself losing your balance, as if you were intoxicated.Like most MS symptoms, these problems can be temporary (during a flare-up or relapse), or they can be a permanent result of the progression of multiple sclerosis.
These symptoms are more difficult to deal with. For problems with coordination ilsoniazid can be tried or low doses of anti-epileptic drugs (carbamazepine or sodium valproate).In severe cases of tremor, consideration might be given to stereotactic surgery, whereby a small piece of brain tissue, which is causing the problem, is removed. Sometimes brain stimulation during stereotactic surgery can help.
Changes in cognitive function
At some point in the course of your illness you may notice changes in cognitive function, such as your short-term memory and speed of thinking.You may also have difficulty concentrating, making it hard for you to focus your attention and complete more than one job at a time.Other problems may arise in the form of not being able to do mental arithmetic so easily any more.In some patients these symptoms can occur early in the disease; in others, they can come later.
Brain exercises e.g crossword puzzles, sudoku, computer games, etc.
Bladder problems and urine incontinence
Many PwMS may develop trouble with their bladder, and this can take on three different forms:

  • Urge incontinence: – urination starts immediately when the first signs of a full bladder are felt,
  • Incontinence, or
  • Retention – the inability to completely empty the bladder.

It is also possible that you have a combination of these conditions
The way in which these problems are tackled depends on their underlying cause.

If an urge problem or incontinence is involved, you could use incontinence articles. If these have insufficient effect, drugs can be prescribed (such as oxybutinine) to reduce the excessive urge. Urge problems can also occur at night.Another approach is to reduce urine production during the night by taking certain hormone preparations (ADH – Anti diuretic hormone). Alternatively, your physiotherapist can give you exercises to strengthen the appropriate muscles.Retention is more difficult to deal with and can lead to bladder infections. If too much urine is retained, it may become necessary to empty the bladder once or twice a day with a catheter. A tip is to double-void: Go to the toilet when you feel the need and again 5 minutes later.Finally you can consult a urologist, who can prevent or reduce a great deal of discomfort.
Bowel problems
PwMS may experience problems with bowel control. As MS progresses and you develop a more sedentary lifestyle, you may also be troubled with constipation.Urge incontinence of the bowel, where it is difficult to stop once the need is felt to empty the bowels, is less common.
Pay attention to diet – eat enough raw fruit, fibres, vegetables and drink lots of water. When a dietary approach fails to work, and even old-fashioned remedies such as prunes are not successful, laxatives can be used such as bisacodyl or enemas.
Sexual dysfunction
Having multiple sclerosis can lead to problems related to sexual activity, especially if your bladder or bowels are already affected.Men with MS can find it difficult to achieve or maintain an erection.In women, MS often causes a loss of sexual sensitivity, pain during intercourse, an inability to achieve an orgasm, or a reduction in naturally produced lubrication.
Discussing them with your partner can often best solve problems related to lovemaking. Keep in mind that tension in a relationship will worsen any sexual problems you may have with your partner.You may also seek help from a specialist (sexologist). This can help you to find alternative ways of expressing affection for one another.
Mood changes/Depression
Although relatively rare (5%), PwMS have been known to experience inappropriate cheerfulness (euphoria) at some stage throughout the course of the disease.Depression is a more common symptom. Periods of depression are sometimes linked directly to physical changes in the brain caused by the disease. Understandably, it may also be an emotional reaction to having the illness and learning to cope with the symptoms and the challenges they represent. If you are experiencing feelings or symptoms of depression or hopelessness, discuss them with your doctor because treatment for depression is available.
Contact a social worker, a psychologist or a psychiatrist. In mild forms of depression it can often be sufficient if you regularly express your feelings to someone you trust. More severe forms of depression may require medication (anti-depressants) to improve your mood and enable you to once again continue with your daily routine. More of the common anti-depressants are amitriptyline, fluoxetin and fluvoxamin.

 

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