Symptoms Seen in MS

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Symptoms Seen in MS

• Many different symptoms depending on the
  location of the lesions
• Each individual has different symptoms, and some
  the same as the next person with MS
• It is a rare symptom that doesnt have some
  management potential
• Poor management leads to decreasing function and
  quality of life

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Nurses Role in Symptom Management

• Recognize symptom
• Encourage communication about the symptom
• With right person
• At the right time
• Follow-through with management

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Symptoms Change

• Some are intermittent
• Some are continual
• Some worsen
• Therapy has to be geared to what the patient is
  experiencing now but flexible enough to change
  when the symptom does

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Common Symptoms

• Fatigue
• Sensory changes paresthesias, tingling
• Visual changes
• Motor dysfunction weakness, spasticity
• Bowel, bladder, and sexual dysfunction
• Depression

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Less Common Symptoms

• Cognitive dysfunction
• Speech and swallowing problems
• Neuropathic pain
• Tremor and decreased coordination
• Lhermittes sign
• Vertigo

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Rare Symptoms

• Seizures
• Hearing loss, tinnitus
• Paralysis

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Nursing Issues in MS Care

• Educate patients and families
• Manage symptoms
• Coordinate services
• Promote health and well-being
• Inspire hope

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Heat Sensitivity

• Many people affected, but not all
• Heat can be external or internal
• Symptoms occurring in the presence of heat are
  not an exacerbation of MS but a reaction to heat
  (pseudoexacerbation)

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Fatigue

• What is fatigue?
• A feeling of physical tiredness or lack of energy
  that many people experience from time to time
• A subjective lack of physical and/or mental
  energy that is perceived by the individual or
  caregiver to interfere with usual and desired
  activities

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MS Fatigue (Lassitude)

• Comes on easily, without warning
• Prevents sustained physical functioning
• Is worsened by heat
• Makes it difficult to work productively
• May appear early in the disease

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MS Fatigue

• Is not related to level of disability
• May affect motor function
• May affect cognitive function

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Fatigue May Be Caused by Other Factors

• Sleep deprivation or interruption
• Insomnia/sleep apnea
• Restless leg syndrome
• Spasms and spasticity
• Urinary problems
• Medications

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Fatigue May Be Caused by Other Factors

• Deconditioning
• Fatigue of handicap
• Depression
• Muscle fatigue
• Short-circuiting fatigue
• Increased weakness in muscle with fatigue
• Worsens if muscle is repeatedly asked to perform

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Fatigue May Be Caused by Other Factors

• Systemic disease
• Thyroid
• Anemia
• Cardiovascular disease
• Renal disease
• Liver disease

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Fatigue

• May accompany relapses. Sudden onset or worsening
  of fatigue is often associated with other
  neurologic problems.

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Management

• Depends on sources of fatigue
• Sleep problems need evaluation
• If bladder related, need bladder work-up
• Spasticity and spasms need evaluation and
  management
• Restless legs respond well to medical treatment
• Decrease caffeine

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Management

• Deconditioning
• Physical therapy to provide exercise program
  suitable for MS
• As patients increase endurance, fatigue should
  decrease

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Muscle Fatigue

• Patients need to understand that some exercise is
  good, but overuse will worsen fatigue.

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Fatigue of Handicap

• Physical and occupational therapy to evaluate
  gait, transfers, movement, and equipment.

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Nutrition

• Evaluate current dietboth content and timing
• Eating smaller amounts more often usually helps
• Following the pyramid is essential

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Depression

• Manage pharmacologically and with professional
  therapy
• Exercise will help
• Support groups

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Cognitive Problems That Worsen With Fatigue

• Evaluate cognitive problems
• Learn compensatory techniques to help with
  fatigue or ones that will prevent getting fatigue

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If Felt to Be MS Fatigue

• Work with occupational therapist to learn fatigue
  management and energy conservation techniques
• REST!!!!!!
• Pharmacological intervention

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Pharmacological Intervention

• Modafinil
• Amantadine
• Fluoxetine
• Pemoline

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Motor Symptoms

• Weakness
• Physical therapy
• Encourage adaptive equipment
• Decreases fatigue
• Increases safety
• Increases activity in community
• Strengthening exercises

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Motor Symptoms

• Spasticity
• 60 of people with MS have cortical spinal
  involvement with some degree of spasticity
  accompanying this process
• Occurs commonly in the quadriceps, hamstrings,
  and gastrocnemius muscles

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Spasticity Impacts

• Gait
• Seating
• Hygiene
• Comfort

• Energy level
• Sexual activity
• ADLs
• Skin health

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Spasticity, If Present, May Worsen With

• Infection
• Relapse
• Constipation
• Some medications

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Management of Spasticity

• Stretching, movement
• Physical therapy intervention
• Stretching program
• Evaluation and recommendations for AFO, adaptive
  equipment

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Oral Pharmacologic Intervention

• Baclofen
• Tizanidine
• Neurontin
• Valium
• Clonidine
• Dantrium

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Injections

• Botox Local paralysis to muscles lasting 3
  months. Allows injected muscles to go through
  rigorous stretching program while maximally
  effective. May need re-injection.
• Phenol Local obliteration of nerves in a given
  area. May need re-injection as nerves regenerate.

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Surgical Interventions

• Insertion of intrathecal baclofen pump
• Surgery may be needed if contracture has occurred

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Spasticity Conclusion

• Spasticity, if managed from onset, generally does
  not reach contraction stage.

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Cerebellar

• Tremor
• Physical therapy, occupational therapy
• Pharmacologic
• Klonopin, Neurontin, surgical interventions
• Ataxia/dysmetria
• Physical therapy, occupational therapy
• Adaptive equipment
• Balance and coordination exercises

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Visual

• Decreased acuity
• Scotoma
• Pain
• Color desaturation
• Diplopia
• Nystagmus

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Sensory

• Numbness, hypersensitivity
• Other sensory phenomena
• Dysesthesias (mild to severe)

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Pain

• Pain does occur in MS
• Pain is what individual says it is
• Pain is an individual, learned, social, and
  cultural response

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Pain

• Pain Sources
• Mechanical problems
• Standing
• Walking, sitting, lying
• Equipment problems
• Canes, walkers
• Beds
• Skin problems

• Other Medical Problems
• Osteoarthritis
• Back problems
• Contractures
• Frozen shoulders
• Compression fractures
• Avascular necrosis

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Pain Classifications

• Paroxysmal onset (acute pain syndrome)
• Nonacute or secondary pain (related to relapse)
• Iatrogenic pain (caused by treatment)
• Insidious onset (chronic pain syndrome)
• Mechanical, musculoskeletal, greater than 6 months

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Neuropathic Pain

• Demyelinated nerve fibers
• Described as burning, tingling, shooting,
  stabbing, electric shocklike, searing, worse at
  night
• Responds poorly to standard treatment

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Neuropathic Pain

• Trigeminal neuralgia
• Tonic spasms
• Zingers (electric shocklike pain)

• Back pain
• Headaches
• Extremity dysesthesias

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Treatments for Pain

• Tricyclic antidepressants inhibit reuptake of
  serotonin and norepinephrine
• Imipramine, amitriptyline, nortriptyline,
  desipramine
• Anti-epileptics act to block sodium channels
• Dilantin, Tegretol, Neurontin, Lamictal,
  Topamax

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Treatments for Pain

• Topical agents
• Capsaicin, lidocaine, heat and cold
• Nonnarcotic and narcotic opioids
• Cannabis, Ultram, oxycodone (OxyContin),
  methadone

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Treatments for Pain

• Pain from other sources
• Treat the source
• Look at walking, seating, chair position, bed
  position
• Look at skin
• Look at spasticity
• Rule out arthritis, musculoskeletal problems

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Speech and Swallowing Impairment

• Dysphasia
• Articulation
• Speed of delivery
• Decreased breath support
• Dysphagia
• Mechanism of swallow may be uncoordinated
• Often see silent aspiration

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Dysphagia

• At risk for aspiration
• At risk for poor nutrition and weight loss
• Diagnosis
• Bed-side evaluation
• Modified barium swallow
• Safe swallowing techniques
• PEG
• Dietary modifications

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Cognition
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What Is Cognition?

• Thinking skills
• Understanding language and expression of thoughts
  and ideas
• Concentrating, shifting attention, multitasking
• Learning and remembering new information
• Planning and performing complex tasks
• Solving problems

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Cognitive Dysfunction in MS

• May be experienced by 4570 of people with MS
• Not related to physical disability
• May occur early in disease

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Cognitive Dysfunction in MS Is

• Under recognized
• Under diagnosed
• Misdiagnosed

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Cognitive Dysfunction

• Often correlates with findings on MRI
• Number of lesions
• Location of lesions
• Presence of atrophy

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Effects of Cognitive Dysfunction

• ADL
• Household management
• Personal care, family care
• Employment
• Recreational activities
• Relationships
• Social interactions

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Areas Affected

• Information processing
• Verbal and visual memory
• Attention/concentration
• Word retrieval
• Reasoning/problem solving
• Visual/spatial abilities
• Executive functioning

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Patterns of Cognitive Deficit

• Cognitively intact 2436
• 1 domain affected 4356
• Multiple domains affected 2022

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Signs of Cognitive Dysfunction

• Trouble remembering
• Word-finding problems
• Slowness in or inability to understand what is
  heard or written
• Difficulty with following directions
• Trouble with decision making
• Emotional changes
• Forgetting your thought mid-sentence

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Signs of Cognitive Dysfunction

• Poor performance reviews at work
• More hours to accomplish the same job
• Difficulty starting a project
• Difficulty finishing a project
• Problems with balancing the checkbook
• Problems with following a recipe
• Car accidents

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Other Causes of Cognitive Dysfunction in MS

• Fatigue
• Mental fatigue
• Slows speed of processing information, accuracy,
  and reaction time
• Depression
• Working memory
• Stress

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Diagnosis

• Neuropsychologist
• Speech/language pathologist
• Occupational therapist

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Emotional Issues in MS

• Grief
• Depression
• Bipolar disorder
• Mood swings
• Emotional incontinence

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Depression

• Occurs in 35 of general population
• May occur in approximately 60 of people with MS
• Under recognized, under diagnosed

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Depression and MS

• Psychological basis dealing with the disease
• Pathophysiological mechanism related to
  demyelination in the brain and immune
  dysregulation
• See less in purely spinal cord disease
• See more in patients with brain atrophy

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Signs of Depression

• Loss of appetite
• Increased appetite
• Increased sleep
• Decreased sleep

• Irritability
• Altered personal relationships
• Sadness

• Less pleasure in activities

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Management

• Medications
• Psychotherapy
• Both
• Exercise
• Support groups
• Spirituality

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Emotional Lability

• Pathologic crying and/or laughing
• Inability to control
• Usually out of proportion to amount of sadness or
  happiness
• Usually a sign of emotional distress
• Usually responds well to antidepressants