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S Y M P T O M M A N A G E M E N T I N

M S

A M B E R P E S K I N , A G C N S - B C , M S C N

O C H S N E R M U L T I P L E S C L E R O S I S C E N T E R

M A R C H 1 5 , 2 0 1 9

DISCLOSURES

• AcordaTherapeutics Speakers Bureau--2015-2018

• Biogen Speakers Bureau--2019

FATIGUE• Most common and debilitating symptom of MS

• Can be primary or secondary

– Co-Q-10 500mg daily

– B12

– Amantadine 100mg once or twice a day

– Provigil/Nuvigil

– Adderal/Ritalin/Focalin/Vyvanse

– Exercise

– Energy conservation

SPASTICITY

• Affects 40% of MS patients

• What is spasticity?

– Tightness, cramping, stiffness in the muscles

– Painful muscle spasms/involuntary contractions

– Clonus

– Impairs mobility

– Usually worse at night

SPASTICITY• Muscle relaxers

• Stretching

• Intrathecal baclofen pump

• Physical therapy

• Botox

G AIT D ISTURBANCE

• Walking speed

– Ampyra

• Foot drop

– AFO, Walk-Aid/Bioness

• Imbalance—cane, crutch, walker (U-

step)

MOOD DISTURBANCE

• Causes:

– physical changes in the brain

– emotional response to the stress of dealing with MS.

• Depression/Anxiety

– Anti-depressants

– Anti-anxiety agents

– Counseling

– Support groups

– Yoga

COGNITIVE ISSUES

• Concentration, problem solving, decision making,

short-term memory, word finding

• Can create problems at home and at work

• Other causes?—fatigue, medications, depression

– Cognitive testing, using calendars, reminders, notes,

pacing, cognitive rehab, EXERCISE

• Failure of bladder to store

urine

– Urgency, Frequency,

Incontinence

• Failure of bladder to empty

– Frequency, Retention,

Hesitancy, Interrupted

Stream

• Urinary Tract Infections—UA,

culture, Abx if needed

BLADDER DYSFUNCTION

• What can we do about it?

– Bladder ultrasound

– Medications—Ditropan, Detrol,

Vesicare (decrease bladder

emptying); Tamsulosin, Doxazosin,

Terazosin (improve emptying)

– Botox—relaxes the muscle, reduces

incontinence, improves quality of life

– Timed Voiding

– Intermittent Catheterization

– Referral to Urology/Urogynecology

BOWEL DYSFUNCTION

• Incontinence

• Diarrhea

• Constipation

• Neurogenic bowel, medication, lack of activity

• Recommendations for Improvement:

• Increase water intake

• Eat more fiber and healthy oils!

• Laxatives—bulking agents, osmotic laxatives, stimulant laxatives, stool

softeners

• The right position—Squatty Potty

SLEEP ISSUES

• Insomnia

– Sleep aides

– Sleep hygiene

• Obstructive sleep apnea

– CPAP

• Restless legs/Spasms

• Nocturia

PAIN/SENSORY DISTURBANCE

• Spasms

– Baclofen/Tizanidine

• Numbness/tingling

• Neuropathic pain—burning, electrical

shocks, shooting pain, hot/cold

sensations, itching

– Gabapentin, Cymbalta

• Trigeminal neuralgia

– Carbamazepine

• L’hermitte’s sign

HEAT SENSITIVITY

• Cooling vests

• Cooling towels

• Lightweight clothing

• Adequate hydration

• Exercise in cooler parts of the day

• REST!

A FEW OTHERS…

• Tremor

– Propranolol, primidone

• Vertigo/dizziness

– meclizine, vestibular rehab

• Fine motor coordination—occupational therapy

• Pseudobulbar Affect

– Nuedexta

• Slurred/stuttered speech

– Speech therapy

• Trouble swallowing, choking

– Swallow evaluations

• Vision impairment

EDUCATE YOUR PATIENTS!

• MS symptoms CAN improve!

• Don’t smoke!!

– Tobacco use in MS patients results in worsening vision, urinary problems, depression, and anxiety.

– Patients who smoke have greater disability.

– Smoking can also lead to an increased progression and a lower quality of life.

• Exercise

• Eat well

THANK YOU!!QUESTIONS?