Symptomatic Treatment
The symptoms of the disease can be influenced in each stage of the disease if the symptoms are troubling the patient.
However, it is necessary to reasonably consider the amount of medicines used so that their effects do not counteract each other and so that they do not burden the patient and worsen their quality of life. Some symptoms are far easier to influence with rehabilitation, particularly physical and mental therapy.
Spasticity and Walking Disorders
Spasticity (increased muscular tension, spasms) and related walking disorders can be influenced by baclofen, tizanidine and some anti-epileptic drugs. The treatment needs to be started with small doses and needs to be managed according to its effect. Physiotherapy is an important part of the treatment of spasticity. If spasticity is severe and limits not only the patient’s mobility but also the care of their personal hygiene, it is possible to apply botulinum toxin in the most affected muscles or it is possible to insert a catheter into the spinal canal, through which baclofen is released from a subcutaneous reservoir on the abdomen directly to the spinal cord (a baclofen pump).
Cannabinoids, extracts from cannabis containing tetrahydrocannabinol (THC) and cannabidiol (CBD), may help in those cases where other treatments of spasticity or neurogenic pains failed. However, their effect is not miraculous. There is a single registered sublingual spray where it is possible to set the dose accurately and limit adverse reactions. Patients with RS do not develop addiction and are not exposed to a risk of transitioning to “hard” drugs. Patients often experiment with cannabinoids on their own; however, it is necessary to point out that use of cannabinoids has a negative impact on cognition so it is not recommended by any means at the beginning of the disease and in those cases where it is possible to use other ways to mitigate the symptoms.
In order to increase the walking speed, fampridine (4-aminopyridine with gradual release) has been newly included in treatment and approximately 30 % of patients respond well to it. It speeds up the transmission through a demyelinated nerve fibre. The response to the medicine is tested by measuring the walking speed without therapy and after several hours.
Depression
This is an often undetected, denied and neglected symptom of MS. Sometimes, it only manifests itself as fatigue; sometimes it is apathy, thoughts that everything is pointless, even suicidal thoughts. Unlike the classic (referred to as major) depression, the depression related to MS is characterised by less self-blaming and self-criticism. In the eyes of the patient, life loses its meaning, especially if the patient’s life was based on health as an automatic matter of course to which everyone is entitled. Many patients are able to deal with the rebuilding of their value ladder on their own; others need help with this. This help can come from a physician, friends, a psychologist, a cleric. No person should ever be left alone in depression.
Up to 50 % of patients with MS suffer from depression without any connection to the severity of their affliction. Conversely, in old textbooks, it is possible to find reports that patients with RS are disproportionately euphoric. At present, we almost never see this, mostly with severe disability and long course of untreated disease. Today, even depression can be well influenced by treatment. Suicidal rate for patients with MS is 7 times higher than in the general population; therefore, suicidal thoughts need to be detected in time.
Administration of antidepressants should always be accompanied with an offer of psychotherapy, which should definitely be more accessible to patients with MS than it has been up until now.
Sometimes, the problem is not an actual depression but it is increased anxiety, irritability. Sometimes, there is weeping alternating with laughter without adequate stimuli. These manifestations may be troubling for both the patient and the people around them, and therefore it is unnecessary to resist the administration of medicines that can suppress these symptoms and, as a result, mitigate the stress from disproportionate anxiety or unpleasant behavioural manifestations.
Disorders in the area of intellectual performance (cognitive disorders) and memory are more difficult to influence, if they are not caused by depression. Intellectual exercise is one of the most important things. This is why it will not be beneficial to any person with MS, if they must leave their job. Contacts with people, communication, absorption of new information and its processing is an exercise, which the brain needs so that the connections among nerve cells do not cease to exist. This is why, for example, it is meaningful even for elder people (even without MS) to study a new language or study at a university of third age even at a more advanced age.
Sphincter Problems (Urological Problems)
Up to 85 % of patients with MS suffers from problems with urination to a varying degree. Besides carrying out the basic urine test and urine culture test, which may reveal a hidden infection (the patient is often unaware of it due to the reduced sensitivity of their mucous membrane), it is necessary to find out whether residual urine is not responsible for the problems. The solution is that the patient learns to catheterize on their own (usually more than 100 ml of residual urine). This is called clean intermittent self-catheterization. If the bacteria are not eradicated in spite of that, an urologist will prescribe antibiotics. In less serious cases, medicines are used, which, however, may be troubling due to adverse reactions (sleepiness, dry mouth). Physiotherapy is also recommended for strengthening the muscles of pelvic diaphragm.
Patients often address their problems with urination by reducing their intake of fluids. By doing so, they limit the possibilities of their organisms to get rid of harmful substances, which are normally excreted in urine, and damage their entire urinary tract system. For example, the inflammation of renal pelvises (pyelonephritis) is a resulting complication
Problems with stool are somewhat less frequent and more difficult to resolve. The problem is more often constipation, which needs to be influenced by dietary measures (for example, by including a large amount of fibres in the diet, leaving white flour from the diet or possibly adding soaked grains mixed with yoghurt and fruit to the diet), laxative mineral waters, exercises in regular defecation. Laxatives always have only a short-term effect and they need to be regarded as the last resort. Constipation gets worse with lack of physical exercise, which is a risk particularly for persons confined to bed or a wheel chair.
Involuntary discharge of stool is a matter that is almost impossible to resolve, unless a regular defecation reflex is successfully developed (for example, early in the morning) and unless the consistency of the stool is successfully influenced through diet. As concerns diarrhoea, this situation needs to be addressed with a physician immediately because it can be an infectious disease, which needs to be treated.
Fatigue
Many medicines have been tried to influence fatigue, mostly without success. It is always necessary to rule out associated diseases: thyroid gland disorders, anaemia, chronic infection. The most effective way to influence fatigue is physical exercise, specifically a combination of aerobic and anaerobic exercise.
With MS, the approach to influencing fatigue should be comprehensive:
1. Change of regimen
– sleep and rest during the day
– change of the level of activity at home and at work
2. Change of dietary and eating habits
– balance of macronutrients: the ratio between proteins and carbohydrates controls the release of glucagon and insulin and influences the production of “good” eicosanoids, which support the immune response, have an anti-inflammatory effect, reduce the sensitivity of pain receptors and reduce fatigue:
– drinking caffeine beverages
3. Pharmacological therapy
– influencing the actual disease
– suppressing inflammations
– symptomatic therapy of depression, pain, spasticity, tremor
– targeted influencing of fatigue – amantadine (dopamine agonist), pemoline (stimulates the CNS)
4. Psychotherapy
– influencing anxiety
– influencing depression
– teaching how to cope with stress
5. Ergotherapy
– choosing energy-saving strategies
– choosing aids making it easier to perform ADLs
– modifying the person’s environment
6. Physiotherapy
– symptomatic treatment of spasticity, pain, balance disorders, tremor, muscle weakness, breathing disorders
– influencing the deconditioning of the body
– cold therapy
Pain
Painful symptoms are painful spasms in limbs where it is necessary to influence the muscle tension with antispastic drugs as well as typical neuralgias of trigeminal nerve manifesting themselves with a lashing pain in the face. Tingling and burning sensations, abnormal sensations particularly in lower limbs (paraesthesia) may not be accompanied by any movement disorders but they can make the life of a person with MS less pleasant.
Carbamazepine is the basic medicine for seizure-type symptoms, painful symptoms and paraesthesia. It is one of the basic medicines used to treat epilepsy. Its dosage is determined on a case-by-case basis; the treatment needs to be introduced very slowly because it may increase fatigue temporarily. If the treatment does not bring relief after several weeks, there is no point in continuing the treatment. It is possible to try out a different anti-epileptic drug, which has already been subjected to several clinical trials with MS. Commencement of the treatment and the side effects are similar. With neuralgia of trigeminal nerve, which resists treatment, it is possible to see a neurosurgeon. Today, the procedures are gentle and effective. It often happens that the nidus of inflammation forms directly at the point where the trigeminal nerve branches out from the CNS.
Sexual Problems
More than 50 % of men suffer from erectile dysfunction; rarely, this can also be the first symptom of MS. At present, there are many medicines, which even patients with MS can use; only if these medicines do not have a sufficient effect is it necessary to carry out a more detailed examination.
However, first it is necessary to rule out the influence of such medicines as antidepressants, anxiolytics and medicines reducing muscle tension. Women have problems with spasticity of thigh adductors, reduced sensitivity and moisturization of vaginal mucous membrane. Lubricants and antispastics can provide relief.
Once again, psychotherapy and assistance in finding a satisfactory way of fulfilling a partner relationship without stress and anxiety is a necessity. The path to the solution begins with the partners learning to talk openly about their feelings and problems.
Tremor and Cerebellar Disorders
Tremor cannot be influenced well; it is possible to try out clonazepam but the desired effect is mostly achieved by doses, which significantly worsen fatigue. The neurosurgical procedures known from treatment of Parkinson’s disease are not applicable to MS.
Swallowing Disorders
In later stages of the disease, problems with swallowing may appear. A speech therapist is able to teach a patient manoeuvres, with which it is possible to make the act of swallowing safer; another alternative is to modify the consistency of food.
