| | Multiple sclerosis (MS) affects the nervous system the way a road block affects freeway traffic. The progressive, degenerative disease of MS damages or destroys the body’s myelin. Myelin coats and protects nerve fibers in much the same way that insulation covers electrical wires, facilitating the normal transmission of electrochemical impulses along nerves. The demyelinated areas, called plaques, block some nerve signals entirely and delay others.Patients with MS have a variety of symptoms, depending on the location of the plaques in the central nervous system. Part 1 of this two-part series discussed the demographics and symptoms of MS. This article covers medical and surgical treatments and the nursing implications of caring for patients with MS.MS is often diagnosed through clinical findings. The National Multiple Sclerosis Society offers the following diagnostic categories:1Definite MS: Consistent course (relapsing-remitting with at least two relapses separated by at least one month or slow or step-wise progression for at least six months). Documented lesions in more than one site in the CNS. Absence of other more likely neurologic explanation.Probable MS: History of relapsing-remitting symptoms. Only one current sign associated with MS. Single bout of symptoms with signs of more than one lesion, with good recovery, then variable symptoms. Absence of other more likely neurologic explanation.Possible MS: History of relapsing-remitting symptoms. No evidence of signs establishing more than one lesion. Absence of other more likely neurologic explanation.A definitive diagnosis cannot be made on the basis of laboratory tests alone. However, cerebrospinal fluid may show abnormal findings suggestive of MS, such as increased white blood cells and elevated proteins and antibodies.2 An evoked potential test (similar to an electroencephalogram) is more specific; it measures the speed of the brain’s response to visual, auditory, and sensory stimuli. It’s possible to detect lesions on these pathways even before they’ve caused clinical symptoms.2,3The most specific test available today is MRI. However, it must also be interpreted in conjunction with clinical symptoms because there are other conditions characterized by similar lesions, such as polyarteritis and lupus erythematosus. The contrast agent gadolinium helps differentiate new lesions from old. While MRI provides only an anatomical picture of lesions, a newer, related technique called magnetic resonance spectroscopy yields information about the brain’s biochemistry in MS.2Education, treatmentBefore discussing specific treatments for MS, it’s worth reviewing some general principles to consider when developing a plan to help patients live as well as possible and cope with symptoms that cannot be improved.4MS patients and their families need to be well-educated about MS. The better informed patients are, the better their adaptation to MS.MS patients should take steps to improve their health, including exercising, eating well, avoiding stress and fatigue, and breaking harmful habits.MS patients need highly individualized care plans because the disease is so variable.MS patients have an illness that is treatable, although not curable. Some patients and families believe MS is always severely disabling, but for most patients, it is not.Medications used for MS fall into two groups. The disease-altering medications treat or prevent relapses or slow progression of disability. Other medications treat specific symptoms.4 The disease-altering therapies will be discussed in greater detail as they may be unfamiliar to some.Three new anti-MS drugs have been approved by the Food and Drug Administration (FDA) in the past five years. They are the first medications proven to reduce the number and severity of exacerbations and to slow the overall progression of physical disability for patients with relapsing forms of MS.5Interferons are proteins that help regulate the immune system. They also have antiviral properties. Genetic engineering has produced a reliable source of this naturally occurring substance.6 Interferon beta-1b (Betaseron) was the first interferon approved for MS, and it’s been in use about five years. It’s administered subcutaneously every other day. Treatment has been shown to reduce the relapse rate by 31 percent. Twenty-seven percent of patients using interferon beta-1b were relapse-free, compared to 17 percent of those on a placebo. MRI shows that fewer new plaques form. The most common side effects are mild injection-site reactions and flu-like symptoms for a few hours after each injection.5Interferon beta-1a (Avonex), approved in May 1996, is administered intramuscularly once a week. It results in a decrease in the progression of disability, a 32-percent reduction in relapses annually, and fewer new plaques. Side effects are similar to those of interferon beta-1b, but may occur less frequently. Ongoing studies are needed to determine optimal dosage, duration of therapy, and advantages and disadvantages of each form of interferon. Interferon beta-1a appears to be better tolerated and seems to result in less progression of disability.5 Studies are under way to determine interferon beta’s effectiveness on progressive MS.1Glatiramer acetate (Copaxone), approved in December 1996, is believed to inhibit certain autoimmune processes. It’s administered by subcutaneous injection daily. In a two-year study, patients taking the drug had a 29-percent lower annual relapse rate than those on placebo. The proportion of patients having no relapses during the test was 34 percent compared to 27 percent for those not on the medication. There was less worsening of disability, and for some, a small improvement. The most common side effects are mild injection-site reactions and brief episodes of flushing, shortness of breath, and palpitations. It’s a good alternative treatment for patients who’ve developed neutralizing antibodies to interferons and are no longer helped by them.5Steroids, the other disease-altering medication used for MS, are often given during a relapse because of their anti-inflammatory properties. These include adrenocorticotropic hormone (ACTH), prednisone, prednisolone, methylprednisolone, betamethasone, and dexamethasone. There is evidence that intravenous methylprednisolone helps patients during acute exacerbation by reducing the duration and severity of symptoms during the attack. However, there is little support for the use of steroids to treat progressive forms of MS. There are also indications that steroids are more helpful for people with motor rather than sensory symptoms.2 Serious side effects include increased susceptibility to infection, osteoporosis, gastrointestinal bleeding, Cushing’s syndrome, hyperglycemia, and atherosclerosis.The immunosupressants cyclosporine and methotrexate may be used for progressive forms of MS to help control the immune system dysfunction.MS symptoms are generally treatable. A wide range of medications can be used to treat specific symptoms. (See “Treating the Symptoms.”)Rehabilitative therapiesMS usually affects mobility and ambulation. Leg weakness, gait imbalance, and spasticity all can be managed with proper rehabilitative methods and equipment. A multidisciplinary approach is important to maintain and restore function and to prevent deterioration. Not all patients with MS become disabled. In fact, most won’t. But many can benefit from rehabilitative services.Physical therapy is important to help restore movement and function, using stretching and range of motion exercises, gait training, and assistive devices such as canes, walkers, and wheelchairs. Many of the complications of immobility (contractures, frozen joints, and decubitus) can be prevented with good physical therapy. Spasticity can be decreased with physical therapy. Transcutaneous electrical nerve stimulators (TENS units, small pacemaker-like boxes that deliver mild shocks to the nerves through electrodes placed on the skin) may alleviate pain. For people with less serious forms of MS, a home exercise program can help maintain long-term independence.Occupational therapy focuses on activities of daily living that involve the arms and hands. An OT works with patients on dressing, eating, and writing and can recommend assistive devices to help with these activities. An OT can prescribe exercises to develop fine coordination or to help compensate for tremors or weakness.Speech therapy can help with the difficulties with communication and eating that some patients experience. Brainstem lesions are the source of motor and sensory problems of the tongue and oral and facial musculature. For those with intractable aspiration, feeding by gastrostomy tube is required.Surgical treatmentSurgical treatment plays only a small role in managing MS symptoms. The most frequent surgical procedure is the implantation of a subcutaneous pump (usually in the abdomen) that continuously delivers baclofen (Lioresal) into the spinal canal to relieve spasticity. A rhizotomy (destruction of a spinal nerve root or the trigeminal nerve) can treat pain refractive to medical therapy. Severe spasticity unrelieved by conservative treatments can be helped by chemical nerve blocks, rhizotomy, tenotomy (cutting of a tendon), or neurectomy (cutting of a nerve).3 These approaches are extreme and have serious consequences, such as muscle wasting, that must be weighed against the potential benefits.Few diseases have such a wide range of symptoms. Some patients can live a nearly normal life, while some progress to disability and need assistance with ADLs. Most fall somewhere in between. Because MS is a chronic disease and has so many aspects to its care, coordination of the care plan and patient-family education by nursing case managers are critical. Many MS patients are on multiple medications, and interactions need to be understood. Some of the most common problems to address include:7,8Impaired physical mobility due to weakness and spasticity: People with relapsing MS can often maintain an active exercise program and should be encouraged to do so, avoiding overheating and overexertion. Ensure that the patient and family members perform exercises as instructed by the PT, OT, or speech therapist and use assistive devices properly. Those with progressive forms of MS need specific activities to lessen spasticity and prevent contractures.Fatigue related to stress of coping and the disease process: The severity of fatigue is often misunderstood by friends and family, and its impact on the patient must be clearly communicated to them. It’s important for the patient to learn to plan ahead, prioritize, and pace activities. Rest periods may be helpful.Overheating can temporarily worsen symptoms even in well patients and must be avoided. Utility companies often offer reduced rates for those with documented MS so the home can be kept cool enough by fans and air conditioning. Cool showers and cotton clothing can help with overheating.Bladder and bowel dysfunction: Adequate fluid intake is important to prevent urinary infection and bladder stones. Nurses should teach patients to manage urinary retention or incontinence through use of a bladder training program or intermittent catheterization. Medications and immobility often cause constipation. Exercise, fluid intake, and judicious use of suppositories and bulk-type laxatives may help.Psychosocial and emotional factors: Counseling can help the patient and family handle the uncertainties of MS. Alterations may be necessary in family, parental, sexual, and work roles. A patient who pursues a healthy lifestyle through diet and exercise and by avoiding smoking, excessive drinking, and stress can better tolerate the symptoms of MS.Financial factors: A case manager can work with the patient and family to ensure access to community support systems. Early referral to the local chapter of the National Multiple Sclerosis Society is helpful; the organization educates patients, families, healthcare professionals and funds research. The case manager serves as the patient’s advocate with the HMO or insurance company to help obtain approvals and authorizations, to ensure contracted providers are used, and to coordinate medical equipment.What’s in the future?There’s a great deal of research going on about MS, funded by organizations like The Myelin Project, the National Multiple Sclerosis Society, and the National Institutes of Health. The experimental is becoming the standard of care more quickly than in the past, and some of the treatments listed below may become mainstream in the next couple of years.2,4,5Myelin-producing cells have been successfully transplanted into animals with an MS-like disease, resulting in production of new myelin.Bone marrow transplantation is being explored as a treatment for the most severe forms of MS in an effort to overcome immune system dysfunction.Monoclonal antibodies, peptide therapies, neutralization of certain T cells, and insulin-like growth factor are under investigation.Development of a vaccine for use in susceptible individuals is under way.Other experimental work involves lymphatic system radiation, bee venom, plasmapheresis, and intravenous immunoglobulin.Years ago, physicians weren’t necessarily in a hurry to confirm the diagnosis of MS; some patients really didn’t want to know. After all, not much could be done to stop the progression of the disease. Today, early diagnosis is vital. Because beta interferon and glatiramer acetate have proved effective in decreasing relapses and slowing the progression of disability, these medications should be started on a timely basis for appropriate patients.Nurses–along with therapists, physicians, and mental health professionals–are important members of the team needed to provide the best care for MS patients. The nurse is well-suited to make physical assessments, especially those related to mobility, swallowing, vision, skin, and bladder and bowel function. With an explicit nursing care plan, the disease once labeled “the crippler of young adults” can be managed so patients maintain a sense of wellness and purpose in spite of their illness. There is help for MS patients, and you can be the one to provide it.ReferencesNational Multiple Sclerosis Society. (1998). [Online].National Institute of Neurological Disorders and Stroke, National Institutes of Health. (1998). [Online].Aminoff, M.J. (1997). “Nervous system.” Current Medical Diagnosis & Treatment-1997. Stamford, Conn.: Appleton & Lange Publishers, 925-927.Rakel, R.R. (Ed.). (1997). Conn’s Current Therapy. Philadelphia: Saunders Co., 937-946, 955-956.Rudick, R.A., et al. (1997). “Management of multiple sclerosis.” New England Journal of Medicine, 337(22), 1,604-1,611.Spratto, G.R., & Woods, A.L. (1997). Delmar’s Therapeutic Class Drug Guide. New York: Delmar Publishers, 1,334-1,335.The Lippincott Manual of Nursing Practice, Sixth Edition. (1997). Philadelphia: Lippincott, 387-389.”Improving Care for Persons With Multiple Sclerosis: Nursing in the New Millennium.” (1997). National Multiple Sclerosis Society Conference, Dec. 10-11, 1997, written transcript. 1-141.Obtain one continuing education hour for this course, #808A, by completing this exam. |
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