Diagnosis and Treatment of Specific Impairments

1
Diagnosis and Treatment of Specific Impairments

• Multiple Sclerosis
• National Clinical Guidelines for Diagnosis and
  Management in Primary and Secondary Care

2
WHO- International Classification of Functions

• Impairment Loss of a structure or a function
• Weakness
• Spasticity
• Ataxia
• Loss of sensations
• Disability/ Activity Limitation Inability to
  perform an activity
• Mobility
• Communication
• Social Interactions
• Activities of Daily Living
• Handicap/ Restricted participation Inability to
  fulfil ones role
• Parental
• Vocational
• Recreational
• Social

3
Prevalence of Symptoms

• Fatigue 39-78
• Bladder 31-59
• Bowels 39- 58
• Weakness/Mobility 63-89
• Spasms 21-49
• Balance 54-82
• Sensory loss 33-63
• Pain 28-36
• Vision- 33-51
• Memory 34-46
• Swallowing 33-43
• Speech 23-51
• Sexual dysfunction 55-70
• Pressure ulcers ?

4
Fatigue-Cause

• Prevalence 39-78
• Symptomatic-
• Depression
• Drugs,
• Sleep,
• Pain,
• Poor nutrition

5
Fatigue Interventions

• Drugs
• Amantidine
• ? Modafinil

• Behavioural modification
• Training
• Cooling devices
• Electromagnetic threapy
• Bee venom
• Acupuncture/Acupressure
• Yoga

6
Evidence Amantidine

• 4RCTs- 236 subjects
• Small effect at 200 mg daily ( Overall
  improvement, patient choice to continue
  medication)
• Number to be treated -?1/7
• Cost per year 200
• Cost benefit- No data on
• cost of management / loss of earnings due to
  fatigue in MS

7
Interventions

• Behavioural modification
• Physical Training
• Cooling devices
• Electromagnetic threapy
• Bee venom
• Acupuncture
• Acupressure
• Yoga

• No
• Rigorous
• Trials
• Branas et al Treatments for fatigue in MS a
  rapid and systematic review. Health Technology
  Assessment 2000 4 No 27

8
Fatigue

• Consider fatigue
• Consider depression
• Other factors causing fatigue
• Review medications
• General advice regarding fatigue management,
  aerobic exercises, energy conservation
  techniques
• Small benefit from amantidine

9
Modafinil- Open Label-1

• 72 subjects
• Fatigue severity Scale , Modified Fatigue Impact
  Scale, Visual analogue scale for fatigue, Epworth
  sleepiness scale
• Tolerated 90 completed the study
• Adverse events- Headache, nausea, fatigue
• No difference between 200 and 400 mg
• Rammohan KW, etal J Neurol Neurosurg Psychiatry
  2002 72 179-183

10
Modafinil- Open Label-2

• N- 50
• Open label
• Scales Fatigue severity Scale , Epworth
  sleepiness scale, Overall satisfaction with
  treatment
• 100 mg to 400 mg depending on response
• Self appraisal 41/50
• Scales 43/50
• 3 discontinued due to dizziness and nervousness
• Zifko et al J Neurol 2002 249 983-987

11
Modafinil- RCT

• Randomised double blind placebo controlled
  parallel group study
• 115 subjects, stable disability, MFIS
• 5 weeks
• 100 mg increased by 100 mg per week up to maximum
  of 400 mg. No change between 21 and 35 days
• Primary outcome MFIS on day 35.
• Intention to treat analysis

12
Modafinil in MS RCT

• Improved in both groups
• No significant difference
• There was no improvement of fatigue in patients
  with MS treated with modafinil v/s placebo
  according to modified fatigue impact scale
• Stankoff et al Neurology 2005 64 1139-43

13
Aerobic exercises

• Treadmill training Delayed and immediate 16
  subjects
• 10 meter walk- decreased
• Van den Berg et al JNNP 2006
• Aerobic exercises in MS n 8
• GNDS, 6 meter walk
• Kileff and Ashburn Clin Rehabil 2005
• Surakka et al 2004, n95
• Motor fatigue at knee ( static 30s sustained
  contraction) reduced fatigue in women (
  p0.0014)

14
Bladder

• 31-59
• 25 Catheter, 14 Indwelling catheter
• 78 incidents/ 226 Ms subjects of bladder problems
  in one year in ( Oxfordshire audit)
• Impact Emotional distress, curtailed social
  activity, disturbed sleep and increases risk of
  pressure ulcers UTI.
• Reduces QoL as measured by SF-36
• Nortvedt M et al Multiple Sclerosis 2001

15
Interventions

• Non pharmacological techniques
• Devices
• Drugs
• Surgical interventions

16
Recommendations

• Each professional in contact with a person with
  MS should consider whether the person has any
  problems in controlling micturition
• Frequency
• Urgency
• Nocturia
• Difficulty in passing urine
• Incontinence

17

• Any person with MS who has bladder symptom
  should
• Post micturiton residual volume measured
• Assessed for UTI- Dipstick
• Treat UTI

18
Urge Incontinence

• Advice to changes to clothing and toilet
  arrangements
• Intermittent self catheterisation if there is a
  high residual volume and the person is able and
  willing
• Anticholinergic medications
• Oxybutynin or tolterodine
• Check for post voidal residual urine

19

• Desmopressin 100-400 micrograms orally and 10-40
  micrograms intranasally- A
• Nocturia
• Failed other meassures and control incontinence
  brief period ( eg travel)
• Should never be used more than once in 24 hours

20

• Incontinence Despite treatment
• Refer to specialist continence services
• Pelvic floor exercises
• Electrical stimulation of pelvic floor
• Convene drain for men/ pads for women

21

• Intermittent Self catheterisation
• Longer term- Urethral/ suprapubic
  catheterisation
• Intravesical Botulinum Toxin Context of Research

22
UTI

• Prophylactic use of antibiotics and cranberry
  juice should not be recommended
• Cranberry 5 studies
• 3 reviews on antibiotic prophylaxis No effect.
  Increases drug resistance

23

• New urinary tract symptoms
• Malaise
• Fever
• Increase in weakness
• Spasticity
• Urine Dipstick
• Culture
• Appropriate antibiotic
• gt3 UTI per year- Residual urine, continence
  services

24
Catheters

• Only after all non-invasive methods have been
  tried
• To be reviewed regularly, to check whether less
  invasive methods can be used
• Drainage system should be emptied regularly
  before the bag is overfull Bladder washouts
  should not be routinely used

25
Bowels

• Immobility
• Drugs
• Neurological control of defecation
• 43- 54Constipation
• 29- 51 incontinence
• 39- 68 Bowel dysfunction
• Social embarrassment, pressure ulcers, curtailing
  activities

26
Recommendations

• Each professional in contact with a person with
  MS should consider whether the person has any
  problems controlling bowel function- urgency,
  pain, constipation, incontinence

27

• Constipation ( Bowels open less than twice a
  week)
• Fluid intake
• Dietary changes
• Oral laxatives
• If no success- suppositories or enemas
• Faecal incontinence- Constipation with
  overflow.

28
Weakness

• 63-89
• Contributing factors Fatigue, poor balance, poor
  cardio-respiratory fitness
• Assess the motor power using a valid scale
• Aerobic training
• Neurophysiotherapist
• Teach techniques and provide equipments to
  optimise motor performance
• Postural abnormalities specialised supportive
  equipments- seating, beds, wheel chairs.

29
Spasticity and Spasms

• Spasticity- 49
• Spasms- 21
• It maybe necessary to reduce spasms or spasticity
  without expecting a functional benefit as they
  themselves cause pain and distress
• Benefits Reduce burden of care, enable sitting,
  reduce risk of pressure ulcers, prevent
  contractures

30

• Consider spasticity in any person with motor
  weakness
• If present/ increased- look for infection/pain
• Persistent spasticity should be assessed by a
  neurophysiotherapist and taught
• passive stretching and physical techniques to
  reduce spasticity and prevent contracture

31
Step-2

• Consider more specific measures only if
  spasticity and spasms are causing pain, distress,
  limiting individuals functions.
• Baclofen/ gabapentin- initial drugs
• Only if unsuccessful Tizanidine, diazepam
• clonazepam
• -dantrolene
• Combinations should be used only after seeking
  further specialists advice

32
Step-3

• Team specialising in assessment and management of
  spasticity.
• Standing and weight bearing
• Splints
• Serial casting
• Special seating
• Intrathecal baclofen
• Phenol injections to motor points

33
Botulinum toxin- B

• Relatively localised hypertonia or spasticity not
  responding to other treatments
• By someone with appropriate experience and
  expertise
• Followed by active input from a
  neurophysioytherapist
• In the context of a specialist MS/ rehabilitation
  services

34
Contractures

• Shortening of the soft tissues around a joint
  that limits the passive and active movements at
  that joint
• Prevalence- not known
• When they develop- not known
• Impact- Pain, care, mobility, sitting, expensive
  care packages

35

• Consider preventive measures in people with
  weakness and/or spasticity
• Treat spasticity
• Prevention
• Stretching , positioning
• Treatment
• serial casts
• splints
• botulinum toxin
• surgery

36
Ataxia

• 37- 82
• Interventions
• Ondansetron
• INH
• Thalamic stimulation

37
Recommendations

• Specialist neurorehabilitation team for
  techniques and equipments
• Severe and intractable- neurosurgical team from a
  specialist centre

38
Sensory losses

• 63 - 87
• Technique and equipment
• Personal safety

39
Visual problems

• Impaired vision- 10 -33
• Double vision- 51
• The individuals ability to read from newspaper,
  book or other written material or to see TV
• Optometrist- glasses
• Specialist ophthalmology clinic
• Nystagmus interfering with vision- Gabapentin-
  time limited trial by a suitable specialist

40

• Unable to read
• Low vision equipment and adaptive technology
• Specialist social services team
• Register as partially sighted

41
Pain

• Neuropathic pain
• Musculoskeletal pain
• Incidental pain unrelated to MS
• Often incorrectly diagnosed and managed

42
Pain- recommendations

• Each professional whether pain is a significant
  problem or a contributing factor for their
  disability
• All pain should be subject to full clinical
  diagnosis and referral to appropriate special
  services if required

43
Musculoskeletal pain

• Assessed by a specialist therapist
• Exercises
• Passive movements
• Better seating
• If non pharmacological interventions are not
  effective- analgesics
• TENS
• Antidepressants
• Do not use ultrasound, laser, anticonvulsants
• CBT if person has sufficiently well preserved
  cognition -

44
Neuropathic pain

• Sharp shooting pain/ painful hypersensitivity
• Gabapentin -
• Carbamazepine
• Amitriptyline
• Specialist pain service if persisting

45
Cognitive losses

• 43-46
• Impaired memory-34
• Frontal lobe functions- 33
• Contributing Factors Drugs, Depression, Fatigue
• Impact ADL, judgement, work, legal decisions,
  communications, social interactions

46

• Consider cognitive problems in persons with MS
• When making a complex medical decision like
  starting a new treatment- assess cognition and
  ascertain their ability to understand and
  participate adequately
• If cognitive impairment-
• review drugs
• Depression

47

• Offer a formal cognitive assessment
• Advise about financial and other vulnerability to
  abuse
• Ask whether results can be communicated to other
  people

48
Communication and Speech

• 23- 51
• Usually due to dysarthria
• Cognitive losse

49
Emotionalism

• Tendency to cry or rarely laugh when this is not
  the felt emotion and often without any ability to
  control this behaviour
• 10-32
• Assessment by some one with suitable expertise
• Tricyclic antidepressants
• Selective serotonin reuptake inhibitors
• Behavioural management strategies

50
Depression

• 36
• People with MS have higher rate of suicides than
  people with other chronic disabling conditions.
• Primary- Specific impairment
• Secondary - disability, Altered life
  circumstances, pain , social isolation or loss of
  employment

51

• Screening question-
• Do you feel depressed?
• If severe depression liaison psychiatrist
• Look for possible contributing factors ( Chronic
  pain, social isolation)
• CBT
• Antidepressants
• Consider anxiety

52
Anxiety

• 16-25
• Specialist assessment
• Psychological based treatment
• Antidepressants/Benzodiazepines

53
Swallowing Difficulties

• 30-43
• Malnutrition
• Chest infections

54
Recommendations

• Unable to transfer independently
• Any signs of bulbar dysfunction
• Eye movement problems/ speech/ataxia
• Chest infection
• Screening question Difficulties with chewing, or
  swallowing
• Whether they altered diet due recently

55

• Any person with any abnormality should be
  assessed by a SALT
• Adjustment in seating
• Chest physiotherapy
• Short term- NGT
• Check weight- monthly
• Discuss regarding PEG and document their wishes

56

• Indications for PEG
• Recurrent chest infections
• Inadequate food or fluid intake
• Prolonged/ distressing feeding
• NGT more than a month
• PEG to be inserted by a suitable specialist
• Full training to family/ carers who are going to
  be involved in feeding

57
Communication

• Dysarthria
• Cognitive loss
• Communication with people outside home
• Over telephones

58

• SALT- Techniques to improve and maintain speech
  production and clarity
• Alternative non verbal communication
• Augmentative aid to communication
• Recommendation 4

59
Sexual dysfunction

• 55- 70 in men with MS
• General population- 12
• Contributing factors
• Motor impairments
• Spasticity
• Pain
• Sensory loss
• Bladder dysfunction
• Bowel dysfunction
• Mood
• medications

60

• Men with MS
• Ask experience erectile dysfunction
• Look for contributory factors
• Sildenafil 25-100mg
• Intraurethral Aiprostadil/ intracavernosal
  papaverine

61

• Women with MS ask about failure of arousal,
  lubrication, anorgasmia
• Ameliorate contributing factors
• Provide information about locally available
  services

62
Pressure ulcers

• High risk due to
• Limited mobility
• Impairment of sensations
• Under nutrition
• Cognitive loss
• 10/226 developed pressure ulcers over 10 month
  period

63
Recommendations

• All persons with MS who uses a wheel chair should
  be assessed for pressure ulcers
• Nutritional status
• Suitable equipment
• Manual handling techniques

64

• Appropriate specialist mattress
• Inspect at risk areas
• Regular turning should not be depended upon as a
  policy for preventing pressure ulcers

65

• If pressure ulcers occur
• Investigate as an adverse event
• Seek advice from a specialist service
• Low loss mattress

66
Complementary therapies

• Use of unlicensed interventions that are not
  generally recognised by health professionals as
  influencing the disease process or ameliorating
  specific symptoms
• Expensive
• Risk
• Some evidence to suggest that may benefit but
  not sufficient to recommend
• Recommended to evaluate any therapies by
  themselves, including risks and costs
• Encourage to discuss and inform doctors and
  health care professionals, if they decide to use.

67
Suggested review check list activity domains

• Since you were last seen or assessed has any
  activity you used to undertake been limited,
  stopped or affected?
• Are you still able to undertake as you wish
• Vocational activities 9 work, education, )
• Leisure activities
• Family roles
• Community activities
• Domestic activities
• Washing , dressing, using toilet
• Getting about and getting in and out of the house
• Controlling environment( opening doors, switching
  things on and off, using phone)

68
Questions Impairment domains

• Since you were last seen, have you developed any
  new problems with
• Fatigue, endurance, being over tired
• Speech and communication
• Balance and falling
• Chewing and swallowing
• Unintended change in weight
• Pain or abnormal sensations
• Control over your bladder and bowels
• Control over your movements
• Vision and eyes
• Thinking and remembering
• Mood
• Sexual function and partnership relations
• How do you get on in social stiuvations
• Are there any new problems that you might think
  be due to MS that concern you?