Symptomatic management and rehabilitation in multiple sclerosis.

Although agents that have a partial benefit on relapses in multiple sclerosis (MS) are available, there is little to suggest that we are able to influence disease progression in any meaningful way—thus the need to manage the accumulating impairments and disability that accompany progression actively. Attempting to evaluate and treat the wide range of fluctuating and interacting symptoms associated with MS can be frustrating and at times demoralising for patient and physician alike. Additionally, available drug treatment is limited both in its eYcacy and in the evidence available to guide its use. Many agents are poorly tolerated, often because they will exacerbate co-existing symptoms. Given the limitations of drug treatment both for symptom management and disease progression, it is essential that the neurologist is aware of other approaches to management, knows when and how to refer to other disciplines, and is able to explain the reasons for the referral. Equally, it is important that the patient leaves the consultation with a clear management strategy and not with the old adage ringing in their ears “it is because of your MS and there is nothing to be done.” A key element in symptomatic treatment is the involvement of the patient in their management. This requires that they have an understanding of their symptoms (for example, spasticity) and are taught how to minimise their impact (for example, positioning, standing programme, etc). In approaching the patient with established MS, a detailed assessment of their symptoms—their character, severity, and particularly their impact on the patient’s day-to-day life—is essential. The first question to ask is: “Does this symptom relate to MS or is there an entirely diVerent explanation?” This may not always be straightforward. Patients and their general practitioners usually ascribe any new symptoms to MS and patients are usually worried about the possibility of another relapse. This may be reasonably straightforward for characteristic symptoms such as Lhermitte’s phenomenon, paroxysmal ataxia, and dysarthria, but is more diYcult for sensory disturbance or discomfort in the lumbar area, which may well be secondary to other MS symptoms such as weakness and spasticity but may also result from nerve root compression. Clinical examination may be helpful but it may also be necessary to carry out further investigations to exclude other pathologies. Next, ask whether the symptom is having a major impact on day-to-day living and to establish what additional symptoms co-exist. The responses to these questions may determine whether or not drug treatment is appropriate and will influence the choice of approach. For example, an element of stiVness in the lower limbs may not warrant drug intervention unless it is aVecting mobility. Physiotherapy assessment may help determine this. The use of anti-spasticity agents may be limited because of their side eVects if, for example, the patient also suVers from severe fatigue. It is important to consider all therapeutic options—not just drug treatment but also input from disciplines with particular expertise, such as physiotherapist, uroneurologist, etc. Consider a multidisciplinary assessment if the situation is particularly complex or there have been notable changes in a number of areas. This should not be restricted to patients with very severe disability but should also be directed to those with potential to improve, even if only for the short to medium term. Involvement of other disciplines needs to be coordinated. The goal of every treatment approach should be to encourage self management and to provide the patient with a sense of control over their disease. Thus a sensible management strategy for the majority of symptoms should include: c education c therapy input c drug treatment. Finally, it is important to remember that this is a progressive condition, and the patient will need periodic reassessment; treatments that were inappropriate or considered excessive (for example, baclofen for spasticity) may need to be reconsidered.