Elsevier

The Lancet Neurology

Volume 4, Issue 10, October 2005, Pages 643-652
The Lancet Neurology

Review
Symptomatic therapy and neurorehabilitation in multiple sclerosis

https://doi.org/10.1016/S1474-4422(05)70193-9Get rights and content

Summary

Multiple sclerosis (MS) is associated with a variety of symptoms and functional deficits that result in a range of progressive impairments and handicap. Symptoms that contribute to loss of independence and restrictions in social activities lead to continuing decline in quality of life. Our aim is to give an updated overview on the management of symptoms and rehabilitation measures in MS. Appropriate use of these treatment options might help to reduce long-term consequences of MS in daily life. First, we review treatment of the main symptoms of MS: fatigue, bladder and bowel disturbances, sexual dysfunction, cognitive and affective disorders, and spasticity. Even though these symptomatic therapies have benefits, their use is limited by possible side-effects. Moreover, many common disabling symptoms, such as weakness, are not amenable to drug treatment. However, neurorehabilitation has been shown to ease the burden of these symptoms by improving self-performance and independence. Second, we discuss comprehensive multidisciplinary rehabilitation and specific treatment options. Even though rehabilitation has no direct influence on disease progression, studies to date have shown that this type of intervention improves personal activities and ability to participate in social activities, thereby improving quality of life. Treatment should be adapted depending on: the individual patient's needs, demands of their surrounding environment, type and degree of disability, and treatment goals. Improvement commonly persists for several months beyond the treatment period, mostly as a result of reconditioning and adaptation and appropriate use of medical and social support at home. These findings suggest that quality of life is determined by disability and handicap more than by functional deficits and disease progression.

Introduction

The many symptoms (panel 1) associated with multiple sclerosis (MS) cause functional impairment and handicap. The symptom pattern depends on the location of lesions in the CNS, although most inflammatory foci do not cause symptoms. The most common symptoms in relapsing-remitting MS are visual (46%) and sensory disturbances (41%), whereas in primary progressive forms of MS the most prevalent symptoms are gait disorders (88%) and pareses (38%).1 Other symptoms such as bladder problems and cognitive disturbances commonly develop later in the course of the disease and can become the most noticeable. The consequences of these functional deficits in activities of daily life are variable. Many patients commonly view fatigue as having the most adverse consequences in daily life, followed by disturbances of balance, pareses, and bladder disorders.2 MS has an early disease onset, a progressive course, and very long duration with a median survival time of about 40 years from diagnosis; thus there is a high prevalence of disabilities with consequences in personal as well as social domains. 15 years after diagnosis, around 50% of patients with MS use walking aids and 29% need a wheelchair.3, 4 During the first 10 years of disease, 50–80% become unable to work.5 Thus, the main burden of the disease manifests during the 5th and 6th decades of a patient's life, a time when most people are particularly active socially as well as in their careers. Socioeconomic consequences of MS are substantial: the direct and indirect costs for one person with MS per year are estimated at around ¤50 000 or US$62 000, and there is a strong correlation between costs and increasing score on the expanded disability status scale (EDSS).6 Half of the direct costs are attributable to care of 17% of patients—those with the most severe disability of whom 6·5% live in nursing homes.7

For many patients with MS, quality of life can deteriorate and they lose their independence and become less able to participate in social activities. Treatment of the symptoms of MS is essential and it requires a multidisciplinary approach encompassing drug therapy, psychological counselling, and physiotherapy.

Rehabilitation can be defined as an active process of education and enablement, which is focused on the appropriate management of disability and minimising limitation of handicap, with the goal of achieving full recovery. However, with a condition such as MS in which full recovery is not possible, goals become focused on achieving the best physical, mental, and social potential of patients so that they can remain, or become, integrated into a social environment that is appropriate for them. The longer-term benefits from management of symptoms and emotional status help to compensate for functional deficits and enable patients to adapt to their circumstances more readily.

This paper provides an overview of management options for each group of symptoms that accompany MS and examines clinical-trial evidence that supports the efficacy of neurorehabilitation. In 2004, a group of experts in MS from Germany, Switzerland, and Austria published a comprehensive review and consensus statement on symptomatic treatment and rehabilitation in MS;8 it consists of existing evidence based literature and neurologists' therapeutic experience who have dealt with these problems over a long time.

Section snippets

Fatigue

Fatigue is the single symptom that patients identify as interfering most with their daily activities. The causes are multifactorial. A poor sleep pattern, resulting from pain, nocturia, and spasticity, is commonly the cause. Another equally important factor might be the immunological processes of MS. Several of the cytokines involved in the pathogenesis of MS are known to induce sleep, especially interleukin, which affects the hypothalamic axis and results in reduced cerebral metabolism.9 Motor

Bladder symptoms

Bladder symptoms are particularly incapacitating in daily life. Spinal-cord disease in MS is thought to be the main cause of pelvic-organ dysfunction. Impairment of bladder function is commonly characterised by urgency, which is the consequence of detrusor hyper-reflexia. The symptom of urgency is in many cases coupled with urinary frequency resulting from reduced bladder capacity. A few patients also have difficulty in initiating micturition or are unable to achieve complete bladder emptying.

Sexual dysfunction

Many patients with MS experience sexual dysfunction.36 In a comparative study, sexual dysfunction was found in 73% of patients with MS compared with 39% of those with other chronic diseases and 13% of healthy controls.37 The main complaints for women are anorgasmia or hyporgasmia, decreased vaginal lubrication, and reduced libido. In men, the main complaints are impotence or erectile dysfunction, ejaculatory dysfunction, orgasmic dysfunction, and reduced libido.37 These symptoms can have an

Chronic constipation

Chronic constipation is a substantial source of distress for patients with chronic neurological diseases including MS. Non-specific measures to control constipation include: body fitness programmes, dietary intervention in the form of fibre, avoidance of chocolate, and adequate intake of fluids. However, increased fluid intake can in turn complicate co-existing bladder problems. Pharmacological interventions are in the form of laxative-type agents.43, 44

Cognitive deficit and affective disturbances

40–65% of patients with MS have some degree of cognitive deficit.45 These deficits can occur early in the course of the disease and can have long-term effects on patients and their families. Unemployment, social isolation, and the need for personal assistance at home are more likely in patients with cognitive impairment (figure 1),46 and these patients also have a high risk of developing depression. Many patients with cognitive deficits, particularly early in the course of MS, have to give up

Pain

Pain in MS can be the result of demyelination in one of the pain-conducting pathways. The most common form is trigeminal neuralgia, in which the block is in the root entry zone of the trigeminal nerve.60 Other nerve regions are affected as a result of similar processes. The increased pain perception is a result of abnormal impulse transmission caused by demyelination and is best treated with antiepileptic drugs.61 Other sources of pain are indirectly related to the disease. Wheelchair use (

Spasticity

Difficulties arising from spasticity include limitations in the range of movement and malpositioning of the joints, commonly accompanied by pain, and limitations of normal pursuit of movements. Individual factors and type and distribution of spasticity must be taken into account in decisions on therapeutic options. Spasticity can initially be managed with exercise (figure 3), changes in daily activities, physiotherapy, occupational therapy, or a combination of these methods. If these approaches

Neurorehabilitation

Evidence-based research on the effectiveness of neurorehabilitation69 is compromised by difficulties in trial design. There are no specific guidelines on the duration of treatment or its intensity. Controlled studies are rare owing to the justifiable reluctance, on ethical grounds, to withhold therapy judged to be the best. Moreover, masking of treatment blinding is never possible, although masking of observers might be possible.

Conclusions

Despite newer immunomodulating therapies, there is a continuing demand for treatments that address the negative effects of MS symptoms on daily life. Symptomatic treatment and rehabilitation are effective in this respect. There is, however, much scope for further research on more effective and more tolerable drug treatments and the accurate nature and extent of rehabilitation techniques in MS. The main priorities are to define which treatment modalities are most effective and to identify the

Search Strategy and selection criteria

Data for this review were identified by searches of MEDLINE with the search terms “multiple sclerosis”, “rehabilitation”, “management”, “spasticity”, “fatigue”, “sexual dysfunction”, “cognitive deficits”, “incontinence”, and “pelvic organ dysfunction” in April 2005, without limit on year of publication. More recent publications, however, were preferred if they were of similar content. References were also identified from relevant articles and through searches of the authors' files. Only

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