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Symptom Management

Symptom management is an essential component (Cohen, 2008; Henze et al., 2006) of comprehensive MS care. While disease management therapies reduce disease activity and slow progression for many people, it is the ongoing management of symptoms that allows people to function in their daily lives with optimal comfort, safety, participation, and quality of life. Given the wide variety of neurological symptoms that can occur in MS, interdisciplinary care is the key to effective management.

Working with patients to manage their symptoms requires awareness not only of the functional impact each symptom might be having, but also the ways in these visible and not-so-visible symptoms affect them emotionally, socially, and vocationally. For most people with MS, the symptoms that are obvious to others at home and at work represent only a small part of they are experiencing – and coping with – on a day-to-day basis. The symptoms that others cannot readily see or understand may actually have the greater impact on people’s lives and interactions with others.  Click here  to see the National MS Society’s publications for your patients, and here for the publications catalog in PDF.

Symptoms of Multiple Sclerosis: Management Strategies and Psychosocial Implications

Below are links to professional publications, tools to assist with communicating about these symptoms with your patients, and patient education resources.

Ambulation Problems

Additional Resources

For information on Spasticity, please select it from the drop down menu above.

  • Symptom
  • Treatment
  • Psychosocial Implication
  • Ataxia
  • Intervention:
    • Referral to PT: mobility aids; exercise
  • Weakness
  • Intervention:
    • Referral to PT: mobility aids; exercise
    Medication:

Resistance to use of mobility aids:

  • Perceptions of self: damaged; weak; “giving in” to MS
  • Others’ perceptions: less intelligent; less competent

Bladder Dysfunction

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication
  • Failure to store (urgency, frequency, incontinence, nocturia)
  • Interventions:
    • check for UTI; scheduled voiding; avoidance of diuretics
    Medications:
    • Anti-cholinergic/anti-muscarinic agents [oxybutynin, tolterodine , hyoscyamine sulfate, propantheline bromide; trospium chloride, solifenacin succinate]
    • onabotulinumtoxinA
  • Failure to empty (urgency, hesitancy, double voiding, feelings of incomplete emptying)
  • Check for UTI; intermittent self-catheterization (ISC); may require indwelling catheter
  • Combined failure to store/failure to empty
  • Combination of the above interventions and medications
  • Fear of drinking liquids
  • Anxiety over loss of control
  • Fear of leaving vicinity of bathroom
  • Embarrassment/shame; fear of incontinence during intercourse; increased fatigue due to interrupted sleep
  • Fear/embarrassment related to catheter use

Bowel Dysfunction

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication
  • Constipation
    (Note: untreated constipation can exacerbate spasticity)
  • Interventions:
    • Bowel training; adequate fluid intake; high-fiber diet; exercise
    Medications:
    • polyethylene glycol, psyllium, docusate, bisacodyl
  • Fecal impaction
  • Manual disimpaction
  • Diarrhea (typically resulting from constipation)
  • Disimpaction and relief of constipation
  • Fecal incontinence
  • Bowel program; anticholinergic medication (for hyperreflexic bowel)
  • Discomfort
  • Embarrassment
  • Society isolation
  • Fear of loss of control
  • Anxiety about leaving the house, being around other people

Cognitive Dysfunction

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication
    • Memory impairment
    • Impaired attention/concentration
    • Slowed processing speed
    • Impaired executive functions
    • Impaired spatial relations
    • Impaired word-finding ability

    Note: Cognitive deficits are often missed in a standard neurologic exam. Read more about brief screening batteries.

  • Interventions:
    • cognitive rehabilitation (S/LP, OT, or neuropsychologists)
    • Restorative approach: direct retraining exercises (have only limited benefit for daily activities)
    • Compensatory approach: aims to improve function via substitution of compensatory strategies/tools for the impaired function
    Medications:
    • disease-modifying agents may slow onset/progression; no other medications have been shown in controlled trials to improve cognition in people

 

  • Individual: denial; anxiety; loss of self-esteem/self-confidence; depression; may interfere with self-care and independence
  • Interpersonal: family strain; marital strain; impaired communication; role shifts within the family
  • Employment: major cause of high unemployment rate in people with MS
  • Healthcare: may affect communication with providers, coordination of care, and compliance with treatment

Fatigue

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication

  • Primary (neurologic): overwhelming lassitude or tiredness that can strike at any time of day, regardless of activity level or amount of sleep

    Secondary: resulting from disturbed sleep; depression; extra exertion due to impairments; medications

  • Interventions:
    • Address secondary contributing factors (primary sleep disturbance, nocturia, pain, spasticity, periodic limb movements); refer to PT (energy conservation; moderate aerobic exercise; mobility aids) and OT (work simplification/energy conservation; nap schedule; use of assistive devices at home/work; cooling strategies/devices
    Medications:
    • amantadine, modafinil, armodafinil, fluoxetine
  • Inability to carry out activities at home and at work (a major factor in early departure from the workforce and changes in family roles)
  • Fatigue of this magnitude affects mood and quality of life
  • Invisible symptom that is easily misinterpreted by others as laziness or disinterest

Mood Changes

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication
  • Mood changes of various kinds are very common in MS
  • Interventions:
    • periodic screenings by physician to identify changes in mood; referral to mental health professional for assessment and management, which may include a combination of psychotherapy, medication, and exercise.
  • Depression

  • SSRI antidepressants

    SNRI antidepressants

    [Note: antidepressant are typically prescribed at inadequate doses for people with MS; every effort should be made to identify the most effective medication at the optimal dose with the fewest side effects]

  • Anxiety

  • SSRI antidepressants

    SNRI antidepressants

  • Irritability
  • Low dose valproic acid; SSRI antidepressants
  • Pseudobulbar affect (10% of people with MS)
  • Dextromethorphan + quinidine (Nuedexta – FDA-approved for this purpose); SSRIs, tricyclics
  • Emotional issues tend to be underreported to the healthcare team, and undertreated when they are reported (with untreated or undertreated depression contributing to the high rate of suicide in MS).
  • Mood changes can interfere with:
    • Self-care
    • Treatment adherence
    • Role performance at home and work
    • Interpersonal relationships
    • Quality of life

Pain/Sensory Problems

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication
  • Sensory symptoms (from loss of myelin): numbness, tingling
  • No treatment required unless interfering with function; medication if necessary; referral to PT/OT if necessary
  • Primary pain(from loss of myelin):
    • Trigeminal neuralgia (sharp facial pain)
  • Medications:
    • carbamazepine, oxcarbamazepine, gabapentin
    Surgery:
    • radiofrequency rhizotomy; radiofrequency electrocoagulation; glycerol rhizotomy
  • Primary pain
    • Neuropathic pain
  • Medications:
    • gabapentin, tricyclics, pregabalin, duloxetine
  • Primary pain
    • Dysesthesias (electric shock-like sensations in trunk or extremities)
  • Medications:
    • tricyclics, pregabalin, gabapentin; Lidoderm patch
    Other:
    • topical application of capsaic acid cream; behavioral self-management (mindfulness, meditation)
    • hypnosis, cognitive behavior therapy
  • Primary pain
    • Retro-orbital pain (with optic neuritis)
  • Medications:
    • High-dose IV steroids

     

  • Secondary pain (musculoskeletal): resulting from poor posture/balance in ambulatory individuals or improper use/fitting of wheelchair
  • Interventions:
    • Referral to PT: gait and balance training; assessment of all seating (home, automobile, work, and wheelchair/scooter);
    Medications:
    • analgesics
  • Clumsiness, balance problems, and loss of dexterity from sensory loss
  • Discomfort that is sometimes excruciating
  • Increase in fatigue caused by medications and interrupted sleep

Note: People often told by doctors that MS does not cause pain. Yet Chronic pain is distracting, depressing, and debilitating

Sexual Dysfunction Problems

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication
  • Primary (result of neurologic impairment): impaired arousal; sensory changes; reduced vaginal lubrication; erectile dysfunction; inability to achieve orgasm
  • Interventions:
    • Education; evaluation; counseling; sexual aids to enhance stimulation
    Medications:
    • Men:
      • Oral medications: sildenafil, vardenafil, tadalafil;
      • Injectable or insertable medication: alprostadil
      • Prosthetic devices
    • Women:
      • Lubricating substances; enhanced stimulation
  • Secondary (resulting from other MS symptoms): fatigue; spasticity; bladder/bowel problems; sensory changes interfere with sexual activity.
     
    [Note: Impaired arousal, erectile dysfunction, and inability to orgasm can also result from medications taken to relieve other symptoms, most notably antidepressants.]
  • Interventions:
    • Evaluation of medications that might be interfering with sexual function
    • Effective management of other MS symptoms [link to sx management page] to reduce impact on sexual function

     

     

     

     

  • Tertiary (resulting from disability-related attitudes/feelings): feeling unattractive; unable to attract a partner; believing that sexuality is incompatible with disability
  • Individual and couple’s counseling and education
Individual:
  • significant impact on gratification, self-esteem, self-confidence; difficult/embarrassing to discuss with healthcare providers
Interpersonal:
  • significant impact on all intimate relationships:
    • Sexual activity can be difficult, exhausting, painful, and unsatisfying
    • Lack of arousal can be misunderstood and resented by partner
    • Learning new ways to be intimate can be frightening and difficult
    • Caregivers may become disinterested in, or uncomfortable with, their disabled partner
    • Person with MS may be reluctant to become intimate with new partner

Spasticity

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication
    • Phasic spasms (flexor or extensor)
    • Sustained increase in muscle tone

    Note: Some degree of spasticity may be required to support weakened limbs and promote functional mobility.

  • Spasticity can range from relatively mild to quite severe, and treatment is approached in a step-wise fashion
    1. Rehabilitative PT: stretching, gait assessment, and balance training, if needed
    2. Oral medications: baclofen, tizanidine, dantrolene, clonazepam, gabapentin, levatiracetam (phasic spasticity), clonidine, diazepam
    3. Intrathecal baclofen pump
    4. onabotulinumtoxinA injections into individual muscles (FDA-approved for upper limb spasticity)
    5. Surgery

 

  • Spasticity can increase fatigue and interfere with functioning at home and at work
  • Spasticity can interfere with sexual activity and comfort
  • Oral medications may increase fatigue and weakness
  • Surgical implantation of pump in abdomen can be frightening
  • Severing of tendons is irreversible

Dysarthria & Dysphonia

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication
  • Poorly articulated, slurred, hypophonic speech
  • Interventions:
    • Referral to S/LP for assessment; exercise program; training with augmentative or alternative communication devices, if needed
  • Slurring can be misinterpreted as drunkenness or lack of intelligence
  • Slow, slurred, and/or dysphonic speech interferes with communication and interactions, and increases the risk of isolation

Dysphagia

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication
  • Difficulty in swallowing that can lead to aspiration and/or inadequate nutrition
     
    Note: Dysphagia can occur even early in the disease course; early recognition and treatment can promote comfort, safety, and optimal nutritional status
  • Interventions:
    • Referral to S/LP for assessment; exercise program; modified diet; non-oral feeding strategies, if needed
  • Fear of loss of control, choking
  • Blenderized foods
  • Mealtime fatigue
  • Loss of pleasurable mealtimes
  • Loss of ability to eat orally

Tremor

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication
  • Involuntary movements of the arms, legs, or head; tremor can be the least treatable and most debilitating symptom of MS
  • Interventions:
    • Referral to PT for balance/coordination exercises; Referral to OT for tools; weights on limbs, eating or writing utensils
    Medications: (success may be minimal but all can be tried)
    • propranolol clonazepam, hydroxyzine, primidone, isoniazid, topiramate, buspirone, ondansetron, gabapentin
    Other:
    • Deep brain stimulation may be considered
  • Loss of control—severe tremor is a major threat to independence
  • Increased fatigue caused by medications

Vertigo

  • Symptom
  • Treatment
  • Psychosocial Implication
  • Severe dizziness and nausea caused by inflammation in the brainstem
  • Interventions:
    • Referral to OT for vestibular rehabilitation
    Medications: 
    • Meclizine; benzodiazepines; IV fluids and high-dose corticosteroids if nausea prevents the use of oral medications
  • Vertigo interferes with functioning at home and at work

Visual Impairment

Additional Resources

  • Symptom
  • Treatment
  • Psychosocial Implication
  • Optic neuritis—temporary loss or disturbance of vision, often accompanied by pain; may also cause a “blind spot” (scotoma) in center of vision
  • Medications:
    • High-dose corticosteroids
    Interventions:
    • Training in visual compensation, environmental modifications, adaptive equipment, as needed
  • Diplopia—double vision
  • Interventions:
    • Training in visual compensation, environmental modifications, adaptive equipment, as needed
  • Nystagmus—rhythmic jerkiness or bounce in one or both eyes
  • Medications:
    • Baclofen, clonazepam, gabapentin
    Interventions:
    • Training in visual compensation, environmental modifications, adaptive equipment, as needed
  • Visual symptoms can threaten independent functioning (e.g., driving), increase fatigue, and interfere with activities at work and at home