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When we honestly ask ourselves which person in our lives means the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand.
Henri Nouwen
Four Hot Topics:Balance, Fatigue Spasticity and HeadacheMonique M. Canonico DOAssistant Professor, John A. Burns School of Medicine
2014 Lecture Series- NMSS
Overview
Balance Fatigue Spasticity Headache
Balance
Balance issues may affect over 50% of people living with ms
Study was done in 2008 by Cameron et al Tested by SSEPs Subjects with MS demonstrate differences
in the delay in postural response latencies between their two legs
4 Strengthening and Balance Exercises to Try at Home
1 Heel raises/toe raises: Stand up on tippy-toes and hold for 5 seconds, lower, and then rock back on your heels by lifting your toes up, and hold for 5 seconds. Do this 10 to 15 times. 2 Leg balance: Stand on one leg and hold for up to 30 seconds. Add in challenges like raising your arms to the side or holding overhead to make the exercise more difficult. Repeat this on a variety of surfaces, such as tile, carpet, and standing on a foam cushion to strengthen the connections between physical movement and mental association. 3 Foot exercises: Toes and feet play an important role in balancing. Use your toes to pick up small objects, like marbles or tissues, off the floor. This strengthens the calf and intrinsic muscles of the feet. Do this 5 to 10 times on each side. 4 Balance: Walking in a heel-to-toe pattern forward and backward. Take 5 to 15 steps in each direction. As you train, be aware of your MS symptoms. Challenge yourself but do so in a safe environment
What is a pseudoexacerbation?
There is no evidence whatsoever that exercise in persons with MS can lead to an exacerbation. As a matter of fact, in studies of persons with MS who exercise aggressively there was no higher incidence of exacerbation than non-exercisers.
Gratitude is the fairest blossom which springs from the soul.
Henry Ward Beecher
Tai Chi
Tai Chi is a wonderful approach to balance training. The research has been very, very clear that persons with MS, when they use Tai Chi as balance training that it does improve their balance.
Find a place inside where there's joy, and the joy will burn out the pain.
Joseph Campbell
Fatigue
Fatigue: a complex symptom of MS
• Common disabling symptom
• Up to 75% of MS patients affected
• Worst complaint in 14-40% (50-60% ?) of MS patients
• Lack of physical, mental energy
• Tiredness following ordinary exertion
• Unrelated to effort, especially during relapses
• Transient or chronic, isolated or linked to relapses
• By definition, not a relapse by itself
• Circadian pattern
• Interferes with normal activities
• Major limiting factor in social, familial,
professional activities: ↓ quality of life
• Not restricted to relapsing periods
• Not strictly related to the handicap
based on EDSS
• Intensive inpatient rehabilitation trial ↓
fatigue in MS
Fatigue scales
o FSS (Fatigue Severity Scale, Krupp et al., 1989)
o FAI (Fatigue Assessment Instrument, Schwartz et al., 1993)
o FRS (Fatigue Rating Scale, Chalder et al., 1993)
o FIS (Fatigue Impact Scale, Fisk et al., 1994)
•MFI (Multidimensional Fatigue Inventory, Smets et al., 1995)
o FAMS (Functional Assessment of Multiple Sclerosis, Cella
et al., 1996)
o MFIS (Modified Fatigue Impact Scale, MS Council, 1998)
o FDS (Fatigue Descriptive Scale, Iriarte et al., 1999)
o FSMC (Fatigue Scale for Motor function and Cognition,
Penner et al., 2009)
Non-pharmacological approaches to MS fatigue
• Acknowledgement of this MS symptom
• Learning to manage fatigue (practical arrangements in
daily living, adjustments in professional, familial and
social activities)
• Improvement of sleep
• Strategically timed daytime rest
• Regular physical exercise (avoid physical
deconditioning)
• Behavioral therapy (emotions and coping capacity
influence how fatigue is perceived)
• Recognition of favorable factors (e.g. cooling)
• Avoidance of predisposing factors (e.g. heat)
Treatment of MS fatigue
• Amantadine hydrochloride
– Marked or moderate improvement in 47% MS patients vs.
1% controls (Canadian MS Research Group, 1987)
– RA Cohen & Fisher, 1989: improvement in some aspects of
fatigue (energy level, sense of well-being, perceived attention
and memory, problem solving capacity) in 15/22 MS patients
– 100 mg qd or bd
– Caution: hepatic disease, heart failure, edema, hypotension,
seizures, glaucoma
– Adverse events: livedo retic., nausea, headache, insomnia,
dizziness, nightmares, confusion, edema, orthostatic
hypotension
Treatment of MS fatigue
• 4-aminopyridine (more effective than 3,4-AP), K+
channel blocker (Polman et al, 1994; not confirmed by
Rossini et al, 2001)
– Side effects: headedness, abdominal pain, confusion,
seizures
• Fampridine (4-AP prolonged release, 10 mg; Goodman AD
et al, 2009)
– Improvement of walking ability, speed
– Contra-indications: epilepsy,heartdisorders – Review
process ongoing in Switzerland
Treatment of MS fatigue
• Modafinil 200 mg/day
(Rammohan et al, 2002; Stankoff
et al, 2005; un-/–
Recommendation: 100 mg qd or
bd
– Side effects: agitation,
dizziness, headache, insomnia,
diarrhea, arrhythmia,
hypertension
– Caution: cardiovascular
disease, oral contraceptives
Treatment of MS fatigue
• Aspirin 1.3 g/day (Wingerchuck et al,
1998; 2005)
– Tested vs. placebo in 30 MS patients;
benefit of aspirin measured by the MFIS
and patient preference
• Randomized 3-arm study (Oken et al,
2004) suggests that:
– Participation to either yoga or
exercise class for a 6 month
period reduced the severity of
fatigue compared with a waiting
list control group
Spasticity
Spasticity
stiffness of the limbs resulting from increased muscle tone
Results from demyelination that occurs in nerves that regulate muscle tone. It most frequently affects the group of muscles known as the antigravity or postural muscles, which include the calf muscles, thigh, buttock, groin, and back.
-people with MS who are affected by weakness in the leg muscles, may find mild stiffness helpful in standing and moving. People often experience a worsening of stiffness the more quickly they move their limbs. So, one rule of thumb with spasticity is to move slowly and steadily.
Spasticity
84% are reporting at least some symptoms of spasticity
• 30% are suffering from moderate to severe symptoms
• 1/3 are modifying or discontinuing daily activities because of spasticity
• only 38% are taking medications to control their spasticity (60% DMT)
Spasticity
Spastic Syndromes in MS
Variable distribution- affects both upper and lower limbs
Decreased muscle tone of trunk Changing degree of spasticity depending
on activity, posture and time of day Combined with ataxia
Factors Increasing Spasticity • infections (urinary a.m.)
• pressure sores• pain (even if not perceived by patient)• thrombosis• bladder disturbances, obstipation• fatigue• temperature (heat, cold)• posture (sitting in wheel-chair, supine position)
• emotional stress, anxiety
Tips from Others: Cramps
Muscle cramps can be helped by adding potassium: Melon is a good source.
organic, unfiltered apple cider vinegar made into a drink is also very helpful
Eat bananas and broccoli
Cramps: Tips cont.
Potassium, hydrate with an electrolyte. Gatorade, or Nuun. Hammer makes a product called Endurolytes as well.
Drink healthy teas. Gatorade (as long as the cramps
are not bad), soma for bad cramping Stay hydrated! Pickle juice is great…Old natural
remedy
Cramps: Tips cont.
tonic water. It is the quinine in the tonic water that makes them go away. Diet tonic is horrible, go for the real stuff.
For the Dysesthesias that can involve a girdle band-like pressure, drink any hot liquid. This causes me severe sudden pain and this is the only way that I can get relief but it helps instantly
Cramps: Tips cont.
For bad pain make a massage oil from 2 tea bags and 1/2 cup of canola oil that has been sitting in the sun for a day either out-side or on windowsill. You can use whatever teabags you want. For pain treelike peppermint
Cramps Tips Cont.
Meditate on the muscle that is cramped Deep breathing Ice packs
Meds
Flexeril Robaxin Valium (night) Baclofen Gabapentin dantrolene Magnesium Voltaren cream
Neurotoxin injections
Pros• effect limited to treated muscles • no effect on other muscle groups, no generalized side-effects • well tolerated
Cons ● invasive ● limited to few
muscle groups ● increased
weakness ● transient effect ● high costs
Headache
Headache
Headache is a common problem for people living with multiple sclerosis (MS) - many report suffering from migraine and/or tension type headache. A survey focusing on migraine in people with MS noted that 41% met the study criteria for migraine, compared with about 10% of Canadians in the general population.
MS patients with headache tend to have developed MS at an earlier age, and to have significantly higher rates of relapses and pain-related complaints compared to those who don't have headache. Migraine seems to occur more often in younger people with relapsing-remitting MS, while a smaller proportion of tension-type headache tends to affect individuals who are older, male, and have secondary progressive MS.
Despite the link between MS and migraine, it is not clear if headaches exacerbate MS, or if MS contributes to migraine-like headaches.
Studies comparing MRI scans of MS patients with headache to those with no headache have observed a non-significant association between a greater number of mid-brain plaques and an increased likelihood of headaches, especially headaches with migraine characteristics.
What Type is Your Headache?
Tension Cluster MIGRAINE
Tension
Less common Temporal areas Treat with anti inflammatories
Cluster
100% on ONE side Males older drinkers Night Severe
Migraine
With aura 15% Without aura 85% Usually have one side more common Throbbing 4 hours to many days nausea Light sensitivity Try triptan
Migraine Triggers
Food Wine Smells Sleep deprivation Stress Hormonal changes Vog
MS medications and headache!It is not clear as to whether or not the class of interferon beta (IFNB) medications increase the frequency and duration of headache. Some studies have noted newly devil- oped headaches or an increase in existing headaches in individuals when they begin taking an IFNB for MS, while other studies have seen no difference in headache between patients taking and not taking IFNBs. Studies of headache in patients taking COPAXONE® (glatiramer acetate) or an INFB have suggested that the increase in headache seen with IFNBs compared with COPAXONE® may be due to the different brain pathways used by these drugs.
Migraine Treatment
Herbals
magnesium 800 mg a data
B2 400 mg a day
Butterbur extract
-Triptan for rescue
-Preventives
Review
Balance Fatigue Spasticity Headache
Love Story