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This learning activity aims to increase the nurse’s knowledge of the disease process of multiple sclerosis and the medical and nursing management of the affected individual.
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This learning activity aims to increase the nurse’s knowledge of the disease process of multiple sclerosis and the medical and nursing management of the affected individual.
This learning activity is designed to allow the learner to:
- describe pathophysiological changes that occur in multiple sclerosis
- explain proposed risk factors for multiple sclerosis
- describe clinical manifestations of multiple sclerosis as they relate to destruction in the various areas of the central nervous system
- briefly outline how multiple sclerosis is diagnosed
- describe pharmacological management of multiple sclerosis during an exacerbation, in modulating the disease course, and in symptom management
- discuss nursing care aimed at managing/controlling symptoms, promoting independence, and dealing with the chronicity of the disease
Multiple sclerosis (MS) is the most common immune-mediated demyelinating disease of the central nervous system (CNS). Demyelination destroys the myelin, a fatty protein substance covering the nerve fibers and acting as an insulator. This demyelination results in impaired transmission of nerve impulses in the brain, optic nerves, and spinal cord (Honan, 2019).
MS can occur at any age but typically becomes apparent in young adults between the ages of 20 and 40 and rarely affects those over 60. MS affects women up to three times more often than men. Approximately 400,000 people in the US are affected by MS. There is currently no cure for MS, so treatment goals instead focus on intervening during exacerbations, delaying disease progression, and managing chronic symptoms (Bauldoff et al., 2020; Hoffman & Sullivan, 2017; Honan, 2019).
Anatomy and Physiology
The fundamental unit of the CNS is the neuron or nerve cell. Each neuron comprises a cell body, dendrites, and an axon (see Figure 1 below). The neuron is responsible for the transmission of electrochemical impulses. Afferent or sensory neurons transmit impulses from the peripheral nervous system (PNS) toward the CNS (see figure 2 below). Efferent or motor neurons transmit impulses away from the CNS toward the PNS. When a neuron receives an impulse from another neuron, the result can be excitation (increasing action) or inhibition (decreasing action). The dendrites, thin projections extending from the neuronal body, receive impulses passed further down the axon for transmission to other cells. Many axons are surrounded by a myelin sheath, a white covering composed of lipids that provides insulation and helps speed nerve impulse transmission. Due to this white appearance, myelinated axons are known as white matter. Nonmyelinated axons are known as gray matter. When there is a defect of the myelin sheath, such as what is seen with MS, impulses cannot travel as efficiently from the brain to the rest of the body or vice versa (Bauldoff et al., 2020; Ignatavicius et al., 2018).
An autoimmune process is triggered in patients with MS, disrupting the blood-brain barrier and allowing lymphocytes to enter the CNS tissue. The lymphocytes produce immunoglobulin G (IgG), an antibody that attacks and damages myelin; this causes demyelination and triggers inflammation, resulting in edema (see Figure 3 below). Once the demyelination occurs, nerve impulse flow is interrupted. This disruption leads to various clinical manifestations depending on the area(s) affected. The areas in the CNS that are most often affected in patients with MS include the optic nerves, chiasm and tracts, cerebrum, brainstem, cerebellum, and spinal cord. As the inflammation subsides, the myelin can regenerate, and the symptoms of the disease may temporarily subside. Unfortunately, after repeated inflammatory attacks on the myelin, the damage becomes irreparable, and areas of the underlying axons begin to degenerate, leading to scarring or plaques. As a result, the individual is left with permanent, irreversible damage (Bauldoff et al., 2020; Honan, 2019).
There are four clinical subtypes of MS: (a) relapsing-remitting, (b) primary progressive, (c) secondary progressive, and (d) progressive-relapsing (Olek & Howard, 2022)
The most common subtype of MS is relapsing-remitting MS (RRMS; see Figure 4 above). Approximately 85% of individuals with MS suffer from this disease course. Women are 2-3 times more likely to suffer from RRMS than men. RRMS is characterized by periods of remission interspersed with clinical manifestation exacerbations or relapses. During relapses, new symptoms may develop, and old symptoms may reappear. Relapses or exacerbations can last days to months. Patients may experience almost complete recovery or absence of symptoms when remissions occur. Over time, remissions become less complete, with more residual baseline symptoms. Remission may be instantaneous or occur slowly. Between relapses, there is an absence of disease progression. Patients with RRMS often develop more brain lesions, inflammatory lesions, and spinal cord lesions seen on magnetic resonance imaging (MRI) as they age. Relapses that lead to permanent disability are not common in RRMS. One study of 1078 patients found that only seven patients experienced permanent disability requiring an assistive device such as a cane, crutch, or brace to ambulate 100 m (Hinkle & Cheever, 2018; Hoffman & Sullivan, 2017; Honan, 2019; National Multiple Sclerosis Society, n.d.-f; Olek & Howard, 2022).
Primary progressive MS (PPMS; see figure 4 above) is characterized by continuous neurologic deterioration from the onset of clinical manifestations. With this form, the disease never goes into remission. The patient may experience plateaus, temporary minor improvements in symptoms, or acute relapses. Disabling symptoms steadily increase as the disease progresses over time. Approximately 10 to 15% of individuals with MS have this disease course. The average age of onset is 40 years old, ten years older than the average age of patients diagnosed with RRMS. There are no imaging tests available to differentiate PPMS from RRMS; therefore, differential diagnosis is made based on patient history and symptoms.
Patients with PPMS often present with spinal cord syndrome with asymmetric spastic paraparesis that worsens over months. These patients have a poorer prognosis than patients diagnosed with RRMS (Hinkle & Cheever, 2018; Ignatavicius et al., 2018; National Multiple Sclerosis Society, n.d.-c).
Progressive-relapsing MS (PRMS) is characterized by a gradual neurologic deterioration from the onset with acute relapses. The term progressive-relapsing MS has become obsolete. This form of MS is now characterized as a subcategory of PPMS known as PPMS with active disease (National Multiple Sclerosis Society, n.d.-e).
Secondary progressive MS (SPMS; see Figure 4 below) is characterized by gradual neurologic deterioration with or without relapses which develops after an initial period of the relapsing-remitting disease. Although some improvement may be noted after a relapse, there is no actual recovery period. Approximately 40% of patients with RRMS will eventually progress to SPMS. The transition for patients who progress to SPMS usually occurs 10-20 years after their initial diagnosis. There are no criteria for determining when RRMS has transitioned to SPMS; therefore, the diagnosis is often made retrospectively. There are different subcategories of SPMS, including active, not active, with progression, or without progression. Currently, the primary go
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Risk Factors
Although the etiology of MS is unknown, there is speculation that environmental factors and genetic susceptibility play a role in triggering the immune response that damages the myelin sheath, which can progress to involve the oligodendrocytes, axons, and neurons. Research suggests that contracting infectious mononucleosis following exposure to the Epstein-Barr virus (EBV) may play a role in developing MS. Other suggested environmental risks include smoking, vitamin D deficiency, ultra-violet light exposure, obesity in childhood or adolescence, repeated head trauma or concussions, and treatment with anti-tumor necrosis factor-alpha (Bauldoff et al., 2020; Hinkle & Cheever, 2018; Honan, 2019; National Multiple Sclerosis Society, n.d.-d; Olek & Howard, 2022).
Genetic predisposition increases the risk for non-Hispanic Whites. There is a greater frequency of MS in temperate regions and latitudes away from the equator. The prevalence of MS is highest in the northern US, southern Canada, Europe, New Zealand, and southern Australia. MS is less common in Asia and rarely seen in tropical or subtropical regions. One retrospective study of Americans diagnosed with MS found that non-Hispanic White Americans developed the disease earlier (31.1 years of age) than Black Americans (33.7 years). Black Americans had a shorter time between diagnosis and the initiation of treatment. Therefore, access to healthcare was not considered a contributing factor to the increase in debility seen in this population. Although diagnosed later in life, Black Americans are more likely to develop an ambulatory disability, multifocal symptoms, and disease limited to the optic nerves and spinal cord than White Americans (Hinkle & Cheever, 2018; Hoffman & Sullivan, 2017; Honan, 2019; National Multiple Sclerosis Society, n.d.-d; Olek & Howard, 2022).
Diagnosis
MS can be challenging to diagnose because symptoms may be intermittent and mimic other disease processes. A detailed history and physical and thorough neurological examination are essential. The neurological examination should assess for optic neuritis by checking for color desaturation or visual loss, eye movement abnormalities, including internuclear ophthalmoplegia (impaired horizontal eye movements) or nystagmus (jerking movement of the eyes either vertically or horizontally); upper motor neuron involvement causing spasticity, hyperreflexia, or a positive Babinski sign; ataxia and gait disturbance; hemisensory loss and bilateral sensory loss or paresthesia in extremities. Although there are no clinical findings unique to MS, there are findings highly indicative of MS. Unless contraindicated, patients being evaluated for MS should, at minimum, have Magnetic resonance imaging (MRI) of the brain and spine without contrast. An MRI is used to identify the presence of lesions (plaques) within the CNS. It is the gold standard diagnostic test for MS. (Hoffman & Sullivan, 2017; Olek & Howard, 2021). Absolute contraindications to MRI use include:
- cardiac implantable electronic devices such as a pacemaker or implantable cardioverter-defibrillator (ICD)
- metal intraocular foreign bodies; it is vital to ask each patient if they have ever welded without wearing proper eye protection or had a facial injury involving metal
- implantable neurostimulator
- cochlear implants/ear implants or hearing aids; a 1.5-tesla MRI scanner is compatible with the BAHA cochlear implant if the battery is removed before testing
- drug infusion pumps, including those used for insulin, analgesics, or chemotherapy delivery
- catheters that have metal components, such as a Swan-Ganz catheter
- any foreign metal objects, including bullets, shotgun pellets, or shrapnel; it is important to ask patients to be honest about the possibility of having any foreign metal objects in their body
- cerebral artery aneurysm clips
- magnetic dental implants
- tissue expander
- artificial limbs should be removed before scanning; this does not include artificial joints following total knee arthroplasty (TKA) or total hip arthroplasty (THA)
- piercings should be removed before scanning (Ghadimi & Sapra, 2021).
It is essential to get a complete patient history to determine if any contraindications are present before entering the MRI room. It is also important to determine if the patient is claustrophobic, as an MRI of the brain and spine requires the patient’s upper body to enter the narrow MRI machine opening. If anxiety or claustrophobia inhibits the completion of testing, the patient may require a referral to a facility with an open MRI or premedication with an anxiolytic (Ghadimi & Sapra, 2021).
An MRI is the most definitive test available for diagnosing a patient with MS; however, it is only one of several diagnostic tests that can be used. For patients with typical symptoms but insufficient clinical data and MRI results to confirm a diagnosis of MS, a lumbar puncture can be performed to obtain cerebrospinal fluid (CSF). The CSF is then analyzed for an increased number of T-lymphocytes (which indicate an immune response), elevated levels of IgG, and oligoclonal bands. Evoked potentials and optical coherence tomography (OCT) may also be done. Evoked potentials are used to detect subclinical changes in the function of the CNS. Evoked potentials may also help locate the anatomical region of lesions when the area cannot be clearly visualized using imaging. During the test, the patient is exposed to sensory stimuli (e.g., flashing lights) to activate areas of the brain. During this, the brain’s electrical responses to the stimuli are recorded. In patients with MS, the brain’s response to the stimuli is delayed due to demyelinated nerve fibers. OCT uses infrared light waves to image the retina at high resolution and measure the thickness of the nerve fiber layer. In 85% of patients with MS with optic neuritis, the thickness of the retinal nerve fiber layer is reduced. OCT also shows the retrograde degeneration of unmyelinated retinal nerve fiber layer axons, which occurs with demyelination of the optic nerve. These tests provide support for the diagnosis of MS. A brain CT scan may also reveal atrophy or white matter lesions (Bauldoff et al., 2020; Levin, 2021; Olek & Howard, 2021).
The McDonald criteria can help a healthcare practitioner determine if a diagnosis of MS is indicated based on the patient’s presenting symptoms, assessment findings, and the MRI and other diagnostic testing results. One of the critical requirements for a diagnosis of MS using the McDonald criteria is evidence of damage to the CNS that is disseminated in time (DIT) and disseminated in space (DIS), which means that damage occurred to distinct areas of the CNS on separate dates. The McDonald criteria use MRI evidence extensively and suggest that an MRI is performed on all individuals for whom a diagnosis of MS is possible (Spain & Wooliscroft, 2017).
Although the McDonald criteria can help determine if a diagnosis of MS is appropriate, it cannot differentiate between MS and other similar neurologic disorders. If the McDonald criteria are met, and there is no better diagnosis for the presenting symptoms, a diagnosis of MS is given to the patient. If the criteria are not entirely met, but MS is suspected based on all other findings, the patient is diagnosed as possibly having MS with necessary follow-up and reevaluation scheduled. If criteria are not met, and a different disorder better explains the patient’s symptoms, a diagnosis of MS is not given. Diagnosis is especially challenging in patients that are either younger or older than the average age of onset, have unspecific MRI results, present with atypical symptoms, or have already been diagnosed with a progressive illness. The revised version of the McDonald criteria (outlined above) reinforced the importance of MRI results, clinical presentation, and CSF analysis. (Olek & Howard, 2021).
Signs and Symptoms
Clinical manifestations of MS are varied and are primarily determined by the location of any current lesion or lesions. The sudden onset of a symptom may indicate a relapse. Any symptom experienced can be acute or chronic. Some patients may experience an acute symptom that they never fully recover from, leading to a chronic symptom. When managing MS symptoms, it is essential to focus on the non-visible effects and the physical manifestations of the disease, as these symptoms often have the most significant impact on the patient’s life (National Multiple Sclerosis Society n.d.-i).
Fatigue
Fatigue is one of the most common complaints among patients diagnosed with MS. It is often one of the most disabling symptoms, but the cause of fatigue in MS is poorly understood. Individuals with MS may describe it as the lack of physical or mental energy to complete daily activities. Fatigue is typically reported to be worse in the afternoon. Influencing factors may include depression due to the chronicity of the disease, deconditioning, and high temperatures (Hinkle & Cheever, 2018; Honan, 2019).
Visual Disturbance
When lesions or plaques develop in the optic nerves or their connections, the patient may experience diplopia (double vision), blurred vision, nystagmus, scotomas (blind spots), and even periods of total blindness. Visual disturbances are commonly experienced by patients diagnosed with MS. In 25% of patients with MS, optic neuritis was the initial symptom, and 50% of all patients with MS will experience optic neuritis during disease progression. Visual disturbances can significantly impact a patient’s ability to function independently or continue working (Honan, 2019; National Multiple Sclerosis Society, n.d.-i).
Swallowing Disorders
If the cranial nerves innervating speech and swallowing are affected, the individual may experience dysarthria (slurred speech) and dysphagia (difficulty swallowing). Therefore, it is recommended that once a diagnosis of MS is made, the primary care provider refer the patient to a speech-language pathologist (SLP) for a full workup of oropharyngeal and esophageal swallowing function to obtain a baseline against which to compare future changes. The most common MS-related swallowing disorders include xerostomia (dry mouth), decreased coordination in processing food in the mouth, delayed pharyngeal swallow, reduced laryngeal excursion, and reduced tongue base retraction. Dysphagia can lead to aspiration or a fear of choking, resulting in inadequate nutritional intake. The goal of managing dysphagia is to keep the patient on a regular texture diet for as long as possible. Once regular texture food becomes a safety concern, the SLP can perform a modified barium swallow study (MBS) to assess oral and pharyngeal swallowing function, followed by an esophagram or a fiberoptic endoscopic evaluation of swallowing (FEES) looking at esophageal function. Once swallowing function is analyzed, the SLP can recommend texture modifications (e.g., pureed diet or thickened liquids). If follow-up studies determine that the patient is aspirating despite changes to diet texture or the patient cannot maintain proper nutritional intake via the oral route, non-oral feeding options should be considered (Hinkle & Cheever, 2018; Logemann & Burnham, 2018).
Pain
Lesions on the sensory pathways may cause the individual to experience debilitating pain. A physical assessment finding associated with sensory pathway involvement is Lhermitte’s sign, a shock-like sensation felt down the arms and back when the individual performs cervical flexion. Disruption of these sensory axons can also lead to numbness, paresthesia, or dysesthesia. One systematic literature review found that 63% of patients with MS experience pain. The same review further delineated that 51% experienced headaches, 27% had neuropathic pain, 20% reported back pain, 17% had a positive Lhermitte’s sign, and 4% experienced trigeminal neuralgia. Individuals with different subtypes of MS report pain differently, with 69.8% of patients with PPMS, 70.3% with SPMS, and 50% of those with RRMS experiencing pain. The pain experienced by patients with MS is of greater intensity, has more impact on daily activities and quality of life, and requires higher doses of analgesic medications than the pain experienced by individuals without MS (Hinkle & Cheever, 2018; Honan, 2019; Maloni, 2016).
Patients with MS experience different types of pain. Dysesthetic pain is continuous central neuropathic pain felt in the extremities. Dysesthetic pain is experienced by 1 in 5 patients with MS making it the most common type of constant pain. It mainly affects the legs and feet and is described as tingling or burning. This type of pain is indicative of the presence of plaque in the cervical or thoracic spinal cord. Although dysesthesia is challenging to eliminate, medications are available to decrease symptoms (Maloni, 2016). For more information, see the Nursing CE course Pain Management.
Neurocognitive Changes
When patients have active lesions in the cerebellum or basal ganglia, they may demonstrate ataxia (impaired coordination of movements) or tremors. Cognitive and psychosocial problems may indicate frontal or parietal lobe involvement and may present as memory impairment and loss of concentration (Hinkle & Cheever, 2018; Honan, 2019).
Spasticity
When the motor pathways of the spinal cord are affected, the individual may have spasticity (muscle hypertonicity) of the extremities. Spasticity is most commonly experienced in the legs. The resulting painful spasms can affect the patient’s mobility and functional independence and disrupt sleep. Clinical indications of spasticity include decreased range of motion (ROM), difficulty relaxing muscles, loss of voluntary control of muscles, pain, experiencing muscle tightness, difficulty initiating movements, and an increase in deep tendon reflexes. The Ashworth Scale is a method of grading spasticity on a 5-point numerical scale from 0-to 4, with 0 being no resistance or increase in muscle tone and 4 being limb rigidity (Hinkle & Cheever, 2018; Honan, 2019; Kushner & Brandfass, n.d.).
Bladder/Bowel/Sexual Dysfunction
Other symptoms associated with spinal cord involvement include bladder, bowel, and sexual dysfunction. When individuals experience bladder dysfunction, it typically falls into one of the following categories: (1) hyperreflexic bladder, or inability to store urine; (2) hyporeflexic bladder, or inability to empty the bladder; or (3) a mixture of both types (Hinkle & Cheever, 2018). Urodynamic studies are a set of tests used to measure the functional status of the lower urinary tract by evaluating the pressure-flow relationship between the bladder and urethra. These studies analyze the filling, storage, and voiding phases. Simple, noninvasive urodynamic tests include postvoid residual (PVR) and single-channel cystometrogram (CMG). PVR testing measures the amount of urine remaining in the bladder after complete urination using a bladder scanner. CMG assesses the sensation of bladder filling, fullness, and urgency. This is done by inserting a catheter and filling the bladder to measure capacity and storage pressures. The goal of urodynamics is to determine the correct diagnosis of lower urinary tract dysfunction. Bowel dysfunction is common in MS, with 60% of patients reporting fecal incontinence or constipation. Patients experience a higher prevalence of constipation than incontinence. Management of bowel dysfunction is guided by the cause, disease progression, or medication side effects. Bowel incontinence can be caused by sphincter dysfunction, constipation resulting in overflow or rectal overload, or diminished sensation. Bulk agents can also promote fecal consistency in those who have incontinence due to constipation. Sexual dysfunction can be due to erectile or ejaculatory dysfunction in males and orgasmic dysfunction and vaginal dryness in females (Bauldoff et al., 2020; Gill & Kim, 2019; Holland & Kennedy, n.d.).
Mood Changes
There are various mood changes that patients diagnosed with MS may experience, including depression, anxiety, irritability, and pseudobulbar affect (PBA). PBA affects 10% of patients with MS. It is characterized by uncontrollable laughing or crying. These issues tend to be underreported by patients to their healthcare providers and undertreated when they are reported. Untreated or undertreated depression has contributed to the high rate of suicide among patients with MS. Completing proper depression screening is essential when treating patients with MS. Mood changes can interfere with self-care, treatment adherence, performance at home or work, relationships, and quality of life (National Multiple Sclerosis Society, n.d.-i). For more information on depression, see the Nursing CE course on depression.
Disease Severity
The effects of MS are highly variable, and each patient’s experience is unique. The impact of MS on an individual is determined based on the severity of symptoms, frequency of relapses, rate of worsening, and residual disability. Patients with MS report that progressive disability is their most important concern. There are different scales available that healthcare professionals can use to measure disability in patients with MS. The Kurtzke Expanded Disability Status Scale (EDSS) is an updated version of the original Disability Status Scale (DSS) and is used to score clinical disability in patients with MS. The scale was updated and expanded to more accurately reflect the levels of disability seen clinically in patients diagnosed with MS. The scores range from 0 for a clinical examination within normal limits to 10 for death related to MS. There is also a scale that allows patients to self-score called the Patient-Determined Disease Steps (PDDS) scale (Olek & Howard, 2022).
Symptom Management
While treatment modalities can increase periods of remission and slow the progression of MS, it is effective symptom management that improves the patient’s ability to function and experience a better quality of life. Due to this impact on a patient’s daily life, symptom management is considered an essential component of disease management (National Multiple Sclerosis Society, n.d.-i).
Fatigue
Medications used to manage MS-related fatigue include dextroamphetamine (Adderall), methylphenidate (Ritalin), modafinil (Provigil), and amantadine (Symmetrel). Adverse effects of dextroamphetamine (Adderall) and methylphenidate (Ritalin) include mood changes, tachycardia, hypertension, and insomnia. Modafinil (Provigil) may cause headaches, vision changes, chest pain, and irregular heart rate. It also decreases the effectiveness of oral contraceptives. Amantadine (Symmetrel) is an antiviral used off-label to treat MS-related fatigue. The mechanism by which it is effective for MS-related fatigue is unknown; however, it may be due to dopamine reuptake (Levin, 2021; National Multiple Sclerosis Society, n.d.-i; Vallerand & Sanoski, 2017).
Visual Disturbance
High-dose corticosteroids such as prednisone (Deltasone) and methylprednisolone (SoluMedrol) can help reduce optic neuritis. Side effects of corticosteroid treatment include increased appetite, hypertension, palpitations, difficulty sleeping, and hyperglycemia. Visual disturbances are challenging to treat and may become permanent; therefore, it is also important to refer patients to an ophthalmologist who specializes in decreased vision that can provide patients with adaptive equipment and educate them on environmental modifications (Goodman, 2021; Levin, 2021; National Multiple Sclerosis Society, n.d.-I; Vallerand & Sanoski, 2017).
Swallowing Disorders
There are three types of non-oral feeding available to ensure that a patient’s dietary requirements are met while decreasing aspiration and risk for pneumonia. The first is a nasogastric (NG) tube which can deliver tube feedings straight to the stomach. NG tubes should not be left in for longer than two weeks; therefore, this is not a long-term solution. The second option is total parenteral nutrition (TPN) or partial parenteral nutrition (PPN), administered intravenously. TPN must be administered through a central venous line, while PPN can be administered via a peripheral line. Both types of intravenous access cannot be kept indefinitely and are not appropriate as a long-term non-oral feeding option. The last non-oral feeding option involves the insertion of a feeding tube. Percutaneous endoscopic gastrostomy (PEG or G-tube) tubes are inserted through the abdominal wall directly into the stomach. In some cases, the feeding tube is inserted into the jejunum of the small intestine and is therefore called a J-tube. A PEG and J-tube are the only long-term options available for patients unable to tolerate oral intake. Although these feeding tube options decrease aspiration risk, they do not eliminate the patient’s risk (Logemann & Burnham, 2018).
Pain
Patients with MS often experience neuropathic pain from the damage to the nerves. Some medications FDA approved for depression and seizure disorders are used off-label to manage neuropathic pain in patients with MS. These medications include the serotonin and norepinephrine reuptake inhibitor (SNRI), duloxetine (Cymbalta), and the anticonvulsants gabapentin (Neurontin) and carbamazepine (Tegretol). All three medications can cause dizziness and drowsiness. Carbamazepine (Tegretol) can cause rare but severe effects, including toxic epidermal necrolysis, Stevens-Johnson syndrome, aplastic anemia, and agranulocytosis (Levin, 2021; Vallerand & Sanoski, 2017). For more information on pain management, see the Nursing CE course Pain Management.
Ataxia
Medications that can treat ataxia include the antiepileptic gabapentin (Neurontin) and the potassium channel blocker dalfampridine (Ampyra). The side effects and contraindications of gabapentin (Neurontin) are discussed above. Dalfampridine (Ampyra) is FDA-approved to improve mobility in patients with MS. Side effects of dalfampridine (Ampyra) include urinary tract infection (UTI), dizziness, and nausea (Hinkle & Cheever, 2018; Levin, 2021; Vallerand & Sanoski, 2017).
Spasticity
Treating spasticity involves the use of both pharmacological and nonpharmacological interventions. Muscle relaxants help depress the CNS to reduce pain and inhibit reflexes at the spinal level, reducing muscle spasm frequency. Baclofen (Lioresal) is FDA approved to treat spasticity in MS. Adverse effects include drowsiness, dizziness, and weakness. Abrupt discontinuation of baclofen (Lioresal) may result in seizures or hallucinations. If spasticity is severe and not sufficiently controlled with oral medications, placement of an intrathecal baclofen (Lioresal) pump may be indicated. As an adjunct to oral medications, botulinum toxin (Botox) injections directly into the specific muscle and phenol nerve blocks can be effective, especially in difficult to manage cases. Physical therapy for spasticity should be initiated as soon as possible following the initial onset of symptoms. The focus of physical therapy should be on stretching and ROM, strengthening, and improving balance (Bauldoff et al., 2020; Hoffman & Sullivan, 2017; Honan, 2019; Kushner & Brandfass, n.d.; Levin, 2021).
Bladder/Bowel/Sexual Dysfunction
Anticholinergics may be prescribed for bladder spasticity. Overactive bladder can be managed with darifenacin (Enablex), a selective muscarinic antagonist that works by relaxing the smooth muscles of the bladder. Adverse effects include constipation, nausea, and UTI. Tamsulosin (Flomax) also relaxes the bladder muscles to improve urine flow and bladder emptying. Adverse effects include dizziness, diarrhea, and insomnia. In addition, ascorbic acid (Vitamin C) may be recommended to acidify the urine, making bacterial growth less likely, thus decreasing UTI risk (Goodman, 2021; Hinkle & Cheever, 2018; Vallerand & Sanoski, 2017).
There are many interventions available to help return bowel function to baseline. Increasing fluid and dietary fiber intake can increase bowel regularity. Any bladder dysfunction experienced by the patient should be addressed before recommending increased fluid intake. Increasing dietary fiber to 25 g/day for females and 38 g/day for males is essential. If the patient is unable to get adequate fiber through nutritional modifications, bulk supplements such as psyllium (Metamucil), wheat dextrin (Benefiber), or methylcellulose (Citrucel) can be used to supplement dietary intake. Patients using these bulk supplements must be able to consume 6-8 glasses of fluid per day to prevent potential impaction. Liquid sugar concentrates, such as sorbitol (Arlex) and lactulose (Enulose), soften the stool, have very few side effects, and are good options for long-term use. Other oral interventions that can help prevent or treat constipation include docusate (Colace), magnesium hydroxide (Milk of magnesia), and polyethylene glycol (MiraLAX). Rectal interventions can consist of suppositories, such as glycerin (Glycerol) or bisacodyl (Dulcolax), or the use of enemas, such as fleets or mineral oil. Anticholinergic drugs can also be used to treat incontinence caused by hyperactive bowel. Baclofen (Lioresal) and tizanidine (Zanaflex) used to help minimize other MS symptoms can contribute to fecal incontinence and may require a dosage change to reduce side effects (Holland & Kennedy, n.d.).
Males experiencing erectile dysfunction may benefit from oral medications such as sildenafil citrate (Viagra), tadalafil (Cialis), or vardenafil hydrochloride (Levitra). Other options to obtain an erection include injectable medications, such as papaverine (Pavabid) or alprostadil (Caverject), and mechanical devices. Females experiencing vaginal dryness may benefit from using water-soluble lubricants (Bauldoff et al., 2020). For more information on sexual dysfunction, see the Nursing CE course on sexual dysfunction.
Mood Changes
Patients experiencing PBA now have an FDA-approved treatment option, dextromethorphan HBr and quinidine sulfate (Nuedexta). The most common side effects include diarrhea, dizziness, vomiting, weakness, and edema. For patients suffering from depression and anxiety, cognitive behavior therapy and commitment therapy are recommended as treatment options (National Multiple Sclerosis Society, n.d.-I; Vallerand & Sanoski, 2017). For more information on depression, see the Nursing CE course on depression.
Treatment
Glucocorticoids
During an exacerbation, the goal is to decrease inflammation and induce remission. A high-dose glucocorticoid, such as intravenous methylprednisolone (SoluMedrol), intravenous dexamethasone (Decadron), or oral prednisone (Deltasone) are used to exert anti-inflammatory effects on T-cells and cytokines. The healthcare provider (HCP) should actively monitor for adverse effects, including hyperglycemia, hypokalemia, hypertension, palpitations, lower extremity edema, mental disturbances (e.g., manic psychosis), avascular necrosis of bone, and gastrointestinal (GI) perforation (Goodman, 2021; Honan, 2019; Olek & Mowry, 2022; Vallerand & Sanoski, 2017).
Monoclonal Antibodies
The use of monoclonal antibodies has decreased relapse rates in patients with RRMS. Examples of monoclonal antibodies used in RRMS include natalizumab (Tysabri), ocrelizumab (Ocrevus), ofatumumab (Kesimpta), and alemtuzumab (Lemtrada). Natalizumab (Tysabri) is designed to hinder the movement of damaging immune cells from the bloodstream across the blood-brain barrier into the brain and spinal cord. Natalizumab (Tysabri) has shown to be more effective than many other MS disease-modifying treatments, particularly oral and injectable therapies. In clinical trials, natalizumab reduced the relapse rate by 54-68% compared to the 33% seen with interferon beta-1a (Avonex/Rebif) or glatiramer acetate (Copaxone) treatment. Although rare, progressive multifocal leukoencephalopathy (PML), an opportunistic infection, caused by the human polyomavirus 2 (previously the John Cunningham [JC]) virus, can occur. PML is characterized by the onset of dementia, progressive weakness, vision changes, coma, and may lead to death (Goodman, 2021; National Multiple Sclerosis Society, n.d.-b; Olek & Mowry, 2022; Smelkowska et al., 2018; Wilson et al., 2017).
Ocrelizumab (Ocrevus) is used to treat relapsing or primary progressing forms of MS. Adverse effects include dizziness, hypotension, tachycardia, respiratory infection, edema, and infusion site reactions. If infusion site reactions occur, the infusion may be slowed down (Goodman, 2021; Levin, 2021; Vallerand & Sanoski, 2017).
Ofatumumab (Kesimpta) is used to treat relapsing forms of MS. Ofatumumab (Kesimpta) should be administered subcutaneously only. Infusion reactions are common and can occur up to 24-hours following injection. The most common side effects include upper respiratory infection and headache (Goodman, 2021; Levin, 2021; Vallerand & Sanoski, 2017).
Alemtuzumab (Lemtrada) is effective in treating relapsing patterns of MS. Alemtuzumab (Lemtrada) is administered in different courses. Alemtuzumab (Lemtrada) increases the risk of severe and sometimes deadly autoimmune disorders such as immune thrombocytopenic purpura (ITP), anti-glomerular basement membrane disease, and certain cancers, including thyroid cancer, melanoma, and lymphoma. Severe and life-threatening infusion reactions can occur; therefore, patients must be closely monitored during infusion (Goodman, 2021; Levin, 2021; Vallerand & Sanoski, 2017).
Immunomodulators
Disease-modifying Therapy
Disease-modifying therapy (DMT) aims to reduce, not eliminate, the frequency of relapses, the length of the relapse, and the number and size of the lesions (plaques) visible on the MRI. Following diagnosis, these medications should be started as early as possible. These medications are not prescribed to improve symptoms (American Academy of Neurology [AAN], 2018; Honan, 2019).
Interferon beta-1a is available in an intramuscular form under the brand name Avonex. Interferon beta-1a is available in a subcutaneous form under the brand name Rebif. The primary mechanism of action of interferons is reducing inflammation by limiting the movement of inflammatory cells to the CNS through the blood-brain barrier. A common side effect of all interferon beta medications is flu-like symptoms such as fevers, chills, and body aches, which can be reduced by concurrent administration of acetaminophen (Tylenol) or ibuprofen (Motrin) and administering the medication at bedtime. Additional side effects include leukopenia, thrombocytopenia, anemia, liver dysfunction, fetal abnormalities, and depression. Liver damage is a common adverse effect of interferon beta-1a (Rebif). The individual and family should be advised to notify the HCP if thoughts of suicide are experienced or expressed to others (Goodman, 2021; Honan, 2019; Smelkowska et al., 2018; Vallerand & Sanoski, 2017).
Glatiramer acetate (Copaxone) is available as an injectable. It may take up to six months to demonstrate effectiveness. It is believed to affect T-cell activation and proliferation. Adverse reactions include swelling, inflammation, and redness at the injection site. Glatiramer acetate (Copaxone) may also affect immune function and increase the patient’s risk of contracting an infection (Honan, 2019; Levin, 2021; Smelkowska et al., 2018; Vallerand & Sanoski, 2017).
Fingolimod (Gilenya) is a daily oral medication that helps trap immune cells in the lymph nodes resulting in a decrease in the frequency of relapses and a delay in disability. Monitoring is required for at least 6 hours after the first dose and periodically during therapy due to the risk of bradycardia and hypotension. Side effects include headache, upper respiratory infection, flu-like symptoms, and increased liver enzymes (Bauldoff et al., 2020; Levin, 2021; Vallerand & Sanoski, 2017).
Antineoplastics
Mitoxantrone (Novantrone) can help reduce the frequency of relapses in individuals with SPMS or worsening RRMS. Cardiac toxicity is a severe adverse effect and may not occur until years after the last dose. Therefore, close monitoring is required to evaluate the patient for decreased left ventricular function; an echocardiogram should be performed before each dose. Due to the risks of cardiac toxicity, ovarian failure, male infertility, and promyelocytic leukemia, coupled with the limited evidence of effectiveness, treatment with mitoxantrone should only be initiated if the benefits greatly outweigh the risks (Hinkle & Cheever, 2018; Levin, 2021; Olek & Mowry, 2022; Vallerand & Sanoski, 2017; Wilson et al., 2017).
Nonpharmacological Management
Complementary and alternative medicine (CAM) includes a variety of interventions that can help patients living with MS. When an intervention is used with traditional treatment, it is considered complementary, and when used in place of conventional medicine, it is considered alternative (National Multiple Sclerosis Society, n.d.-a). There are a variety of different CAM approaches used by patients with MS.
- Food and diet: various diets are promoted as MS cures; however, no diet has been found effective in modifying the course of MS following diagnosis. Healthcare providers recommend that patients with MS follow the same high-fiber, low-fat diet recommended for all adults.
- Exercise: patients with MS can experience several benefits from regular aerobic exercise; some report reduced fatigue, improved bowel and bladder function, increased strength, and mood improvement.
- Stress management: increased stress can have health implications for all patients, including those diagnosed with MS; individuals have used meditation and Tai chi to decrease stress levels.
- Acupuncture: this therapy is becoming more popular in Western medicine; some studies suggest that acupuncture can decrease pain and improve gait (National Multiple Sclerosis Society, n.d.-a).
The problem with CAM is that most interventions are not FDA-approved. Although some researchers have begun testing the effectiveness of interventions such as vitamin D supplementation, exercise, acupuncture, and cooling techniques through clinical trials, there is still no definitive data demonstrating their effectiveness (National Multiple Sclerosis Society, n.d.-a).
Other healthcare disciplines should also be involved in the care of patients with MS. A physical therapy consultation can help the client with exercises to improve muscle function and determine the need for assistive devices to maintain safety through fall prevention. An occupational therapy consultation will help determine if the client needs assistive devices for fine motor skills to promote independence and suggest measures to promote energy conservation (Hinkle & Cheever, 2018). Consultation with an SLP is needed if the individual is experiencing speech or swallowing problems (Honan, 2019).
Nursing Care and Implications
The nurse should work collaboratively with the affected individual to develop a plan of care that addresses the physiologic, social, and psychological problems associated with MS.
Promoting Physical Mobility
Measures should be implemented to improve mobility. Progressive resistive exercises help to strengthen weakened muscles. Walking can help to improve gait and proprioception of the legs and feet. Because muscle spasticity may interfere with normal function, an orthotic may be prescribed to maintain normal functional positioning and help to reduce the risk of contracture. Activities that help decrease spasticity include swimming, stationary bicycling, and progressive weight-bearing exercises. Individuals should stop exercising before feeling fatigued since fatigue can aggravate MS symptoms. If ataxia is present, the patient is at increased risk for falls. These individuals should be taught to walk with their feet apart to widen the base of support which helps to improve stability. If the individual experiences loss of proprioception, watching the feet while walking may help. Assistive devices such as a walker, cane, or braces may be needed to facilitate walking. Training with a physical therapist in the proper use of these devices is essential for them to be effective. If gait is not stable enough to ensure safe mobility, a wheelchair or motorized scooter may be needed (Hinkle & Cheever, 2018).
Along with immobility comes the risk for complications, such as pressure ulcers and deconditioning of the muscles for respiration. Skin assessments should be performed frequently, especially for those who use a wheelchair. Deep breathing and coughing exercises help prevent the pooling of bronchial secretions. Perimenopausal women with MS are at increased risk for osteoporosis due to estrogen loss, decreased mobility, and high-dose corticosteroid therapy during exacerbations (Hinkle & Cheever, 2018).
Preventing Fatigue
Activities of daily living (ADLs) should be arranged to include rest periods to preserve energy. Individuals should be encouraged to prioritize activities that help to promote independence and control. Essential activities should be performed in the morning when energy reserves are the greatest. Heat can exacerbate fatigue, so it should be avoided when possible. Pain management needs to be a priority due to the effects pain has on reported levels of fatigue (Bauldoff et al., 2020).
Enhancing Bladder and Bowel Control
The individual with urinary frequency or urgency and incontinence may benefit from specialized bladder training, called pelvic floor training or Kegel exercises. This includes immediately addressing the urge to void (readily accessible bedpans or urinals) and following a voiding schedule. Developing a voiding schedule starts with short intervals of 1.5 to 2 hours where the individual drinks a measured amount of liquid and then attempts to void 30 minutes later. The use of an alarm or timer may serve as a reminder if the individual does not have the natural urge to void. The time intervals should be gradually lengthened to increase tolerance. Individuals with urinary retention may perform self-catheterization to achieve bladder control. Males may choose to use condom catheters if incontinence is a concern. Bowel problems may include constipation or incontinence. Constipation can be prevented through adequate fluid and fiber intake and regular stool softeners. A bowel retraining program, or sphincter training, may benefit the individual with constipation or fecal incontinence (Hinkle & Cheever, 2018; Honan, 2019).
Improving Visual Disturbances
If the individual is experiencing diplopia, an eyepatch or a covered eyeglass lens can be used to block the visual impulse of one eye so that only one image is seen. If the individual is confined to bed, prism glasses may assist the individual with reading while in the supine position. Also, large-print and audiobooks may be obtained from local libraries (Hinkle & Cheever, 2018).
Improving Cognitive Function
Some individuals with MS may become forgetful, easily distracted, and emotionally labile. A structured environment with minimal distractions, lists, and other memory aids may help individuals with MS maintain a daily routine. Additionally, adaptation to illness occurs in various ways, including denial, depression, withdrawal, and displays of hostility to others. Family members should be advised that these responses may occur and be as supportive as possible. Unfortunately, MS disrupts the life of the affected individual and the lives of family members (Hinkle & Cheever, 2018).
Promoting Sexual Function
Individuals may benefit from meeting with a sexual counselor to explore other ways of sharing intimacy depending on the type of dysfunction experienced (Hinkle & Cheever, 2018). Bowel and bladder incontinence may also inhibit sexual desire (Honan, 2019).
Strengthening Coping Mechanisms
Because MS typically appears in individuals in the early stage of life, career and family responsibilities are often affected. It is important to stress that no two individuals with MS will have identical symptoms or course of the disease. While some experience significant disability early after the onset of the disease, others have a near-normal lifespan with minimal disability. Role function within a family may change with others taking on the previous role of the affected individual and the role of caregiver. The nurse’s role includes supporting the affected individual and family members to reduce stress and cope with the chronicity of the disease. These include referrals to home health services, individual and family counseling, and local support groups through the National MS Society (Hinkle & Cheever, 2018).
Future Research and Trends
Researchers continue to discover new treatments and diagnostic tools related to MS. Within the last two years, three new medications have been FDA approved for the treatment of relapsing forms of MS: ozanimod (Zeposia), monomethyl fumarate (Bafiertam), and ofatumumab (Kesimpta). In addition, researchers are currently trying to understand how gut bacteria may influence the severity of MS, which may uncover approaches to stopping MS. They are also testing different methods to protect the nerves from demyelination and repair the myelin that has been damaged. Large clinical trials are currently being conducted on new approaches to treating progressive MS (National Multiple Sclerosis Society, n.d.-g).
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