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Aliza Ben-Zacharia, DrNP, MSCN

Aliza Ben-Zacharia, DrNP, MSCN. Neurology Teaching Assistant Mount Sinai Medical Center New York, New York. MS Symptoms vs Relapses vs Treatment Side Effects. MS symptoms Chronic or ongoing indicators of MS lesion damage to certain areas of the brain or spinal cord MS relapses

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Aliza Ben-Zacharia, DrNP, MSCN

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  1. Aliza Ben-Zacharia, DrNP, MSCN Neurology Teaching Assistant Mount Sinai Medical Center New York, New York

  2. MS Symptoms vs Relapses vs Treatment Side Effects MS symptoms • Chronic or ongoing indicators of MS lesion damage to certain areas of the brain or spinal cord MS relapses • Sudden worsening of any MS symptom or the appearance of new symptom lasting at least 24 hours, separated from a previous exacerbation by at least 1 month and occurring in absence of environmental, metabolic, or infectious processes MS treatment side effects • Distinguishing treatment side effects from MS symptoms/relapses

  3. Managing Symptoms of MS • Screening for symptoms • Every follow-up visit • As needed • Questionnaire • History/neurologic exam • Goal: symptom reduction • Maintaining QOL despite symptoms • Reduction of symptom progression through adherence to disease-modifying treatments • Prioritization of symptoms and individualization of care

  4. Common MS Symptoms • Fatigue • Walking impairment • Spasticity • Cognitive impairment • Bladder dysfunction • Pain • Mood instability • Sexual dysfunction

  5. MS Fatigue • One of the most common (80%) symptoms • One of the most disabling symptoms • Primary reason to stop working • More likely than other types of fatigue to interfere with daily responsibilities • Occurs daily, starts suddenly • Can start early in the morning, even after restful sleep • Worsens as day progresses, and with heat and humidity • Cause unknown National Multiple Sclerosis Society. http://www.nationalmssociety.org/about-multiple-sclerosis/what-we-know-about-ms/symptoms/fatigue/index.aspx.

  6. Assessing MS Fatigue • Modified Fatigue Impact Scale (MFIS) • Assessment of sleep pattern • History of exercise/activity level • Assessment of medications that may lead to fatigue, ie, anti-spastic medications • Other comorbidities, such as thyroid disease, diabetes, depression

  7. Managing MS FatigueLifestyle Changes • Physical therapy/exercise • Good nutrition • Weight management • Enough sleep • Going to bed on time • Management of other symptoms that interfere with sleep • Rest breaks • Prioritization of tasks; maintaining realistic expectations • Letting others help • Avoid excessive caffeine, multitasking, overheating

  8. Managing MS FatiguePharmacologic Strategies (Off-Label Uses) • Amantadine hydrochloride 100−200 mg/d early in day (100 mg around noon)1 • Selective serotonin reuptake inhibitors (SSRIs)1 • Modafinil 100−200 mg/d early in day2 • Armodafinil: longer lasting isomer of modafinil–50, 150, or 250 mg1 • Amphetamine-type therapies1 • Methylphenidate, can start at 5 mg PO in AM and titrate to effect; 10 mg in AM and around noon or early afternoon is common • Can use long-acting formulations • Possible contraindications 1. Personal communication: Aliza Ben-Zacharia; oral communication on 8/25/10. 2. National MS Society. http://nationalmssociety.org/about-multiple-Sclerosis/what-we-know-about-mstreatments/medications/modafinil/index.aspx.

  9. Walking Impairment • Gait description • Ataxic • Spastic • Paretic • Foot drop • Disabling impact • Negatively impacts work productivity, employability, and income • Impairs activities of daily living, ie, driving • Significantly affects QOL

  10. Factors Involved in Walking Impairment • Muscle weakness • Results in toe drag, foot drop, vaulting • Spasticity • Loss of balance • Sensory deficit • Affects the ability to feel the floor, know where the foot is • Fatigue • Increases walking impairment National Multiple Sclerosis Society. http://www.nationalmssociety.org/about-multiple- sclerosis/what-we-know-about-ms/symptoms.

  11. Assessing Walking Impairment • Timed 25-Foot Walk (T25FW) • 500-meter walk (Extended Disabilities Status Scale [EDSS]) • 6-minute walk (6MW) • Assess posture • Assess use of a device (ie, cane) • Assess overuse of joint compensating Fischer JS, et al. Multiple Sclerosis Functional Composite – Revised. National Multiple Sclerosis Society, 2001.

  12. Managing Walking Impairment • Dalfampridine—previously known as fampridine SR or 4-aminopyridine SR • FDA approved January 2010 • Indication: to improve walking speed in patients with MS • This is not a disease-modifying therapy • Mechanism: K+ channel blockade • Enhances conduction of action potentials in demyelinated axons through inhibition of K+ channels • Appropriate candidates • Contraindicated in patients with history of seizures or moderate to severe renal impairment • Monitor patients with history of multiple urinary tract infections Dalfampridine [PI]. Hawthorne, NY: Acorda Therapeutics; 2010.

  13. Managing Walking Impairment • Dalfampridine dose: 10 mg BID (12 hours apart) with/without food • Dose-dependent side effect: seizures • Seizures at doses of 15 mg BID were >4 times higher than rate at recommended maximum dose of 10 mg BID • Managing missed doses • Patients should be advised not to take double or extra doses if a dose is missed, as this may result in seizure Dalfampridine [PI]. Hawthorne, NY: Acorda Therapeutics; 2010.

  14. P <.001 Responders (%) Dalfampridine Phase III Studies • Dalfampridine 10 mg BID (n = 229) or placebo (n = 72) x 14 weeks • Response = consistent improvement on timed 25-foot walk • Walking speed improved by 25% among dalfampridine responders vs 5% with placebo (Trial 1)1 1. Goodman AD, et al. Lancet. 2009;373:732-738. 2. Goodman AD, et al. Mult Scler. 2008;14:S2989 (abstr P909). 3. Dalfampridine [PI]. Hawthorne, NY: Acorda Therapeutics; 2010.

  15. Amy Perrin Ross, MSN Neurosciences Program Coordinator Loyola University, Chicago Maywood, Illinois

  16. Spasticity • Results from demyelination in the descending corticospinal, vestibulospinal, and reticulospinal CNS pathways • Can be manifested in a variety of muscle groups depending on the lesion location • Spasticity may increase over time without new CNS lesions • Very cold temperatures may aggravate spasticity Crayton H, et al. Neurology. 2004;63(suppl 5):S12-S18.

  17. Modified Ashworth Scale Abbreviation: ROM, range of movement. Bohannon RW, Smith MB. Phys Ther. 1987;67:206-207.

  18. Spasticity Management • Rehabilitation • Stretching exercises • Physical therapy • Casting • Oral medications • Baclofen • Tizanidine • Gabapentin • Intrathecal baclofen

  19. Botulinum Toxin (BTX) for Spasticity • Wrist and finger spasticity1 • Randomized controlled trial (RCT) in 126 patients with increased flexor tone after a stroke • One-time injection: BTX 200−240 units vs placebo • BTX-treated patients had greater improvement in personal hygiene, dressing, pain, and limb position than placebo patients through week 12 (P <.001) • Upper limb spasticity2 • RCT in 91 patients with excessive muscle tone in elbow, wrist, and fingers after a stroke • Up to 2 treatments of BTX 90,180, or 360 U vs placebo • Greater decrease in muscle tone in BTX-treated patients in wrist (P ≤.026), elbow flexors (P ≤.033), and fingers (P <.031), compared with placebo group 1. Brashear A, et al. N Engl J Med. 2002; 347:395-400. 2. Childers MK, et al. Arch Phys Med Rehabil. 2004;85:1063-1069.

  20. Botulinum Toxin for MS SpasticityNew 2010 FDA Indication • Treatment of distal arm spasticity in adults • Select dosage on muscles affected, severity of muscle activity, prior response to treatment, and adverse event history OnabotulinumtoxinA [PI]. Irvine, CA: Allergan, Inc; March 2010.

  21. Spasticity Treatment Options Slide courtesy of Aliza Ben-Zacharia, DrNP, MSCN.

  22. Cognition − The Mind’s Abilityto Store, Organize, andRecall Information • Each person’s experience is unique and evolving • Most symptoms are mild • Affects up to two thirds of patients with MS • MS can affect cognition indirectly • Widespread impact affecting • Employment • Social relationships • Activities of daily living Burks JS, Johnson KD, eds. Multiple Sclerosis: Diagnosis, Medical Management, and Rehabilitation. Demos Medical Publishing; 2000.

  23. Assessing Cognitive Impairment • Simple processing efficiency • Symbol Digit Modalities Test (SDMT) – Oral Version1 • Complex information processing efficiency • Paced Auditory Serial Addition Test (PASAT)2 • Verbal learning and verbal memory • Logical Memory subtests (LM-I and LM-II) of the Wechsler Memory Scale – Revised3 • Verbal learning: LM-I • Verbal memory: LM-II • Cognitive questionnaire4 • Benedict R, et al. Clin Neuropsychologist. 2002;16:381-397. 2. Cutter GR, et al. Brain.1999;122:871-882. 3. Wechsler D. The Psychological Corporation, San Antonio, Texas, 1987. 4. Benedict RHB, et al. Mult Scler. 2003;9:95-101.

  24. Managing Cognitive Impairment • Nonpharmaceutical interventions • Cognitive rehabilitation and psychotherapy • Memory aids (ie, recordings, lists, mnemonics, etc) • Assistive technologies (computers, electronic calendars) • Minimization of distractions • Addressing possible contributors to cognitive impairment (ie, medication side effects, sleep disorders, infections, thyroid conditions, etc)

  25. Managing Cognitive Impairment • Pharmaceutical interventions • Interventions slowing further impairment: reinforce use of disease-modifying agents to minimize atrophy and burden of MRI disease • Reduce the use of other medications that may be sedating and contribute to cognitive impairment • No effective pharmaceutical agent currently available

  26. Patient Education • Provide the information needed to promote active participation in care and symptom management • Promote maximum health potential towards wellness • Promote coping and adaptation • Promote empowerment towards improved QOL and hope

  27. Role of the Nurse • Empower patients to live with their disease and adjust as much as possible • Teach and educate patients and their families • Counsel and support patients and families • Advocate for patients and families

  28. Managing Symptoms of MS Conclusions • Continuing treatment to minimize risk of relapses, new lesions, and disease progression that result in increased MS symptoms • Address MS symptoms that interfere with QOL • Symptoms need to be recognized in order to treat • Address 1 or 2 symptoms per visit—prioritize • Through counseling and treatment, most symptoms can be managed • Refer to specialists as needed for optimized symptom control

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