Multiple Sclerosis




© Springer International Publishing Switzerland 2017
Maggi A. Budd, Sigmund Hough, Stephen T. Wegener and William Stiers (eds.)Practical Psychology in Medical Rehabilitation10.1007/978-3-319-34034-0_16


16. Multiple Sclerosis



Kevin N. Alschuler1  , Aaron P. Turner2, 3 and Dawn M. Ehde4


(1)
Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA 98133, USA

(2)
Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA

(3)
Department of Rehabilitation, School of Medicine, University of Washington, Seattle, WA, USA

(4)
Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA 98108, USA

 



 

Kevin N. Alschuler

Email:


Keywords
Multiple sclerosisRehabilitation psychology



Topic


Multiple sclerosis (MS) is a chronic and progressive central nervous system disease characterized by immune-mediated demyelination and neuronal damage within the brain, spinal cord, and optic nerves. While the exact cause of MS is unknown, it is thought to result from a combination of one or more environmental triggers and genetic vulnerability [1]. MS is characterized by significant variability in the type and severity of symptoms, as well as the pattern and rate of progression.

Individuals with MS experience a constellation of symptoms and co-occurring conditions, including sensory problems, cognitive difficulties, weakness, spasticity, paresthesia, pain, visual disturbance, heat intolerance, fatigue, bowel/bladder dysfunction, and emotional changes. However, the specific symptoms and their severity differ widely among individuals:


  1. A.


    Key Concepts


    1. 1.


      Diagnosis

      Diagnosing MS is challenging: there is no one test that definitively diagnoses MS, and many of its symptoms are nonspecific and/or suggestive of other CNS disorders. Diagnosis of MS is often based upon the revised McDonald criteria [2] which specifies characteristics of the medical history, neurologic exam, and MRI that are indicative of MS. Occasionally, other tests, such as evoked potentials and spinal fluid analysis, are instrumental in differentiating MS from other conditions. Given that the individual symptoms experienced by a person with MS are not unique to MS specifically, diagnosis also involves ruling out other potential etiologies.

       

    2. 2.


      Disease course

      MS is conceptualized in terms of four types of disease course [1]:


      1. a.


        Relapsing-remitting MS (RRMS) is the most common course, affecting an estimated 85 % of people with MS at time of initial diagnosis. RRMS is characterized by distinct attacks or exacerbations of neurologic symptoms (relapses), followed by a return to prior function or partial recovery (remissions).

         

      2. b.


        The majority of individuals with RRMS eventually progress to secondary progressive MS (SPMS) , at which point their disease may progress with or without relapses. The prevalence of this conversion is unknown given the recent advances in disease management, as described below.

         

      3. c.


        Primary progressive MS (PPMS) affects approximately 10 % of people with MS and is characterized by steady progression of neurologic symptoms from the onset of the disease.

         

      4. d.


        Progressive-relapsing MS (PRMS) is the least common disease course and involves a steady progression of disease from onset with episodic exacerbations (which may or may not result in some recovery).

         

       

     

Data on the natural history of MS suggest that at 15 years’ postdiagnosis, approximately 50 % of people will require an assistive device to walk, and 20 % will require a wheelchair. However, current disease-modifying therapies are used in an effort to slow the onset of these symptoms.


  1. 3.


    Management of underlying disease


    1. a.


      Although there is no cure for MS, a number of disease–modifying therapies (DMT) are used to decrease disease activity and slow progression in individuals with relapsing forms of MS. To date, there are no approved DMTs for PPMS. Current medications come in three forms (oral, injectable, infusion,) and each comes with a profile of benefits and side effects. For the average patient with RRMS, early intervention with DMTs is associated with less disability over time relative to patients who do not take DMTs.

       

    2. b.


      To combat the inflammatory process that causes acute relapses and reduce their duration, patients are often prescribed 3–5 day infusions of high-dose corticosteroids. Alternatives, such as oral steroids and an injectable gel (ACTH) are also emerging as alternatives to infused corticosteroids.

       

     

  2. 4.


    Symptom management

    The remainder of medical treatment primarily focuses on managing symptoms and improving health-related quality of life via a range of interventions, including medications, behavioral interventions, and rehabilitation:


    1. a.


      Medications are available to alleviate the severity of many MS symptoms, such as pain, fatigue, and bladder/bowel dysfunction.

       

    2. b.


      Cognitive and behavioral interventions are recommended for the management of MS symptoms in an effort to maximize the individual’s ability to engage in the activities that promote highest quality of life:


      1. i.


        Rehabilitation psychology is frequently consulted to address questions related to adjustment to disability, depression, anxiety, cognitive assessment, cognitive rehabilitation, health behavior change, relationship conflict, and sexual functioning.

         

      2. ii.


        Rehabilitation interventions, such as physical therapy, occupational therapy, and speech and language pathology, are prescribed when there are opportunities to improve or maintain physical or cognitive functioning.

         

       

     

  3. B.


    Terminology


    1. 1.


      Exacerbation or relapse



      • Episode of new symptoms or a worsening of existing symptoms.


      • To be considered an exacerbation, the symptoms must experience a minimum of 24 h and not occur within 30 days of a prior attack.


      • Severity of exacerbations can vary in terms of severity, symptoms experience, and length.


      • Individuals with MS also experience pseudo–relapses, which are temporary worsening of symptoms due to physical and psychological stressors that resolve when the stressor is resolved. The variability in presentation of relapses, along with the presence of pseudo-relapses, makes the identification of relapses difficult.


      • Relapses are followed by recovery, but the individual may or may not return to his or her prior level of functioning.

       

    2. 2.


      Lesion



      • Hallmark characteristics of MS on MRI


      • Areas where the myelin has been damaged (demyelination)


      • May be present in the brain or spinal cord


      • Sometimes quantified in terms of lesion load, such that individuals with more lesions are said to have higher lesion load.

       

    3. 3.


      EDSS


       

    4. 4.


      Other


       

     


Importance






  • Incidence and prevalence : MS is the most common acquired neurologic disability found in young adults [5]. The estimated worldwide prevalence of MS is more than 2.3 million people, including more than 400,000 individuals in the USA [1]. MS is more prevalent among women (2–3 times more prevalent than in men), Caucasians, and individuals from northern latitudes [5].


  • Onset, duration, and lifespan : The onset of MS is typically between the ages of 20 and 50 years [5], although it also occurs in children and older adults. As the lifespan of people with MS is only 5–10 years shorter than healthy adults [6], the typical person with MS faces many years of managing the disease and its effects.


  • Impact on functioning and quality of life : Individuals living with MS often must make a number of lifestyle and behavioral changes to manage not only the effects of the disease but also its treatments (e.g., adapting to physical or cognitive impairments, adhering to disease-modifying therapies). As a chronic neurologic condition, many daily activities can be affected by MS, including physical functioning, activities of daily living, vocational functioning, role functioning, and leisure pursuits. The course, specific symptoms, and severity of disease progression vary considerably between and within individuals, making it an unpredictable chronic condition to manage. Health-related quality of life is significantly lower in patients with MS relative to healthy controls, the general population, and patients with other chronic diseases such as diabetes, hypertension, arthritis, and epilepsy [7].


  • Financial impact : MS has been associated with substantial costs to individuals, their families, and society. As many as two-thirds of adults with MS are unable to maintain employment [8]. Uncertainty about the future, decreased independence, and financial hardship are common [9, 10]. Given that MS often occurs during child-rearing years, it may affect parenting and performance of other family roles [11]. At a societal level, the economic costs attributed to MS in the USA have been estimated to be as high as $13 billion per year [9]; costs include both direct costs for medical care and indirect costs such as lost wages, lost productivity (including sick leave), and caregiving costs.


Practical Applications





  1. A.


    Assessment and management of MS symptoms and associated concerns

    As with all medical conditions, the biopsychosocial model serves as a useful basis for the assessment and management of MS symptoms. Individuals with MS present with a constellation of symptoms that are primarily managed (versus eliminated). Treatment focuses not only on symptom severity but also symptom interference with functioning and quality of life. The following are common symptoms and associated concerns experienced by individuals with MS, along with recommendations for the assessment and management of those symptoms:


    1. 1.


      Fatigue

      As many as 90 % of people with MS experience persistent fatigue, and 40–60 % report it as their most incapacitating symptom [12]. In MS, fatigue involves a lack of physical and/or mental energy; fatigue negatively affect activities of daily living, participation in valued roles, and quality of life [12].



      • Assessment: The severity and impact can be obtained using a 0–10 numerical rating scales or by measures such as the Fatigue Severity Scale [13] and Modified Fatigue Impact Scale [14].


      • Interventions: Medications such as amantadine hydrochloride and modafinil are sometimes used for fatigue; evidence of their benefits is mixed. Rehabilitation approaches including energy conservation [15], heat management, and physical activity [16] have some evidence for decreasing fatigue and its negative impact in MS. Treatment of comorbid factors that may exacerbate fatigue, such as depression or insomnia, is also indicated.

       

    2. 2.


      Pain

      Approximately 50–65 % of adults with MS experience chronic pain [17–19]. Although pain can be widespread, it is most commonly found as affecting the legs, hands, and feet. Pain may be musculoskeletal, neuropathic, or both. In MS, chronic pain has been associated with poorer health-related quality of life, including greater interference with daily activities, vitality, emotional health, and social functioning [20]. Pain-related cognitions and coping behaviors and social variables have been strongly associated with pain intensity, physical functioning, and psychological functioning in MS samples [21]. (Individuals may experience acute pain, particularly during an exacerbation, but the more commonly experienced pain in MS is chronic.)

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Jun 25, 2017 | Posted by in PSYCHOLOGY | Comments Off on Multiple Sclerosis

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