Managing Individuals with Multiple Sclerosis
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             Therapeutic Strategies
               Labe C. Scheinberg
     Copyright (c) 1994 by the American Neurological Association
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    The management of individuals with multiple sclerosis
    (MS) is divided into the prophylactic, curative, symp-
    tomatic, and restorative phases.  It en@s medical or
    pharmacologic measures, surgical measures, psycholog-
    ical, and physical or rehabilitative methodologies.  Of-
    ten there is overlap with rehabilitation employing med-
    ical, psychological, and surgical intervention.  Some of
    the things I will mention are so basic to the tenets of
    medical practice that I am embarrassed to mention
    them here, except that from my observations, they are
    so often neglected in the daily management of MS
    patients that they need restatement.
      Few diseases are as complex in the overall manage-
    ment or as difficult to evaluate as MS in a patient.  It
    often requires over the course of the illness, the multi-
    ple disciplinary intervention of a host of medical and
    nonmedical health professionals.  The latter includes
    such people as advocates to the disabled, health policy
    planners, and environmental designers or engineers.
    There are, for the neurologists who are usually the
    managers of the patient in the course of the illness,
    several important principles.
     Neurologists should keep in mind that there is no
    prophylaxis for the disease, no cure, or even any
    proven effective disease-modifying agents.  I wrote this
    prior to the latest disease-modifying breakthrough and
    I sort of want to reserve judgment on this, though
    numerous claims are made in the media every year.
    However, there are nwnerous effective symptomatic
    treatments for things such as spasticity, pain, urinary
    findings, and so forth.  These axe frequently over-
    looked.
     I think the biggest breakthrough in the care of the
    MS patient was not the discovery of an immunosup-
    pressant agent, but that by Jack Lapides, a urologist at
    the University of Michigan, who reintroduced, and I
    say reintroduced because it was present for many years,
    but Lapides reintroduced intermittent self catheteriza-
    tion for patients.  I think this has made a great deal of
    difference in the management and life expectancy of
    MS patients.
     A decade or two ago, we would have at least I pa-
    tient a week admitted to the hospital with advanced

  urosepsis, and we would have a great many fatalities as
  a result of this.  For the past 5 years or more, we have
  not had any cases of severe urinary tract infections, no
  urosepsis, and almost no deaths due to to this. I think the 
  life expectancy and the quality of life have improved a
  great deal in the management of MS.  I think the ad-
  vances we have made in the management of MS have
  been made as a result of our directing our attention Io
  specific symptoms in MS patients and not to any of the
  scientific advances that we have made.
     I see patients who come in with spastic paraparesis
  are in great pain, cannot abduct their legs for the sake
  of sanitation, even giving stories that when they have
  their menstrual periods, the neighbors have to be
  called in to abduct the patient's thighs for sanitary nap-
  kins.  These are things that are easily handled but are
  totally neglected because the patients and doctors are
  looking for the 'breakthrough."
    The neurologist should also keep in mind that he is
  able to manage anything that does not require surgery
  or long-term deep psychologic therapy.  There is a 
  temptation to overuse consultants.  For example, it is
  not necessary to ask for ophthalmological consultation
  of intemuclear ophthalmoplegia or for optic neuritis
  or request urological consultation for simple urinary
  findings. This referral often leads to fragentation and
  increased cost of care.  There is the need for the neurol-
  ogist to play a very active role in the early diagnostic
  revelations and education of the patient and family and
  not to relegate these matters to social workers, nurse
  clinicians, or even a chapter volunteer whose only ex-
  pertise is based on personal or family experience with
  MS.
    This sort if thing I see as very important.  The neurol-
  ogist should take the responsibility of telling the pa-
  tient and talking to the patient, educating the patient.
  You cannot relegate this to someone else..
    If you want to take care of MS patients you should
  learn some rehabilitation.  I have done this and learned
  a great deal about the management of MS patients.
  Most of what we do in the improvement of our MS
  patients is through the patient's own abilities, by expo-
  sure to rehabilitative measures.


Copyright (c) 1994 by the American Neurological Association