Symptomatic therapy and rehabilitation in primary progressive multiple sclerosis

Abstract

Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating disease of the central nervous system and a major cause of chronic neurological disability in young adults. Primary progressive MS (PPMS) constitutes about 10% of cases, and is characterized by a steady decline in function with no acute attacks. The rate of deterioration from disease onset is more rapid than relapsing remitting and secondary progressive MS types. Multiple system involvement at onset and rapid early progression have a worse prognosis. PPMS can cause significant disability and impact on quality of life. Recent studies are biased in favour of relapsing remitting patients as treatment is now available for them and they are more likely to be seen at MS clinics. Since prognosis for PPMS is worse than other types of MS, the focus of rehabilitation is on managing disability and enhancing participation, and application of a "neuropalliative" approach as the disease progresses. This chapter presents the symptomatic treatment and rehabilitation for persons with MS, including PPMS. A multidisciplinary approach optimizes the intermediate and long-term medical, psychological and social outcomes in this population. Restoration and maintenance of functional independence and societal reintegration, and issues relating to quality of life are addressed in rehabilitation processes.

Figure 1

Components of international classification of functioning disability and health. (Printed with permission: WHO-ICF [15].)

Figure 2

Life overlap diagram: interface between neurology, rehabilitation and palliative care in the management of persons with long-term neurological conditions and primary progressive multiple sclerosis. (Printed with permission: Turner-Stokes et al. [41].)

Figure 3

Clinical decision making flow chart for treating fatigue in MS. (Adapted from: MacAllister and Krupp [48].)

Figure 4

Managing urinary incontinence in patients with long term neurological conditions including primary progressive MS. (Printed with permission: RCP 2008 [25].)

Figure 5

Management of bowel problems in MS. (Adapted from: Miller et al. [49].)

Box 1

Types of MS. Adapted from Polman et al. [11].

Box 2

Subcomponents of comprehensive rehabilitation. Adapted from: Steins et al. [16].

Box 3

Phases in rehabilitation process. Adapted from: Steins et al. [16].

Box 4

Challenges in MS rehabilitation.

Box 5

Primary and secondary factors in multiple sclerosis fatigue.  (Adapted from: MacAllister and Krupp [48]).