Spasticity
o Physiotherapy
o Baclofen
o Gabapentin
o Diazepam
o Sativex
o Dantrolene
o Intrathecal baclofen
o Botox
Bladder dysfunction
o Poor emptying (residual >100ml),
- may benefit from intermittent self catheterisation
- Bladder compression
- Botox
o Urge/ frequency
- Anticholinergic such as oxybutynin
- Solifenacin (Vesicare)
- Darifenacin
- Mirabegron (no cholinergic SE)
- Amitriptyline
Bowel dysfunction
o Incontinence
- Regular toileting
Impotence/sexual dysfunction
o Multiple types
o Treatment specific to cause Sildenafil etc.
Tremor
o Types:
- Holmes tremor
- Postural tremor
- Resting tremor (rare)
o Management:
- Botox
Fatigue
o Will occur at some stage in 95% of patients
o Most disabling symptom in 55% of patients
o Occurs daily in 2/3 patients with progressive MS
o Sleep is not restorative
o Take care to distinguish from depression
o Treatment:
- Energy conservation
- Pacing
- Graded exercise
- Avoid/treat triggers
- Medications:
Amantadine
Modafinil RCTs equivicol no clear benefit
SSRI
Dexamphetamine and methylphenidate
Fampridine
Flavonoid rich cocoa drink (small RCT positive after 6 weeks)
Sleep disturbance
o Aetiology:
- Spasticity
- Nocturia
- RLS
- Depression
o Management:
- Exercise during the day ++
- Amitriptyline
-
Depression
o Treatment:
- Duloxetine better if pain
- Mirtazepine sedating, ?help get to sleep
- Venlafaxine more energising might be better if fatigue is prominent
- Amitriptyline help with sleep
Pain
o Usual neuropathic pain medications
o Trigeminal neuralgia treat as per usual TGN
o Consider botox for focal symptoms
Cognitive impairment
o Brain fog
o Does not correlate well with brain lesions
o Correlates better with atrophy measures
o Management
- Specific cognitive rehab
- Compensatory techniques
- Pacing
- Exercise might help (at least helps other symptoms)
- Medications no benefit