Health

Management of Symptoms
Multiple sclerosis may cause progression over time.  The spectrum of involvement and the degree of disability varies tremendously from person to person.  There are some individuals who will have a fairly stable condition with very limited decline in function, while others may experience a more rapid progression of their neurological decline and worsening disability.

Therefore, management of the symptoms related to multiple sclerosis will likely change over time and require continual reassessment.  Understanding the potential consequences of multiple sclerosis will help individuals recognize and intervene to minimize disability and maximize function (see Table of Symptoms for symptoms that are discussed in this section).

Symptoms Associated with Multiple Sclerosis
1.Anxiety and stress
2. Bladder problems
3. Bowel problems
4. Depression
5. Fatigue
6. Heat sensitivity
7. Muscle stiffness (spasticity)
8. Numbness
9. Osteoporosis
10. Pain
11. Sexual problems
12. Sleep problems
13. Speech problems
14. Swallowing problems
15. Thinking (cognitive) problems
16. Tremor
17. Visual difficulties
18. Walking and balance problems
19. Weakness

Anxiety and Stress
Anxiety and stress are common in MS.  There are many causes for anxiety and stress, including the stresses of daily living and the challenges of dealing with the symptoms of MS and the unpredictability of the disease.

Stress may affect the symptoms of MS and possibly the underlying disease process.  Stress does appear to worsen the chronic daily symptoms of MS, such as fatigue or walking difficulties.  The effect of stress on the disease process of MS is less clear.  Some, but not all, studies indicate that stress may actually worsen the disease by provoking new disease activity.  Some of the uncertainty in this area may relate to the fact that there are different types of stress and that individuals have variably abilities to cope with stress.

It is important to be able to recognize stress and anxiety.  At times, it may be obvious that one is experiencing significant stress.  At other times, it may be less clear.  The symptoms of stress and anxiety may be emotional as well as physical.  The emotional aspects of stress include anxiety, irritability, sadness, and feeling overwhelmed.  Physical symptoms of stress include sweaty palms, rapid heart rate, stomach discomfort, and fatigue.
 
The process of identifying important stressors may be done on one’s own or with the guidance of a health professional.  Important areas to consider are family, work, finances, and MS-related factors. 

For treatment of mild stress and anxiety, one can identify stress and stressors and then use various measures to decrease stress:
• Decrease or modify stressful aspects of your life.
• Make plans for how you will do necessary tasks.
• Exercise:  Multiple studies have shown that exercise, even in modest amounts, can decrease anxiety and stress.  Exercise may be done through conventional means, which often involves working with a physical therapist to develop an appropriate exercise program, or through unconventional methods, such as tai chi and yoga.

There are specific methods that produce a state of decreased anxiety and muscle relaxation known as the relaxation response: 
• Meditation:  Meditation aims to produce relaxation by focusing concentration, relaxing the body, and diverting attention from stressful thoughts and feelings.
• Guided imagery:  This technique involves creating images that have specific effects on the mind and body, such as producing relaxation by imagining a tranquil location.

For those who have high levels of stress and anxiety, it may be important to work with a health professional (psychologist, psychiatrist or other physician, social worker, counselor) who can assist with diagnosing the cause of the stress and anxiety and who can provide access to other forms of therapy:
• Psychotherapy:  Short- or long-term psychotherapy may be an especially helpful method for identifying stressors and developing strategies for coping with stress.
• Medications:  There are many medications that decrease anxiety.  Some of the older anti-anxiety medications have multiple side effects and may be habit-forming.  Newer medications, including medications that have anti-depressant as well as anti-anxiety effects, are generally well-tolerated and are not addictive.

Bladder Problems
Bladder dysfunction occurs frequently in individuals who have multiple sclerosis.  As in most issues related to multiple sclerosis, bladder dysfunction can vary tremendously from person to person.  In some individuals this may simply be a mild annoyance, while in others it may significantly impact quality of life.  Understanding why bladder dysfunction occurs in multiple sclerosis and the steps for appropriate management are very important for overall health and well-being.

Bladder dysfunction in multiple sclerosis is most often one of two types.  These include difficulty storing urine (detrusor hyperreflexia) or difficulty voiding urine (detrusor sphincter dyssynergia or DSD).  These will be further described in a later section.

Bladder management in multiple sclerosis is important to maintain quality of life. To accomplish ideal bladder management, it is necessary to understand the anatomy of the bladder and how it functions normally with multiple sclerosis. If this information is understood and management and follow-up are appropriate, then complications that may interfere with life can be eliminated or greatly reduced.

Anatomy
When discussing the anatomy of the bladder, it is necessary to also consider the kidneys and the connection between the kidneys and the bladder. Discussion of the urinary system is often divided into two parts. 

The first part, the upper urinary tract, includes the kidneys, the ureters and the ureterovesical junction. The kidneys are two bean-shaped organs located on each side of the spine in the back part of the abdomen. The role of the kidney is to filter waste material from the bloodstream and excrete it from the body through urine. Once the waste product (urine) is separated in the kidney, it travels down the ureter (the tube between the kidney and the bladder) to the bladder, where it remains until urination is initiated.  The ureterovesical junction (UVJ) is the area where the ureter enters into the bladder wall. This is a very important area because it acts as a “one-way valve.” The ureter enters the bladder wall at an angle such that, as the bladder fills with urine, it begins to compress this entry location. This helps to prevent urine in the bladder from traveling up the ureter to the kidney as it begins to fill.

The other part of the urinary system is the lower urinary tract, which includes the bladder, sphincter and urethra. The bladder is divided into two areas: the detrusor and trigone. The detrusor (the top part of the bladder) is made up of crisscrossing muscle fibers. The trigone (the lower part of the bladder) is often referred to as the bladder neck. The sphincter is further divided into the internal and external sphincter. The internal sphincter is at the junction of the bladder and the urethra--it is made up of circular muscles that are not controlled voluntarily. The external sphincter is under voluntary control--it is that muscle you squeeze when you have a full bladder and are trying to delay urination. It is also the muscle that is relaxed when it is time to urinate. The urethra is a tube that connects the bladder to the outside.

Normal Voiding (Emptying the Bladder) of Urine
There is a very coordinated response of the nervous system to control the complex process of emptying the bladder. In the resting phase, when the bladder is filling with urine, the bladder relaxes and the internal sphincter or bladder neck contract to prevent voiding. When it is time to empty the bladder, the bladder contracts and, at the same time, the internal and external sphincters relax.  At this point, the brain also tells the external sphincter to relax, allowing urine to flow out through the urethra.

Nervous System Control of the Bladder 
There are three parts of the nervous system that are responsible for control over the complex process of urine storage and elimination from the bladder.  This includes the frontal lobe of the brain, a region at the base of the brain (the pons), and the spinal cord.  Injury to any of these areas may lead to bladder dysfunction.

Urination, also called micturition, is initiated by a micturition reflex that starts when the bladder begins to stretch as it fills with urine.  This is referred to as a reflex, because once the bladder fills up and stretches, the nerve impulses travel from the bladder to the end of the spinal cord, the sacral spinal cord.  The message is then sent back to the bladder causing contraction.  This situation happens in infants and urination occurs whenever the bladder fills to a certain level.  Later in life, around age 2 to 3, the brain is able to stop this reflex until a desired time to empty the bladder.

The brain is able to detect when the bladder is filling up with urine and make a conscious decision to inhibit or stop the bladder from contracting.

The brainstem is an area at the base of the brain.  A specific area in the brainstem that that has a role in urination is called the pons.  The pons is responsible for the coordinating bladder and sphincter activity. 

Injury Location and Bladder Function

• Detrusor Hyperreflexia
Detrusor hyperreflexia usually occurs with injury to the brain and not the pons or spinal cord.  Therefore, there is limited or absent inhibition of the micturition reflex by the brain.  In this situation, the bladder fills up with urine and, when it reaches a certain level, the bladder begins to contract.  Because the pons is not damaged, there is a normal coordination of the bladder and sphincter contraction.  That is, when the bladder contracts, the sphincter relaxes and vice versa.  The difficulty for the individual is that they may have limited or no control over bladder contractions and voiding.  The voiding of urine at an undesired time is referred to as urinary incontinence.

Detrusor hyperreflexia is usually a condition that is safe for the bladder and kidneys.  The symptoms can range from an annoying feeling of having to urinate all the time to frequent urinary incontinence or accidents.

Detrusor External Sphincter Dyssynergia (DESD)
If the injury is below the pons, the micturition reflex continues without the coordination of the pons.  In this condition, the bladder contracts when full, but the bladder neck and sphincter do not relax as they do during normal urination. The condition where the bladder and sphincter actions are not synchronized and actually oppose each other is called detrusor external sphincter dyssynergia (DESD). DESD can lead to excessively high pressures within the bladder, which can further lead to an abnormal structure of the bladder wall. This abnormal structure and high pressures can eventually lead to a dangerous complication of reflux of urine from the bladder up toward the kidneys. Reflux may increase the pressure on the kidney and cause serious damage if not appropriately managed.  With the appropriate management, the bladder and kidneys may remain healthy.

Atonic (Flaccid) Bladder
This is a rare condition in multiple sclerosis.  In situations where the bladder does not contract, it is referred to as atonic, which means without tone or contraction.

Management
The first step in the management of new bladder complaints in multiple sclerosis is evaluation for potential treatable causes.  This most often involves the evaluation for a urinary tract infection.  If this is present, antibiotics are prescribed to treat the infection and reevaluation can occur after completing the entire course of antibiotics.

Another common evaluation is to check a post-void residual (PVR) after the individual urinates.  This determines how much urine is left in the bladder after attempting to completely empty.  A normal bladder will completely empty with no residual urine.  Most clinicians will accept a PVR of 100 milliliters (about three ounces) or less.  If a significant amount of urine is retained within the bladder, there is a higher likelihood of developing a urinary tract infection (due to stagnant urine).  If no urinary tract infection is present and there is no retained urine, detrusor hyperreflexia may be present.

Urodynamic testing monitors the pressure in the bladder and can help determine the relationship between the bladder (detrusor) and the external sphincter.  Urodynamics can determine the whether the individual has detrusor external sphincter dyssynergia (DESD) or detrusor hyperreflexia.  If DESD is present, urodynamics will be able to determine whether the pressure in the bladder is at an unsafe level.

Detrusor Hyperreflexia
Management of detrusor hyperreflexia is aimed at decreasing the overactive bladder contractions.  This is usually accomplished with the addition of a medication in the class of anticholinergics.  Anticholinergics include medications such as oxybutynin (Ditropan), tolterodine (Detrol), oxybutynin patch (Oxytrol), flovoxate (Urispas), and hyoscyamine (Levbid).

These medications may have side effects, including dry mouth, urinary retention, constipation, blurred vision, irregular heartbeat, confusion, and dizziness.

Detrusor External Sphincter Dyssynergia (DESD)
Long-term management is focused on eliminating DESD and lowering the pressures that are in the bladder to prevent deterioration of the bladder wall structure and reflux of urine up towards the kidney. This is accomplished with various drainage techniques or medications: 

Drainage Method Options

• Intermittent Catheterization (IC)
This method to drain the bladder is preferred in individuals who have appropriate finger dexterity and no other reasons why they cannot perform IC such as strictures or scar tissue. Intermittent catheterization is a process of inserting a small tube through the urethra into the bladder to allow urine to drain freely. Once urine has completely drained from the bladder, the catheter is removed. This process is repeated every four to six hours or as needed. 
 
• Reflex Voiding
This is a method that is usually only used by men. Reflex voiding occurs when the bladder is able to spontaneously contract with enough force to cause urine to be evacuated from the bladder and out through the penis. Reflex voiding usually requires the use of medications to decrease sphincter activity, which decreases the resistance of urine exiting the bladder.

• Foley (Indwelling) Catheter
A Foley catheter is similar to an intermittent catheter but it has a small balloon on the end of the catheter that goes into the bladder. This balloon is inflated with sterile water via a separate port once it is in the bladder. Foley catheters are meant to stay in the bladder for prolonged periods of time. This type of bladder management is often preferred for patients who cannot perform intermittent catheterization because of limited finger dexterity or other physical reasons why a catheter cannot be inserted several times a day.

• Suprapubic Catheter
This has the same indications for use as the indwelling (Foley) catheter. A suprapubic catheter is described by the method in which the catheter enters the bladder. A Foley catheter is used, but it enters the bladder through the lower abdominal wall. A small surgical hole is created through the lower abdominal wall just above the bladder. A suprapubic catheter is beneficial in that it does not lead to erosions of the urethra or epididymitis (an infection of a part of the testicle).

• External (condom) catheter
Condom catheters are used exclusively in men. This device is similar to a condom used for conception prophylaxis during sexual intercourse except that the tip of the catheter is open and attaches to a tube and drainage bag. Condom catheters should be changed every day to help prevent urinary tract infections and to perform skin evaluation to prevent breakdown.

Commonly Used Medications in DESD

Anticholinergics
The overall goal in the treatment of DESD with medications is to eliminate the incoordination between the bladder and sphincter. This is accomplished by relaxing the bladder with medications known as anticholinergics.  These medications:
• Prevent bladder contractions
• Are used in intermittent catheterization to prevent contraction of the bladder between catheterizations
• Are used in indwelling and suprapubic catheters to prevent permanent shrinkage of the bladder down around the indwelling catheter balloon.

Anticholinergics include medications such as oxybutynin (Ditropan), tolterodine (Detrol), oxybutynin patch (Oxytrol), flovoxate (Urispas), and hyoscyamine (Levbid).
Side effects of these medications include dry mouth, urinary retention, constipation, blurred vision, irregular heartbeat, confusion, and dizziness.

Follow-up
It is important to have an ongoing relationship with your physician to monitor the function of your urinary system.  Individuals with the detrusor hyperreflexia can often be managed with medications according to their reported symptoms.  Individuals with DESD require closer monitoring to ensure the health of the kidneys.  In multiple sclerosis, changes can occur with the progression of the disease and changes in locations of the nervous system that are affected.  Therefore, it is important to have regular follow-ups and a low threshold for investigating for a change in the type of bladder dysfunction.  For example, an individual may initially be diagnosed with a detrusor hyperreflexia because of involvement of the brain, but this may change to DESD if the spinal cord becomes involved.  This may require a change in management to maintain the health of the urinary system.

Lifelong follow-up of bladder and kidney function is crucial to maximizing health in multiple sclerosis. The exact time of follow-up and procedures performed will depend on each individual's circumstance and their managing physician. Many procedures are used to monitor bladder and kidney function:

• Annual blood tests can easily be performed to follow the level of creatinine of the blood. Creatinine rises when kidney function begins to deteriorate. Another way to measure creatinine is by collection a urine sample for 24 hours.

• Urodynamics is a diagnostic test that monitors the pressure in the bladder and the presence or absence of detrusor external sphincter dyssynergia (DESD). 

• A cystogram is a procedure where contrast dye is injected into the bladder through a catheter and an x-ray is then taken of the bladder, ureter and kidneys. This x-ray will show the shape and size of the bladder and most importantly if reflux is present. Reflux can be seen as the contrast dye in the bladder is traveling up the ureter towards the kidneys.

• A cystometrogram (CMG) is often performed as part of urodynamics. In this procedure a catheter is inserted into the bladder and filled slowly with water or carbon dioxide. This is used to show how the bladder functions as it is filled with urine. During this test, pressures within the bladder are measured as well as the specific volumes at which the bladder begins to contract.

• Ultrasound can be used to evaluate the kidneys and ureters. It can often be used to identify hydronephrosis, which is a dilation of the ureter that occurs with reflux. Ultrasound can also identify stones that may be present.

• Renal scan is a test that measures kidney function. A radioisotope is injected into a vein, which then flows through the kidney. Multiple pictures are taken of the kidneys over a period of 30 minutes to one hour and interpreted by a computer. Renal scans can determine the function of the kidney by how well it is able to filter the blood.

Bowel Problems
The most common bowel problem for people with MS is constipation.  There are several factors that may cause MS-related constipation:
• Impaired nerve input to the intestines due to MS lesions in the brain and spinal cord.
• Decreased fluid intake, possibly because of bladder difficulties that are provoked by fluid intake.
• Limited physical activity which may then decrease bowel activity and the passage of stool.

A good diet is essential for good bowel control.  Regular eating times and balanced meals are important.  Constipation may be improved with adequate intake of fluid and fiber, the portion of plant products that is not digestible.  Fiber intake may be increased by increasing intake of fiber-rich foods, such as raw fruits and vegetables, nuts and seeds, and whole grain cereals and breads.

Regular bowel movements may be facilitated by developing a bowel program.  With a bowel program, one should select a convenient time to have a bowel movement—the most effective time is usually shortly after a meal.  It is then important to attempt to have a bowel movement at this time every day, even though, initially, it may not be possible to pass any stool.  It may be helpful to drink some warm liquid prior to defecating.

If constipation persists with simple measures of establishing a bowel program and increasing food and fiber intake, then medications may be necessary.  The type of medication needed depends on the cause of the constipation:
• Decreased bulk of stool:  In this situation, bulk formers are helpful.  Commonly used bulk formers include Metamucil, Perdiem, FiberCon, Citrucel, and Fiberall. 
• Hard stool:  Stool softeners may be used to decrease the hardness of stools.  Stool softeners include Colace, Surfak, and Chronulac.
• Difficulty expelling stool:  If stool cannot be adequately expelled, then stimulation of the rectum and intestines with medication may be helpful:
o Mild oral laxatives, which act as chemical irritants to the bowel, include Pericolace, Perdiem, and Milk of Magnesia.
o Suppositories, which act on the rectum or large intestine, include glycerine suppositories and Dulcolax.
o Therevac mini-enemas are simple to administer and provide lubrication for bowel movements

For constipation that does not respond to simple measures, it is important to work with a health professional to determine the optimal approach.  Some of the medication-based approaches are available over the counter, but they must be used in a thoughtful, reasonable manner in order to obtain maximal benefits and avoid habit-forming approaches.

Depression
Depression is quite common in people with MS.  At some point during the disease, approximately 50 percent of people with MS experience significant depression. 

There are varying degrees of sadness and depression.  Mild, intermittent sadness due to daily life situations is normal.  More severe sadness due to significant life events, such as death or major financial or work difficulties, is also normal.  Major depression, or clinical depression, refers to a more serious condition that is not normal and may significantly interfere with life.  Those with major depression usually feel sad and also have other symptoms that affect their ability to function.  Technically, major depression is characterized by the presence of at least five of the following symptoms for at least two weeks:
• Depressed mood
• Fatigue
• Decreased interest and pleasure in activities
• Sleeping more or less than normal
• Significant increase or decrease in weight or appetite
• Significant feelings of guilt or worthlessness
• Thinking difficulties, including decreased ability to concentrate and make decisions
• Agitated or slowed behavior
• Thoughts of death or suicide

There are multiple causes for depression in people with MS.  The life changes created by the disease, especially at the time of diagnosis or at the time of an attack, any cause depression.  It is also believed that some MS lesions may alter brain function in a way that leads to depression.  Finally, there are two commonly used MS medications that may cause depression:
• Steroids-these medications, which are used to treat attacks, may cause sadness (or, alternatively, a high-energy state).
• Interferons-although not definitively known, it is believe that these medications, which include Rebif, Betaseron, and Avonex, may cause depression or worsen a pre-existing depression.

The two main conventional approaches for treating depression are medications and psychotherapy.  There are many different FDA-approved antidepressant medications.  Older antidepressant medications, known as tricyclic antidepressants, are not commonly used.  There are several newer classes of antidepressant medications, which include fluoexetine (Prozac) and others known as SSRIs (selective serotonin reuptake inhibitors).  These antidepressants have fewer side effects than the tricyclic antidepressants.  It is important to recognize that it may take 4-8 weeks for these medications to have their full antidepressant effect.  It is also important to know that these medications may cause various side effects, including insomnia, sedation, nausea, headache, and sexual difficulties,  It is important to work with a health professional to monitor for beneficial as well as adverse effects to these medications.

The other conventional treatment strategy for depression is psychotherapy.  With the broad use of antidepressant medications, psychotherapy is sometimes forgotten.  For some people, the most effective approach may actually be medications in conjunction with psychotherapy.  There are many options for psychotherapy:  individual, couple, group, or family.  Barriers for obtaining psychotherapy include inadequate health insurance coverage and social stigma.  Psychotherapy may be especially helpful for:
• Adjustment issues:  these occur in response to events that require changing one’s outlook or developing new coping strategies, such as an initial diagnosis, an attack, or new symptoms.
• Caregiver concerns:  caregiving may cause significant stress on the person with MS as well as the caregive.
• Situations that require new insight:  psychotherapy, unlike medications, may help one develop psychological skills to better cope with current as well as future situations.

There are many unconventional, or alternative, treatment strategies that are claimed to be effective for depression.  Many of these have undergone limited formal investigation.  Of the strategies that have been investigated, the two that appear to be most effective are:
• Exercise:  this may be done with conventional methods (often developed with a physical therapist) or unconventional approaches, such as tai chi or yoga.
• St. John’s wort:  this herbal therapy appears to be effective for mild-moderate depression but not for severe depression; it should not be used in conjunction with antidepressant medications and it may cause side effects, including sedation and sensitivity to sun light.

Whether one uses a conventional or unconventional therapy, it is essential to recognize that depression is a serious medical condition.  One must work with a health professional to diagnose, treat, and monitor the condition. 

Fatigue
Fatigue is the most common disabling symptom of multiple sclerosis.  Seventy-five to ninety percent of individuals with multiple sclerosis experience fatigue.  Fatigue is a major reason for unemployment in multiple sclerosis.

The exact cause of fatigue is unknown.  Several reasons have been suggested.  Some have claimed that the frontal lobe of the brain has low metabolism levels which leads to fatigue.  Others have stated that there is a block of the transmission of nerves within the brain that have lost some of their myelination, but this explanation has lacked proof in studies.  Another study reported a decrease in recruitment of specialized neurons in the spinal cord (alpha motor neurons) that activate muscles.  Because of this, there may be an increase in energy demand when contracting muscles.  Finally, some report that the muscles of flexion and extension do not cooperate and fight against each other (one group should relax while the other is contracting, but instead they contract at the same time) increasing the energy demand and fatigue.

When describing fatigue in multiple sclerosis, it should be divided into two main types.  The first type is primary fatigue and the other is secondary fatigue. 

• Primary fatigue is fatigue that is directly related to the multiple sclerosis and caused by the process of the disease. 

• Secondary fatigue is fatigue that is caused by factors other than the disease process of multiple sclerosis.  Examples of secondary fatigue include infections, medical conditions, excessive heat, medications, and possibly poor sleep.

According to the Multiple Sclerosis Council for Clinical Practice Guidelines, fatigue can be divided into acute and chronic fatigue. 

• Acute fatigue is fatigue that is new or increased within the previous six weeks and limits functional activities or quality of life. 

• Chronic fatigue is fatigue that is present for any amount of time on 50% of the days for more than six weeks and limits functional activities or quality of life.

When assessing fatigue in multiple sclerosis. the first objective is to identify any potential causes that may be reversible and causing secondary fatigue.  This investigation will require a history, physical examination, and possibly laboratory studies.  If no identifiable conditions are identified, then a diagnosis of primary fatigue is appropriate.  In this situation, multiple strategies may be tried:

• Energy effectiveness strategies: this involves completing an activity diary to identify factors that may worsen fatigue, which may include heat exposure, stress, or sleep problems.  Once these are identified, activities can be prioritized.

• Aerobic exercise: daily aerobic exercise is recommended, being careful not to overheat.  It is recommended to perform an exercise program 3-5 sessions per week to a moderate level of exertion for 3 to 30 minutes.  It is recommended to only increase by 10% per week.

• Equipment modifications: these modifications are performed to maximize function while minimizing extra effort to accomplish a task, such as self-care or mobility.

• Environmental modifications: these modifications are consistent with achieving Universal Design at home and work, air-conditioning, and transportation to decrease over exertion.

• Medications:  modafinil (Provigil) and amantadine (Symmetrel) are effective for multiple sclerosis-related fatigue.

Heat Sensitivity
It has been recognized for years that heat may aggravate MS symptoms.  Worsening of symptoms with relatively small increases in body temperature occurs in 60 to 80 percent of people with MS. The “hot bath test” was one of the earliest tests for diagnosing MS. In this test, which is no longer used, people suspected of having MS were placed in a hot bath and monitored for worsening of symptoms. Also, early in the course of MS, the only recognizable feature of the disease may be a symptom, such as weakness, numbness, or visual blurring, which occurs only in situations that increase body temperature, such as exercise, fever, or warm showers or baths.
While warming may aggravate symptoms, cooling may improve symptoms.  Limited research studies have found that cooling produces improvement in multiple MS-associated symptoms, including weakness, fatigue, spasticity, walking difficulties, urinary difficulties, speech disorders, visual difficulties, sexual problems, incoordination, tremor, and cognitive difficulties. This beneficial response to cooling is the basis of cooling therapy.
Cooling therapy has a scientific rationale. Nerve cells with damage to the insulating portion of the cell (the myelin), which is what occurs in MS, exhibit impaired or blocked signal conduction with very small increases in temperature. Thus, small decreases in temperature may enhance nerve signal transmission.
Cooling may be produced with various techniques.  Simple measures include using fans or air conditioners, taking cool baths or showers, drinking cold liquids, using ice packs, avoiding warm environments, and wearing cotton clothing.  More technical approaches utilize garments, such as vests, that produce body cooling. Cooling garments may be passive or active. Passive garments, which are simpler and more portable than active garments, use evaporation or ice packs for cooling.  Active garments, which appear to provide more effective cooling than passive garments, have coolants that circulate through the garment. 
In general, cooling garments are well tolerated. It may be uncomfortable when the cooling begins. Also, handling the garment may be cumbersome.
There are individual variations in the amount of cooling and the extent of benefit. In some people, there is little or no decrease in body temperature with cooling. In approximately 10 percent of people with MS, there may actually be a paradoxical response in which symptoms actually worsen with cooling.
Cooling garments are available from several sources and are manufactured by:
• Akemi Inc., 8700 Commerce Park Drive, Suite 212, Houston, Texas, 77036, 800-209-2665
• Cool-Sport, 2008 West Carson Street, Suite 211,Torrance, California, 90501-3297, 310-618-1590
• CoolSystems, Inc., 929 Camelia Street, Berkeley, California, 94710, 510-559-3940
• Jenkins Comfort Systems, P.O. Box 10063, Augusta, Georgia, 30903, 888-508-6908
• Life Enhancement Technologies, Inc., 807 Aldo Avenue, Suite 101, Santa Clara, California, 95054, 800-779-6953
• Maverick Marketing Ventures, Inc., P.O. Box 38159, Colorado Springs, Colorado, 80937-8159, 888-244-5569
• MicroClimate Systems, Inc., 965 East Saginaw Road, Sanford, Michigan, 48657, 800-397-3004
• Polar Products, Inc., 540 South Main Street, Suite 951, Akron, Ohio, 44311, 800-763-8423
• Shafer Enterprises, L.L.C., 10 Andrew Drive, Suuite 200, Stockbridge, Georgia, 30281, 800-345-3176
• Steele Incorporated, P.O. Box 7304, Kingston, Washington, 98346, 888-783-3538

Muscle Stiffness (Spasticity)
Spasticity is best described as an increase in muscle tone (tightness or difficulty moving an arm or leg through its range of motion), increase in reflexes (when a physician taps on a tendon with a reflex hammer), involuntary movements, and the presence of clonus (that is, when the foot is placed on the ground, it beats up and down).

When an individual is diagnosed with multiple sclerosis, there is often no evidence of spasticity or it is very mild.  Some will describe spasticity as having heavy arms or legs or that it feels like walking through water with resistance.  As multiple sclerosis progresses, an increase in spasticity may be one of the most obvious symptoms.

Spasticity can vary throughout the day and may be affected by other stimuli. For example, individuals who push a wheelchair often notice that their spasticity is decreased with a greater amount of activity. Medical issues can also lead to an increase in spasticity, commonly occurring when individuals develop urinary tract infections or experience pain.  The position of the body may have an impact on the degree of spasticity.  Some individuals may have worsened spasticity when in the seated position and others while standing.

Why does spasticity occur in multiple sclerosis?
The normally functioning brain and spinal cord have nervous tissue and nerve tracts that are inhibitory (decreases tone and spasticity) and excitatory (increases tone and spasticity). Before multiple sclerosis deveops, the two systems that maintain normal tone are well-balanced. 

With multiple sclerosis, this balance may be disrupted and an increase in tone and spasticity may occur. For example, there are nerve tracts that start in the brain and travel down the spinal cord to the organs and muscles.  Some of these nerve fibers function to inhibit or dampen the reflexes and tone in the muscles. If these are damaged, the balance is tilted toward being more spastic. In multiple sclerosis, demyelination can limit or prevent the transmission of these inhibitory nerve impulses and the excitatory tracts take over the balance.  When axons are damaged, these nerve fibers may lose the ability to conduct signals.

What can be done about spasticity?
First, it is important to mention that not all spasticity requires treatment. Spasticity may be beneficial because it can maintain muscle bulk and circulation by causing muscle contractions that return blood flow to the heart.  Spasticity should be treated if it is interfering with function.  For example, if the spasticity is painful, continuous, annoying, or interfering with transfers or sleeping, it probably should be treated.

What is the treatment for spasticity?
The first approach to treatment does not involve medications. Some individuals may control their spasticity simply by stretching several times throughout the day. Stretching does decrease the spasticity, but the beneficial results may be temporary.

For individuals who use a wheelchair, correct positioning is important in managing spasticity. Spasticity is usually increased when the hip angle is increased (as when one moves from the sitting position to the lying position). This positional change of the hip can also occur when an individual in a reclining wheelchair changes from the sitting position to the reclined position. Therefore, many individuals use a tilt-in-space seating system instead of a reclining back. A tilt-in-space wheelchair keeps the angle between the legs and torso in the same position but tilts the user backwards to change the area of pressure. In addition, the position of the foot on the footplate may have an effect on spasticity. If the ball of the foot is the only part of the foot that is touching the footplate, spasticity will likely be increased and clonus will occur. 

Splints may also be made to help inhibit spasticity in the upper and lower extremities. Some individuals use cryotherapy (cold), which involves the placement of ice bags (some use a bag of frozen peas) over the muscle groups that suffer the most problematic spasticity. A cool or cold object should not be kept in the same location for more than 20 minutes. Applying cold can often decrease the spasticity for up to several hours, but is a temporary method of relief. Another option is to apply a cooling vest that has channels of circulating cooling fluid.  Finally, some individuals use a home neuromuscular electrical stimulation device to contract the muscle and decrease the spasticity, but these results are also temporary.

What medications are used to treat spasticity?
Oral medications are often used to treat spasticity in multiple sclerosis. When medications are used, it is recommended to start at a low dose and slowly and gradually increase the dosage as required—these should be prescribed by a physician. Many of the medications used to treat spasticity may cause symptoms that are similar to those directly related to multiple sclerosis.  These include somnolence, fatigue, weakness, and cognitive slowing.  Some medications also require monitoring of liver function, especially when combined with the disease-modifying agents.  Spasticity medications include:

• Baclofen is frequently used in multiple sclerosis. This medication is given three to four times per day. If discontinued, the baclofen dose must be slowly decreased—it may cause hallucinations, delusions, and seizures if stopped abruptly.

• Tizanidine (Zanaflex) is one of the newest medications used in the treatment of spasticity. This medication is often used alone but may be combined with other medications, such as baclofen.  Zanaflex has been shown to be beneficial in patients with multiple sclerosis. This medication is usually given three to four times per day. The manufacturer recommends that a blood test which looks for liver inflammation be monitored after starting this medication.

• Dantrolene (Dantrium) is the only medication used for the treatment of spasticity that has a direct effect on the muscle instead of the nervous system. This medication affects both normal muscle and spastic muscle and is thought by some to result in muscle weakness. Dantrium is another medication that has a potential serious side effect of increasing liver enzymes and causing liver failure. Therefore, a blood test that monitors for liver inflammation should be followed after starting this medication.

• Benzodiazepines are a class of medications that are used widely throughout the medical field for various reasons, including the treatment of spasticity in people with multiple sclerosis. This medication has limited use because of the side effects, which include significant drowsiness and decrease in cognitive function. Examples of these medications include diazepam(Valium), clonazepam (Klonopin), and lorazepam (Ativan). Benzodiazepines are sedating.  As a result, these medications may be especially helpful for nighttime spasms. 

• Clonidine (Catapress) is similar to Zanaflex (tizanidine), although it is believed to have increased side effects of low blood pressure and sedation. Therefore, most individuals will prefer to use Zanaflex instead of Catapress. An exception to that preference is when oral medications cannot be used, because clonidine is available in a transdermal (skin) patch.

• Gabapentin (Neurontin) was developed as an anti-seizure medications but appears to decrease spasticity in individuals with multiple sclerosis. Neurontin is also commonly used to treat pain that occurs after multiple sclerosis. Therefore, it can be a beneficial medication that treats two problems at the same time — pain and spasticity.

What if medications do not adequately control spasticity?
Some patients cannot tolerate the side effects of the oral medications. Drowsiness and cognitive difficulties are common side effects that prevent some patients from using oral medications. In addition, some individuals are on maximum doses of multiple anti-spasticity medications with inadequate reduction in spasticity.

Some of these individuals are appropriate candidates for intrathecal baclofen. Baclofen can be administered via an intrathecal route to the nervous system. There is a space within the spinal cord referred to as the "thecal space." 

A small catheter is inserted into this intrathecal space and anchored to the surrounding spinal column. A small tube is routed under the skin to the front lower part of the abdomen and connected to a battery-powered pump. This pump has a reservoir where the baclofen is stored. This stored baclofen is then slowly transported to the thecal catheter which then delivers a predetermined dose of the drug into this intrathecal space. The intrathecal space is an ideal location for the delivery of baclofen, because spasticity begins in the nervous system. In contrast, when pills are taken by mouth they have to be digested, enter the bloodstream and then cross into the fluid surrounding the brain and spinal cord (cerebrospinal fluid or CSF).  Since the baclofen is delivered directly into the CSF, it requires a much lower dose, which results in significantly decreased cognitive side effects.

With intrathecal baclofen, there is a higher concentration in the low back than in the neck.  As a result, the decrease in spasticity is much more apparent in the lower extremities than the upper extremities.

The life of the pump is directly related to the battery life, which is dependent on the rate of baclofen infusion. It is estimated that a battery will last three to six years before replacement is required. Replacement is performed by a surgeon who removes the pump and replaces it with a new pump. The catheter that is tunneled under the skin and anchored to the spinal column is not removed. The new battery is then hooked up to the previous tubing.

How do I know if I will benefit from a baclofen pump?
Before people have baclofen pumps surgically placed, they undergo an evaluation by a physician. Those who cannot tolerate oral medications or are inadequately treated with maximum doses of medications are considered for a trial. A trial consists of a single intrathecal injection of baclofen followed by an examination to assess for a decrease in spasticity or tone. If there is a decrease in spasticity or tone, they are usually referred to a surgeon who places the baclofen pump. Once the pump has been placed, the dosage is increased or decreased by a physician or nurse via a programming machine through the skin. 

Can injections help with the treatment of spasticity?
Botulism toxin (Botox or Myobloc) can be used in the treatment of isolated areas of spasticity in multiple sclerosis. This medication can show positive results within three days of injection and peak results in 14 days. The resulting muscle weakness can last between three and six months. Another option is to inject phenol, a type of alcohol, onto the nerve which causes nerve damage. This damaged nerve can grow back and repair itself within months to years. Phenol's effect of causing a decrease in spasticity lasts much longer than Botox but can have an increased chance of an unpleasant sensation in the distribution of the nerve.

Is there a role for surgery in the treatment of spasticity?
In the past, surgeons cut the spinal cord to attempt to decrease spasticity—this was not a very successful procedure.   More recently, a very selective surgery has been performed that cuts the fibers that carry sensation back to the spinal cord. This surgery is called a selective dorsal rhizotomy; it is not used infrequently today in the treatment of spasticity in multiple sclerosis.

Numbness and Tingling
Numbness is one the most common MS symptoms.  It may occur during an attack.  Or, it may be a symptom that does not fully recover after an attack—in that case, it may be a chronic symptom that fluctuates on a day-to-day basis.

If numbness occurs in the setting of an attack, then steroids (orally or intravenously) can be used for treatment.  If numbness is the only symptom during an attack, then steroids are usually only used if the numbness is clearly a manifestation of a new attack and the numbness is significant enough that it interferes with functioning.  For attacks in which numbness is present along with other symptoms, such as weakness or clumsiness, the numbness may be the slowest symptom to recover.

For chronic numbness, there are no particularly effective medication-based therapies.  If numbness is accompanied by pain or tingling, then there are medications that may help with those other symptoms (see section on Pain).  At times, numbness may be bothersome because of the anxiety that it causes.  In that situation, there may be vicious cycle in which numbness provokes anxiety and anxiety provokes numbness.  This cycling process may be improved by realizing that mild numbness is not a major MS symptom and developing strategies to cope with the anxiety that is generated by the numbness (see Anxiety and Stress section). 

Osteoporosis
For years, it has been recognized that older women are prone to osteoporosis, a medical condition in which bones are weakened and vulnerable to fractures.  More recently, studies have demonstrated that osteoporosis does not just affect older women--it occurs in a variety of medical conditions, including MS.  Among those with MS, it appears that osteoporosis is under recognized and that osteoporosis therapies, such as vitamin D, calcium, and other approaches, are under utilized.  Recent studies also indicate that vitamin D, due to an immune-suppressing effect, may play a role in the underlying disease process of MS.

The term osteoporosis refers to a significant reduction in the density and strength of bones.  Osteopenia is a less severe reduction in bone density.

Osteoporosis is especially important to consider in those with walking difficulty.  People with MS who have walking instability are at risk for falling.  If a fall occurs in someone with osteoporosis, then the risk for a bone fracture occurring with the fall is increased. 

Among those with MS, osteoporosis appears to be relatively common in both women and men.  People with MS have risk factors that make them prone to osteoporosis.  These risk factors include:
• Female sex, especially post-menopausal
• Decreased levels of physical activities, especially walking and other “weight-bearing” exercises
• Use of some medications:
o Steroids-regular use of steroids (as opposed to intermittent use for attacks)
o Thyroid medications
o Seizure medications-these medications, such as phenytoin (Dilantin) and carbamazepine (Tegretol), are sometimes used to treat conditions other than seizures
• Low body weight
• White race

There are multiple other osteoporosis risk factors.   Those that may occur in people with MS or are relatively common include:
• Past history of bone fracture as an adult
• Older age
• Family history of osteoporosis
• Cigarette smoking
• High vitamin A intake (greater than 10,000 international units daily)
• Possibly high caffeine or alcohol intake
• Other medical conditions, including gastrointestinal and hormonal disease

People with MS with risk factors, and certainly those with a history of bone fractures, should be screened for osteoporosis.  The decision about evaluating for osteoporosis is individualized and should be discussed with a healthcare provider.

There are many approaches that will prevent or treat osteoporosis.  If one is at risk for osteoporosis and testing indicates mildly decreased bone density or normal bone density, then preventive measures can be taken:
• Have a regular exercise program, especially, if possible, one that includes walking, standing, or other forms of weight-bearing activities. 
• Determine the intake of vitamin D and calcium, and consider supplements of vitamin D and calcium.  Supplement doses are based on individual needs and should be discussed with a healthcare professional. 
• Limit the use of steroid medications.
• Limit caffeine and alcohol intake and avoid tobacco
• Minimize the risk of falling by using assistive devices and working with physical and occupational therapists.

If one has significantly reduced bone density, then additional, more aggressive medication-based approaches may be taken.  Medications for osteoporosis include alendronate (Fosamax), risedronate (Actonel), and etidronate (Didronel), raloxifene (Evista), and calcitonin (Miacalcin, Calcimar).  The various treatment options should be discussed with a physician.

In addition to its effects on bone health, vitamin D mildly inhibits the immune system.  In theory, mild immune system suppression could be therapeutic for a disease such as MS in which the activity of the immune system is generally increased.  In EAE (experimental allergic encephalomyelitis), the animal model of MS, disease severity is increased by vitamin D deficiency and decreased by vitamin D supplementation.

To determine if vitamin D treatment lessens disease severity in people with MS, clinical studies have been conducted.  An older study indicated that vitamin D supplementation decreased the rate of attacks in people with MS, but this study was small and difficult to interpret.  Another study, which was preliminary and only evaluated a small number of people over a short period of time, found that a form of vitamin D (known as “19 nor”) did not produce any clear beneficial effects.  To clarify the role of vitamin D in MS, further studies are currently being conducted.

Pain
In the past, it was thought that pain was not a common symptom in MS.  Recent studies have shown that pain is actually fairly common in MS--at some point in the course of the disease, about one-half of people with MS will experience pain.

There are many different types of pain.  Some forms of pain are due to MS lesions in the nervous system.  These forms of pain include:
• Trigeminal neuralgia:  This is a severe, stabbing facial pain that may interfere with eating and, when it involves the mouth, be misdiagnosed as a dental problem.
• Dysesthesias:  This is a burning sensation that may occur in variable locations and may be accompanied by tingling and, paradoxically, by numbness.
There are several medications that may be beneficial for nerve-related pain, including some anticonvulsant and antidepressant medications.  In addition, for severe trigeminal neuralgia, surgical therapies may be helpful also.

There are other forms of pain that may occur with MS:
• Headaches:  People with MS are at increased risk for developing headaches.
• Low back and neck pain:  People with MS may be especially prone to strain (also referred to as musculoskeletal strain) of the neck or low back.  Weakness of the arms or legs may provoke this type of pain.  For significant low back or neck pain, it is important to have a medical evaluation to be certain that it is not due to a more serious condition such as a herniated disc.

There are multiple unconventional, non-medication based approaches for treating pain.  Acupuncture may be helpful for some types of pain.  Other therapies that have not undergone rigorous clinical testing but may provide benefit include guided imagery, massage, and meditation.

Sexual Problems
The majority of people with MS experience some type of sexual dysfunction.  About 85% of men with MS have sexual difficulties, while 50-75% of women with the disease have sexual problems. 

There are multiple sexual difficulties that may occur in MS.  For both sexes, sexual symptoms include altered genital sensation, decreased sexual interest, decreased ability to experience orgasm, and other MS symptoms that interfere with sexual activity, such as depression, fatigue, bladder difficulties, or muscle stiffness.  Other symptoms that are specific to women or men are:
• Women:  decreased vaginal lubrication, weak vaginal muscles
• Men:  erectile dysfunction, decreased force of ejaculation, delayed ejaculation

Among the various symptoms, the most common are erectile dysfunction among men and is erectile dysfunction and decreased interest and decreased vaginal sensation among women. 

The appropriate treatment for sexual difficulties depends on the underlying cause.  For example, the neurological symptoms of MS may be the primary cause of some sexual problems:
• Altered genital sensation
• Weak vaginal muscles
• Bladder difficulties
• Muscle stiffness (spasticity)
MS itself may cause erectile dysfunction in men.  MS-associated fatigue may decrease the energy that is available for sexual activity, while depression may decrease interest in sex. 

Medications are another potential factor to consider with sexual dysfunction.  Commonly used MS medications that may cause sexual difficulties include:
• Antidepressant medications:  may decrease sexual interest, arousal, and orgasm
• Spasticity and pain medications:  may increase sedation which may decrease interest in, or energy available for, sexual activity
• Bladder medications:  may cause dryness, which may lead to vaginal dryness and dry mouth

Another factor that may impair sexual function is a decreased ability to experience intimacy.  The emotional and physical effects of MS may alter peoples’ sense of their bodies and their ability to be intimate and communicate with others. 

It is important to work with a health professional, such as a neurologist or primary care doctor, to determine the cause and appropriate treatment for sexual problems.  These physicians should be able to diagnose and treat these conditions or make referrals to appropriate professionals, such as urologists, gynecologists, MS specialist nurses, and mental health professionals.

There are many possible treatment approaches for MS-associated sexual difficulties:
• Vaginal dryness:  use water-soluble lubricants, such as KY Jelly, Astroglide, and Replens
• Decreased vaginal sensation:  use vibrators or other forms of vaginal stimulation
• Erectile dysfunction:  consider oral medications (tadalafil (Cialis)), vardenafil (Levitra), sildenafil (Viagra)); if these are not effective, then consider injectable medications, vacuum devices, surgically-implanted prostheses
• Sexual side effects of medications:  decrease the dose, discontinue the medication, or skip a dose before sexual activity
• Fatigue:  consider fatigue-relieving medications or sexual activity at times of the day when energy levels are higher
• Bladder problems:  decrease fluid intake and empty bladder before sexual activity
• Muscle stiffness (spasticity):  do stretching exercises or medications to decrease stiffness
• Anxiety, depression, difficulties with intimacy:  consider medications or psychotherapy (individual or couples)
As noted, it is important to work with a health professional to determine the correct diagnosis and appropriate treatment for MS-related sexual difficulties.

Sleeping Problems
There are a variety of sleeping problems that affect people with MS.  When sleeping difficulties occur, they may worsen the effects of other MS symptoms, such as fatigue, depression, and cognitive difficulties. 

As with many other MS symptoms, there are multiple potential causes for MS-associated sleeping difficulties:
• Medications:  among the commonly used MS medications, steroids and fatigue-relieving medications (modafinil (Provigil), amantadine (Symmetrel)) may decrease one’s ability to fall asleep
• Bladder dysfunction:  frequent nighttime urination may interrupt sleep
• Emotional difficulties:  anxiety and depression frequently interfere with sleep
• Muscle stiffness (spasticity):  spasticity is typically worse at night
• Periodic limb movements of sleep:  these are involuntary limb movements that interrupt the normal sleep cycle
There are clear treatment strategies for all of the above difficulties—working with a health professional in this area is important for determining the cause and optimal treatment approach.

There are several unconventional approaches that are claimed to be effective for sleeping problems.  Meditation and valerian, an herb, may be helpful.  Since valerian may cause side effects, its use should be discussed with a health professional.  A hormonal dietary supplement, melatonin, may improve sleeping difficulties, but, due to possible immune stimulation, it poses theoretical risks for people with MS.  Kava kava, an herb that was originally used in the South Pacific, is sometimes claimed to effective for sleeping difficulties.  However, it should not be used because it has not been proven to be effective for sleeping difficulties and it may cause severe liver toxicity. 

Speech Problems
Among people with MS, about 25-40% will experience speech difficulty at some time.  These speech difficulties may only be present during an attack or may be chronic symptoms due to an attack.  Slurred speech, which is known technically as dysarthria, may be caused by MS lesions in the coordination part of the brain (the cerebellum) or the part of the brain involved in lip, tongue, and palate movement (the brainstem).

Typically, speech problems are treated by speech/language pathologists.  These professionals determine the specific speech problems and then develop treatment plans, which often involve speech exercises, to improve areas of weakness.

Swallowing Problems
Swallowing is a complex process that requires the coordinated action of many different nerves and muscles.  People with MS may develop difficulty with swallowing, which is known as dysphagia.  Choking is the most obvious symptom associated with swallowing difficulties.  Other indicators of swallowing problems include:
• Slowed eating
• Coughing or spitting during or after meals
• Sensation that food is incompletely swallowed
• Pneumonia
• Weight loss
Swallowing may be evaluated with a test known as videofluoroscopy or modified barium swallow.  Speech/language pathologists are professionals who can make dietary recommendations and develop techniques and exercises to improve swallowing.

Thinking (Cognitive) Problems
In the past it was believed that MS did not typically affect thinking ability.  More recent studies actually indicate that 50-60% of people with MS have some type of cognitive difficulty.  For many with MS, the cognitive difficulty may fairly mild.

MS may affect multiple types of thinking processes.  Memory processes may be impaired in a way that makes it more difficult to learn new information.  In addition, the ability to concentrate on tasks may be decreased and information processing may be slowed.  MS may also impair problem-solving and planning and may cause language difficulties that that lead to word-finding problems.

There are multiple causes for cognitive difficulties in people with MS.  MS-associated brain injury is a common cause for thinking problems.  On the emotional side, depression and anxiety may interfere with cognition.  Finally, medications, especially medications that cause sedation (such as those used for spasticity and sleep), may impair thinking.

To determine the extent and type of cognitive difficulties, one may be evaluated by a neuropsychologist or specially trained speech/language pathologist.  These professionals administer tests that evaluated various types of cognitive ability, such as memory and language.

Several different approaches may be helpful for improving cognitive function.  There are simple strategies that can be developed independently:
• Make lists
• Use calendars for tracking activities
• Put frequently used items, such as keys or wallets, in the same place each time
• Repeat important information
• Keep important documents well organized

Other strategies may be developed with a health professional:
• Prevent cognitive decline by using one of the FDA-approved MS medications, such as interferons (Avonex, Betaseron, Rebif) or glatiramer acetate (Copaxone)
• Rehabilitate cognitive function by working with a neuropsychologist or speech/language pathologist who can develop thinking exercises to improve cognitive ability or techniques to compensate for areas of weakness
• Treat anxiety or depression that may be interfering with cognitive function
• Consider using memory-boosting medications (such as donepezil (Aricept)) which are approved for use in Alzheimer’s disease and may provide benefit for some people with MS-related cognitive difficulties

Small and preliminary studies indicate that some unconventional approaches may be helpful.  Ginkgo biloba may improve some aspects of MS cognitive dysfunction—this herb should be used with the input of a health professional since it may provoke bleeding and seizures.  In those who are heat-sensitive (see “Heat Sensitivity” section), cooling may improve cognitive function, especially during the summer months.

Tremor
Tremors, which are one of the more challenging MS symptoms to treat, are extremely varied.  They may only occur in the setting of an attack or may be continuous.  They may involve the arms, legs, trunk, or head.  .  They may fluctuate hour-to-hour or day-to-day, and may be worsened by stress, anxiety, or fatigue.  They may occur at rest, with certain positions, or with movement.

It is important to have a medical evaluation to determine the specific type of tremor that is present.  Some tremors may be caused or worsened by other medical conditions or medications.

Although tremor may be difficult to treat, there are multiple treatment options.  Medications that are used to treat tremor include:
• Clonazepam (Klonopin)
• Primidone (Mysoline)
• Propranolol (Inderal)
• Buspirone (Buspar)
• Hydroxyzine (Ararax)
• Topiramate (Topamax)
• Ondansetron (Zofran)

There are also non-medication strategies for decreasing the effects of tremor.  These strategies, which may be developed by working with an occupational therapist, include:
• Weighting:  this approach, which is based on the concept that increased weight may decrease arm or leg tremor, involves adding weights to the wrists or ankles or using items, such as pens and eating utensils, that are weighted
• Immobilization:  for particular bothersome tremors that interfere with using the hands or feet, braces can be used to decrease the effects of the tremor on daily functions, such as writing, eating, or walking

Visual Difficulties
Over the course of the disease, about 80% of people with MS will experience some type of visual problem.  Visual difficulties are common in MS because MS affects the central nervous system and the central nervous system plays a critical role in both vision and eye movements.  The two major types of visual symptoms that occur in MS are decreased vision and impaired eye movements.  Decreased vision occurs with optic neuritis and cataracts.  Impaired eye movements occur with double vision (diplopia) and nystagmus.

Optic neuritis
One of the most common MS symptoms, especially early in the course of the disease, is optic neuritis.  In this condition, there is inflammation of the nerve that travels from the back of the eye to the brain.  Proper functioning of this nerve is essential for transmitting visual information from the eye to the brain.  With this condition, there may be multiple symptoms:
• Pain behind the eye
• Blurred vision
• Decreased color vision
• Blind spots
• Flashes of light

Vision is an extremely important neurological function.  As a result, when visual difficulties, such as optic neuritis, occur, it is very important to work with a health professional to clarify the diagnosis and to develop an optimal treatment approach.  Other serious conditions may mimic optic neuritis.  For optic neuritis, the condition may resolve spontaneously but intravenous steroid treatment should be considered in some situations.

Cataracts
In addition to optic neuritis, there are multiple other conditions that may cause visual blurring.  One that may be seen in people with MS and, paradoxically may be provoked by steroid use, is cataracts.  This condition is caused by clouding of the lens of the eye.  If cataracts cause significant visual impairment, surgery may be done to improve vision.

Double Vision (Diplopia)
When an MS attack affects the brain areas that control eye movements, there may be double vision, also known as diplopia.  In this situation, the use of steroids (oral or intravenous) should be considered.  Subsequently, the double vision may resolve or may persist as a chronic symptom. 

Double vision that persists may be very bothersome.  Treatment options, which should be discussed with an ophthalmologist, include:
• Eye patching
• Frosting of one lens on eyeglasses
• Prism lenses, which result in a single image
• Surgery on the eye muscles

Nystagmus
MS may cause nystagmus, jerky movements of the eyes.  This condition is similar to a tremor, but involves the eyes.  When nystagmus is mild, it may not even significantly alter vision.  When it is more severe, it may impair vision (by causing jerky images to be seen) and may be accompanied by nausea, decreased balance, and incoordination.  As with tremor, nystagmus may be difficult to treat.  Medications that may be helpful include clonazepam (Klonopin) and gabapentin (Neurontin).

Walking Problems
Walking is a complex task that requires proper functioning and integration of many different components of the nervous system.  People with MS may have walking difficulty due to impaired function of one or more components of the central nervous system.  Although most people with MS do not need a wheelchair, about two-thirds will require some device that will aid in mobility, such as a cane, walker, or scooter. 

Although it is sometimes stated that people with MS have a very characteristic walking style, there are, in fact, multiple ways in which MS may affect walking.  It is important to work with a health professional, such as a neurologist or physical therapist, who can evaluate walking difficulties and develop appropriate treatment and management strategies.  Factors that may affect walking include:
• Spasticity
Spasticity produces involuntary muscle stiffness which, when present in the legs, may significantly impair walking.  There are multiple strategies that improve spasticity (see the section on “Spasticity” for more details). 
• Weakness
Leg weakness may affect walking stability and endurance.  Unfortunately, there are no medications to increase strength.  However, various forms of exercise may improve strength and optimize leg function (see section on “Weakness”).
• Sensory difficulties
There are several ways in which MS-associated sensory difficulties may affect walking.  Numbness may affect one’s ability to feel the ground.  Another sensory problem that is more difficult to recognize is in the area of proprioception, which is the ability to sense where a body part is without looking at it.  This sensation, which is very important for walking, may be quite affected in people with MS, especially those with spinal cord lesions.
• Vision difficulties
Vision is important for walking because it assists in avoiding obstacles and provides valuable information about where one’s body is in space (for more information, see section on “Visual Difficulties”).
• Dizziness and vertigo
MS may produce a vague feeling of dizziness or lightheadedness, or it may cause vertigo, a more specific condition characterized by a spinning or tilting sensation.  Both of these symptoms may interfere with walking.  It is important to be certain that these symptoms are not due to other conditions, such as heart problems or other neurological problems.  For MS-related dizziness and vertigo, physical therapists may be able to develop treatment strategies known as vestibular training.  For vertigo, some medications, such as meclizine (Antivert), clonazepam (Klonopin), and diazepam (Valium), may be helpful.  However, these medications may not be the best treatment option because they have side effects, may only provide short-term relief, and may interfere with long-term improvement.
• Fatigue
Fatigue may affect walking by decreasing endurance or by provoking other walking-related symptoms (see section on “Fatigue”).

Treatment of walking difficulties depends on the severity of the problem and the factors that are contributing to it.  As noted above, there are specific strategies to manage underlying sympoms such as spasticity and weakness.  In addition to these strategies, assistive devices may be very helpful.  Although there may be a psychological “hurdle” to begin using these devices, it is important to recognize that they can actually make life easier and improve one’s ability to do daily activities.  These assistive devices include:
• Ankle-foot orthosis (AFO):  a brace (worn inside shoe) that keeps the foot and ankle at the appropriate angle for walking
• Canes
• Forearm crutches
• Walkers
• Scooters
• Wheelchairs
It is important to work with a health professional, such as a physical therapist, to determine if an assistive device is needed and which device may be most appropriate.

Many different unconventional therapies have been claimed to be effective for MS-related walking difficulty.  Those that have shown some benefit in limited studies are:
• Cooling:  see section on “Heat Sensitivity”
• Hippotherapy:  also known as therapeutic horseback riding
• Tai chi

Weakness
MS may lead to weakness of many different muscle groups.  Weakness of the limb muscles, especially the legs, is often the most apparent. 

Weakness may be due to MS lesions that interfere with transmission of nerve impulses from the central nervous system to the muscles.  In addition, weakness may be due to deconditioning, or being out of shape.  In this situation, a lack of muscle use may decrease muscle size and cause weakness.

To improve strength and develop an optimal exercise program, one should work with a physical therapist.  These programs are modified as needed for those with disabilities.  Several general types of exercise may be helpful:
• Progressive resistive exercises:  also known as weight-lifting
• Aerobic exercises:  may improve physical strength and also provide general health benefits
• Stretching exercises:  decrease muscle stiffness
• Range of motion exercises:  decrease muscle stiffness and maintain muscle tone in those with more severe weakness