Category: Managing your Multiple Sclerosis

Managing Your Multiple Sclerosis is not a book about what MS is, its causes and diagnosis. It is a practical guide to its management and there is more information to be found in Multiple Sclerosis – the ‘at your fingertips’ guide, which can be found in your local bookshop, library or possibly your nearest health clinic; also the MS Society can provide you with many information sheets on this subject. This new book was written by popular demand from readers of the first book who wanted to know more about practical steps that they could take in their day-to-day living with MS.

  • Mobility and managing everyday life: Driving

    Benefits available

    There are a number of benefits for which you may be eligible. If you receive the higher rate mobility allowance, you will be allowed to claim exemption from vehicle excise duty (road tax) on one vehicle. This exemption is given on condition that the vehicle is used ‘solely for the purposes of the disabled person’. Nevertheless, it is likely that some commonsense latitude will be given.
    If you have the higher rate mobility allowance, you will be automatically eligible for the Blue Badge, which gives parking privileges, and also for access to the Motability Scheme (see below). You will also get VAT exemption on adaptations to make your car suitable, as well as exemption on the repair, maintenance or replacement of these adaptations.

    Motability Scheme

    The Department of Transport has set up a Mobility Advice and Vehicle Information Service (MAVIS) to help people choose an appropriate car for their needs, and they will be able to give advice and assistance. This advice will cover appropriate vehicles and adaptations, as well as issues concerned with your suitability to drive – an issue that may concern many people with MS, especially in so far as eyesight may be affected, as well as the arm and leg movements necessary to control the vehicle, for which additional technical assistance may be needed.
    For people with MS who are receiving the higher rate mobility component of the Disability Living Allowance (DLA), the Motability Scheme can offer a good approach to the purchase of a new car, good used car or an electric wheelchair, through hire purchase. Alternatively, you can hire a car through the same scheme.

    Getting into and out of a car – possible adaptations

    One of the major problems for a disabled person is swinging round from outside the car into a passenger, or a driver’s seat, and of course getting out of the car in the same way. Depending on how much you want to spend, and exactly what your needs are, you could think either of a swivel cushion placed on the seat so that you can swing your legs into the car; or, more elaborately (and more expensively), replacing whole seats and their fittings so that the seat itself swivels; this allows you to back on to the seat from outside, or to rise from the seat to a standing position without having to manoeuvre in and out of the car.

    Ability to drive

    Licence
    You do have to notify the DVLA (Driver Vehicle and Licensing Agency) that you have MS, as it is one of the conditions that may affect your driving ability. If you contact them, you will receive a form PK1 (Application for Driving Licence/Notification of Driving Licence Holder’s State of Health) to complete and return. These forms may be available at your local Post Office. When it assesses your application, the DVLA will normally adopt a positive view, for it wishes to give drivers with a current or potential disability the best chance possible of keeping their licences – the key issue in this respect is public safety.
    Especially if you have been recently diagnosed, you are unlikely to lose your licence. The DVLA will consider the information that you have given on the form (PK1) and, if it believes that your driving ability is not a hazard to other road users, it will normally issue a 3-year licence. Your situation will be reviewed at the end of these 3 years. If you answer positively to any of the questions concerning health problems on form PK1, then you should send a covering letter explaining your situation, and why you believe that you are fit to drive. Without such a letter or explanation, the DVLA might withdraw your licence. It would also be worth talking to your doctor – GP or neurologist – about your driving ability. If they disagree with you about your capacity to drive, or between themselves, or you yourself have concerns about your driving ability, then you should arrange for an assessment at one of the special driving and mobility assessment centres, which you can find via the Department of Transport’s Mobility Advice and Vehicle Information Service (MAVIS) (see Appendix 1).

    Judging your ability to drive
    Doctors consider driving ability in relation to problems with the use of your arms and legs, your eyesight or your reactions. It is clearly a matter of judgement by the GP or neurologist as to whether any of these or other consequences of MS do indeed affect your driving ability and, of course, one of the main problems with MS is its variability. One day you might be able to drive without any difficulty at all. On another day, through the onset of specific symptoms, it might be difficult, or unsafe, for you to do so. The problem both for you and your doctor is making a reasonable judgement.
    Driving a car may well be a lifeline for you. The key issue will be safety for you and other road users. Some other adaptations mentioned earlier might help you to continue driving. So, discuss the issue with your family and friends, and with people in the MS Society (see Appendix 1), who will be able to offer both support and information. In the end, the formal and probably best way to deal with the problem has to be through a driving assessment through a mobility assessment centre. During this assessment, not only your driving ability but also any vehicle adaptations will be considered. The driving assessment centre will write a report – this could be of particular value if, for example, the DVLA decides to rescind your licence, and you decide to appeal against the decision. There is a charge for a driving assessment and this may vary depending on the type of assessment required, so it is important to find out the cost when you arrange it.

    Appealing against a licence withdrawal
    There is an appeals procedure, but it can be lengthy and complex, and you need to seek advice and consider the likelihood of success, as well as the consequences of not succeeding. In any case, if you feel that you want to appeal, it is important that you register your intent to appeal to the DVLA as soon as possible. In the case of England and Wales, this has to be done within 6 months from the date of notification of the withdrawal of the licence, and in Scotland within 1 month of that date. You can withdraw your intent to appeal at any time. Appeals are heard in the local Magistrates Court in England and Wales, and in the Sheriff ’s Court in Scotland.
    You will almost certainly need some formal assistance to appeal, and you ought to bear in mind that it will be difficult to succeed without supporting evidence from your doctor and/or your formal driving assessment, which may not have been available to the DVLA at the time the original decision was made. It would be sensible to consult with someone who has experience of such cases, perhaps the Citizens Advice, your local DIAL (Disability Information and Advice Line) or your local branch of the MS Society who could refer you on to others, even a good lawyer, if necessary. Look in your local telephone book for their addresses. It is salutary to know that the DVLA has often in the past sought to recover its expenses from those who have appealed unsuccessfully, and this could amount to several hundred pounds. So you need to very sure of your grounds before appealing.

    Telling the insurance company
    Your insurance company cannot stop you holding a driving licence – only the DVLA or the Courts can do that. However, insurance companies do require that you disclose all material factors that may af fect your driving. MS is one of these factors. If you do not disclose the information, this may invalidate your insurance and, if you are not insured (at least on a third-party basis), you are not allowed to drive. So it is essential to tell your insurance company about your MS because, if you do not and then a legitimate claim arises which has nothing to do with the MS, you may find that you are in difficulty.
    Generally, as long as you have a valid driving licence, the most significant problem that you may face is a slightly increased insurance premium. Ask for several quotations from a number of companies to make sure that you are getting the best value. You also ought to read the small print on any policy proposal because you may need to be wary of unacceptable or difficult endorsements to the policy.
    You could also contact some of the insurance companies who are now specializing in insuring disabled drivers. A list is obtainable through RADAR (Mobility Fact Sheet No.6), which sets out these companies, and broadly what they offer (see Appendix 2). You might even lower your premium!

    Other transport

    We have already discussed the possibility of getting an outdoor electric wheelchair or an electric scooter (sometimes called pavement vehicles) which, depending on the terrain near where you live, could be of great help in giving you more independence and ability to travel reasonable distances for shopping or leisure activities.
    There are other forms of transport that you may find helpful, but these tend to vary according to which area you are living in. You can get in touch with the Social Services Department of your local authority for advice.

    • There are Dial-a-Ride minibus schemes, especially for people with mobility problems. Often you have to join the scheme first, and there might be a waiting list. However, when you have joined, you will be collected from your home and then dropped back again, often at a reasonable cost.
    • Some areas have taxi voucher schemes that give a number of low or no-cost journeys. These are usually in operation where people cannot take advantage of free or concessionary bus fares. Although taxi fares generally can be expensive, sometimes people do not realize how expensive maintaining a car is, and you could find that using taxis for short journeys compares very favourably.
    • For longer journeys outside your area, there are organizations such as Tripscope, which can help you plan such journeys, and from whom you may be able to obtain escorts if necessary.
    • Sometimes, other organizations, such as St John Ambulance Brigade and the British Red Cross, and local organizations and clubs, such as Rotary, Lions, Round Table and the Soroptomists can also provide escorts. Have a look in your local telephone book for their addresses.
    • Your local MS Society branch or region may be able to help.

  • Mobility and managing everyday life: Aids and equipment

    Occupational therapy

    Many of the aids and much of the equipment that you might need are available through an occupational therapist or at least you are likely to be able to obtain their advice on what to have. Occupational therapy is mainly concerned with helping people to manage any difficulties they may have in ‘daily living’. You will almost certainly be offered a consultation with an occupational therapist (OT) at some point but, if you are not and want such professional advice, your GP or neurologist should be able to refer you to an OT to assist you. You also may need to use an OT if you wish to obtain aids and equipment through your local NHS Trust or Department of Social Services.

    Walking aids

    Many people with Multiple Sclerosis experience problems in walking. Sometimes this is temporary, e.g. during an attack or exacerbation, sometimes it is more long term as the MS develops. A major problem is often a difficulty with balance, causing staggering, in which you fear you may fall. Of course, using a mobility aid (walking stick, crutch, and so on) is something that many people with MS dread, for it appears to be a very visible sign both to yourself and others that the MS is progressing. However, once your balance has started to deteriorate significantly, people with MS often report that, when others see them, with no mobility aid, staggering and losing their balance, they seem to think that the person with MS is drunk. Thus dealing with this problem is important socially and physically, to prevent falls and possible injury.
    A mobility aid is the usual way to overcome these problems, and your physiotherapist or OT can help here. Mobility aids range from one or two canes (walking sticks), to one or two crutches used under the forearms, to light walkers which have four legs (Figure 8.6). Both canes and crutches can have several short legs to give increased stability. Ensure that whatever you use deals with the problems you have or might have, and that you are comfortable using it. You may need to experiment a bit to get the right combination of mobility aids for different situations. For example, although some people are worried that walkers are amongst the most visible of mobility aids, because they operate in front of you they give you more stability, and may even reduce fatigue from walking. They may also have a seat, or a basket to allow you to carry things. Keep your situation under review, and make sure that the mobility aid you are currently using is really the one best for you.
    Mobility aidsFigure 8.6 Mobility aids.

    Chairs and wheelchairs

    For many people with MS, the day when they feel that they have to consider using a wheelchair is a big day in their lives. However, we all have to adapt to declining mobility as we get older, and to using additional means of getting around. Although there is still some social stigma attached to being in a wheelchair, the situation has dramatically changed in the last few years: in particular, changes in wheelchair design, the use of wheelchairs for highly successful sports activities, and the advent of the electric scooter mean less dependence on others than previously.
    Sometimes the use of a wheelchair may be a relief – in the sense that it can help avoid some of the most awkward and exhausting struggles to get around, both for you or your partner or family members. In any case, you may only need it on an occasional basis.

    Guidelines for choosing a chair
    The general rule is, of course, that you should choose a chair that is comfortable for you – particularly when you are using it for longer periods. However comfortable the chair, you must move regularly, at the very least by shifting your position, to try and avoid pressure sores and enhance your circulation. Maintaining a good posture is especially crucial if you are sitting for long periods. More specifically, the height of your chair should be such that your hips, knees and ankles rest at right angles. The depth should allow your thighs to be well supported without undue pressure behind the knee, and arm rests should be set at a height where your shoulders are relaxed when your forearms are placed on the rests. You should also have a chair that allows your head to be supported.

    When to buy a wheelchair
    It is best to make a gradual transition to wheelchair use, if you can, over weeks, months or years. When you find that:

    • the effort, perhaps particularly outside the home, required to walk some distance is too much;
    • walking aids tend to assist you less;
    • you are getting increasingly concerned about falling

    then it will be worth considering using a wheelchair, at least for some activities.
    All but a few people with Multiple Sclerosis should be able to make a gradual transition to a wheelchair. This may overcome the ‘all or nothing’ approach, which many people with MS fear.
    If it is outside the home that you need to use a wheelchair first, you could think of getting around in a combination of ways: using a wheelchair for some things and a walking aid for others. Where there are sufficient supports – perhaps around the home – you may be able to walk relatively unaided for a few steps. In this way, you can conserve your precious energy, still undertake some active exercise, and maybe actually increase the range of activities that you are able to do.

    Advice
    It is important that you obtain good independent advice about the appropriate type and specification of wheelchair for your needs. An increasing number of companies are now producing wheelchairs of all kinds but it is best to ask someone who professionally assesses wheelchairs, usually an occupational therapist or a physiotherapist. The NHS also operates Wheelchair Service Centres, where assessment is undertaken, and to which you should be referred for advice.
    You might be able to get financial help via the mobility components of the Disability Living Allowance. See the section on Benefits in Chapter 13.

    Types
    There are several types of wheelchair that you need to consider depending on your circumstances (Figure 8.7):

    • Up until recently the most common was a manual wheelchair, powered by yourself – for which you need sufficient upper body strength and, for going some distance, endurance, and relatively low and predictable levels of fatigue.
    • For people who may need to use a wheelchair from time to time, portable (collapsible) wheelchairs are available to take with you in a car.
    Powered wheelchairs are increasingly used by someone who cannot stand well or transfer easily, and has not got sufficient upper body strength to propel a wheelchair manually. They are usually driven by means of a small control arm, battery driven, heavy and very solid, and are not easily transportable – so a specially adapted car or van into which the wheelchair can be driven is usually needed.
    • A very popular, but relatively expensive, alternative for people who have not got the upper body strength to propel a manual wheel- chair, but who can stand, transfer well and have reasonable balance, is an electric scooter. The scooter looks like an electric golf cart – it is battery driven with three or four wheels, and is steered and controlled through the handlebars. There are now many types of electric scooter, some of them relatively portable, although they are still very heavy.

    Powered wheelchairs, and particularly electric scooters, are enabling people with MS to have a radically new approach, not only to their mobility but also and just as important, to their social relationships. Rather than being pushed from behind, people now feel more in control. They can move at the pace of others, talk to them side by side and establish again a more equal – and independent – relationship, at least in this aspect of their lives. Research is now indicating how important the advent of electric scooters is for opening a new phase in the mobility of people with MS.

    Which is best for you?
    The criteria used to assess which type of mobility aid is best suited to you are generally:

    • your ability to stand, balance and transfer;
    • your ability to use the controls on a powered chair or vehicle;
    • your upper body strength;
    • the nature of your activities, particularly the balance between indoor and outdoor activities;
    • the terrain outside and inside your house, and
    • the availability of someone to assist you.

    Wheelchair typesFigure 8.7 Wheelchair types: (a) manual, (b) powered, (c) electric scooter.

    Your memory and cognitive status will be assessed if, for example, you are likely to travel very far on your own. Professional advisors like to reduce to the minimum any risks that you might run by using a vehicle such as a scooter – you may feel it is appropriate for you to have one, but they may feel that you are only just able to control it. This view frustrates people with MS who sometimes feel their capacities are greater than those estimated by their professional advisor.

    Negotiating between wheelchair and chair
    When your leg muscles are weak, and the neurological control of them is very damaged, moving from a seated to an upright position is often very difficult. You may well need some professional advice and demonstration as to how best to accomplish this – possibly with aids, or someone who can help. As a general rule be sure you have any walking aid that you regularly use nearby, wear shoes, and always stand on a non-slip surface. The usual procedure to get up is to put your feet slightly apart and flat on the floor, and then to pull them back a little towards the chair. Place both hands on the chair arms, and then ease yourself forward so that your bottom is near the front of the chair. Then lean slightly forward, lift your head and look straight in front. You should then push down on your hands and heels, and straighten your hips and knees.
    When you move from a standing to a sitting position, the procedure is rather simpler, and involves turning round, so that you can feel the chair with the back of your legs. Use the chair arms to lower yourself into position. Of course, if you are getting in and out of a wheelchair, ensure that the chair is stable and that the wheelchair brakes are on! It is possible that in time you might need further assistance. There are inflatable and portable cushions to help you rise from a chair, and there are also a number of mechanical aids, usually incorporated into the chairs themselves, that hydraulically assist the actions of sitting and standing – although these can be expensive.

    Bathroom aids

    Baths and showers
    Ensure that getting in and out of the bath is as safe and easy as possible and that, when you are in the bath, you can relax without worrying. Working out how to clean yourself properly is often a relatively minor problem compared to getting in and out of the bath! Negotiating a bath requires both balance and strength. There are several things that can be done in stages (Fig. 8.8):

    Bath aids

    Figure 8.8 Bath aids: (a) grab bars and seat; (b) hoist.

    • Ensure that non-slip mats are both in the bath and on the floor.
    • Install grab bars at crucial points so that you can lower yourself in and pull yourself out. The siting of these is very important – consult your occupational therapist or other skilled person, to make sure that they can really help you.
    • Even if there is not someone else actually in the bathroom with you, it is good to have someone you can call on if you do get into difficulty.
    • If grab bars are not sufficient, perhaps because you have not got enough strength to use them, then you may need to consider other options, including bath seats both for transfer, and for use in the bath.
    • Bath hoists are also available that help to lift you in and out of your bath.
    • Another possibility, if it proves too difficult to negotiate the bath,
    is to install a shower: the larger types will have sufficient space for a shower chair or bench to sit on and will be easier to access than a bath. With a hand-held, temperature-controlled shower attachment, you should have a reasonably enjoyable experience, even if it isn’t quite the same for some people as a bath!

    Toilet aids
    Toiletting aids are important for, traditionally in our society, going to the toilet yourself is an indication of independence. Continuing to go to the toilet completely by yourself for as long as possible is an issue that many people feel strongly about, even between partners who have known each other for many years. Although having other people to assist you is a problem for both sexes, many men in particular are not so used to helping others with such issues on an everyday basis, such as young children or older parents, or indeed their partners.
    Clothing. A number of procedures can help. For men, one of the first things that you could do, if you have difficulties in controlling finger movement, is to readjust your type of clothing, to enable you to urinate from a standing position, or to take of f or loosen your trousers and underwear. Buttons on trousers are not often not easy to manage, so a zip is usually slightly more user friendly; if zips are difficult to operate, Velcro fastenings will still look good and fasten well; they can be used on underwear as well. Women may find this similarly helpful when they are wearing trousers.
    Toilet. If you have limited movement, or are a bit unsteady, you will need to be very careful in lowering yourself on to the toilet. You need to check where your arms and feet are, and stand directly in front of the seat, then bend your knees until you can touch the sides of the seat with your hands, and lower yourself down slowly. When raising yourself use the toilet seat to push yourself off. Check that the toilet seat is secure before embarking on lowering or raising yourself !
    As far as the toilet itself is concerned, there are a range of adaptations which may be of help:

    • Grab bars can be placed on adjacent walls if they are near enough.
    • Where a toilet is standing away from a wall, you could consider an over-the-toilet adjustable frame, which has arm-rests to help you raise and lower yourself (Fig. 8.9).
    Over-the-toilet frameFigure 8.9 Over-the-toilet frame.

    • There is an increasingly wide range of commodes.
    • You can install a slightly elevated toilet seat.

    The number of different adaptations in this area is increasing rapidly, so consult your occupational therapist, and look at other sources of information about such products.
    Toilet paper. One of the most trying problems for people with MS is using toilet paper, for the manoeuvre involves considerable movement and dexterity. You might find a wet cloth more useful than toilet paper, or you might consider using a squeezy bottle full of (warm!) water. There is also special equipment, such as a toilet-paper holder, which could help. A bidet might be easier, although this may well not fit into your toilet area, can be rather expensive to install, and would need fitting to your water supply. Recently a portable toilet/bidet has been launched that might help people who are worried about travelling and having to deal with conventional, and therefore problematic, toilets elsewhere. You may find a toilet that automatically washes and dries you where you are – this is the kind of development that could help many people with MS considerably.
    Public toilets. Finally, when you are out and about, you can obtain a special key from RADAR for public toilets for disabled people. More and more of these toilets are being made available.

    Dressing aids

    The problem with dressing, or undressing for that matter, if you have limited movement and dexterity, is not just the difficulty but also the time involved in doing them. Although you may be able to accomplish dressing now, in due course it can become such a frustrating and time- consuming process, that you have got little energy left to do anything else. As usual, it is a compromise between attempting to use all the traditional fittings on clothing, and having some which are easier to do up or undo. Of course everyone wants to look good in the clothes they are wearing, and it is often a question of trying to balance being fashionable (or not being unfashionable!) with clothes that are easy to manage. Women are in a slightly better position socially than men, in being able to use more accessories, such as jewellery or scarves, to complement whatever clothes they are wearing.
    In general, tight-fitting clothes are harder to manage than looser ones, whatever kinds of fixings are on them. Try:

    • large rather than small buttons;
    • trousers or skirts with elasticated waists;
    • dressing aids such as dressing sticks and button hooks.

    One of the trickiest problems for men is that of collars, ties and buttoned shirts. Most of the buttons on shirts can be left done up, so that the shirts can be slipped over the head, If this is a problem, buttonholes can be closed, then the buttons sewn on the outside of the shirt and Velcro strips placed behind them, so that when all the strips are closed it looks as though the shirt is buttoned in the traditional way. As far as ties are concerned, clip-on ones may be easier to use than the usual hand- tied ones or, alternatively, ties can be left already loosely tied and slipped over the head, and then tightened in place.

    Shoes and socks
    These cause real problems for people with MS, for they involve a range of movement, together with fine dexterity, both of which can be compromised. One way forward is to investigate the possibility of different ways of tying your shoes. If you are able to reach your shoes, then there are Velcro shoe fastenings, and various devices to tighten laces, and you can learn single-handed tying techniques. If you cannot reach your shoes, then slip-on shoes are a better idea; you could convert your lace-up shoes into slip-ons with elastic laces, if the shoe tongue can be stitched into place. Long-handled shoe horns will help you put on slip-on shoes.
    There are a range of other aids available to help pull on (and take off) socks and tights – these usually work through gripping the socks or tights with the end of a hand-operated long-handled tool.

    Bed aids

    People with MS often find it hard not so much getting into the bed but getting out of it again, in particular, getting up from low, and particularly soft, mattresses.
    You can try rolling onto your side and, facing the edge of the bed, try pushing yourself up with your underneath arm and, at the same time, swinging your legs over the bed. Once you are sitting up with your legs on the ground, it becomes easier to push up from the bed. There are some other things that you could try:

    • Cloth strips attached to the mattress will help you to pull yourself up.
    • You could position a grab bar, or even a floor-to-ceiling bar nearby, so that you can manoeuvre yourself to a standing position.
    • A bedpull (a rope or piece of strong webbing) lying on top of the bed and attached to the floor or other secure object, or a frame resting by the side of the bed could help.
    • You can raise the bed, but do ensure that this is done securely.

    If these strategies do not work, you could consider a completely or partially electrically operated bed or mattress, but really you should seek advice from your occupational therapist, and/or Social Services Department before embarking on this expensive choice.
    As far as turning in bed at night is concerned, this can be quite a problem. There are a number of minor adjustments you can make that may help, after checking the softness of the mattress. Changing your bedclothes or nightdress or pyjamas might help. Some people find that silky bedclothes allow them to turn much more easily than other fabrics. Night socks might also help you get a grip to turn over. A more expensive solution is to purchase a special mattress that assists turning, if these other strategies do not work.
    There may be additional problems here that require a different solution: how often do you need to get out of bed during the night to go to the toilet? If this is excessive or difficult, then consult your GP or neurologist to see if some solution, in the form of medication or otherwise, can be found for this.

    Kitchen aids

    Many people in the household gather in the kitchen and a very diverse range of activities go on there, so it is often worrying when mobility or dexterity problems arise. It is still likely that women will be the main users of the kitchen, despite apparent changes in social attitudes and the household division of labour. However, increasingly other household members like to undertake some tasks in the kitchen, and so it is important to ensure that several household members can use the kitchen easily. It is possible to adapt a kitchen completely for a person with MS, but in a sense this can create problems for other users. In effect, by enabling one person, you can disable others.

    Design
    If you are starting from scratch, or have decided on a major change in your kitchen area, then the main considerations are likely to be:

    • accessibility
    • safety
    • ease of use, and
    • whether other users of the area will be affected.

    Obviously the height of worktops and the sink area, especially if you are in a wheelchair, are important considerations. Think about arrangement and access to cupboards, storage areas and cooking facilities, so that you have to move as little as possible, especially if you are likely to be carrying things from one place to another. If you are not yet using a wheelchair, it would still be sensible to think of possible problems when you are making major changes – consider overhanging worktops, for example, so that they can be used from a seated position. Some kitchen systems allow for adjustment with changing circumstances: seek advice from your occupational therapist or specialist kitchen manufacturer about what is available.
    The point at which you decide to, or indeed have to, make some major changes in your kitchen area varies so much between individuals and the household situation, that it is difficult to make hard and fast rules about when you should embark on them. Other factors will be critical, particularly resources, and whether you can get additional financial help for such alterations from your local Social Services Department, usually through your occupational therapist.

    Food preparation and cooking
    There are two broad ways to look at this issue. The first way focuses on using foods which are pre-prepared in various forms, thus minimizing the amount of food preparation that you or members of your household have to undertake. There has been a revolution in this area over the last few years, leading to a major increase in prepared foods, instigated by changing lifestyles and the vastly increased number of women who are undertaking several jobs at once, both inside and outside the home.
    Although almost all people, and especially women, feel that they may be neglecting their families by using the staggeringly wide range of convenience foods, many now use such food increasingly to save time and energy. If people with MS do the same, they are not doing anything unusual, but just following a general trend. Many of those foods that are harder for people with mobility problems to prepare – potatoes, salads and vegetables, for example – can now all be purchased in pre-prepared form. Although there is an additional price to pay for these foods, and maybe a minor loss in nutrition, this is more than compensated for by the saving in time and energy that is spent preparing everything yourself
    – just like most people without Multiple Sclerosis! You have to strike a balance between convenience and possible modest drawbacks in terms of nutrition. If you are worried about any nutritional issues, you should consult your doctor, or ask for a referral to a dietitian or nutritionist.
    The second way is to consider additional aids and equipment that may be available to help you in the kitchen area. These may range from things like non-slip mats to secure mixing bowls, to high stools to work on, special trolleys, and padded handles to ensure a better grip. A wide range of everyday kitchenware, such as knives, forks, spoons, ladles, and so on, are now available in a form that will help you get a better grip. You will quickly find those aids that help you most. Try and phase what you do, so that you do not feel exhausted from working overlong on single tasks without a break. Look for special recipe books that not only suggest nutritious foods, but also show short cuts in food preparation.
    Using a microwave oven, especially the modern combination types, can be easier than a conventional one and, although it can be seen as just another short cut, cooking interesting food in such an oven can be quite a challenge. One of the additional benefits of a microwave oven is that it generates less external heat than a conventional oven and this could be an important point for people with MS who are very sensitive to heat.
    There is another issue here in relation to cooking and that is safety. Many people with MS have a problem with grip or sensation, and this, together with a hot food or utensil, is not a recommended combination! It is important to keep your eyes on whatever you are carrying, and to use this as a double check to ensure that you are carrying it firmly enough. By and large you should hold things with both hands, rather than with one or two fingers. Choose cups, for example, with two handles, or at least one large handle. In particular, try to carry hot liquids in containers with fitted lids so that, if you do drop them, there is less danger. Wearing rubber or special kitchen gloves can be helpful. For the most part, carrying and holding things is just a question of getting used to the changes in your sensations and grip, and being deliberate and careful about moving things, especially items that are hot.

    Writing aids

    Conventional pens and pencils are amongst the most difficult items to use if you have problems with grip, or indeed tremor. Pens or pencils that are much bigger in diameter than normal ones and have a less smooth surface are becoming fashionable now because they are ergonomically better for everyone’s fingers, and you should be able to find a selection of these in a large stationery shop or suppliers of products for people with disabilities. You could try putting elastic bands around pens and pencils to make them easier to use.
    The issue of tremor is in some ways more complex: it is of limited use being able to grip a pen if your writing is such that people have difficulty in reading it. This problem can be managed by weighting your wrist, for example, or by using weighted pens etc., which may dampen down the tremor. However, there is still a problem if you do not have much strength in your wrist. In this case there are various devices, writing guides for example, which help you to form letters and words, lessening the effect of the tremor. You will have to experiment to see if you can find ways of reducing the effect of both lack of grip and of tremor to produce sufficiently good results to be read by others.

    Computers
    A computer can be costly to buy and costly in terms of the time and effort of training yourself to use it to the full. One of the difficulties at present is the very rapid change in computer systems. No sooner has one been bought than the next – ‘enhanced’, ‘better’, ‘faster’ – model takes its place. It is an industry geared to continuous change, and it is quite likely that the computer you have just bought will be ‘out of date’ almost immediately. So you need to think very carefully about what you might want to use a computer for, how easy it is to use, and what support will you have in terms of help with programmes or the machine itself, if you get stuck. It would be good idea, if you have a friend with a computer, to check out how easy it is for you to use – in terms of the screen, keyboard and ‘mouse’. (Most systems operate with this small matchbox-sized object, which you hold, move and ‘click’ with a finger to give on-screen commands, although there are other keyboards that do not need the mouse.) This will enable you to see whether you can control the computer easily and have the dexterity to do so. You could think of learning to use a computer as a bit of a challenge!
    There are an increasing number of ways in which computers can be controlled even if you do not have the dexterity to use a keyboard or a mouse. There are various pointing devices which can be used. There has also been very rapid progress in voice-activated computer systems in recent years, and some of these can adapt to individual voices even when, as a result of the Multiple Sclerosis, words may not be formed exactly as they should – or are slurred in some way. However, if the way you say words is changing a lot, then this can be a problem because you may have ‘to train’ the computer yet again to recognize your voice. In this respect you should investigate the resources available at specialist Communication Aids Centres (see Chapter 9), regarding not only communication itself, but also the many innovative ways in which people with a range of disabilities can both use, and control, computer systems.
    Increasingly there are local classes being run for older or disabled people in the use of computers, and even if you cannot get to them, you may be able to talk to someone who runs the classes for advice. You might be able to get a trial run; then seek independent advice about what machine and software you should buy – and especially what support you will receive afterwards. Salesmen for particular machines can be very convincing, and you should not just rely on their advice. This is why you should always try and seek advice from someone you know or a specialist centre, who will understand both what you want to use a computer for and be familiar with the problems that you may have. Of course, there are all kinds of more exotic things you can do with a suitable computer, including using the internet – the World Wide Web for information and communication – sending and receiving faxes or emails, and doing a whole range of things other than writing a letter using a word processing package. However, you should be realistic about what you are likely to be able to do. Some people get addicted and it becomes their life, but for others the computer stays in the corner with hardly any use.
    If you have children, particularly older children, they are probably already using computers and would like nothing better than to demonstrate their skills at the expense of their parents!

    Help around the house

    The issue of housework can be difficult one, particularly for women; despite lots of changes in attitudes, ‘keeping a good home’ is still a commonplace expectation, even if it is not so openly stated now. For a woman whose life has been in the home, or who is now largely confined to home having given up a job, keeping the house clean and tidy may be something that both she – and perhaps others – see as an indication of her ‘usefulness’, and, thinking about housework in another way, it is good exercise. It can then be a wrench, even for women who do not care for housework at all, to lose even routine household tasks. For all these reasons, retaining even a very modest range of household activities is important, to feel that you are contributing to the household overall.
    A couple of things might help here:

    • Arrange things in your house as comfortably and safely as possible for yourself and others in your household. You may then have to compromise over who arranges what room, as long as you have
    the least disruptive pattern of furniture that you need to be able to move around safely.
    • There is a range of equipment that you can use from a standing position, or even at a distance from a sitting position, and this may allow you to do a little at a time, although the heavier jobs, and particularly those which involve moving around equipment – like vacuum cleaners – may need to be undertaken by others, unless you are very careful. You should be able to get further advice from your OT about available equipment and finding ways of managing to do at least some of the housework yourself.

  • Mobility and managing everyday life: Exercises

    A physiotherapist would normally recommend a programme of management geared to the diagnosis of your mobility problems.
    The main aim of exercising is to:

    • try and keep as many muscles as possible in good working order;
    • strengthen those that have become weak;
    • help keep joints mobile;
    • help prevent them from getting stiff;
    • help your coordination and balance;
    • improve your circulation – and in doing so help other body functions;
    • help reduce spasticity in more advanced MS;
    • help prevent pressure sores.

    Types of exercise

    A number of different types of exercise might be recommended depending on this diagnosis.

    • For your overall fitness, general exercises may be recommended, not necessarily linked to any particular movement symptom of your MS.
    • Exercises to improve your cardiovascular fitness will increase your heart rate, and are good for your circulation.
    • Stretching exercises will decrease the risk of spasticity and contractures. These exercises work by stretching muscles and tendons to increase their flexibility and elasticity.
    • Resistance exercises, with the use of weights or other devices, help increase the strength of muscles that have been weakened.
    • Range of motion exercises focus on improving the degree of motion of joints in the body, and aim to overcome, as far as possible, difficulties caused by stiffness in joints or problems in tendons and ligaments.

    There are several different ways in which exercises may be undertaken:

    • What are called active exercises are those that you can undertake yourself without any help, and you may use weights or changes of position to give more resistance (to increase the value of the exercise).
    • Self-assisted exercises are ones in which you can use one part of your body to assist another, e.g. by using a stronger arm to assist a weaker arm.
    • Active assisted exercises are those in which another person is needed to help you from time to time, but in which you still do most of the exercising yourself.
    • Passive exercises are those performed on you by others when you cannot easily move yourself, e.g. moving your arms or legs for you, to increase the range of motion.

    As you can see from these different types of exercise, you will not always need to have the physiotherapist present. Even in relation to passive or active assisted exercises, other people, once they know how to help, can assist you. Indeed the normal pattern is for you to have an assessment and a small number of sessions with a physiotherapist initially – usually five or six over a period of a few weeks – and then for you to work on the agreed exercises on your own or with a member of
    your family. You would probably return to the physiotherapist for periodic assessments thereafter to check how you are getting on.

    Self-help exercises

    Overall, one could say that exercise will help you maintain your maximum independence. Some floor and chair exercises are shown in Figures 8.1 and 8.2. Passive exercise is shown in Figure 8.3.

    Regular sessions

    Many people with MS find it puzzling, or even very disturbing, that physiotherapists will see them and assist them directly for several sessions, and then end regular consultations. This is for the following reasons:

    • Pressures of time and resources mean that it is difficult for physiotherapists to continue to give regular (weekly or fortnightly) sessions beyond the initial phase of therapy.
    • The training of physiotherapists emphasizes their evaluating role, in which the onus is on transferring responsibility as much as possible to the patient (client) for continuation of an agreed exercise programme.

    An important feature of exercise is that it continues on a regular basis and that as much as possible is undertaken by the person with MS. Unfortunately, there is often a conflict between the view of physiotherapists, who consider that one of their main tasks is to ensure that people with MS undertake an agreed programme on their own or with family assistance, and the views of people with MS, who often feel that the support provided by regular and continuing visits to a physiotherapist is vital. It is often difficult to resolve this conflict, although some pattern of occasional consultations can often be agreed.

    Caution

    Be careful not to get overheated or exhausted, which may on occasion lead to a temporary increase in some MS symptoms (see Chapter 6). Your own commonsense will normally tell you when you are exerting yourself too much. Generally, if you exercise carefully and regularly, with periodic breaks, you should find that you can get the most reward from the exercise.

    Floor exercisesFloor exercisesFloor exercisesFloor exercises
    Figure 8.1 Floor exercises.

    Chair exercises
    Chair exercises
    Chair exercises
    Figure 8.2 Chair exercises.

    Passive Exercise

    Figure 8.3 Passive exercise.

    Having a helper

    In general, the physiotherapist should have indicated how a friend or partner can help but, apart from following those instructions carefully, the following broad points may apply:

    • Get them to encourage you to undertake as much movement as possible, but don’t let them impede your movements.
    • They should allow you to perform a passive exercise (an exercise undertaken with/on a person by another person), as smoothly as possible.
    • They shouldn’t apply increased pressure at the most extreme points of the movement and, if a spasm occurs when they touch a limb, wait to see whether the spasm ceases and then let them help for as long as the movement is comfortable.

    Guidelines

    Most of the guidelines are quite sensible if you think about them.

    • Try and undertake those exercises that you have been recommended to do by a physiotherapist regularly, preferably every day – unless the physiotherapist indicates otherwise.
    • Whether you have been given advice by a physiotherapist or not, it would be wise to try and move around as much as you can, and to sit and stand as erect as possible. Posture is very important. When
    it is bad, it may produce muscle and joint strains, and secondary back problems. Furthermore, bad posture in a wheelchair or other chair may have more profound constrictive effects on your breathing and chest.
    • Try to exercise within your own capacity, i.e. do not get overtired, and try not to worry if you perform less well on a bad day. Everybody’s performance varies from day to day.
    • Also try and recognize when you need professional advice about problems that you are experiencing and that are not being helped by your current pattern of exercises.

    Sports

    The diagnosis of MS in itself should make no difference as to whether you continue to play sports or not. The key issues are whether you enjoy playing the sport, whether you feel that you can play the sport as well, or nearly as well, as you did before, and whether you feel that there are any inherent problems, e.g. a significant risk of injury, that might affect your life in other ways. People without MS have to consider these issues as well. You might be able to change your approach to sport later, perhaps by playing at a different level, if you feel that there may be problems for you at the highest competitive level. Nevertheless, sporting exercise is good for you, especially if you enjoy and benefit from it.

    Fatigue and exercises

    If you feel too tired to exercise, the key to solving this problem may be working out ways in which you can take advantage of the times when you feel less fatigued in order to do modest but well-targeted exercise. Look carefully at the day-to-day activities you undertake, to see whether they might be rearranged and result in less fatigue. Sometimes, introducing rest periods and using specific aids for certain activities will result in less fatigue, and the chance to undertake limited and helpful exercises. You may also need, perhaps in consultation with a physio- therapist, to review the exercises to make them less vigorous. After all, it is not only a question of getting your exercise regimen right, but of getting a good balance between exercise and relaxation.

    Weakness and exercise

    Physiotherapy, or exercise in general, cannot ‘mend’ the damaged nerve fibres that lead to less effective control of muscles. Weakness in the legs, and problems of balance, may be due directly to less effective nerve conduction, but exercise may help other causes of weakness. Devise a programme of exercise with your physiotherapist making sure that any special exercises that you do undertake, e.g. resistance exercises through using weights, are in fact likely to help you.
    After an MS attack, some people find that they cannot walk. Whilst normally some recovery is usual from the symptoms experienced at the height of an attack, the extent of this recovery can vary a lot. If demyelination has been quite substantial, there is little you can do through an exercise programme to reduce this damage, but you should still do leg exercises in order to keep your muscles as strong as possible, and to maintain flexibility so that, if more spontaneous recovery occurs, you will be able to take advantage of this. In any case it is very important to continue undertaking leg exercises, so that you can sit more comfortably and avoid some of the problems that can come with prolonged sitting.

    Spasticity and exercise

    A regular programme of stretching and related exercises can help muscular development, or at the very least help prevent the muscles wasting away. Keep your joints, tendons and ligaments as flexible as possible. Avoid positions where spasticity is more likely. Keep your head as central as possible when doing exercises and, if spasticity does occur, do a passive exercise as smoothly as possible to relax your muscles. On occasion it has been found that towels dipped in iced water and applied to the relevant area for a few minutes at most may help the muscles to relax. Unfortunately, as MS progresses, even with the most helpful exercise programme, additional means – usually prescribed drugs – may be necessary to assist the spasticity. You should consult your neurologist or GP about these.

    Swimming

    Swimming is a good form of exercise for everyone, but especially for people with MS, because your body weight is supported by the water. Weakened muscles can operate in this environment and will strengthen from the resistance. In addition, as swimming involves many muscle systems in your body, it can help to increase coordination.
    Your main practical problems may be issues such as where the changing rooms are in relation to the pool, and obtaining assistance to reach, and return from, the pool. There are now more and more swimming pools and leisure centres offering special sessions for people who need special help, and it might be worth trying one of these sessions at first. If such sessions are not available, try lobbying your local leisure centre/swimming pool for one. It may be worth asking whether there are quiet times of the day when the pool will be freer, and assistance is more likely to be available.
    Functional electrical stimulation (FES) can help some people with
    ‘foot drop’. A small box sends electrical stimulation to muscles in the lower leg, so that you can regain useful movement. This is connected to a pressure pad in a shoe that enables the impulse to be triggered when you are walking, improving mobility. (See Appendix 1 for address of the FES Team.)
    One point may prove to be important and that is the temperature of the water. The temperature that many people with MS find comfortable is about 30°C (86°F). Much lower temperatures appear to be too cold, although still tolerable, whereas much higher temperatures, often found in jacuzzis or spa baths, are sometimes associated with the onset of (temporary) MS symptoms. Also, in relation to your swimming activities, if you have troublesome bladder control, it may be worth discussing this with your neurologist or GP beforehand to try and ease your concerns.

    Foot drop and exercise

    ‘Foot drop’ occurs when the muscles of the foot and ankle become weak, caused by poor nerve conduction, and either your ankle may just ‘turn over’ or, more commonly, your toes touch the ground before your heel – in contrast to the normal heel–toe action – and this might lead you to fall. This is quite a common problem in MS. There are two ways of dealing with it. One way is by exercising the relevant muscles as much as possible, through passive exercises if necessary. However, this may not be enough to prevent the problem once it has occurred. A special brace may be helpful, which supports the weakened ankle and allows you to walk again with the normal heel and toe action, if your leg muscles are strong enough to allow this (Figure 8.4). You may need to consider using a wheelchair or scooter, at least occasionally.
    One of your feet ‘turning in’ is another problem that some people with MS have. In this situation the muscles turning the foot out have weakened, and the muscles and tendons on the inside of the foot have become shortened – largely due to disuse. In addition the ankle joint may be more rigid and stiff. Thus it is vital for people with MS to try and prevent such a situation occurring by exercising the muscles controlling the ankle as much as possible. It will be important to seek some help from a physiotherapist when the problem has arisen to ensure that you undertake the correct exercises and, if necessary, have a supporting brace.

    Leg brace

    Figure 8.4 Leg brace.

    Wheelchairs and exercise

    Although it may sound paradoxical, it is almost more important for someone confined to a wheelchair to undertake regular exercise than someone who can walk. You should try and undertake exercises that maintain the movement and flexibility in your joints as much as possible
    – through the ‘range of motion’ and stretching exercises described earlier. As far as possible, try and maintain also your upper body strength – this is particularly important for good posture, which itself will help prevent some of the more problematic aspects of being in a wheelchair for a long time. Exercising your neck muscles will also help you to maintain a good posture. If possible, it is very helpful just to stand for a few minutes each day, with the help of someone else or with an increasing range of equipment now available for this purpose. It is known that bone density tends to decrease (causing ‘osteoporosis’) more quickly if weight is not borne by the legs and feet on a regular basis and low bone density is also one of the contributory factors of fractures. This is another reason why standing should, if possible, be undertaken – even if only for a very short period. As with sitting in a chair, you ought to learn specific exercises to be able to shift your weight on a regular basis, to prevent skin breakdown at the points where your body is in contact with the wheelchair, and ultimately to prevent pressure sores. (See Figure 8.2 for exercises that you can do sitting down.)

    Pressure sores

    As noted earlier, exercise can help prevent pressure sores. They are very dangerous once they arise, and yet they are entirely preventable. Basically, as the name suggests, they arise when the skin begins to break down from too much continuous pressure, from a chair or bed, for example, on key points of your body. Once this pressure has been applied for a long time, blood circulation to the area lessens or ceases, the tissues get starved of oxygen, and the skin and related tissues break down. Such pressure sores are particularly dangerous because, left untreated, they can lead to infection of the underlying bare tissue or to blood infection (‘septicaemia’), which can threaten your life. Most people do not get pressure sores because they move very frequently and thus pressure is never exerted on one point of their body for long enough for a pressure sore to develop.Pressure sore areas

    Figure 8.5 Pressure sore areas.

    Danger areas are the lower back, the shoulder blades, the insides of knees, hips, elbows, ankles, heels, toes, wrists, and even sometimes ears (Figure 8.5). Pressure sores are more likely if you are in a wheelchair, or are sitting or in bed for long periods of time.
    Initially, a pressure sore may just look like an area of reddened skin, or even a small bruise. It can look like a blister or weal, which may break to reveal a small or even a large hole where the skin has been damaged more fundamentally. It is likely to be very painful but, if sensation has been lost, you may not be aware an ulcer is forming so visual checks are also necessary. It is important to act immediately and contact your doctor, for once the damage has occurred it is very unlikely to get better without considerable treatment.
    Preventative therapy, i.e. regular movement every hour or two, is vital, especially for people in wheelchairs or in bed. If you can stand for even a short time, or shift your weight from time to time and from place to place, this is helpful. There are also a number of products that may help:

    • ripple mattresses
    • foam rings
    • gel or air cushions
    • water beds
    • pads
    • specific textures of clothing and bedding, especially sheepskin.

    Sometimes the bedclothes can be lifted off the body by means of a cradle. You should wear nightdresses or pyjamas that chafe as little as possible.
    The usual person to treat pressure sores is a District Nurse who will come in regularly to manage them. The treatment usually involves antibiotic cream or powder in and around the area. The aim is to prevent infection and to restore circulation, by keeping the skin clean and dry. The sore may be left exposed to the air during the day, but dressed with a sterile dressing at night. More serious sores may require substantial hospital treatment.
    There is a great deal of development work currently underway on the management of pressure sores because, not only are they very painful, inconvenient and potentially dangerous for people with MS, but they are also very expensive to treat, at home or in hospital, and often involve very long-term nursing and medical care.

  • Mobility and managing everyday life: Professional help

    Although there has been an explosion of health and fitness clubs, which might be thought to help people with mobility or other similar difficulties, very few of them have staff who will be aware of Multiple Sclerosis and its effects on movement. So it’s a good idea to seek the help of members of the key profession dealing with mobility and movement problems, and that is physiotherapy. Normally you will be referred for a consultation with a physiotherapist by your neurologist or GP. Check, either with your referring doctor or with the physiotherapist, that they have had experience of managing people with Multiple Sclerosis.
    A physiotherapist will normally undertake a number of assessments of your movement ability. These would include generally:

    • evaluating your general posture and body movements;
    • taking account not only of what you can do in the clinic, surgery or hospital, but also what problems you may have in and around the home and work;
    • measuring the strength of various muscles, as well as assessing how flexible your joints, tendons and muscles are;
    • testing the sensations that you may have in or around your muscles, as well as your ability to sense cold and heat.

    Some physiotherapists, particularly in leading hospitals, may undertake what is called ‘gait analysis’, i.e. a formal assessment of how you move, particularly how you walk, investigating things like speed, rhythm of movement, stride and step length. This analysis helps to determine exactly where your movement problems lie in order to help correct them. Physiotherapists increasingly like to know about your own history and your worries about your movement problems, and to try and work with them, as well as with those problems that they have detected themselves.

  • Mobility and managing everyday life

    Mobility or movement problems can be variable depending on the overall disease development, and on whether you are currently in the middle of an attack or in remission. The main aim is to maintain as much mobility as possible, in particular to avoid what might be called ‘secondary’ damage in the form of wasting (‘atrophied’) muscles, which occurs as a result of prolonged lack of use.
    In the early stages of MS, movement problems may be relatively limited or infrequent, and indeed many people find that they can continue physically with almost all the things that they did before. You may have sometimes to temper or reduce the more vigorous of your activities. As long as you are relatively active, are sensible in relation to the overall approach to exercise, and do not appear to have significant individual problems of movement, you may not need professional help or support at this stage. Do talk the situation over with your neurologist or, failing that, your GP, both of whom can refer you to professional help if they feel it necessary. Sometimes movement problems can creep up on you and, without realizing it (or perhaps not wanting to realize it), you may need more help than you first thought. In general, exercise is best thought of as a preventative process, not so much a curative one, so it is best undertaken at an early stage.

  • Fatigue, cognitive problems and depression: Mood swings and euphoria

    As far as emotional and attitudinal issues in Multiple Sclerosis are concerned, early research suggested that some people were emotionally labile (meaning their emotions fluctuated rapidly), and that other variable emotional symptoms or states arose that appeared to be specific to people with the disease. However, it proved difficult to tell whether the problems were a personal – indeed an emotional – reaction to the onset of MS, or were caused by the Multiple Sclerosis itself. Current research is indicating that there are problems of an emotional kind that might be linked to the disease itself, as well as personal reactions to it.
    Mood swings may be caused by the effects of demyelination in particular parts of the central nervous system that control moods and emotions, or by everyday frustrations and issues that arise in managing and think- ing about the effects of MS. Either way, recognizing that mood swings exist is the first step in being able to manage them more effectively.
    In more extreme cases, mood swings are refer red to medically as a ‘bipolar disorder’, with relatively rapid and severe swings between depression and elation. Medical assistance should be sought in such cases.

    Euphoria

    One of the first symptoms that doctors described over 150 years ago was an ‘elevation of mood’ in some people with MS. This was also called ‘an unusual cheerfulness’ that seemed not quite appropriate in someone with a long-term medical condition. In fact, some of these attributions of
    ‘elevated mood’ were not linked to the Multiple Sclerosis itself, but to the circumstances in which it was diagnosed. However, since that time, the idea that some people with MS may occasionally have what is often described as ‘euphoria’ has become more accepted. This can be linked with mood swings that may take people with MS through a range of emotions from depression, perhaps to anger and indeed to ‘euphoria’ over a period of time.
    The previous clinical concern with euphoria has led to far less attention being paid to the much more serious problem of depression, which we have just discussed. It is possible that, in some people with MS, a euphoric presentation has cloaked an underlying depression. Euphoria is viewed as a widespread phenomenon because of the very positive reactions – the relief almost – that some people with MS feel once diagnosed. Because the process, and the communication more so, of the diagnosis may take some time, some people felt that their symptoms may have been due to even more serious conditions – a brain tumour, for example, or that they were ‘going mad’. Some doctors have treated the, often profound, relief of some of their patients on hearing that they
    ‘only’ have Multiple Sclerosis, as indicating a euphoric state caused by the MS, rather than an understandable relief that they have a condition far less threatening than others they had feared.
    Although inappropriate laughter may occasionally be embarrassing, it seems to be a result of damage to a particular part of the nervous system, and may require professional help to manage – this particular phenomenon of ‘euphoria’ seems to be overemphasized and, in terms of everyday symptom management, other emotional problems, particularly those centred around depression, are more harmful and significant.

    Effects of drugs

    Any drug that has powerful effects on symptoms is likely to have a wider range of effects – what we usually call ‘side effects’ – that we don’t usually want. In particular, drugs that act in various ways on symptoms related to the central nervous system may well have effects on your moods and feelings.
    Steroid drugs in particular – still quite widely used in relation to managing attacks or exacerbations of MS – may have mood-changing properties. These properties are not always predictable, and people can sometimes have quite strong reactions to steroid drugs. Perversely, some people may feel more depressed, while others may feel more cheerful on them. There is something which has become known as a steroid ‘high’, where people can become more active (indeed ‘hyperactive’) on the drugs, and then feel a ‘low’ when they come off them; others may experience quite bad mood changes from such drugs. Try monitoring yourself and get a family member to discuss any changes that they see in you, and then report such changes to your neurologist or other doctor treating you.
    Some other drugs may have mood-changing effects, especially if you suddenly increase or decrease the dose that you are taking. For example, baclofen (Lioresal), a drug very widely used to control spasticity, has been known to produce major effects on mood; for example, if a high dose is withdrawn suddenly, people may feel very agitated, experience substantial mood changes, or even hallucinate. So is sensible to report any untoward reactions that you may have with your drugs to your GP or neurologist before gradually reducing the dosage. Other drugs, such as diazepam (Valium), used for relaxing muscles, may make you feel very relaxed! Sometimes low doses of antidepressants, used to treat urinary problems or some sensory symptoms, may also change your mood.
    Although we don’t want to exaggerate the number of mood or emotional reactions that you might have to the drugs being taken for symptoms, these additional side effects, which can occur relatively soon after you have decreased or increased doses, may be caused by them. If you are in doubt, report your symptoms to your GP or neurologist, and seek their advice as to how best to manage them.

    Management of mood swings

    Family and friends are often the first people to recognize that mood swings are occurring. For all of us, relationships with other people are bound up with knowing what they will do in a relatively predictable way. If this expectation breaks down, as it may do if mood swings (technically described as ‘emotional lability’) are serious, then family relationships may suffer substantially. For some families these problems can be very difficult to handle, and thus external advice and help can be sought.

    Counselling and/or drugs and cognitive behaviour therapy
    After a consultation with your GP or neurologist, you may be able to get counselling or have a systematic discussion of your family and personal problems arising from the mood swings; if counselling fails, a tricyclic antidepressant (such as amitriptyline) might be prescribed. There is also increasing but still unsystematic evidence that fluoxetine (Prozac) may offer some help in this situation. As we noted earlier, previous administrations of steroids – usually to treat exacerbations of the MS – may have prompted some increase in mood swings (see above), in which case a drug such as lithium or carbamazepine might reduce these swings. Cognitive behaviour therapy has been found useful also in people with mood swings in Multiple Sclerosis.

    Self-help
    Often your emotional response to a situation may be just rather ‘too
    strong’ for the particular situation concerned. You could try breathing deeply, pausing before the tears or laughter come, particularly in stressful situations. If you find yourself laughing or crying without any apparent cause – indeed your mood may be totally at variance with this expression of emotion – and it is difficult to stop, almost certainly this is a result of damage caused by MS itself, probably to areas of the brain controlling the release of emotional expression. This problem has to be managed socially, which is not an easy task, but you could be prescribed medications which have some dampening effect on the release of emotions. It would be best to consult your GP or neurologist about these matters.

  • Fatigue, cognitive problems and depression: Depression

    The incidence of depression amongst people with Multiple Sclerosis has been a matter of controversy for many years. In the early years of research it was thought that relatively few people with the condition had ‘clinical’ depression, but more recent research indicates that the level of depression is far higher than was previously thought.
    Recent research suggests that up to 50% of people with MS (compared to only 5–15% of people without) will experience serious depression at some point in their lives, and at any one time perhaps one in seven may be experiencing this kind of depression. It is a very broad subject and could fill a book in its own right. An inspirational personal account on coping in MS is given in Multiple Sclerosis – a personal exploration by Dr Sandy Burnfield.
    Sometimes people ask about the incidence of suicide amongst people with Multiple Sclerosis. Although it is difficult to give precise figures, it does appear that the rate of suicide is higher for people with MS compared with the general population. There may be many reasons for this:

    • Depression is associated with a higher rate of suicide – and as we have indicated people with MS have a higher rate of depression.
    • There are also many other life crisis-based circumstances that may be linked with suicide whether or not people have MS.
    • The consequences of having MS may, however, be linked more with things like general stress, employment problems, and problems with money, family or relationships, than for some other people.
    • Also, when people feel a lack of hope for the future, sometimes suicide may seem an option.

    In all these circumstances, it is very important that all avenues are explored for help, for through the management of depression and feelings of hopelessness, often situations that seem hopeless at the time are then viewed differently. Psychotherapy and or medication can assist greatly here.
    Of course there is a related major debate under way, which is about the extent to which people can, or should be able to end their life if they
    wish – if necessary with assistance – if they are acting rationally knowing what they are doing and in full command of all their faculties. Such assistance is currently illegal in Great Britain and a number of recent high profile court cases have confirmed this position. This debate raises considerable emotions on all sides and no doubt will continue to be a matter of great controversy.

    Management

    As far as depression is concerned, it is important that you seek medical help partly because there are various forms of depression that may require dif ferent kinds of management. It is good that you have recognized that you may need help, because much can be done for you. Initially you may feel that seeking such help is a ‘waste of time’, or indeed carries with it some kind of stigma, similar to what people some- times feel is associated with mental illness or ‘weakness’, but a sensible approach can substantially prevent you feeling miserable and improve your relationships.

    Counselling and cognitive behaviour therapy
    Depending on the nature of the depression, you may be of fered counselling – and this is increasingly available both in general and hospital practice – or, rather more rarely, psychotherapy in larger and more specialist centres. In certain situations, where it may be helpful to discuss the depression in a family context, family therapy might be offered, although this again is very likely to be at the largest and most specialist centres. It is possible that these more specialist forms of therapy will involve onward referral, for assessment through a psychiatrist, for example. Cognitive behaviour therapy has been found very effective in some people with Multiple Sclerosis.

    Drugs
    More usually, you may be prescribed one of the antidepressant medications. Until recently, ‘tricyclic antidepressants’ were the most commonly used drugs, such as imipramine (Tofranil), amitryptiline (Elavil) and nortriptyline (Pamelor). However, another family of antidepressants, called ‘serotinergic antidepressants’, is now being prescribed much more regularly, drugs such as fluoxetine (Prozac), for example. These drugs have to be carefully administered and monitored, so it is important to follow medical advice. A combination of counselling and drug therapy may be needed.

  • Fatigue, cognitive problems and depression: Cognitive problems

    Research has identified two broad areas where Multiple Sclerosis seems to be involved or has effects that are not so much to do with the mind in general, but with what are more neatly and technically considered as cognitive issues on the one hand, and attitudinal and emotional issues on the other.
    Cognitive issues are those that concern our thinking, memory and other skills, which we use to form and understand language; how we learn and remember things; how we process information; how we plan and carry out tasks; how we recognize objects, and how we calculate. It was thought until recently that memory loss and some other cognitive problems were a rare occurrence. However, more recent research has suggested that a range of cognitive problems varying widely in type and severity may be present in many people with MS.
    Of course people with MS, just like anyone else of a similar age and sex, can suffer mental illness or dementia but, clinically, people with MS do appear to have more depression (see next section) compared to other people, and perhaps have what might be called mood swings rather more often. More recently, studies have shown that many people with Multiple Sclerosis have some problems with memory and with what are called their cognitive abilities, and these seem to be associated with the effects of the disease. It is thought that MS could lead to a subcortical dementia but this is not inevitable. We discuss depression and mood swings later in this chapter.

    How to recognize the problem

    We can all change without necessarily realizing the nature or extent of that change – until someone tells us. Sometimes people with MS may be so depressed or anxious that they think their cognitive problems are worse than in fact they are; on the other hand, they may not want to acknowledge them at all, for they do not want to think that MS may affect their cognitive as well as their physical functions. In addition to the general variability of symptoms, an issue that we have indicated is characteristic of MS, we have also noted that previously it has been very difficult to link cognitive performance to any other aspect of MS. However, more recently, studies using MRI (magnetic resonance imaging) have shown that the more general the demyelination the more likely it is that significant cognitive problems will also exist. Moreover, MS lesions in certain areas of the brain seem to be associated with cognitive difficulties. Further work will, it is hoped, be able to identify more precisely the relationship between certain kinds of cognitive problems and areas of the brain affected by Multiple Sclerosis.
    In addition, during acute attacks of MS, it has been observed that cognitive performance – memory and concentration, for example – may get significantly worse and then improve again; on the other hand, if the cognitive problems have arisen gradually and have been present for some time, then it is unlikely that they will improve substantially.
    Family perceptions may be more accurate on occasions but, although we all suffer from memory lapses from time to time, it may be tempting for you or some family members to put down every piece of forgetfulness to the Multiple Sclerosis. To avoid possible uncertainties, concerns or perhaps even recriminations, you should seek an objective assessment of any cognitive problems, if possible with a referral to a clinical psychologist, or more specifically to a neuropsychologist – usually from your neurologist.

    Professional opinions
    Until the results of recent research, many GPs and neurologists did not consider cognitive symptoms to be a major issue in relation to MS. Because the understanding and use of language is quite good in people with MS, in a single or occasional interview or consultation, it may be hard for a doctor to pick up more subtle but still important cognitive prob- lems. As we have suggested, it is far more likely that those who are with you, and see you everyday, will notice these things first. People with MS have found that cognitive problems can be one of the main reasons why they have to go into residential care or why they become unemployed.

    Tests
    Formally, the range and extent of any cognitive problems can be measured and monitored through what are known as ‘neuropsycho- logical tests’, usually given by a psychologist. They would involve some verbal and written tests focusing on things like your memory and your ability to solve problems of various kinds. These tests are becoming more sophisticated and you may be given a group (often called a ‘battery’) of tests that could take perhaps an hour or more to do. Your performance on these tests is then compared to those of normal healthy adults, and it is assumed that, unless there are other explanations, a much lower performance on one or more tests is due to MS. These tests are only given routinely in some clinical centres at present and, because this is still one of the developing areas of research and clinical practice in MS, you may need to attend specialist centres to obtain such an assessment.
    Because some medications may affect your performance in tests, you should make the person who is testing you aware of what medication you are currently taking. The testing process itself may be problematic for other reasons. For example, many of the tests used for people with MS require a degree of coordination and manual dexterity, and this may be compromised by other ef fects of Multiple Sclerosis. Also, a problem in one area of cognition can affect performance in a test in an unrelated area, or it may be difficult to compare tests involving spoken responses with tests involving written or manual responses.

    What might affect cognition?

    Emotional state
    Your emotional state may affect your cognitive performance, but the exact relationship and mechanism is not yet clear. Some studies have shown that depression seems to be related to cognitive performance, and others have shown the opposite.

    Heat
    Heat, or getting hot, may affect your cognitive performance, as it may influence other symptoms from time to time. Although little research has been undertaken on heat and cognition, on the basis of research on other symptoms it would be reasonable to conclude that if, for example, your memory could have been affected in this way, it would be likely to return to normal with a reduction in the temperature.

    Medication
    Medication may also affect cognition, particularly those that have cen- tral nervous system effects, such as sedatives, tranquillizers, certain pain killers and some steroid treatments. You should be aware of this possi- bility while you are doing everyday tasks that require concentration.

    Cognitive problems found in Multiple Sclerosis

    We must re-emphasise that the variability of cognitive problems in MS is very wide, some people do not have any cognitive problems and in others they are very mild. However, for information, the sort of problems that research has revealed are as follows. Memory loss is the most frequently found cognitive problem in MS. This may involve problems with short- term memory – failing to remember meetings or appointments, forgetting where things are and so on. There is also some evidence that people with MS may find it harder to learn new information. There are also difficulties with what is called abstract reasoning in some people with MS – that is the capacity to work with ideas and undertake analysis or decision-making in relation to such ideas. Sometimes speed of information processing may be af fected in Multiple Sclerosis – things seem to take longer to think about and do. It may be more difficult to find words, and concentration can tend to wander more readily. In addition it is possible that capacity to organize things spatially becomes more difficult – for example putting together self-assembly furniture is more of a problem.

    Management

    Drugs
    At present there are no drugs approved and accepted for the management of such problems as memory or concentration in MS. Memory problems are, of course, not limited to people with MS, and there is considerable research in this area. However, the cause of memory problems varies between different conditions, so drugs that might be helpful for people with Alzheimer’s disease, who have very severe memory problems, would not necessarily be useful for people with MS. Nevertheless, there is increasing research to see whether a number of drugs, often originally developed for other purposes, might help people with MS.
    There is some evidence that drugs used to assist fatigue may have modest effects on some cognitive problems. There are currently trials to see whether the drug pemoline might help cognitive function, and preliminary research on amantadine has suggested that it might have some ef fect on information processing. A drug with the proprietary name of Aricept, used for the treatment of memory disorders in Alzheimer’s disease, is being studied to see whether it has any similar effects in people with MS. However, whilst in Alzheimer’s disease this drug appears to increase the availability of a substance called acetylcholine, a neurotransmitter, this does not seem to be relevant to the cognitive problems in MS.
    It is possible that beta-interferons and other recent drugs used to help manage Multiple Sclerosis itself may have some effect on cognitive function, for, as we have noted, that function tends to be more problematic the larger the number of lesions in the CNS. If the speed with which this increase is lessened, then there could be some effect on cognitive function. However, until recently, it has not been usual to include neuropsychological tests in clinical trials of such drugs, so further detailed research is needed and is now being undertaken.
    Finally there has been publicity recently about the possible use of preparations of ginkgo biloba (made from the leaves of the Ginkgo biloba tree which grows in the Far East) for problems of memory and concen- tration. Trials of ginkgo biloba in people without MS have produced mixed results, early trials being promising but a major recent trial suggesting that it has little or no effect on memory and concentration. There have been no systematic trials on people with MS as yet and so no formal evidence that it could assist with their cognitive problems. In any case there are always problems in ensuring the purity of the active ingredient in such a product, and you should be cautious about its use.
    Overall the investigation of possible drug therapies for cognitive problems is a large area of current research and it is hoped that major advances will be made in the next few years in this area.

    Professional help
    This is a very rapidly developing area of professional interest in relation to cognitive problems. Until recently, the main professions in these aspects of everyday living have been occupational and speech therapy. So, as part of the process of managing everyday activities, occupational therapy helps you to organize your environment, as well as your skills, to the maximum advantage. Speech therapy helps you with speech production problems, particularly if you take some time to articulate what you wish to say.
    Some occupational therapists, particularly in North America and now in Britain, are developing special skills to help people with their memory and cognitive problems – often described collectively as cognitive rehabilitation. This is an approach designed to try and improve the everyday functioning of people with cognitive impairments resulting not only from Multiple Sclerosis but also other central nervous system disorders, such as head injury or stroke.
    There are two broad approaches to cognitive rehabilitation. The first of these is to try to restore the lost functions, often through retraining, with the use of repetitive techniques such as learning lists, and helping people to re-acquire skills with progressively more complex tasks. The second is based on the idea that, because it will be difficult to regain the lost functions, compensatory strategies are needed, in which other devices and procedures are used, such as trying to minimize distractions, or using other means of reminding you about activities that you need to do. Both of these approaches are designed to help people manage their everyday lives better despite any cognitive impairment.
    We need to repeat that cognitive rehabilitation, as a formal programme, is not available everywhere for people with MS. At present, following assessments, you will probably have most contact with an occupational therapist, whose skills focus substantially on the abilities needed to accomplish everyday activities, but we expect that many such therapists will increasingly be using at least some of the key techniques for managing problems that you may have in the area of memory or concentration.

    Self-help

    People with MS can be affected by a range of cognitive problems, and it is difficult to advise you precisely without knowing exactly what they are.
    The difficulties often mentioned specifically – concentration and memory
    – are quite common.
    Concentration. Everyone has occasional problems concentrating on things. Sometimes the problem is that we have many things going on at the same time – television, other people talking and a whole range of other activities going on. However, for someone with MS, concentrating on one of these activities – a conversation, for example – can be quite difficult, when so much else is happening. So the key thing is to try and have only one thing going on at a time – a conversation or the television, not both at the same time. You might have to move between rooms to achieve this. Find out when and where problems for you are most difficult, and then work on reducing the distractions to the minimum. Obviously changing your pattern of normal activities to help you concentrate may not be easy, but may be preferable to having continuing concentration problems.
    Memory. There are many ways in which you can jog your memory. Some of these are routine, and may appear overpedantic or fussy for someone who has only minor memory difficulties, but all help to deal with shor t-term memory problems. For example, just making sure that clocks and watches show the right time; ensuring that today’s date is prominently displayed somewhere; having a message board to note activities for today and tomorrow; having a list of activities that you are intending to do, with times and dates, perhaps in the form of a diar y or similar record. Although this might seem almost too formal, note things down that you have agreed to do, or that you and other s think impor tant, so that it doesn’ t appear that you have forgotten it.
    If you have difficulty with reading, check with your doctor whether you have any of the several potential eye problems associated with MS, that may interfere with your ability to read. Secondly, try and find a strategy to read in a particular way to maximize your ability to retain a story line.
    As a broad guideline, the more of your senses that you use, the more likely you are to remember and retain ideas. Most people read things silently. It may be worth repeating what you read out loud, or at least key parts of it; or relate some elements of the story to another person; or write key ideas down. In this way, using more than one of your senses – writing, seeing, hearing and saying – you stand a better chance of remembering the story, or indeed other material. Admittedly, this approach may require some tolerant support from those around you but, if you are making a big ef fort to improve your memory, they will probably feel that they are gaining too.
    You may find that you do not need to go to these lengths to help your memory – you could work out the main lines of the story or newspaper article by ‘skim reading’ so that, although you may have lost the element of surprise (about the ending of a story, for example!), you will have got an overall view of the text.

  • Fatigue, cognitive problems and depression: Fatigue

    Fatigue or tiredness is one of the most debilitating symptoms of Multiple Sclerosis and one that worries many people. Up to 90% of people with MS experience overwhelming tiredness at least some of the time. Fatigue in MS is often associated with:

    • heat (or being hot);
    • activity – using motor skills, or being mobile;
    • sleep disturbances;
    • particular mood states (such as depression – see later section);
    • some cognitive problems that may occur in MS (see later section).

    At present there is no one known cause of fatigue in MS. Some argue that the best way to manage fatigue is to consider it as a symptom arising from several different sources and thus requiring different techniques to manage it. In fact it might rather better to talk of ‘Multiple Sclerosis fatigues’ in the plural. We could distinguish what we might call:

    • normal fatigue resulting from everyday exertion etc., which is managed by rest;
    • ‘Multiple Sclerosis fatigue’, which seems to result from the MS itself and for which it is difficult to find any other immediate cause, and which may well require drugs to control it;
    • muscle fatigue, which may appear in an arm or leg, for example after or during a walk; rest may be needed and cooling may be helpful here;
    • fatigue from depression, often managed through the treatment of the depression itself;
    • fatigue from drugs themselves, occurring as a side effect – being aware of this possibility should prompt you to consult your doctor if fatigue seems to be related to a drug you have taken;
    • fatigue from the underuse of muscles – just as fatigue can result from overuse, it can also result from underuse, it is important to keep your muscles in the best condition you can.
    • fatigue from managing Multiple Sclerosis – living with MS is fatiguing for most people, so pacing your activities as well as taking advantage of as many helpful pieces of equipment as possible will be important;
    • fatigue from loss of sleep – this is of course a problem not just for people with MS and will compound other kinds of fatigue, so the reasons you are losing sleep need to be addressed.

    Management of fatigue

    Although it is important that your symptom is recognized as genuine by medical and other healthcare staff (which has been a problem in the past), you will probably have to manage many of the day-to-day aspects of fatigue yourself, for drug therapies (see below) are often only partially successful.

    Self-help

    • Identify activities that appear to precede the fatigue and avoid them whenever possible.
    • Develop ‘pacing’ strategies, trying to work intermittently with rest periods, or use some other ways of relaxing during the day.
    • When the fatigue seems to be related to particular times of the day, focus your activities at other times.
    • Try longer term ‘pacing’ too, trying to balance activities over periods of days or weeks.

    People with MS may do something that they enjoy or indeed have to do, knowing that they will have a couple of ‘bad fatigue days’ following this activity. However, ‘fatigue management strategy’ tends to be a complicated business, taking a lot of energy in itself to think through all the possibilities that might occur.

    Professional support
    Specific and carefully planned exercise programmes have been found to reduce feelings of fatigue, but only temporarily. Behavioural therapy can help to alleviate other psychological symptoms that might exacerbate the fatigue, but these non-drug professional approaches have not been successful so far for most people with Multiple Sclerosis over the medium and longer term.

    Drugs
    Some drugs have helped, the two most well known being magnesium pemoline (Cylert), which stimulates the CNS, and amantadine hydro- chloride (amantadine; Symmetrel), an antiviral agent. It has also been suggested that fluoxetine (Prozac) may help in managing MS fatigue.
    Some antidepressants, particularly those that have a low sedative effect, may help the tiredness even if you are not clinically depressed. Beta-interferon drugs may have some effect on fatigue if, indeed, they help the immune system.
    Fatigue may be one thing that affects cognition, although it is still not yet clear exactly how this happens. Some people with MS feel fatigued almost simultaneously as they notice problems with their memory or concentration (see below). Self-rated fatigue is linked with certain forms of memory problems, as well as reading comprehension. However, if fatigue is treated with a prescribed drug, it does not appear to influence cognition. In order to try and understand this process, fatigue in people with MS has been compared to that in people with chronic fatigue syndrome (CFS), but it is not clear whether the two are the same; indeed, when fatigue severity is the same between the two groups, people with Multiple Sclerosis showed more widespread cognitive problems.

  • Fatigue, cognitive problems and depression

    Until a few years ago, the symptoms associated with MS that we discuss in this chapter were often ignored or underplayed by doctors and neurologists. This was, in part, because MS was considered then to produce mainly – often only – physical symptoms directly (and obviously) related to the damage occurring in the nervous system. Other symptoms seemed – at the time – to be very difficult to relate to nervous system damage in this way, so fatigue, cognitive problems and, to a substantial degree, depression, were often seen as not related to the disease process itself. There has been a very substantial change over the last decade and now much greater professional attention is being paid to people who have these symptoms.