Articles on Medical Diseases and Conditions

Tag: baclofen

  • 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.

  • Sensations and pain: Pain

    For many years Multiple Sclerosis was considered, medically, to be a painless disease, probably because the process of demyelination was thought in itself not to be painful. However, people with MS themselves have known for many years that specific symptoms could cause considerable pain, and this is now being recognized.
    Chronic pain is experienced by about 50% of people with Multiple Sclerosis. Although pain is more common amongst people with severe MS, and amongst older people with the disease, almost everyone will experience some kind of pain at some point.

    Trigeminal neuralgia

    Trigeminal neuralgia is a very acute knife-like pain, usually in one cheek, and sometimes over one eye, but it rarely affects both sides of the face. It is caused by the lesions of Multiple Sclerosis damaging trigeminal nerve pathways. Drug treatment usually includes carbamazepine (Tegretol), although this drug does produce side ef fects, which may be a problem. The primary side effect is sleepiness, so the drug may be started in low doses and then given in higher doses until the pain is controlled. It is also possible that phenytoin, which has a milder action than that of carbamazepine, may be used, or less commonly, baclofen, which is usually given for spasticity. Another approach is to try and block the inflammation; if this is associated with a relapse, steroid therapy is given. If there is a continual problem of trigeminal neuralgia linked to several relapses, then a prostaglandin analogue called misoprostal (Cytotec) can bring relief. In some cases, various surgical operations, including the
    ‘gamma knife’, can destroy the relevant nerve pathways. Even if the trigeminal neuralgia reappears, as it can do, then the treatment can be started again, and it will almost certainly reduce the pain.

    Jaw pain

    There are other types of pain that may affect the facial area, which may not be linked to particular forms of myelin damage: temporomandibular joint (TMJ) pain affects the jaw area, or you may get more general migraine or tension headaches. Drug therapy can help counteract this pain, but in each case will be dependent on a careful investigation of the cause of the pain, and particularly the extent to which it appears to be linked to the Multiple Sclerosis, or to something else.

    Pain from unusual posture and walking patterns

    Pain from poor posture when sitting or lying, and from unusual walking patterns, is quite common. In most cases the pain does not result from the neurological damage of MS, but from its effects on movement.
    In fact one of the most common kinds of pain treated by neurologists in relation to Multiple Sclerosis is low back pain, often arising from an abnormal sitting posture or from a way of walking that has developed as a result of damage to the control of leg muscles. This may result in a pinched nerve from ‘slipped discs’, or other back problems, which can also be caused by unusual turning or bending motions. Painful muscle spasms may also result.
    So it is important to pay careful attention to how you sit and how you move in order to lessen such difficulties. You may need to seek advice from a physiotherapist in relation to both posture and movement. Comfort may be obtained by:

    • massage of the back, if carefully undertaken
    • ultrasound
    • TENS
    • specific exercises, to relieve muscle spasms
    • drugs designed to reduce spasms, and finally
    • surgery, if there are disc problems.

    Other painful conditions, particularly painful swelling of the knee(s) or ankle(s), can result through problematic patterns of walking. You must seek careful advice in relation to these conditions. It is possible that orthopaedic doctors, recommending conventional orthopaedic exercises for such conditions, may not fully realiz e that having Multiple Sclerosis could mean that such exercises fail to work. It is likely that the swelling/pain of one joint may be easier to remedy through what is called an ‘assistive device’ (e.g. a crutch) to take the weight off a weaker leg, or a knee brace.

    Spasticity and pain

    Muscular cramps and spasms are known as ‘spasticity’. Several muscles contract simultaneously, both those assisting movement and those normally countering it. These muscles will feel very tense and inflexible – this is because what is medically called their ‘tone’ increases, and movement becomes more difficult, less smooth and possibly rather ‘jerky’.
    Spasticity is quite a common symptom in MS and is often very painful: it can occur in the calf, thigh or buttock area, as well as the arms and, occasionally, the lower back. Spasticity can lead to ‘contractures’, where the muscle shortens, making disability worse.
    There are a number of ways of managing spasticity in Multiple Sclerosis:

    • Use your muscles as much as possible in everyday activities, and undertake regular stretching exercises to help reduce muscle shortening.
    • Specific exercise recommended by a physiotherapist, such as swimming, or undertaking stretching exercises in a pool-based environment, should be done on a regular basis – an important point, as spasticity is likely to be a continuing issue.

    Devices to assist in the management of spasticity
    There are specific devices that may be useful for people with Multiple Sclerosis when spasticity occurs regularly in key muscle groups, and exercises alone do not appear to deal with the problem. There are devices to spread the fingers or toes. What are called ‘orthoses’ – in effect braces – keep the hand, wrist or foot in an appropriate position or prevent ranges of movement that may result from, or cause, spasticity. A particularly useful brace may be one that places the ankle in a good position in relation to the foot and thus lessens the possibility of local muscle contractures, as well as lessening the stress on the knee. It is important that all orthoses are specifically suitable for the individual concerned, as of course body shapes and sizes vary considerably.

    Drugs
    There are several drugs available to help muscles relax, and ensure that as few of your activities as possible are affected. It is difficult to target spasticity specifically, so some people may need medication occasionally, in the day or at night, and others may require more continuous medication. It is difficult to get the balance and the dose right, and this often has to be done on a trial and error basis.
    One of the most common and effective drugs for spasticity is baclofen (Lioresal), but it can have side effects; some people find it hard to tolerate high doses. Effective doses may vary widely for different individuals. Normally this drug is taken by mouth, but other ways of administration are being developed to help people with more severe symptoms.
    Other muscle relaxants, such as the widely used diazepam (Valium) can also be used, but they may have general sedative effects, causing drowsiness; this is why diazepam might be particularly helpful at night. People are also worried about whether they might become dependent on these drugs in the longer term.
    There are some newer drugs in the process of being introduced, which on their own, or in combination with the more established drugs, may target the spasticity more specifically:

    • Dantrolene (Dantrium) tends to reveal and possibly exacerbate any muscle weakness that may be present, and its effects should be carefully monitored.
    • Tizanidine (Zanaflex) is a relatively new drug, and may work in some cases when baclofen and other drugs do not; it can also be used in conjunction with baclofen. It produces more sedation than baclofen but less weakness.
    Some other drugs work best for specific muscle groups in the body – such as cyclobenzaprine HCl, which is useful for the back muscles, although it may work for other muscle groups as well. It can also be used in relation to another drug for spasticity.
    In relation to chronic spasms, which may result in a complete arm or leg being extended or stiff, carbamazepine may be used, although baclofen can be very helpful. Cortisone can sometimes be used to assist short-term control of such spasms – although it is not for long-term use because it has a range of side effects.
    It is possible that any or all of the drugs above may become less effective over time and thus one of the possibilities is to stop taking the drug concerned for a period of time before starting it again.
    There are other drugs undergoing trials at present in relation to the control of spasticity. One of the most promising is cannabis (or, in practice, combinations of cannabinoids – the chemical constituents of cannabis).
    There may be occasions, especially later in the course of Multiple Sclerosis, when treatment needs to be more robust to reduce very severe spasticity. This might take the form of injections, directly into the nerve or muscle concerned, with phenol or alcohol or, more recently, botulinum toxin, which damages the nerve and produces what some call a ‘nerve block’ preventing the spasticity from occurring.

    Spasticity and surgery
    Surgical intervention may be tried in relation to spasticity if other means of control fail. This can take several forms. Nerves controlling the specific muscles of the leg may be deactivated using what is called a ‘phenol motor point block’. This may make the legs more comfortable but clearly does not assist mobility. Other techniques may help spasms in the face – indeed botulinum toxin (Botox), which is increasingly being used for cosmetic purposes, may help small but very irritating facial spasms. Sometimes nerves or tendons controlling specific muscles that are producing major problems might be cut if there are no other easy means of control.
    A relatively recent development is the use of baclofen pumps to deliver the drug directly into the spinal canal to control spasticity. This process is still expensive and is what doctors would call an ‘aggressive’ treatment for spasticity, although it does allow a much finer and more detailed management of the flow of the drug.

    Pain from other Multiple Sclerosis symptoms

    Apart from the types of pain that we have already discussed, there are other sorts that can be associated with MS symptoms, such as that from:

    • urinary retention or infection;
    • pressure sores (later on in the disease), if not treated as early as they should be;
    • eye conditions, especially ‘optic neuritis’, when the optic nerve swells.

    In general, if the source of the problem is treated, the pain will disappear, although the management of the neurological causes of pain is more difficult than management of pain from other sources.