Articles on Medical Diseases and Conditions

Tag: Spasticity

  • 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.

  • 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.

  • Sexual relationships: Problems during intercourse

    Incontinence

    If you haven’t had one already, visit your doctor for an assessment of the problems you have with incontinence. Try and ensure that you have no urinary infections, which can make your bladder problems worse if left untreated.
    The following advice can help reduce the risk of ‘accidents’ during intercourse:

    • Reduce your intake of fluids for an hour or two beforehand.
    • If you are self-catheterizing, do so shortly before you begin.
    • If you are taking drugs to reduce urgency because of a bladder storage problem, take these about 30 minutes beforehand
    to ensure as far as possible that no spontaneous bladder contractions occur.
    • You may need to ensure more vaginal lubrication, with something such as K-Y Jelly.
    • Check out gently and sensitively positions in which you both feel comfortable, and in which you feel you are less likely to have problems with leakage.
    • If the woman has an indwelling catheter, then several positions may be better than others (remember also to empty the collecting bag, and tape the catheter to prevent it moving): a rear entry position may be easiest to manage, lying on your sides with the man behind; or, while the man kneels, the woman could lie on her back with her legs over his shoulders.
    • Alternatively if the man kneels and, as it were, sits on his knees with the woman in front of him with her legs over his shoulders, then gentle movements in this position should be more comfortable. If the woman has problems with spasticity in her legs, then such a position is likely to reduce the possibility of annoying cramps and rigidity.
    • The male partner could use a condom, which might be useful for other reasons as well.

    Pain

    Low levels of sexual arousal can reduce lubrication in the woman, but it can also be due to damage to nerve pathways in the mid- and upper spinal cord area, which leads to inadequate stimulation of the lower nerve pathways to the genital area; certain drugs taken for other purposes – such as urinary problems – also dry up vaginal secretions. Sometimes lubrication can be helped by direct stimulation of the genital area; or try to set up an environment which is relaxing and conducive to sexual thoughts and experiences. As far as additional lubrication is concerned, K-Y Jelly or a similar water-soluble substance can be very helpful. Substances like Vaseline are not recommended because they do not dissolve in water, and they are likely to leave residues which could give rise to infections. They can also create holes and tears in condoms.

    Spasticity

    Check with your doctor that the general control of your spasticity is as good as it can be. Try and keep your muscles as well toned as possible through regular exercises, and use appropriate drugs such as baclofen as necessary to give additional control.
    There are also certain positions for sexual activity that appear to make the muscular spasms less likely, although it is important that you explore other possibilities than those mentioned below, for you may find another position that suits you both very well. For a man who may have difficulty with spasms or rigidity in his legs, then sitting in an appropriate chair (without arms) would allow his partner to sit on his penis either facing him or with her back to him. For a woman, lying on her side may help, perhaps with a towel or other material between your legs for more comfort. Your partner can then approach you from behind. Another possibility is to lie on your back towards the edge of your bed with the lower part of your legs hanging loosely off the bed.

    Fatigue

    As with other symptoms associated with MS, it is important to discuss this with your doctor who will assess the best means of managing it. Although there are one or two drugs which may help (for example amantadine or pemoline) and which – if prescribed for you – might be taken a few minutes before sexual activity, currently the best help is through various appropriate lifestyle changes.
    Consider when you feel least fatigued. Although this may not necessarily be the time when you feel that you should be having sex – such as in the morning, or during the day, rather than at a more conventional time – you may be less tired and enjoy it more. Rather than thinking of sexual intercourse as the major element, you could agree with your partner to engage in some other less energetic sexual activities
    – such as gentle stroking or foreplay – that you could participate in more frequently. As with so many other aspects of living with MS, it is a question of finding ways to adapt to the situation through experimentation.