Ask the Doctor

Q: How does an individual with MS manage general surgery? What concerns should a patient have about exercise and physical therapy (PT) during the post-op period?

A: People with MS should thoroughly understand the risks as well as benefits of a surgical procedure. Some reports claim general surgery may increase the risk of an MS attack, but this is not confirmed. However, if the patient is having a spinal or epidural anesthesia where needles go near the spinal cord or
surgery that penetrates the brain, I am more concerned.

Does this mean that individuals with MS should not have surgery? No, but it does mean that elective surgery, such as cosmetic surgery, should be given extra thought. Nonetheless, many of my patients have had cosmetic surgery with little or no problems. Obviously, if an appendix or a gall bladder needs to be removed or a broken arm needs to be pinned, MS becomes a secondary concern.

Post-op issues are also important. My MS patients often have a longer recovery time than expected along with more fatigue, and a mild increase in past symptoms during the post-operative period, especially with a slight elevation in temperature. Surgery can be performed on people taking the current immunomodulating agents such as the ABCR drugs (Avonex®, Betaseron®, Copaxone®, and Rebif®). However, continuous long-term steroid therapy before surgery may reduce the healing of the surgical wound as well as reduce the body’s ability to mount an effective attack against infection.

After surgery, the importance of becoming active by beginning movement and exercise programs has been emphasized recently. However, sometimes fatigue limits one’s ability to exercise. Therefore, I recommend that individuals with MS exercise to a tolerable level, before reaching significant fatigue. They should also work with their surgeon, physician, and/or physical therapist to maximize the positive effects of exercise during this period. Prolonged immobility after surgery can lead to a number of undesirable effects, such as increased fatigue, decreased strength, increased muscle spasms, increased depression, and blood clots.

Q: I am becoming more fatigued. What advice do you have for me?

A: I consider a number of issues when I see a patient with increasing fatigue. First, I look for other medical conditions that may increase fatigue, such as low thyroid, anemia, or infection.

Second, I evaluate current medications that the individual is taking, including complementary and alternative supplements that may be contributing to one’s fatigue. For example, tizanidine (Zanaflex®), baclofen (Lioresal®), carbamazepine (Tegretol®), and some health store products can cause fatigue. I sometimes need to look up the effects of different herbal therapies.

Third, once I have determined that the fatigue is specifically caused by MS, I formulate a treatment plan that includes:
a) A non-medicine approach, such as cooling and lifestyle changes (which may include altering sleep and work habits). Moderate exercise and yoga have also been shown to have positive affects on fatigue.
b) A pharmaceutical approach, such as modafinil (Provigil®, a medication that seems to be the strongest anti-fatigue medication at this time), or amantadine (Symmetrel®). I tend to avoid habit- forming stimulants such as methylphenidate (Ritalin®) and Dexedrine®, although they can be useful in certain situations. Some individuals have found that SSRI antidepressants are helpful in relieving fatigue as well.
c) A psycho-social counseling approach to address such issues as coping, depression, stress, and anxiety – all of which can contribute to fatigue.

Q: How often should I get physical therapy?

A: Physical therapy (PT) can play an enormously positive role in the health and wellbeing of individuals with MS. Studies have shown that an appropriate exercise program helps fatigue, stress, and depression. PT can also address safety issues, such as preventing falls and accidents from climbing stairs.
The physical therapist can help design an individual program that keeps your MS in perspective. Appropriate stretching and strengthening exercises can increase function dramatically at times. The physical therapist can help people with MS develop their own at-home program to maximize their function.
Therefore, while scheduling continual PT for life is unnecessary, periodic evaluation and updates on therapy can be very useful (as needed when you notice more problems with stiffness, balance, and strength). PT is often recommended following an exacerbation to maximize recovery. This typically will mean two to six weeks of therapy, one to three times weekly. 

Jack Burks, MD, is a neurologist who specializes in MS. He is the chief medical officer for MSAA and president of the Multiple Sclerosis Alliance. Additionally, Dr. Burks is a clinical professor of medicine in neurology at the University of Nevada School of Medicine in Reno, Nevada, and a member of the Medical Advisory Board of the National MS Society. He has edited two textbooks on MS, and in the 1970s, Dr. Burks established the Rocky Mountain MS Center in Colorado, one of the nation’s first comprehensive MS centers.