Ask the Doctor
Q: I am receiving physical and occupational therapy for a broken hip, but the nurses do not understand the variable nature of MS, and are pushing me beyond my capability. How can I get the hospital or nursing home staff to understand MS?
A: Rehabilitation for hip fractures can be more difficult for individuals with MS for many reasons. MS-related fatigue, spasticity (stiff muscles around the hip and thigh), muscle weakness, movement-triggered spasms or sudden jerking, pain, bladder and bowel problems, and lack of coordination, can all complicate the hip fracture rehabilitation process.
In spite of all of these added issues, dynamic rehabilitation therapy is important to get the hip working to its maximal capacity. Inadequate rehab will likely lead to even more problems in the long-run. The key to successful rehabilitation is a balancing act to provide adequate therapy while dealing with the challenges of MS outlined above.
Insurance coverage dictates that a certain number of hours each day must be devoted to rehabilitation in an effort to minimize one's hospital stay. You may try requesting that you be allowed to rest between each half-hour session to better cope with fatigue and other MS symptoms.
This answer may help you and the hospital rehab team to work together within your limits. A consultation with the rehab team and an MS expert in neurology or rehab may also be helpful. A list of comprehensive MS centers is available through the Consortium of Multiple Sclerosis Centers' (CMSC) website (at www.mscare.org) or by calling MSAA's Helpline at (800) 532-7667.
Q: What is the status of research and trials with stem cells?
A: I believe stem cell research has exciting potential for individuals with MS. Two types of stem cell research are usually associated with MS -- the first is a stem cell transplant, also known as a bone marrow transplant (BMT). The second uses embryonic stem cells which may come from the blood in the umbilical cord.
Bone marrow transplants are only used for those who are severely affected by MS and who are not responding to the ABCR drugs (Avonex®, Betaseron®, Copaxone®, Rebif®). This process knocks out the immune system and puts back cells that are not activated to attack myelin. Bone marrow transplants carry a high risk and are still experimental, so they are only recommended in extreme cases.
Embryonic stem cells may be able to make new brain cells, with the potential to help individuals with MS as well as other neurological conditions, such as Parkinson's and Alzheimer's disease. While these stem cells appear to mature into brain cells, the challenge involves getting these cells into the right location of the brain and functioning in place of damaged or destroyed cells in patients. This research is still in its infancy, but as I stated earlier, its potential is exciting.
Q: What are the best treatments for individuals experiencing cognitive problems with MS? Should they be referred to a neuropsychologist for evaluation? How often should they be tested, and what cognitive symptoms should be of greatest concern to family members?
A: My approach to people with MS experiencing cognitive problems is to:
- Evaluate their medications to see if they may play a role; many medications contribute to cognitive problems
- Evaluate for depression, anxiety, or other emotional problems that contribute to cognitive dysfunction
- Evaluate for infection, such as thyroid problems, urinary tract infection, anemia, blood chemistry, cell abnormalities, and other medical conditions that might contribute to cognitive changes
- Arrange for a neuropsychology evaluation, including testing combined with a plan for dealing with both cognitive and emotional issues
Some MS cognitive symptoms are not obvious. In addition to "forgetfulness," some individuals with MS have more trouble with organization, judgment, focusing, and other "executive functions" which are not easily recognized. Some people have trouble restarting a project that has been interrupted. Family members may misinterpret these subtle changes as "stubbornness, belligerence, or laziness." Many of these symptoms can be managed with the help of a therapist.
After the evaluation, the focus turns to treatment. Strategies to help stay organized, such as keeping lists, are a first step. Staying with each task until completion (avoiding interruptions) often improves work performance dramatically. A cognition retraining expert can make even more specific suggestions.
Medication is another option. Drugs for Alzheimer's disease have been tried to help people with MS. The results have not been dramatic, but some neurologists use these medications and believe they may be helpful for some. The interferons have also been shown to assist with cognitive functioning.
In summary, identifying and treating cognitive problems is very complicated. Most individuals with MS, however, may be helped by conducting a careful evaluation and developing a thoughtful treatment plan.
