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MULTIPLE SCLEROSIS by Megan W. Barrett, MSN, ARNP-c, Multiple Sclerosis Certified Nurse; Research Advocate, North Florida Chapter, National MS Society Important Information for the Family Physician Multiple sclerosis (MS) is a chronic, unpredictable, usually relapsing-remitting, demyelinating disease of the central nervous system. A specific cause has not been identified; however, the etiological associations include genetic predisposition, environmental triggers and autoimmunity. 1 MS is the most common neurological disease in people under the age of 40, and it afflicts more than 400,000 Americans. 2 Its diagnosis is one of exclusion, and its symptomatology mimics that of many other conditions with which people present to their family physicians (FPs). The Institute for Healthcare Improvement, the Robert Wood Johnson Foundation, the U.S. Department of Health and Human Services and the World Health Organization recognize appropriate management of chronic illness as a problem in care delivery. The chronicity of MS, coupled with the fact that the lifespan of people with the disease is similar to that of people without it, mandate the need for FPs to be familiar with the neurological aspects of the disease, as well as the primary care needs of people with it. 3, 4 The most common comorbid conditions in people with MS are hypertension, hypercholesterolemia, arthritis, irritable bowel syndrome and chronic lung disaease. 5 Unfortunately, people with MS tend to lack knowledge about other chronic diseases, and may also dismiss the possibility of acquiring a second chronic illness. 6 The Approximately 85 percent of people with MS start out with a relapsing-remitting course, and about half of these people will experience secondary progressive disease after 10 years. Less common types of MS include primary progressive (10 percent) and progressive relapsing (5 percent). There are six available disease-modifying agents for MS: Avonex (interferon beta 1a), Betaseron (interferon beta 1b), Copaxone (glatiramir acetate); Rebif (interferon beta 1a, Novantrone (mitoxantrone) and Tysabri (natalizumab). 1 These medications require monitoring for adherence, site reactions and/or systemic side effects. The most common primary care needs of people with MS relate to bladder and bowel symptoms, fatigue, sexual dysfunction, depression, acute bacterial or viral illness and pseudoexacerbation related to the latter. A patient’s neurologist may be managing disease-modifying and symptomatic treatment; however, the FP should be well-versed in the drugs used to treat the common symptoms, as well as the monitoring required for the disease-modifying agents in order to ensure that essential elements of chronic illness care are provided. Collaboration between the neurologist and FP is vital in the care of these patients in order to maintain their health and prevent the development of secondary conditions. 10
influence of the FP is extremely important in these cases. Barriers to primary care, including physical barriers to access, patient frustration with lack of primary care provider familiarity or experience with MS and erroneous assumptions, have been identified in the literature as significant roadblocks to the receipt of recommended preventive screening in this population. 3, 7-10 The literature also suggests that recommended screening and counseling needs are not being met in the MS population. So what can a busy FP do to provide appropriate preventive care to this vulnerable population Primarily, consider the disability-friendliness of your office environment. Secondly, make sure that patients with MS are scheduled for preventive health screening visits. If a patient presents to the office for an acute illness, be sure to review screening history at the visit, and schedule testing and follow-up appointments if needed. Thirdly, be aware of your closest comprehensive MS center, local neurologists, rehabilitation and counseling services, and social and community services. Such information can be readily found on the National MS Society’s Web site, http://www.nationalmssociety.org. While a cure for MS has yet to be discovered, recent progress has been made in all of the proposed etiological areas contributing to the disease. Susceptibility genes have been reported, environmental risk factors identified, new therapies targeting autoimmunity and nerve protection are being studied, advanced rehabilitation techniques are being used, and advocacy for people with MS is on the rise. Encouraging healthy lifestyles and being the stimulus for preventive care in this population will increase the likelihood of a healthy life for people with MS. Disclosure: The author serves on speakers’ bureaus for Bayer, Biogen-Idec, Serono-Pfizer and Teva Neuroscience. References 1. http://www.nationalmssociety.org 2. Holland, N. Clinical bulletin: Information for health professionals – Overview of multiple sclerosis. Retrieved September 7, 2008, from National MS Society Web site: http://www.nationalmssociety.org/for-professionals/ publications/clinicalbulletins/download.aspxid=161, 2006. 3. Cheng, E., Myers, L., Wolf, S., Shatin, D., Cui, X., Ellison, G., et al. Mobility impairments and use of preventive services in women with multiple sclerosis: observational study. British Medical Journal, 2001; 323: 968-969. 4. The National Coalition on Health Care, The Institute for Healthcare Improvement. Curing the system: Stories of change in chronic illness care. From http://www.ihi.org/IHI/Topics/ChronicConditions/ AllConditions/Literature/ CuringthesystemStories ofchangeinchronicillness.htm 5. Marie, R., Cutter, G., Tyry, T., Vollmer, T., & Campagnolo, D. Comorbid conditions are common in multiple sclerosis. Paper presented at the Consortium of Multiple Sclerosis Centers, 2007. 6. O’Connell, D. When the diagnosis is MS...& something else. InsideMS, 2005; June-July: 50-53. 7. Beatty, P., Hagglund, K., Neri, M., Dhont, K., Clark, M., & Hilton, S. Access to health care services among people with chronic or disabling conditions: patterns and predictors. Archives of Physical Medicine and Rehabilitation, 2003; 84: 1417-1425. 8. DeJong, G. An overview of the problem. American Journal of Physical Medicine & Rehabilitation, 1997; 76(3): 2-8. 9. Tezzoni, L., McCarthy, E., Davis, R., Harris-Davis, L., & O’Day, B. Use of screening and preventive services among women with disabilities. American Journal of Medical Quality, 2001; 16(4): 135-144. 10. Nosek, M. H., B., Rintala, D., Young, M., & Chanpong, G. National study of women with physical disabilities: Final report. Sexuality and Disability, 2001; 19(1): 5-39. Florida Family Physician 11
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