Depression and Fatigue in MS - Ben Thrower, M.D. - MSFocus Cruise for a Cause 2015

welcome back it is my pleasure to introduce dr. Benton throwing this afternoon thank you so this thank you guys for showing up I know the afternoons are always tough because everyone's had lunch and you're starting to hit that post post meal nodding so if I see you nod off I'll send Randy over to wake you up so so we're going to talk a little bit about depression this afternoon and I'm gonna broaden that out some and also talk a little bit about cognitive dysfunction a little bit about fatigue because sometimes all of those things are playing off of one another as I was putting that the talk together looking for four pictures of hurricanes and tropical depressions it brought back somewhat bad memories for me as Bob that one on the top there's obviously not ivan because how many remember Hurricane Ivan Ivan went up and you know went right up the Gulf Coast and my wife's brother and his wife and their daughter live in Mobile Alabama so they got the heck out of Dodge left left mobile and came out to stay with us in Atlanta well what was left over of Ivan came right inland and went into Atlanta and we had mild hurricane-force winds and lots of rain and as my sister-in-law from Mobile who's a hurricane expert looked up that some of our our vents and the ceiling intakes you notice that water was coming in and she said you've got a leak in your ceiling so being a good husband I got the flashlight went up into the attic and we had the little two by six rafters without anything big to stand on so I was doing a delicate balancing act and looking up as I was walking along the rafters and there was that moment of great clarity when you knew that you were going off that that rafter and I thought I had a fleeting thought it's okay the rafter is gonna break my fall and I was correct because it broke it just like that it was ugly from where I was apparently it was very entertaining from the underside because now there are two legs sticking through the ceiling so yeah so we have a Kevin drywall guy come in but I felt bad or the better when the drywall told me the guy told me that the cable companies keep them on retainer when the cable guys are doing installations in your attic apparently that's a fairly common injury and they wear appropriate protective devices to us yeah yeah what the dad there you go it's good that's a segue so what are some of the symptoms of depression I think if it's fairly obvious when we think about you know a sense of sadness is what most of us would think of but in a lot of people it's not sadness its irritability some people with depression just get a really short fuse you know we'll start it's common that when we're sitting in the room talking to someone we've got the person with them that's and their significant other and we start questioning depression and personal with them that's the saying absolutely not I'm doing great significant other not in a head saying oh yeah yeah irritability road-raging is you not putting up with frustrations and the family a loss of interest or pleasure in things that you would normally have not find to be fun so that could manifest as a lack of interest in sex which renewal address later a lack of interest in eating a lack of interest in going to the movies this is the medical term for this is an Adonia or a lack of hedonism so your things that you would normally find fun just aren't so much fun anymore some people with with depression sleep more some people with depression sleep less or have fragmented sleep so we can go either way some of the other things that we see are a sense of fatigue that's why I wanted to put fatigue and depression into the same talk because how do we separate out what is fatigue or a lack of interest from depression versus fatigue from multiple sclerosis or sell for side effects from medications one of the clues that we can look for is again going back to this thought of anhedonia or a lack of interest if there's something that you would normally want to do go into a movie for instance and you want to go your family is excited about your going and your body is just saying I don't think so I'm too tired someone unplugged my energy supply that may be more fatigue related so fatigue directly rather than a depression if you have no interesting going it just doesn't seem fun at all that may be more that the lack of interest from from underlying depression again the reason that I put the cognitive issues in here is that one of the common symptom complaints that we hear with depression is it manifests as a memory issue and what the person is really saying is that they have poor attention and concentration one of the common symptoms of depression is a lack of attention and concentration so that conversation you had five minutes ago that piece of information that you just read a short time ago when you start to try to recall that it's not there it's and it's really not that you don't remember it it's that you never stored it in the first place so it's really not a memory issue it's a storage problem this is probably more distressing to people because you would think that event just happened a short time ago how can I not remember it it's a lot of the cognitive issues that we see with multiple sclerosis may tie in with depression fatigue will also wreak havoc with your attention and concentration we're going to talk about this kind of circle this three-legged stool of depression fatigue and cognitive dysfunction in some people depression may be reactive and when we think back to you know years ago that if most ms health care providers felt at one point that all depression and multiple sclerosis was reactive you were reacting to a change in your health state you were reacting to what ms was doing to you maybe changing your work status may be changing your role in your family so it was just a natural reaction to a major life stressors and at different points in the MS journey that may still be true so you could still have a reactive depression just because maybe you had a severe relapse and you you're you're stressed about what that relapse has done to your quality of life or maybe you were newly diagnosed so we do still do C reactive depression but it may also be a result of the biological changes that are going on in the central nervous system so we do see people with MS who are doing really quite well now their MS is under good control they're not having attacks or not having progression of disability there are no new lesions on MRI and they're still dealing with depression and so that may be part of the biology itself one of the things that we hear commonly from people with MS and their families is who are dealing with biological depression is can you show me the lesion on my MRI that's causing my depression and I don't know how Randy feels but I can't do that I don't think we know the spot that is responsible for most depression on brain MRI our neuropsychologist friends are always wanting to do that - they'll do neuropsychological testing and say well I found X on the on the memory testing or I found Y on the mood testing show me the spot that's causing that on the MRI and it's pretty rare in multiple sclerosis at least on bringing MRIs that we can get that specific of correlating that spot with that symptom some people feel that depression might also be tied in to the immunology of multiple sclerosis so the you think about the complexity of the human immune system and think of it again as an army with different cells doing different things and those cells are sending chemicals to one another so that they can communicate ultimately without treatment this this sort of communication leads to more inflammation and there is research that suggests that some of the depression we see might be due to this immune dysregulation so that may be part of the issue with mood changes in ms one of the things that that has always been interesting to me when we look at people with multiple sclerosis there doesn't seem to always be a correlation between physical disability and the underlying mood sometimes there is but frequently there's not some of my individuals that I work with who are in power chairs who have a lot of physical challenges seem to have adjusted very well they're happy individuals and then I see someone who's newly diagnosed who has a number two and life is over for that person they're they're really not dealing with it well and so we have to kind of take away that the the myth that depression is always correlated with the degree of physical disability because it may not be so here's that three-legged stool of depression cognitive dysfunction and fatigue when we think about treating depression sometimes there is a tendency to want to go to an antidepressant medication as our first option and that may be appropriate in some individuals but again we've got to look at the bigger picture and realize that sometimes these three symptoms are playing off of one another and sometimes we can impact one symptom one yellow oval there by treating one of the other symptoms so we certainly have a toolbox full of different antidepressants we've got the standard what we call selective serotonin reuptake inhibitors these are your prozac Zoloft axles and now selects and lexapro what they've done with a lot of these medications is try to whittle out the side effects with these drugs so as we kind of go from Prozac one of our original medications to now select say lexapro which are available in generic form they've cut down on a lot of the side effects Randy may talk this afternoon about some of the sexual side effects that we see with these drugs and one of the advantages of some of the newer ones is we may see less of those sexual side effects certainly not zero we have what we call a typical antidepressants so things like well effexor newer drug pristiq which is very very similar to effexor that may be right for some individuals as ms centers we try to be as comprehensive as possible so we would like to manage depression all by ourselves and and for most people we can do that occasionally depression is so severe and if we've tried two or three different medications we may need to get some help from a psychiatrist not us personally but referring out sometimes it may be us personally - that's another story so my my comfort level is usually five if I have you on two antidepressants and I have gotten a dose as high as as is reasonable and your mood is still problem probably gonna get some help from the psychiatrist at that point psychiatrists don't do what we you know what Hollywood shows them doing on television from the old days they're not putting you on the couch and talking about your mom asking how you feel they're mostly managing medications and the options for managing mood disorders has become so many that sometimes it's nice to have that extra help to get someone back on of course one of the things I would throw in as a sidetrack be very cautious about manipulating antidepressant medications on your own some of these drugs you might get away with it you might be okay skipping a dose of a lexapro or a celexa some of these drugs are very unforgiving if you miss a dose effects or venlafaxine would be the prime candidate if you're on a moderate to higher dose of mental faxing I can tell you you do not want to skip that medication friend of ours has multiple sclerosis and was on a pretty good dose of effects or 300 milligrams a day and called up saying that she was having a severe relapse she came in and she had what call correo athetosis she had herky-jerky dancey movements on one half of her body which has been reported in very rare situations as an MS exacerbation questioned her at length about any medication changes nope nope nope taking everything once we got her at the hospital and we're just about to start her solu-medrol turns out she had skipped her effects her for two days put her back on her effexor and within 24 hours the symptoms and stops those can just be be cautious with any of these medications but especially with antidepressants and in terms of stopping those abruptly so we don't always go straight to drugs though when we're treating depression other things may help with with mood disorders so there's a tendency for many people with depression to socially withdraw you don't feel like going out you don't feel like doing much you don't feel like exercising one of the things that we really emphasize is trying to push people back out into the community even if you don't feel like going out for lunch with a friend make yourself go through the motions so you're trying so we're trying to not have you not socially isolate yourself exercise physical activity has been shown to actually help with mood and a lot of a lot of individuals so maybe in some individuals we can not go straight to a medication we might look at lifestyle adjustments referring you to a counselor if there are life stressors if you're newly diagnosed again we might go with an on medication route first what about cognitive dysfunction and fatigue cognitive dysfunction is common in multiple sclerosis depend upon whose survey you you read its present in 55 60 65 percent of individuals if we do neuropsychological testing I think in a perfect world we would do full-scale nor neuropsychological testing on every individual with multiple sclerosis we don't live in a perfect world and there are all kinds of insurance challenges that there Randy mentioned the other problem we run into is neuropsych testing it's just not a lot of fun if you've ever had neuropsych testing you know it's six hours of pencil and paper right-brain left-brain we always warn individuals you're going to come out feeling like you just took the toughest College exam that you didn't prepare for it's designed in some ways to push you to failure find out what you can do with neuropsychological testing we can sort out where are the problem areas in terms of cognition is there perhaps a a mood issue that it's confounding things that we especially like thinking about neuropsychological testing if we are if there are vocational issues if you're looking at leaving the workforce or changing your job we would like to get neuropsychological testing to help guide us along that pathway the fatigue that we see with multiple sclerosis Randy had mentioned the other day that a lot of doctors who work with MS don't realize that fatigue is not all the same thing in MS actually shifting back to cognitive dysfunction for just a second this is that survey that I mentioned that shows the prevalence of cognitive issues so with fatigue and multiple sclerosis it's not all the same thing many people with multiple sclerosis will list fatigue as their number one symptom complaint it's either the first or second most common reason that people change their their job situation with cognitive dysfunction being that the either the first or second most common depending upon who's whose numbers you believe and it is president some point in the majority of people with multiple sclerosis the many forms of fatigue and MS do not correlate with underlying physical physical disability we'll talk some about the extra work effort of overcoming weakness or in coordination and how that might correlate with physical disability so lassitude in multiple sclerosis this is the I didn't do anything to necessarily cause this type of tiredness someone just unplugged my energy supply other descriptors that we've heard is that it's like trying to swim with a fur coat on someone laid a let blanket over me and I can't move overwhelming fatigue that by definition interrupts your daily activities so if you're a little tired just because you've overdone it but you're able to carry on that's probably not the degree of fatigue that we would use to describe lassitude one of the common issues I'm preaching to acquire here that I think people struggle with is when the person with MS tries to describe to someone who's unfamiliar within us that they get fatigue fatigue means something different I think to a person with MS then to a person without MS the National MS Society has that great little brochure but but you look so good because yeah so we so we'll talk a little bit about about treatments for for fatigue make sure I'm covering everything yeah so some of the treatment options for that someone just unplugged me type of tiredness that we see with multiple sclerosis again we're going to talk some about the medications that are out there but we don't always want to go to that right off the bat one of the things that we need to do when thinking about fatigue including lassitude is rule out other potential explanations are you on medications that might be contributing to your to your fatigue unfortunately a lot of the stuff that we give people with multiple sclerosis anti spasticity drugs baclofen XANA flex clonazepam can be very sedating sometimes with interferons there can be some fatigue that goes along with those drugs we around the time that you dosed the medication underlying sleep disorders there are two studies in the past year that looked at how common sleep disorders were in people with multiple sclerosis including obstructive sleep apnea when I was in training when we thought about the person with obstructive sleep apnea we thought about a guy he's big he's got no neck in snore and in multiple sclerosis that may be true but we may also see a thin female with obstructive sleep apnea one more suspicious of sleep apnea one of the first Clues is the person will say you know what when I go to bed at night I'm really tired when I get up in the morning I'm just as tired they don't have restful sleep ideally we'd like to get a little more history at that point and maybe see if there's a family member spouse somebody that can observe the person sleeping and see if you get that typical obstructive sleep apnea story of snore snore snore loud snore deep breath and then nothing and there's a period of silence which your ever watching these individuals seems like it goes on forever you know 15 20 30 seconds sometimes longer and what you'll see if you watch someone during one of these periods of sleep apnea their chest is going up and down but there's no way or going anywhere because they're actually they've occluded their airway then at some point is that oxygen level drops low enough the brain is going to say you know what I don't like this very much and then you kind of get the point and it starts over again so they wake up partially the person was sleep apnea may have no recollection of actually waking up through the night but when you look at the sleep architecture on EEG or brainwave tracings their sleep is not normal and their sleep is not restful typically the trip if there is a as a weight problem we would advise weight loss but a lot of individuals with sleep apnea are going to end up with CPAP one of the pressurized oxygenation devices to try to keep those Airways open at night there are other things obviously they can disrupt sleep one of the cruel of facts of life when you think about spasticity is festus it can be a problem throughout the day but a lot of times it really gets cranked up at night so as soon as you start going to sleep the legs start twitching and jerking you're kicking your spouse that can be disruptive if you have to enter your bladder every thirty minutes every 45 minutes and then you have trouble going back to sleep that's going to be disruptive to your sleep so sleep history medication history are part of the the management of fatigue making sure we can take any of those issues off the table going back to exercise again for fatigue we would like all of our folks to be in some sort of regular exercise program when I think about you know working early on with the jimmie heuga center now the can-do center there one of the points that they make in terms of exercise and a question that you're commonly is what's the best form of exercise for a person with multiple sclerosis it's whatever the person with multiple sclerosis will stick with over a long period of time if I tell you to get on you know the recumbent bicycle and you don't have a recumbent bicycle or you really hate bicycles you're probably not going to do that so we need to find something that's going to be a pro and that the person has access to over over a time so what if we've done all that and now we need to look at a medication for managing fatigue and we're talking about the lassitude the the unplugged energy supply non exertional typically non heat related fatigue we have old-school amantadine or symmetry amantadine is an old anti-influenza drug studies years ago showed that about 40% of people on a good day might get an energy bump from it it is a maintenance drug is something that you generally have to take twice a day every day to see some benefit from it we do here are individuals occasionally that start imagining and say you know this is working really well for me and then three months later not so much sometimes taking a little drug holiday for a weekend or or longer will give will help you recharge your battery and have that drug start working again probably the most effective medication that we have are either provigil or new Vigil so modafinil or armload Avenel on either of these drugs is FDA approved for fatigue and multiple sclerosis and we have had energy or insurance issues trying to get one of those approved for yourself yeah I don't know what the magic trick is to getting provigil a new vigil I'll talk to you later if you know the magic trick what is the magic trick and a very demanding letter so the squeaky wheel crunch yeah so that's some being the squeaky wheel you know giving the insurance company a lot of information one of the problems we've had occasionally now that Georgia has lots of managed care is sometimes that approach assumes that they actually care about information the ace in the hole that the third-party payors always always have if they want to be obnoxious about it is they can say that whatever we're prescribing if it's off-label is experimental and unapproved for whatever we're and that if they go that route our experience has been it's they're really not very interested in all the science that we then we send them but but I do agree you've got to be a squeaky wheel mow daffodils the Gerry generic name for provigil so the only so the only difference between provigil and new Vigil is some molecules come in a right-handed version three-dimensionally and a left-handed version provigil is a mixture of those two new Vigil is all the right-handed version of the molecule and it sticks around a little bit longer I don't think that that's inherently good or bad provigil it may be a little more flexible it can be a twice-a-day drug some people get away with once a day dosing many people with provisional a new vigil can use those on an as-needed basis they don't have to take it on as a maintenance drug so just take it when you need it you may find that the modafinil because it lasts longer maybe it lasts too long and maybe it gets into your bedtime hours and is interfering with your sleep so I don't think that one is inherently better than than the other there is generic modafinil or provigil in reality unfortunately it didn't help our pricing at all yes so the generic is just as expensive as the name-brand on that drug before there was provigil in new vigil we used the stimulant drugs so things like Ritalin and adderall and those drugs are still available there is a little bit of a hassle factor that goes into using these medications these are what we'll call schedule 2 drugs so these are more tightly regulated by the by the FDA what a schedule 2 drug requires is we can't do refills we can't phone it in everything has to be a written prescription so if I was going to give you a month supply now in Georgia what they allow us to do is actually date three prescription assaulted a prescription one is for this month prescription 2 says don't fill for 30 days prescription 3 says don't fill for 60 days but then we've got to see you back generally on every 3 month basis and to get those refilled these are amphetamine like drugs and so there is concern about addictive potential or tolerance I will say in my experience in working with people with MS over the years I have never seen a person with them that's get addicted or tolerant to the adderall or Ritalin and just haven't seen it I've seen people respond too well to it where they take a dose and they feel like they're bouncing off the walls and really don't care to take that anymore if you in just a little sidetrack if you are prescribed medications like Ritalin or adderall or painkillers like hydrocodone oxycontin xanax and you ever have teenagers in your house lock this stuff up these are the biggest drugs of abuse in high schools right now and the we're friends with a number of undercover police officers they have a very very difficult time in high schools we're breaking up the more sophisticated dealers in high schools what they're hoping the kids are doing is selling pot because when they run to have the fire drills in a lot of high schools those are not really fire drills those are to let the drug dogs come through and go through lockers whether the drug dogs will alert to marijuana but the smarter dealers know don't sell marijuana you just sell pills because the drugs don't alert to the pills and the problem and I think it's national but we certainly see in metro Atlanta is that if you get a kid who takes a high codone they will graduate to oxycontin they will get hooked on oxycontin someone's going to tell them you know that pill that you're paying 40 bucks a pill for on the street I can get you a $5 bag of heroin really easy then they're on to heroin and then then you've got a real problem you know so so lock your drugs up if you have any teenagers in your house so we've got the true stimulant drugs that we can use for fatigue in multiple sclerosis there are a couple of balls out there that we sometimes pull out of the Hat for for lassitude and multiple sclerosis acetyl carnitine is an over-the-counter supplement which has been studied they did a double-blind placebo random crossover trial what that means is they have one group of people with MS and fatigue who took a manta diene they had another group of people take the over-the-counter acetyl carnitine they did this for eight weeks they stopped their drugs they didn't know which one they were on they stopped their medication they were on nothing for four weeks and then they flipped groups so they didn't know at any point which they were on and there was a period of time when they were on nothing they did surveys they did fatigue measures and the patients actually preferred the over-the-counter a sealed carnitine a little bit more it's AC e t yl - carnitine c AR ni T IME and it's about a thousand milligrams a day is what you're what you're shooting for another interesting study that looked at people with MS taking 325 milligrams of aspirin a day for fatigue it's only one study that I know of that showed an improvement in in energy levels but again just so that you know that there's some off-the-wall things out there that we can do to manage fatigue we're gonna shift over and talk a little bit about nerve fiber fatigue this is another common type of fatigue and multiple sclerosis in my first talk back on what was it now Wednesday we showed how a normal myelinated axon should work and how normally you have the electrical potential jumping from gap to gap to gap very quick very efficient way to get information from point A to point B now we've demyelinating that nerve fiber and you can no longer jump from captain gap to gap so you get these little reconducted electrical potentials and baby steps over that naked nerve fiber the problem with yep page 11 so the problem with that naked nerve fiber and those little baby steps of Rican ducting the electrical potential is that that's the weak link in the electrical conduction chain so if you do an activity over and over and over again or if you raise your core body temperature or if you do both at the same time you may have that electrical potential just stop altogether you are not causing new damage you're not demyelinating the nerve fiber you just drain the battery electrically once you cool off rest relax you're recharged and ready to go how long it takes to hit that wall across different individuals varies tremendously and to make it even trickier is it varies within the individual themselves drives our physical therapists and our exercise physiologist and trainers crazy sometimes strikes people with them that's crazy that one day they can do 30 minutes of a certain exercise without their foot going numb or their or their vision going down and another day maybe it's only 15 minutes so that line in the sand moves from time to time and I don't know how Randy feels but I would personally rather see the person with them as step up to that line and occasionally cross it rather than never challenge themselves all together because we know people within that's decondition and that is another contributor to fatigue we would have again rather you try to find an exercise routine a wellness program that maybe challenges you just a little bit and again maybe sometimes you overdo it just up just a hair not consistently I was tell people if you're on a treadmill or or in the pool doing something and your vision goes down you're probably done for that day break its okay so some of the cooling strategies I like the second one the best the Shapiro's warping method so I learned this from a guy a long time ago that things that you drink that have that consistency of a Slurpee or slushie tend to drop your core body temperature a little bit more effectively than just ice water so if you're going to go to an exercise drop some ice and a blender throw some water in it and again you may be more effective at dropping here your core temperature well isn't there a national a national day didn't 7-eleven do something that's right and he's got 50% off coupons in his pocket per semester you know we always make the point if you're sitting on the beach that margaritas and pina coladas also have that consistency neck wraps and cool caps so they may not actually drop your core temperature that effectively but but it's it certainly can help out there are tons of products out there many of you are familiar with these I know some of you have these if you go online and you google you know cooling devices cooling vests for multiple sclerosis lots of different companies that are out there it seems like they're more every year we used to recommend blocking steel manufacturing was one of the older ones that had been around steel with an e on the end they do a lot of military police applications and we needed something in our pool at Shepherd Center we had a problem one year this summer in Atlanta where the ideally so we have an Olympic sized pool and they were trying to drop the temperature lower the temperature our spinal cord injured population likes the pool warmer than our MS population and as the ambient outdoor temperature got hotter we were having an awfully hard time dropping the pool temperature down so it crept up a little bit so we wanted to see if we could get a cooling vest that would actually withstand the chlorine and the chemicals and you can get in and out and steel manufacturing actually had something that would stood the rigors of the dunkings repeatedly it raises a question though so what's the ideal pool temperature so you want to do an exercise program you want to do aquatics you're a little concern you go down to the Y and there's an arthritis program there so what's the ideal pool temperature for multiple sclerosis now 85 so we'll do look like both so 85 degrees is what the national as far as I know they still list that in their literature is is the ideal temperature we did a literature search to see where that information came from and I found a study of four individuals done decades ago that was basically where that eighty five degree fahrenheit number came from I think the second answer is actually the more appropriate one the best pool temperatures whatever you seem to tolerate if you have access to an aquatics program and the pool temperatures 90 92 try it see if you get out your noodle and a rag doll that's probably too warm for you many people tolerate that sort of temperature in theory any temperature that's below your core body temperature you should be losing heat it's just that you lose that heat a lot more effectively the cooler the water is one of the problems that we all run into that we don't talk about as much with with cool water is that some people with multiple sclerosis have temperature sensitivity that's the other direction when they get chilled or to cool their spasticity gets worse so so some of them we can get the water a little bit too cool and got covered some of this the other morning but I know some people weren't here so I'll touch on a couple of redundant points gait dysfunction in multiple sclerosis I've got the speak no evil see no see no evil hear no evil because sometimes this is under-recognized 39% of people with multiple sclerosis say that they rarely or never discuss Multan mobility issues with their healthcare provider 49% of caregivers rarely or never discussed these these issues with with the position so when we see you in the exam room if you have mild to moderate multiple sclerosis you may look pretty good we may tap on your knees and check your strength and you may still look pretty good that may not be completely reflective of what you look like out in the community so once we get you outside and it's hot and you're doing extended walking maybe you do have mobility issues that we're just not seen so we need you to to tell us about what's what's going on in medical training especially as a neurologist we are sometimes slaves to history we love our you know our babinski's where we torture at the bottom of your foot but sometimes I really do feel like we get maybe as much if not more information from just listening do you tell us what's going on with your body and and we may get more information from that than from torturing the bottom of your foot not that we don't like torturing the bottom of your foot so gate dysfunction of kind of shifting a little bit in when we think about fatigue and in multiple sclerosis gate dysfunction comes from a lot of different sources in ms spasticity obviously can can affect gait spasticity is a double-edged sword in multiple sclerosis typically in people who have somehow irritated the brain or spinal cord whether it's multiple sclerosis spinal cord injuries stroke the legs want to do this and the arms want to do this so the legs tend to want to extend and that's again a double-edged sword if you have underlying weakness you may actually be using that extensor tone to help with transfers to help with your walking and frequently we can get rid of every bit of that spasticity with medications or you know other things and we may actually make you walk less well by doing that one of the things I like to do in people with multiple sclerosis is get the physical therapists involved early and often to give us some feedback on how much of that tone is the person actually using to help with that of daily living and then we can go from there when we think about treating spasticity the first thing we want to do is remove any noxious stimuli noxious stimuli could be a poorly fitted shoe it could be bladder infections it could be a pressure sore anything that irritates your body can up can sort of rev up underlying spasticity so take away noxious stimuli second step is a good range of motion program so stretching on a regular basis some people with their exercise program really focus on the resistance training the aerobics the core strengthening we want to balance that out with some stretching you can have stretching exercises that are shown to you by a physical therapist you can look at some of the free yoga DVDs that are out there which tends to give you a pretty good range of motion also after those two things then we go to medications with the oral medications that can you know we've got baclofen ins an flexor our two old standbys one of the keys with those drugs is go low and go slow because if we give you too much all at once we're probably going to make you really sleepy if those aren't working out we can sort of graduate and other options sometimes looking at intrathecal baclofen or a baclofen pump if we're just not getting where we need to be with the oral drugs foot drop we'll talk a little bit more about we did that some of that Wednesday nerve fiber fatigue we've covered sensory ataxia we talked about the other day this is the I can't feel my feet and therefore I'm gonna put my feet further apart if you can't feel your feet are at you're always walking like you've had a drink too many if you can't feel your feet what does your brain use to try to make up for that lack of sensory information from down here it's gonna try to use your vision as one of the backups and so yes so good visual issues and sensory issues that that's gonna make life tough but when you think about the visual cues so if your body is using visual cues to make up for the lack of sensory information from the feed you don't want to take those visual cues away you're allowed to walk and chew gum at the same time but don't walk and talk to the person next to you because that's just like closing your eyes you should be focusing on if you have balance issues not talking to the person next to you standing in the shower with your eyes closed wash your hair you're taking your visual cues away and there's nothing soft to land on when you fall in the shower getting up in the middle of the night to go to the restaurant with no night lights on again you're flying blind at home you may have company because you know where all the furniture is if it's daylight hours you know your spouse is and you're grabbing on to them but it's when you don't have those those things to lean on or you're in a strange environment that we see a lot of potentially preventable Falls that are going to happen with the sensory ataxia we don't have a way of fixing that yet but again the core strengthening tends to help compensate for that and then cerebellar dysfunction this affects your your coordination in the arms and legs and in the trunk and this looks like a really big tremor so this is the person who wants to reach out to tuck to grab the glass and the hand is really tremoring and the closer they get the worse it gets many people with cerebellar dysfunction have perfectly normal strength but their walking is significantly affected because of that lack of coordination how many weren't here for that for the foot drop should we go over this one more time we've got a handful we'll just go over it quickly so this is kind of one of my soap boxes I get on because I think a lot of our community neurologists really under recognized the importance of foot drop or ankle dorsiflexion or weakness so again three weakest muscles in the legs and people with them as ability to get your toes up off the floor or ability to bend your knee and the ability to flex your hip if it was just the ability to get your toes up off the floor and you would do something called step edge gait you bring the knee up higher when you're walking but because your ankle dorsiflex there's a weak chances are your hip flexors are weak and so you end up doing something called circumduction swinging the leg out and around to walk not a normal gait pattern very fatiguing it's going to contribute to the underlying fatigue if you do that all day long and we tend to prescribe ankle foot orthotics which look like that and which many people feel like that about great for some people not for everybody alternatives the toe-off device a little bit lighter maybe not a sturdy we've actually had some patients who are really vigorous and they're walking or they're trying to do stairs a lot sometimes actually break those the dorsi strap cheap over-the-counter good if you got just a little bit of foot drop not good if you've got a really severe foot drop and it absolutely does nothing for for lateral instability the walk aid and the bonus devices electrical devices are going to stimulate the the peroneal nerve the nerve on the outside of your knees gonna make your foot come up if you have a significant foot drop and you've never heard of these it's it's worth knowing about it and getting yourself in with a physical therapist so they can give you a trial of one of these they were great for some people not for everybody I say if there's one group that we've really struggled with with the the electrical devices would probably be petite females sometimes the stimulus that you feel and outside of the knee is if you're very small is just too irritating for some individuals but you never know until you put one on somebody and again this was the case study that showed us an actually doubling in a walking speed she still has the walker both with and without the violence to buy something because she also had sensory a taxi and although we've made her walking faster we've not really helped her balance with that devices she still needs her walker we've covered that and then lastly just thinking about the sensory ataxia some of the things that we can do for core strengthening yoga pilates hippotherapy swiss ball exercises i can't remember where I heard that originally he that that's old-school yoga ball physical therapist is going to show you some really simple ways as long as you've got someone to help you out at home to use a yoga ball for a very effective core strengthening the young man in the picture is doing exercise classes is Blake one of our exercise physiologists one of the things that we realized at Shepherd Center years ago is we were doing an awful lot of drug trials usually we have about 15 clinical trials looking at usually disease modifying therapies sometimes symptomatic therapies we had this whole army of physical and occupational therapists when we weren't doing as much rehab wellness based research we really wanted to hire a PhD level researcher who was focused on wellness and just happen to have one fall into our laps leaning in depth Bacchus is a PhD neuroscientists physical therapists who had mainly done research in spinal cord trauma and really wanted to shift over and try to now focus on multiple sclerosis so we were given a significant grant by the Andrew C Carlos family to hire this wonderful lady and she's really sort of ramped up our to complement the drug research with wellness based research funny story on the Carlos family this is that not their original name it was something more along the lines of Carlos appleís they were from Athens Greece one of their ancestors of couple of generations back moved to Georgia found him say itself in Athens Georgia opened a bar and Georgia became very successful at it they grew that into national distributing I think there's a second or third largest third largest alcohol distributorship so when you're having your glass of wine you're supporting multiple sclerosis yes very giving family yep absolutely I can remember with one of the family members who is a patient he was a little distraught because with his strength issues and with his balance issues he was going to have to sell his last harley-davidson and he came in kind of sad faced one day and said he has sold his last harley-davidson and then he perked up he said but there's a blue Maserati in the garage with hand controls in it you

Channel: Multiple Sclerosis Foundation

Views: 10,175

Rating: 4.8994975 out of 5

Keywords: MSF, MSFocus, Multiple Sclerosis (Disease Or Medical Condition), Multiple Sclerosis Foundation, Ben Thrower, Cruise for a Cause, Depression (Symptom), Fatigue (Symptom), Health (Industry), Foundation (Organization Type), Health Care (Industry), Foot Drop, Doctor Of Medicine (Degree), ms, 2015

Id: QE0fERBW1tY

Length: 46min 3sec (2763 seconds)

Published: Fri May 01 2015