DAVID R. MARKS, MD: Hi, and welcome to our webcast. I'm Dr. David Marks. The symptoms of multiple sclerosis can be as numerous as they are frustrating: weakness, spasticity, visual problems and depression, to name just a few. A primary focus of MS treatment is keeping them under control, and it's a constant challenge. The more management techniques you know about, the better the chance that you'll find an approach that works for you.
Here to discuss the options are two experts. First, we have a patient, Rick Sommers. He's an MS patient who lives right here in New York City. Thanks for being here.
And next to him from the physician side we have a neurologist Dr. Jeffrey Greenstein. He's from Temple University. Thanks for being here.
DAVID R. MARKS, MD: Now, there are a whole lot of symptoms. Just kind of run down the list of them.
JEFFREY GREENSTEIN, MD: Problems with vision, weakness, spasticity, problems with bladder or bowel control, pain, depression. There are really a myriad of symptoms that can occur in MS, and many of these are amenable to symptomatic treatments.
DAVID R. MARKS, MD: Let's take them one at a time. Spasticity, how do people manage that?
JEFFREY GREENSTEIN, MD: First of all, it's a very common problem in multiple sclerosis. It can be managed in part by trying to conserve energy, trying to use muscles so that you don't bring out spasticity, or alternatively, in some cases, loosening muscles up when spasticity is there. So there are a number of things that somebody can do without using medications.
However, medications are really a major part of controlling spasticity, and there are a number -- for example, baclofen, tizanidine, a drug called Neurontin or gabapentin, and all of these used, either singly or in combination, can be quite effective in controlling spasticity. Finally, for people with intractable spasticity, there's a technique called using the baclofen pump, which allows us to inject baclofen directly into the spinal fluid, and it acts directly on the spinal cord to reduce intractable spasms.
DAVID R. MARKS, MD: Rick, weakness and fatigue are another one of the symptom groups. I know you've suffered from that.
RICK SOMMERS: Right.
DAVID R. MARKS, MD: How do you manage that?
RICK SOMMERS: It's a question of knowing when to just quit and say, "I'm going," and put your arms up, and getting rest and knowing your limits, and being able to just shut down. The people around you have to know -- and this is a whole other subject I'm sure we could spend our time talking about -- but the people who are around you have to be aware of what you're going through and have to be accepting of the fact that if you're exhausted and you're dealing with spasticity and some of the other symptoms, that there are times you're just not going to be able to keep up.
DAVID R. MARKS, MD: You need a support system?
RICK SOMMERS: Yeah. I think that it starts with yourself, because I think what we need to do is take some of the pressure off of ourselves. The most important thing is to listen to our bodies. I mean, as a doctor, you've probably told patients that for years, but it really is not oversaid. You have to listen to your body and to know "I'm too tired to go out with friends tonight," or "I'm too tired to get up at 6:30 tomorrow morning and go to the gym." There are going to be good days and there going to be bad days, and you just need to listen to yourself and know when to -- what was the old song? "Know when to hold 'em and know when to fold 'em." Know when to just take it easy.
DAVID R. MARKS, MD: Visual problems, another very common problem in MS. How is that managed?
JEFFREY GREENSTEIN, MD: Well, visual problems are actually rather difficult to treat with medications, although there is an experimental group of medications called the aminopyridines, which actually might help vision. One of the most common things, however, with vision is loss of vision or impairment of vision when someone's body temperature goes up, so people have to learn to conserve their energy, to pace themselves so that they don't get overheated -- either, for example, drinking something cold or staying in an air conditioned or climate-controlled environment, and very often these things help with visual problems.
DAVID R. MARKS, MD: Have you had any of these problems?
RICK SOMMERS: Yeah. I was nodding when the doctor mentioned that, because one of my early experiences, even though I had been diagnosed and had been forewarned about the extremes, I was away on vacation on a cruise ship and got into a hot tub. That was not the smartest thing to do. Of course, it sounds great, but the water in the hot tub shocks your body, and I spent a lot of time in there, when I got out, later that night as I tried to focus, I had a lot of trouble with my eyes. Again, MS was really new to me at that point, so I didn't put two and two together. I wasn't nearly as educated as I am now.
DAVID R. MARKS, MD: Have you ever suffered from either cognitive problems, thinking problems, memory problems or depression, those common problems?
RICK SOMMERS: Check, check, check. Yes. You get depressed because you can't remember. I don't mean to make light of it, but the truth of the matter is, yes, it is hard to recall. I think that's part of getting older, but there is no question that the MS comes into play. And depression is certainly something that is inherent to the disease. I don't know anybody that could be diagnosed and not feel it.
DAVID R. MARKS, MD: Is this like normal clinical depression? Do you treat it with the same medications?
JEFFREY GREENSTEIN, MD: Absolutely. In fact, depression does occur more commonly in people with MS, and actually can occur more commonly during periods of exacerbations or worsening of the disease, particularly. It's very treatable, and the same medications that are used for treatment of depression in anyone else can be used in someone with MS who has depression, and it's very gratifying to see people respond very well. It's something we can really do something about.
DAVID R. MARKS, MD: Rick was talking also about forgetting things, having some memory problems. Are there strategies that you give to your patients to try to overcome that?
JEFFREY GREENSTEIN, MD: There are two approaches, again, to using this. One is using a strategy to try to help your memory along, and a newer approach, which is using medications. In terms of helping memory, organizing things in a regular way, leaving things in the same place, regularizing the way you do things, using notes or Palm Pilots or computers, things like that can often help memory. There are some promising studies that suggest that some of the medications that work for Alzheimer's disease may actually work in MS as well, and there are a number of studies that are ongoing at the moment looking at these, so I think it holds a lot of promise for the future.
DAVID R. MARKS, MD: Bladder problems, the last major category we'll talk about. That's a very common problem in MS. I don't know if you've had any problems that you want to talk about.
RICK SOMMERS: Yeah.
DAVID R. MARKS, MD: Tell me what you've done.
RICK SOMMERS: There have been a number of circumstances where my bladder has not functioned as I once knew it would. There are times when I can have a glass of water and I'd better not be too far from a bathroom, because for whatever reasons, my nervous system is telling me, "You have to go to the bathroom," and that's kind of a frightening thing, because you feel like you're at the mercy of however far away you are from a bathroom. And then there are times when you feel like you have to go, and you can't go. And then there are times that it's perfectly normal, as well, so that is one of the many exacerbations that I go through from time to time, and I'm sure it's got to be stress-related as well.
DAVID R. MARKS, MD: This is probably common, and I'm sure a lot of patients don't even want to talk about this problem.
JEFFREY GREENSTEIN, MD: In fact, actually, Rick's highlighted two of the major problems with bladder control. One is the problem of storage of urine, where people may have to try to empty very rapidly -- frequency or urge, as we call it -- and the other is inability to actually empty the bladder, hesitancy, or sometimes inability to empty completely. There are a number of different strategies that are available, both with and without medications, to deal with the issues of bladder control.
DAVID R. MARKS, MD: Very quickly, if you could list them.
JEFFREY GREENSTEIN, MD: There's a medication called oxybutynin or Ditropan, and one called tolterodine or Detrol, which are very commonly used. There are also drugs that are used in hypertension which actually work very well to help with the issue of emptying the bladder. If somebody is totally unable to empty the bladder, they may need to catheterize, either intermittently, or sometimes permanently. But all of these strategies allow us to drain the bladder and prevent the development of infections, which is really the key to managing somebody's bladder in MS.
DAVID R. MARKS, MD: I want to thank you both for joining us. Hopefully we've helped some patients, at least given them some ideas to go to their doctor and talk about. Thank you both.
RICK SOMMERS: Thank you.
JEFFREY GREENSTEIN, MD: Thank you.
DAVID R. MARKS, MD: Thank you for joining our webcast. I'm Dr. David Marks. Goodbye.