Symptom Management in Multiple Sclerosis

March 29, 2019

The multiple sclerosis specialist at the Corinne Goldsmith Dickinson Center for MS at Mount Sinai spoke about improving a patients' quality of life through symptom management.

Stephen Krieger, MD

At the Americans Committee for Treatment and Research for Multiple Sclerosis (ACTRIMS) annual meeting, held in Dallas, Texas, Stephen Krieger, MD, spoke about symptom management in multiple sclerosis care.

Krieger explained that currently, there’s a lot of emphasis on choosing the right disease-modifying therapy for patients, and while that’s important preventative work, it’s also necessary to focus on the present, and how to provide a patient with the best possible quality of life.

To provide additional insight on his approach to symptom management, the multiple sclerosis specialist at the Corinne Goldsmith Dickinson Center for MS at Mount Sinai sat down with NeurologyLive at the meeting for an interview.

NeurologyLive: Can you talk about symptom management in MS care?

Stephen Krieger, MD: A lot of the emphasis on treating MS is on choosing the right disease-modifying therapy and all of that is really preventative work, trying to keep our patients clinically stable, prevent new lesions, new relapses, and disability, but all of those are future events and a lot of that decision-making process is really designed to make nothing happen. We talk about no evidence of disease activity as a treatment goal and basically, it's to keep things stable, but that's a very future-focused aspect of MS care.

Whereas symptom management is right now, it's what we can do to improve our patient's lives, quality of life as we speak. I think sometimes we can be so focused on our MRI metrics and our clinical trial data that we might miss opportunities to do things for our patients that can help them in their present lives.

What’s your approach to symptom management?

In my approach to taking care of MS on an outpatient basis, in my plan in the electronic medical record I have a diagnostic plan, when am I gonna scan this patient next, what am I looking for; a disease-modifying therapy plan, what drug are they on, risk mitigation things of that nature; and then finally a symptom management plan, and that's where I list out all the symptoms that the patients are telling me about right from their very first visit so I’m focused on that and it’s always right in front of me in the room and I don't forget to think about those things. The main symptom that we often think about is fatigue, fatigue is a huge problem in MS, and it can relate to poor sleep, it can relate to depression, it can relate to many side effects of many medicines, and it can be sedating. I try to really go through an inventory of threats to sleep integrity and causes for fatigue for every patient.

We talk a lot about ambulatory disability in MS and mobility itself, so we really focus on what are the impediments to walking, is that related to weakness, spasticity, imbalance, sensory loss, cognitive problems, there are a lot of reasons why someone might have difficulty ambulating or navigating from point A to point B and we really trying to address those things both with physical therapy, occupational therapy, and medicines.

Then there are other symptoms like bladder dysfunction, which can be a huge issue particularly in progressive MS, so it’s important to look for urinary retention, risks for urinary tract infections, etc. When I think about it, the main events that could get a patient with MS particularly progressive MS into trouble medically are falls and injuries related to poor mobility, urinary tract infections, and urosepsis which can often land patients in the hospital, even things like aspiration pneumonia, and wound infections if they are profoundly disabled, and so I really try to focus on what I can do to treat symptoms, improve quality of life and minimize those risks to health and well-being that disability confers, and I think those things are very important.

The last symptom complex that we've become very attentive to in our field and at our center in recent years is cognitive dysfunction, which we're now really trying to screen for with either symbol digit modality testing or computerized cognitive screening or ideally a true neuropsychiatry, a neurocognitive battery to understand the limitations of cognitive function for a given patient. Just as gait can be impaired for different reasons in MS, cognition can be affected in different ways in this disease also it's not a one size fits all MS cognitive problem and screening for that, being attentive to it, treating it, either with cognitive rehabilitation, occupational therapy, managing other medications, all those things I think are important so I've tried to renew my emphasis on MS symptom management, which is an important goal in MS symptom quality care, especially the way the AAN defines quality MS care really focuses those quality metrics on symptom management and quality of life improvement. I think this is sometimes an overlooked component of good MS care and I'm trying to bring renewed awareness to it in my own program and with our own trainees.

Transcript edited for clarity.