Diagnosis

• Clinical presentation:
  • Loss or reduction of vision in 1 eye with painful eye movement (optic neuritis) refer to neuro
  • Double vision
  • Ascending sensory disturbance and/or weakness
  • Problems with balance, unsteadiness or clumsiness
  • Lhermitte’s symptom
• Patients usually < 50, previous neuro Hx and symptoms last > 24 hrs often days weeks then improve
• Don’t diagnose on fatigue alone, must have focal neurology
• Don’t diagnose on MRI imaging alone
• Only Neurologist may diagnose, consistent with inflammatory process and exclude per list below
• MS symptoms:
  • Mobility and balance including falls, need for mobility aids including wheelchair assessment
  • Use of arms and hands
  • Muscle spasms and stiffness
  • Tremor
  • Bladder & bowel incontinence and sexual function
  • Aensory symptoms and pain
  • Speech and swallowing
  • Vision
  • Cognitive symptoms
  • Fatigue
  • Depression

Investigation

• Exclude other diagnoses: FBC, LFTs, U+Es, TFTs, Ca2+, Glucose, ESR, CRP, B12, HIV

Management

• Consultant neurologist to discuss disease, modifying treatment, symptom management
• MDT approach: Consultant neurologist, MS nurse, physiotherapists, SALT, GP

Conservative:

• Exercise: may be beneficial and not harmful
• Vaccination: live vaccination may be contra-indicated if taking disease modifying therapy
• Pregnancy: relapse may reduce during pregnancy but increase 3-6 mths post natally
• Smoking: may increase progression of disability

Symptom Management

• Treat: depression, anxiety, difficulty sleeping, cognitive or memory problems, as well as medical issues such as anaemia or thyroid disease
• Fatigue. Conservative: Explain heat, stress may precipitate. Medical: Amantadine (blocks D2 uptake). Interventional: CBT and Mindfulness
• Mobility: Assess goals and ways to achieve involving rehabilitation (supervised exercise) and physiotherapists
• Spasticity. Treat aggravating factors such as constipation, UTI, pressure ulcers and pain
• Pharmacological:
  • First Line: Baclofen, Gabapentin alone or combined
  • Second Line: Tizanidine or Dantrolene
  • Third Line: Benzodiazepines
  • Refer to specialist if cannot be managed medically
• Oscillopsia (Objects appear to oscillate)
  • First Line: Gabapentin
  • Second Line: Memantine
• Emotional Lability: Amitriptyline
• Neuropathic pain: per CG173
• Symptom review annually

Acute Replace:

• Relapse: new symptoms or worsening existing symptoms lasting > 24 hrs without infection or other cause, after stable for > 1 month
• Medical treatment: PO methylprednisolone 0.5 g daily for 5 days, or IV if failed
• Assess social care needs
• Do not offer vitamin D or Omega 3 fatty acids

NICE Source: CG186 Multiple sclerosis in adults: management. Summary compiled by Dr D P Sheppard MBBS.