Multiple Sclerosis Problem List
by Catherine W. Britell, M.D.

Because MS is often a progressive condition that may have many manifestations, regular medical checkups are a must in order to maximize function and minimize complications. The following is a summary of health issues I try to cover with my MS patients yearly or more often if their symptoms are changing. It's a good idea to keep these things in mind when seeing your physician so that all the issues of importance will be addressed.

Neuromuscular Function: I wank to know as much about I can about the status of the person's neurologic function. I do complete manual muscle testing and sensory testing to document progression/regression of disease. I also make a note of reflexes and muscle tone. Gait evaluation, coordination testing, and visual acuity testing are also necessary so that I can determine if any further diagnostic tests, treatment, equipment, or rehabilitative services are indicated.
Musculoskeletal Function: I check the range of motion of all joints. Any tightness or contracture must be vigorously worked out with physical therapy and home program. If that isn't done, contractures will form, and they will tend to progress and limit gait, transfers and other functioning severely. Painful muscles, tendons, joints should also be noted and treated as possible. Joint problems may indicate that a re-evaluation of mobility methods is in order.
Nutrition: A nutritious, low-fat diet should be followed. Besides the advisability of a low-fat diet for MS patients, I'm very concerned about weight gain, as this will limit mobility and significantly affect self-esteem if it continues. Unintentional weight loss should be evaluated for causes related to malignancy or depression.

General Health Screening: Since I don't do primary medical care, it's important that I assist the patient in finding a primary doctor if he/she doesn't have one. An internist or Family Practitioner should see that the patient has a general physical, routine cancer screening (mammography, pelvic and pap smear in women, prostate evaluation in men, rectal exam in all) and cardiovascular risk management (blood pressure, blood lipids, smoking cessation, etc). People with MS need to avoid other health problems just like everyone else.

Bladder function: Bladder problems are common in MS but patients are often reluctant to talk about them. Therefore, I ask specific questions about bladder function: Are infections occurring? Is there incontinence? Is there retention? If any of these things are occurring, further bladder evaluation and treatment of the problem needs to be done. Often an evaluation by a urologist is indicated in this case. Usually the Rehabilitation Nurse can be very helpful with practical management suggestions.

Bowel function: This is another area where problems occur more often than not, but most people don't like to talk about. I'm concerned about the following questions: Is there severe constipation? Is there incontinence? Does a bowel program need to be organized to keep the patient regular and continent?

Sexual function: Sometimes sexual issues are very important to people with MS; however, because there are so many other issues the person is dealing with, this one often gets pushed into the background. I'm concerned about the following: Is birth control an issue? Are there any risky sexual practices? Are there problems with erections? Are there difficulties with female sexuality? Often open discussion of sexual issues can be quite helpful in identifying solutions and opportunities to improve this part of significant relationships.

Mobility: Can the person get around the home, the neighborhood and the community easily and safely? What are the limitations? Any orthoses, aids, or wheeled mobility indicated at this time? What about driving? Is it safe? Are some adaptive devices needed for the car? Can the car accommodate the mobility aid recommended? Is a van with lift required?

Activities of daily living: Can the patient eat, dress, bathe, toilet, maintain his/her clothing and environment, do shopping, cook, and perform all other necessary functions? Could any training or equipment be of use? If there is trouble in any of these areas, Ocuppational Therapy can be immensely helpful.

Skin Integrity: Has the patient lost sensation on the sitting area? Has careful education about skin protection been done?

Psychological functioning: These issues are often a source of great worry and upset to patients and their families. It's best in most cases to confront them forthrightly and work with the patient to address them. I am concerned about the following questions: Are there any cognitive problems? Is testing needed to determine this if patient is concerned? Is depression getting in the way of functioning? Is support maximized?

Social/family functioning: How a person with MS feels, functions, and lives depends to a great extent on the family and social support he/she has available. Does the family know about and accept situation? Are they maximally educated to be helpful? Are there parenting issues? Can the physician help in any way? Can a social worker help with sorting out finances, communication, agencies, etc?

Vocational: For most of us, our job is a significant part of our identity, and gives us a great deal of our self-worth (not to mention money to live on). Once a person loses a job or stops working because of a disability, it becomes doubly difficult to become re-employed. How can physician aid the patient in staying on the job? Does job accommodation need to be done?

Recreation: Everybody needs to have fun in life...people with MS deserve that at least as much as everyone else. Has the patient and his/her family developed rewarding recreational activities? Is information about accessible recreation needed?

Spiritual Issues: Occasionally, when a person has something bad happen to them that they don't seem to deserve (MS certainly qualifies), they encounter a spiritual crisis. Sometimes long-held beliefs and ideas about one's relation to the Universe may come into question. The individual then becomes vulnerable to spiritual alienation and/or religious charlatanism. Sometimes the physician can be useful as a neutral and compassionate source of support around these issues. By giving the patient as much real, scientific information as possible, the physician can often put the disease in perspective and take away inappropriate guilt or unhelpful mysticism.

In general, people who have MS often feel overwhelmed by all of the ways the disease is affecting them. Often their doctors are a little overwhelmed too. If the physician methodically goes through this list, the patient and physician can develop a multifaceted plan of action to maximize his/her independence and functioning. And if MS patients themselves keep this list in mind, it often enables them to make the best possible use of the health care system by identifying and prioritizing their own issues and problems, and then taking an active part in addressing them.