Prof Broadley

Exercise and other non-drug approaches are often the most effective and acceptable ways to manage common symptoms in MS such as weakness, spasticity and fatigue, an Australian specialist says.

Speaking at PACTRIMS 2018, Gold Coast neurologist Professor Simon Broadley said exercise should be promoted more widely for people with MS because it had some of the highest levels of evidence for effectiveness for improving muscle strength and spasticity.

And while some MS-focused programs involve physiotherapists, it often did not really matter what form of exercise was done, and could be recommended based on patient preference such as tai chi exercises, he said.

Evidence showed that the potassium channel blocker fampridine (Fampyra) could help improve walking distance in about a third of patients, but it was not listed on the PBS, he noted.

Exercise was also an important component of managing spasticity in MS because restoration of lost muscle strength is needed when spasticity is alleviated by other treatment, to avoid collapse, he added.

Management of fatigue in MS requires a comprehensive assessment of the many possible causes, Professor Broadley told the meeting. Fatigue might be secondary to immune responses to drug treatment or a consequence of deconditioning or pain.

Fatigue might also be due to sleep disturbances, which was another key symptom of MS, Professor Broadley noted.

“This is why I have a low threshold for sleep studies,” he said

As well as conditions such as OSA, identifying sleep problems such as insomnia would allow them to be managed with non-drug approaches such as sleep hygiene programs and mindfulness apps, said Professor Broadley.

In contrast, iron supplements appeared to be poorly effective in conditions such as restless legs syndrome in MS patients, and [non- benzodiazepine] hypnotic drugs had well-know drawbacks in managing insomnia, he said.

Depression is another key symptoms of MS, with reactive depression so common that it requires patients to be screened and also forewarned about the condition, according to Professor Broadley.

“I’ve now got into the habit of telling my patients when I diagnose them that they are going to go through a grieving process that will take anything from six to 24 months. And it actually helps a lot to manage their expectations,” he said.

Cognitive Behavioural Therapy and exercise were effective approaches for depression, whereas the evidence for antidepressants was weak and non-existent for SNRIs, he noted.

Professor Broadley finished by acknowledging the high media and political profile of cannabis as a  treatment for MS symptoms such as spasticity, but noted that the evidence for it was weak. Reviews showed that the number needed to treat for spasticity was 36, whereas the number needed to harm for adverse effects was six.

“So you are going to harm six people for every one that you help,” he said.

Professor Broadley also noted that TGA-registered pharmaceutical nabiximols (Sativex) was available but at a cost of $750 for a six to eight week course.

With this cost equivalent to $6000 a year, patients preferred to self medicate with illicit cannabis at one sixth of the cost, he noted.

“Some of them report that it is quite useful,” he said.