Multiple Sclerosis — A Nursing Guide

Overview

Pathophysiology

Disease Subtypes

Clinical Presentation

Visual Symptoms

• Optic neuritis: painful unilateral vision loss; retrobulbar inflammation means "the patient sees nothing and the doctor sees nothing" — but a relative afferent pupillary defect (Marcus-Gunn pupil) is detectable on swinging flashlight test.
• Internuclear ophthalmoplegia (INO): slowed adduction of one eye + contralateral abducting nystagmus — highly suggestive of MS.
• Diplopia, oscillopsia, blurred vision.

Motor Symptoms

• Weakness and impaired coordination, typically beginning in a leg, ascending from distal to proximal.
• Spasticity, hyperreflexia, extensor plantar responses.

Sensory Symptoms

• Paresthesias, numbness, tingling.
• Lhermitte sign: brief electric shock sensation down the spine on neck flexion — characteristic of cervical cord disease.

Cerebellar Symptoms

• Ataxia, intention tremor, dysmetria, dysarthria (Charcot's triad: nystagmus + intention tremor + scanning speech).

Uhthoff Phenomenon

• Transient worsening of symptoms with heat (e.g., hot shower, fever, exercise). Important: this is NOT a new relapse — reversible with cooling.

Cognitive & Psychiatric

• Depression affects the majority of MS patients.
• Cognitive impairment (especially attention, processing speed, memory).
• Pseudobulbar affect (pathological laughing/crying).

MRI Findings

• Gadolinium enhancement = active inflammation (persists 2–8 weeks)
• T1 black holes = axonal loss and atrophy (poor prognosis)

Diagnosis: McDonald Criteria (2017)

• DIS: lesions in ≥2 characteristic locations (periventricular, juxtacortical, infratentorial, spinal cord)
• DIT: new T2/gadolinium lesions on follow-up MRI, or simultaneous presence of enhancing and non-enhancing lesions

Key Nursing Assessments

1. Neurological status: strength, coordination, gait, balance (fall risk)
2. Visual: visual acuity, diplopia, pupillary responses
3. Fatigue level: fatigue affects up to 78% of MS patients — use a validated fatigue scale
4. Bladder function: voiding frequency, urgency, retention, incontinence, UTI history
5. Bowel function: constipation or incontinence
6. Mood: depression and anxiety screening (PHQ-9)
7. Cognitive function: attention, memory, processing speed
8. Pain: type (neuropathic vs. musculoskeletal vs. spastic), location, severity
9. Temperature sensitivity: history of Uhthoff phenomenon
10. Skin integrity: pressure injury risk in those with reduced mobility
11. Medication adherence and injection-site reactions (for patients on self-injectable DMTs)
12. Social support, caregiver burden

Symptom Management

Fatigue (up to 78% of patients)

• First-line: evaluate and treat contributing factors (insomnia, depression, nocturia, pain, spasticity).
• Pharmacological: amantadine 100 mg BID (40% efficacy, well tolerated), modafinil (evidence mixed), methylphenidate.
• Non-pharmacological: energy conservation strategies, occupational therapy, exercise pacing.

Spasticity

• Baclofen (5–160 mg/day in divided doses) — never stop abruptly (risk of severe withdrawal reaction including seizures and hyperthermia).
• Tizanidine (2–32 mg/day); start low at bedtime.
• Physical therapy, stretching, hydrotherapy.
• Intrathecal baclofen pump for severe refractory spasticity.
• Note: reducing tone can unmask underlying weakness.

Bladder Dysfunction (affects 50–80% of patients)

Nursing key: Check post-void residual volume (>50 mL abnormal; >300 mL requires intervention). Recurrent UTIs are a red flag requiring urological referral.

Bladder/Bowel Nursing Interventions

• Timed voiding schedules
• Fluid management (adequate hydration — avoid restriction)
• Bowel program: fibre, adequate fluids, scheduled toileting, stool softeners

Gait and Mobility

• Dalfampridine (Ampyra) — potassium channel blocker; improves walking speed in ~35% of patients. Contraindicated if seizure history.
• Physiotherapy and occupational therapy for compensatory strategies, assistive devices, fall prevention.

Pain

• Neuropathic pain: gabapentin, pregabalin, TCAs (amitriptyline, nortriptyline).
• Trigeminal neuralgia: carbamazepine first-line.
• Lhermitte sign: usually self-limiting; cervical collar may help.

Depression

• Antidepressants: SSRIs/SNRIs — fluoxetine, sertraline, venlafaxine, bupropion (preferred for their "activating" properties in fatigued patients).
• Sedating agents (amitriptyline, nortriptyline, trazodone) useful when pain or insomnia coexists.
• Cognitive-behavioural therapy (CBT) and mindfulness have evidence in MS.

Cognitive Impairment

• Cognitive rehabilitation, compensatory strategies, memory aids.
• Treat underlying depression, fatigue, and sleep disorders.

Sexual Dysfunction (affects 45–74% of women, common in men)

• Erectile dysfunction: phosphodiesterase-5 inhibitors (sildenafil, tadalafil).
• Refer to urogynecology for pelvic floor therapy.
• Address psychological factors: counselling, sex therapy.

Relapse Management

• High-dose IV methylprednisolone 1 g/day × 3–5 days shortens relapse duration.
• Does not alter long-term disability outcome.
• Nursing: monitor blood glucose (hyperglycaemia), blood pressure (hypertension), mood changes (steroid-induced psychiatric effects), GI upset, fluid retention.
• Administer with PPI/H2 blocker for GI protection.
• Plasmapheresis for steroid-refractory relapses.

Disease-Modifying Therapies (DMTs)

Injectable Agents (first-line)

Oral Agents

High-Efficacy IV/SC Agents

Strategy tip from Goldman-Cecil: Start with an oral agent for typical newly diagnosed RR-MS. Switch to a high-efficacy monoclonal antibody if the patient has a severe relapse, multiple relapses, or new MRI lesions. — Goldman-Cecil Medicine

Nursing Care Priorities Summary

Prognosis

• Annual mortality risk ~2× general population; average lifespan reduced by ~8 years.
• ~85% start with RRMS; ~15% are PPMS.
• 1/3 will eventually require a wheelchair; ~50% need assistive devices; ~2/3 have disability preventing employment.
• African Americans and men tend to have more aggressive disease.
• Early immunomodulating therapy appears to slow disability progression.

Key Points for NCLEX / Exams

1. MS is disseminated in time AND space — the diagnostic hallmark.
2. Uhthoff phenomenon = heat worsens symptoms — NOT a relapse; cool the patient.
3. Lhermitte sign = electric shock down spine on neck flexion — cervical cord involvement.
4. Never stop baclofen abruptly — risk of life-threatening withdrawal (seizures, hyperthermia).
5. Post-void residual >300 mL requires intervention.
6. Steroid treatment for relapses speeds recovery but does NOT improve long-term outcome.
7. Optic neuritis — retrobulbar, so the disc looks normal; look for a RAPD (Marcus-Gunn pupil).
8. Gadolinium enhancement on MRI = active inflammation.
9. For fatigue: rule out treatable causes (depression, insomnia, anaemia, thyroid disease) first.
10. Patients on high-efficacy DMTs need JC virus antibody monitoring (PML risk).