Outpatient Management of Multiple Sclerosis Patients

Patients with multiple sclerosis (MS) may have almost all of the deficits that the central nervous system can produce. There are, however, frequently recurring problems that confront neurologists and others in management of these patients. These problems occur so often that it behooves us to be prepared to deal with them thoughtfully. In helping our patients to cope with disabilities, such as paraparesis, coordination problems, bladder dysfunction, and sexual disability, we make it possible for them to lead much more normal and productive lives. If we are able to accomplish even limited improvement of these disabilities, the rewards may be quite striking. Often we are successful in helping patients rcturn to work. This has a significant impact on patient and family both psychologically and financially. In evaluating patients who are suspected of having multiple sclerosis, it is, of course, necessary to take a thorough history and do a complete neurologic examination, especially when the diagnosis is in doubt and the patient is first being seen. Evaluation such as evoked potential testing, magnetic resonance imaging (MRI) scans, or computed tomography (CT) scanning with doubledose contrast studies are all appropriate. Lumbar punctures are frequently indicated at least once and perhaps later, depending on the complications that the patient presents. After having done all of these things, however, the major challenges facing health care providers include continued support. In order to be able to respond to questions and problems, neurologists need to have the help of other health care professionals. These persons can assist with problems such as adjustment to job demands, episodic fatigue or lack of stamina, problems in coordination, especially those duc to paraparesis and spasticity, and other questions. A thorough review by someone, such as an occupational therapist, who can make an assessment of daily living is often very helpful. All of these efforts take time and sometimes seem fairly simple endeavors, but they are the essence of good patient care and have an enormous positive effect on enabling our patients to keep trying rather than despairing. We will describe six examples of patients who have been treated with varying success in an outpatient setting. We recognize, of course, that there are some patients who are very seriously disabled, and for them major modifications and arrangements need to be made either in their own homes or perhaps in a facility for chronic care. We believe in being realistic about the seriously disabled, but we will stress the much greater number of patients who have disabilities for whom careful follow-up outpatient care has become very significant.