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Mastering Multiple Sclerosis
A Guide To Management


Spasticity Management

ch4
p 84

Spasticity is a major problem of MS. Your spastic legs will become more comfortable once you discover a proper dose of medication, and an effective dosage schedule. Learn to use Lioresal or Dantrium, if you have significant Spasticity.

A diagnosis of Spasticity is not difficult. An ankle bounces uncontrollably, or thighs jerk the knees towards each other, when they should be seperated.

These are Spastic Spasms. Leg muscles feel tight and stiff as you walk, and rapidly become fatigued and painful. Movements of fingers and limbs are slowed. Grip is imperfect and standing balance suffers.

Spasticity interferes with all movements. Spasticity eventually produces Loss of Power and sometimes total Paralysis. Spasticity is a major cause of exhaustion among MSers.

p 85

Tightness, Exhaustion, Clonus, Spontaneous Spasms, Pain, Imbalance, Slowed reaction time, Loss of power and Paralysis in the absence of Spasticity, these symptoms often occur individually.

When the Pyramidal Tract is damaged, anywhere in its path from the Brain to the Spinal Cord, they occur together. Lioresal can stop Clonus and Spasms, loosen the tightness, relieve pain, improve balance, make walking easier and significantly lessen fatigue.

No medication brings back lost power, but muscle strengthening exercises are easier and more effective with help from AntiSpastic medication.

p 86

Lioresal (Baclofen) diminishes muscle tightness, it is rapidly absorbed from the intestinal tract and quickly moves to the Brain and Spinal Cord. Apart from its action in reducing Spasticity, it is almost inert.

It does not participate in the chemical reactions of the body and is rapidly excreted in the urine and feces. Lioresal is absorbed and excreted so fast that its biological half life is only two to four hours.

p 88

The usual biological half life of Lioresal is 2 - 4 hours. In some people the biological half life may be as long as 5 - 6 hours or in others it may be as short as a single hour.

Thus, some MSers can take it as infrequently as three times in 24 hours, while some others must take a dose 12 times a day on a regular two hour schedule in order to matain constant control of spastic symptoms.

Liorseal is especially useful for MSers because it relieves Spasticity caused by Spinal Cord lesions. Much MS Spasticity comes from plaques in that part of the nervous system.

A proper dose and dosage schedule will remove unwanted muscle spasms, lessen fatigue and improve gait.

p 89

But effective as it is, Lioresal is still an imperfect answer to MS gait disturbance. It does not improve muscle power and has no effect on the imbalance and incoordination caused by Cerebellar or Sensory malfunction.

Lioresal is effective in relieving that part of the gait disturbance caused by leg Spasticity. Walking depends on gross movements of large muscles.

Tightness of these muscles is relieved by Lioresal. It is less effective in improving function of hands and arms. Accurate fine finger movements depend on precision of Neuronal function, which is unchanged by Lioresal.


ch 5
P 99

Bladder Management

Normal Bladders empty completely. MS Bladders often do not. The residual urine volume is the amount of urine left in the bladder after voiding. This is the major determinant of Bladder management.

p106

Crede Maneuver

Sucessful Crede increases the tidal variation between completely full, and as empty as possible. Crede does not empty the MS Bladder.

It merely improves emptying by forcing excess urine from an enlarged, flaccid Bladder. Use of Crede also helps to prevent further Bladder enlargement by allowing the Bladder wall to contract between voidings.

p107

Many MSers discover Crede without instruction. Sit on the toilet and relax your abdominal wall. Press inwards and downwards. If Bladder sensation is intact, you also feel urgency or a desire to void as you press down harder.

Begin to urinate and push forcibly inwards and downwards, rolling your fist into the abdominal wall against the Bladder. Push down as far as you can into the pelvis, forcing out as much urine as possible.

Double voidings gives your Bladder a chance to empty more completely than it otherwise would. Urinate. Use whatever method works for you. Then get up and do anything else for a few minutes.

This wait allows a tired Bladder to contract down on its residual urine volume and to get ready for another try.

p118

Spastic Bladders

Ditropan (Oxybutyin Chloride) and several other medications reduce smooth muscle spasms in the Bladder and promote Bladder filling.

Take just enough medication to stop the spasms while you are active, without causing constant Bladder flaccidity through chronic overdosage.

The goal of treatment is: A Bladder that has no spasms during the active day, but returns to its spastic state at least once a day, so it can empty completely.

Most MSers first take a single dose for a special occasion. While Ditropan is active, spasms are eliminated, but it should still be possible to urinate from a filled Bladder.

After three to ten hours, Bladder spasms return with increasing urgency. That is the time to empty the Bladder completely.

p119

Urinate each morning and empty the Bladder as completely as possible. Then use a dose of Ditropan large enough to prevent spasms during the day, but not so large that it keeps the Bladder flaccid through the evening.

Most people use one or two tablets each morning. Be certain that your Bladder returns to its old spastic state by suppertime or early evening before you even think of taking another dose!

If Bladder spasms disturb nightime sleep, take a dose before going to bed. This will control spasms till morning.

This advise differs from the package insert. It recommends one tablet three or four times a day without considering the state of your Bladder function.

As a result of this repetitive dosage schedule, the Bladder may develop constant flaccidity. When that happens, frequency and urgency return, because the flaccid Bladder has enlarged to its fullest capacity.

This feels just like the frequency and urgency before Ditropan and can confuse the MSer, who is unaware of the possibility. Worse yet, constant flaccidity encourages the development of Bladder infections.

Use Ditropan, to decrease Bladder Spasticity during most of the day and most of the night. Accept the idea that your Bladder must return to its old nasty spastic state at least once a day, so it can empty as completely as possible.

As you begin, take Ditropan once in the morning and note the duration of action.

To discover your proper dosaage: take one tablet on the morning of the first two days; note the effect on Bladder function, take two tablets on the third and fourth days and note the effect.

p120

The usual dose is one or two tablets. Do not take more than two in any 24 hour period. You will know by the fourth day, which dose works for you.

If you have an important appointment during the day, take an extra dose to get through without embarrassment.

Next day be certain that your Bladder has recovered, or you will end up with a flaccid Bladder. If it seems that Ditropan has stopped working, stop the medication completely for several days.

If you already know self-cath, test yourself for Bladder enlargement and then, through repeated self-cath, document its return to normal.

Ditropan may aggravate Esophageal irritation and Ulcerative Colitis. It can worsen the effects of Prostatic enlargement. It can interfere with sweating, and never use Ditropan if you have Glaucoma.


Urgency With Severe Hesitancy

P121

Spastic legs tire easily and refuse to walk properly on command. Spastic Bladders never tire, but often refuse to urinate on command.

As the normal Bladder wall contracts to begin urination, muscles at the Bladder Neck relax, allowing urine to leave the Bladder and enter the Uretha.

In MS Bladders, the muscles around the Bladder Neck may not recieve the impulse from the Brain to relax when they should; obstructing the flow of urine at the very moment of worst urgency.

It may take 20 minutes of trying, before the Bladder neck muscle finally relaxes and urination can occur. This is called Detrusor-Sphincter DysSynergia (Bladder Wall muscle-Bladder Neck muscle incoordination).

The DysSynergia dysrupts a pleasant day. It is dysagreeable, dysadvantageous and dyscouraging. It makes MSers dysconsolate, dysgruntled and dyscommoded. It is a major nuisance.

The cause of Detrusor-Sphincter DysSynergia is Spasm of muscle at the Bladder Neck.

Dibenzyline prevents Spasm of Bladder Neck muscles, decreases hesitancy improves urinary stream and helps to reduce residual urine volume.

The major symptom is tremendous urgency, coupled with inability to urinate. Seek the cause by requesting Urodynamic Studies; or ask for a prescription of Dibenzyline to determine whether it can provide relief.

The worst side effect of Dibenzyline is dizziness, sometimes worsened by getting up from sitting or lying down.


p122

When To Change From Spasticity To Flaccidity Management

I have trouble advising MSers as they emerge from successful management of a spastic Bladder, and discover to their dismay that this week Ditropan makes things worse.

My first assumption is the Bladder is overdosed, so we stop the pills. This usually improves Bladder function.

If the Bladder has become more flaccid a limited use of Ditropan several days later may again cause incontinence.

For MSers who know self-cath the problem is easier. When Ditropan fails, we check the residual urine volume immediately. If the person has kept records, we then know how the residual urine volume has changed.

Usually we stop Ditropan and return to self-cath. Once the residual falls again, Ditropan might again be useful.

If Ditropan failed because MS caused more Bladder flaccidity, it cannot again be the sole mode of management untill MS again adds Spasticity to Bladder function.

p127
Successful MSers develop a combination of management techniques that help them adjust to change. This requires vigilance and occasional re-assessment of Bladder function.

If you develop expertise, you may be able to do most of this at home. A limited number of techniques emcompass all of Bladder management. Keep a record of successes and failures.

Learn from your doctor and keep the professionals in your life informed. Your aggressive decision to take charge will improve your life in future years.

p128

Master the few techniques of Bladder management so you can continue your life without losing your urine or your composure. You can avoid or manage almost all emergencies.

Individual procedures sound hard, but once they have been mastered they are straightforward and simple. Choose proper management over complications.

Persevere through hard times, because excellent Bladder management for the rest of your life is worth far more, than the limited effort you must invest now.




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