Multiple Skleroz Morbilite Nedenleri ve Yönetimi
Özet
Multiple Skleroz (MS), merkezi sinir sisteminde inflamasyon, demiyelinizasyon ve nöronal kayıpla seyreden kronik bir hastalıktır. Ataklar esnasındaki süreçte MS hastalarında ek semptomlar görülmektedir. Bu bölümde MS hastalarındaki yaygın morbidite nedenleri ve bu durumların yönetim stratejileri anlatılmaktadır. Hastalarda en sık karşılaşılan belirtilerden biri yorgunluktur. Hastalığın kendisi ve eşlik eden durumlara bağlı gelişebilir. Bilişsel bozukluklar MS’in her evresinde ortaya çıkabilir ve bilgi işleme hızı, hafıza ve dikkat gibi alanlarda bozulmalar görülebilir. Depresyon ve anksiyete, yüksek prevalansa sahip olup psikososyal desteğin yanı sıra farmakolojik tedavi gerektirir. Ağrı, nöropatik veya nosiseptif kaynaklı olabilir; tedavi multidisipliner yaklaşım gerektirir. MS ile ilişkili hareket bozuklukları arasında huzursuz bacak sendromu, tremor, ataksi ve spastisite yer alır. Ayrıca üriner disfonksiyon, dışkılama problemleri ve cinsel işlev bozuklukları da sık görülür. Bu semptomlar, yaşam kalitesini ciddi biçimde etkiler. Tedavide farmakolojik yaklaşımların yanında egzersiz, psikoterapi ve diyet gibi destekleyici yöntemler de önemlidir. Erken tanı, düzenli değerlendirme ve bireye özgü yönetim planları, etkin semptom kontrolü açısından kritik öneme sahiptir.
Multiple Sclerosis (MS) is a chronic, immune-mediated disorder of the central nervous system characterized by inflammation, demyelination, and neuronal loss. During disease exacerbations, patients often experience a range of additional symptoms. This chapter explores the most common morbidity-related manifestations observed in individuals with MS and outlines evidence-based management strategies. Fatigue represents one of the most prevalent symptoms and may be attributed to both the underlying disease process and comorbid conditions. Cognitive impairment can emerge at any stage of MS, typically affecting domains such as information processing speed, memory, and attention. Depression and anxiety are also frequently reported and require a combination of pharmacological treatment and psychosocial interventions. Pain in MS may be neuropathic or nociceptive in origin and necessitates a multidisciplinary therapeutic approach. Movement disorders associated with MS include restless legs syndrome, tremor, ataxia, and spasticity. Additionally, urinary dysfunction, bowel disturbances, and sexual dysfunction are common and significantly compromise quality of life. Alongside pharmacological interventions, supportive therapies such as physical exercise, psychotherapy, and nutritional strategies play a crucial role in symptom management. Early diagnosis, regular monitoring, and individualized treatment planning are essential components in optimizing patient outcomes and maintaining functional independence.
Referanslar
Haki M, Al-Biati HA, Al-Tameemi ZS, Ali IS, Al-Hussaniy HA. Review of multiple sclerosis: Epidemiology, etiology, pathophysiology, and treatment. Medicine (Baltimore). 2024;23;103(8):e37297.
Oliva Ramirez A, Keenan A, Kalau O, Worthington E, Cohen L, Singh S. Prevalence and burden of multiple sclerosis-related fatigue: a systematic literature review. BMC Neurol. 2021; Dec 2;21(1):468
Manjaly ZM, Harrison NA, Critchley HD, Do CT, Stefanics G, Wenderoth N, Lutterotti A, Müller A, Stephan KE. Pathophysiological and cognitive mechanisms of fatigue in multiple sclerosis. J Neurol Neurosurg Psychiatry. 2019 Jun;90(6):642-651. doi: 10.1136/jnnp-2018-320050. Epub 2019 Jan 25.
Mills RJ, Young CA. A medical definition of fatigue in multiple sclerosis. QJM. 2008 Jan;101(1):49-60. doi: 10.1093/qjmed/hcm122. Epub 2008 Jan 14. PMID: 18194977.
Tur C. Fatigue Management in Multiple Sclerosis. Curr Treat Options Neurol. 2016 Jun;18(6):26. doi: 10.1007/s11940-016-0411-8. PMID: 27087457; PMCID: PMC4834309.
Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol. 1989 Oct;46(10):1121-3. doi: 10.1001/archneur.1989.00520460115022. PMID: 2803071.
Téllez N, Río J, Tintoré M, Nos C, Galán I, Montalban X. Does the Modified Fatigue Impact Scale offer a more comprehensive assessment of fatigue in MS? Mult Scler. 2005 Apr;11(2):198-202. doi: 10.1191/1352458505ms1148oa. PMID: 15794395.
Penner I, Raselli C, Stöcklin M, Opwis K, Kappos L, Calabrese P. The Fatigue Scale for Motor and Cognitive Functions (FSMC): validation of a new instrument to assess multiple sclerosis-related fatigue. Multiple Sclerosis Journal. 2009;15(12):1509-1517. doi:10.1177/1352458509348519
Hasanpour Dehkordi A. Influence of yoga and aerobics exercise on fatigue, pain and psychosocial status in patients with multiple sclerosis: a randomized trial. J Sports Med Phys Fitness. 2016 Nov;56(11):1417-1422. Epub 2015 Jul 29. PMID: 26223004.
Sánchez-Lastra MA, Martínez-Aldao D, Molina AJ, Ayán C. Pilates for people with multiple sclerosis: A systematic review and meta-analysis. Mult Scler Relat Disord. 2019 Feb;28:199-212. doi: 10.1016/j.msard.2019.01.006. Epub 2019 Jan 3. Erratum in: Mult Scler Relat Disord. 2019 Jul;32:139-140. doi: 10.1016/j.msard.2019.04.027. PMID: 30623859.
Pommerich UM, Brincks J, Christensen ME. Is there an effect of dietary intake on MS-related fatigue? - A systematic literature review. Mult Scler Relat Disord. 2018 Oct;25:282-291. doi: 10.1016/j.msard.2018.08.017. Epub 2018 Aug 21. PMID: 30170268.
Chalah MA, Ayache SS. Cognitive behavioral therapies and multiple sclerosis fatigue: A review of literature. J Clin Neurosci. 2018;52:1-
Meca-Lallana V, Gascón-Giménez F, Ginestal-López RC, Higueras Y, Téllez-Lara N, Carreres-Polo J, Eichau-Madueño S, Romero-Imbroda J, Vidal-Jordana Á, Pérez-Miralles F. Cognitive impairment in multiple sclerosis: diagnosis and monitoring. Neurol Sci. 2021 Dec;42(12):5183-5193. doi: 10.1007/s10072-021-05165-7. Epub 2021 Apr 1. PMID: 33796947; PMCID: PMC8642331.
Margoni M, Preziosa P, Rocca MA, Filippi M. Depressive symptoms, anxiety and cognitive impairment: emerging evidence in multiple sclerosis. Transl Psychiatry. 2023 Jul 19;13(1):264. doi: 10.1038/s41398-023-02555-7. PMID: 37468462; PMCID: PMC10356956.
Johnen A, Landmeyer NC, Bürkner PC, Wiendl H, Meuth SG, Holling H. Distinct cognitive impairments in different disease courses of multiple sclerosis-A systematic review and meta-analysis. Neurosci Biobehav Rev. 2017 Dec;83:568-578. doi: 10.1016/j.neubiorev.2017.09.005. Epub 2017 Sep 8. PMID: 28890199.
Amato MP, Morra VB, Falautano M, Ghezzi A, Goretti B, Patti F, Riccardi A, Mattioli F. Cognitive assessment in multiple sclerosis-an Italian consensus. Neurol Sci. 2018 Aug;39(8):1317-1324. doi: 10.1007/s10072-018-3427-x. Epub 2018 May 15. Erratum in: Neurol Sci. 2019 May;40(5):1097. doi: 10.1007/s10072-019-03852-0. PMID: 29766386.
Amato MP, Goretti B, Ghezzi A, Lori S, Zipoli V, Portaccio E, Moiola L, Falautano M, De Caro MF, Lopez M, Patti F, Vecchio R, Pozzilli C, Bianchi V, Roscio M, Comi G, Trojano M; Multiple Sclerosis Study Group of the Italian Neurological Society. Cognitive and psychosocial features of childhood and juvenile MS. Neurology. 2008 May 13;70(20):1891-7. doi: 10.1212/01.wnl.0000312276.23177.fa. PMID: 18474844.
Nucci M, Mapelli D, Mondini S. Cognitive Reserve Index questionnaire (CRIq): a new instrument for measuring cognitive reserve. Aging Clin Exp Res. 2012 Jun;24(3):218-26. doi: 10.3275/7800. Epub 2011 Jun 20. PMID: 21691143.
Va Benedict RH, DeLuca J, Phillips G, LaRocca N, Hudson LD, Rudick R; Multiple Sclerosis Outcome Assessments Consortium. Validity of the Symbol Digit Modalities Test as a cognition performance outcome measure for multiple sclerosis. Mult Scler. 2017 Apr;23(5):721-733. doi: 10.1177/1352458517690821. Epub 2017 Feb 16. PMID: 28206827; PMCID: PMC5405816.
Kalb R, Beier M, Benedict RH, Charvet L, Costello K, Feinstein A, Gingold J, Goverover Y, Halper J, Harris C, Kostich L, Krupp L, Lathi E, LaRocca N, Thrower B, DeLuca J. Recommendations for cognitive screening and management in multiple sclerosis care. Mult Scler. 2018 Nov;24(13):1665-1680. doi: 10.1177/1352458518803785. Epub 2018 Oct 10. PMID: 30303036; PMCID: PMC6238181.
Efendi, H., & Kuşcu, D. Y. (2018). Multipl skleroz tanı ve tedavi rehberi. Galenos Yayınevi, İstanbul.
Jellinger KA. Depression and anxiety in multiple sclerosis. Review of a fatal combination. J Neural Transm (Vienna). 2024 Aug;131(8):847-869. doi: 10.1007/s00702-024-02792-0. Epub 2024 Jun 13. PMID: 38869643.
Solaro C, Gamberini G, Masuccio FG. Depression in Multiple Sclerosis: Epidemiology, Aetiology, Diagnosis and Treatment. CNS Drugs. 2018 Feb;32(2):117-133. doi: 10.1007/s40263-018-0489-5. PMID: 29417493.
Briones-Buixassa L, Montañés-Masias B, Milà-Villaroel R, Arrufat FX, Aragonès JM, Norton S, Bort-Roig J, Moss-Morris R (2023) The bidirectional effect of stress and functionality in multiple sclerosis and the interaction role of anxiety, coping and social support. J Psychosom Res 170:111375 Bruno A, Dolcetti E, Rizzo FR, Fresegna D
Nick ST, Roberts C, Billiodeaux S, Davis DE, Zamanifekri B, Sahraian MA, Alekseeva N, Munjampalli S, Roberts J, Minagar A. Multiple sclerosis and pain. Neurol Res. 2012 Nov;34(9):829-41. doi: 10.1179/1743132812Y.0000000082. Epub 2012 Aug 21. PMID: 22909889.
Shkodina AD, Bardhan M, Chopra H, Anyagwa OE, Pinchuk VA, Hryn KV, Kryvchun AM, Boiko DI, Suresh V, Verma A, Delva MY. Pharmacological and Non-pharmacological Approaches for the Management of Neuropathic Pain in Multiple Sclerosis. CNS Drugs. 2024 Mar;38(3):205-224. doi: 10.1007/s40263-024-01072-5. Epub 2024 Feb 29. PMID: 38421578.
Jensen TS, Rasmussen P, Reske-Nielsen E. Association of trigeminal neuralgia with multiple sclerosis: clinical and pathological features. Acta Neurol Scand. 1982;65:182–9.
Di Stefano G, Maarbjerg S, Truini A. Trigeminal neuralgia secondary to multiple sclerosis: from the clinical picture to the treatment options. J Headache Pain. 2019;20:20. https:// doi. org/ 10.1186/ s10194- 019- 0969-0
Truini A, Garcia-Larrea L, Cruccu G. Reappraising neuropathic pain in humans—how symptoms help disclose mechanisms. Nat Rev Neurol. 2013;9:572–82. https:// doi. org/ 10. 1038/ nrneu rol.2013. 180
Di Stefano G, Maarbjerg S, Truini A. Trigeminal neuralgia secondary to multiple sclerosis: from the clinical picture to the treatment options. J Headache Pain. 2019 Feb 19;20(1):20. doi: 10.1186/s10194-019-0969-0. PMID: 30782116; PMCID: PMC6734488.
Fryze W, Zaborski J, Członkowska A. Ból w przebiegu stwardnienia rozsianego [Pain in the course of multiple sclerosis]. Neurol Neurochir Pol. 2002 Mar-Apr;36(2):275-84. Polish. PMID: 12046504.
Fryze W, Zaborski J, Członkowska A. Ból w przebiegu stwardnienia rozsianego [Pain in the course of multiple sclerosis]. Neurol Neurochir Pol. 2002 Mar-Apr;36(2):275-84. Polish. PMID: 12046504.
Solaro C, Messmer Uccelli M. Pharmacological management of pain in patients with multiple sclerosis. Drugs. 2010 Jul 9;70(10):1245-54. doi: 10.2165/11537930-000000000-00000. PMID: 20568832.
Osterberg A, Boivie J. Central pain in multiple sclerosis - sensory abnormalities. Eur J Pain. 2010 Jan;14(1):104-10. doi: 10.1016/j.ejpain.2009.03.003. Epub 2009 Apr 8. PMID: 19359204.
Ghosh R, Roy D, Dubey S, Das S, Benito-León J. Movement Disorders in Multiple Sclerosis: An Update. Tremor Other Hyperkinet Mov (N Y). 2022 May 4;12:14. doi: 10.5334/tohm.671. PMID: 35601204; PMCID: PMC9075048.
SÜnter G, KilinÇ Ö, Berk A, AkÇabey S, SaldÜz E, ÖztÜrkÇÜ H, GÜnal Dİ, Agan K. Restless Legs Syndrome/Willis-Ekbom Disease in Multiple Sclerosis Patients with Spinal Cord Lesions. Noro Psikiyatr Ars. 2019 Mar 28;57(4):299-302. doi: 10.29399/npa.23351. PMID: 33354122; PMCID: PMC7735149.
Li Y, Munger KL, Batool-Anwar S, De Vito K, Ascherio A, Gao X. Association of multiple sclerosis with restless legs syndrome and other sleep disorders in women. Neurology. 2012 May 8;78(19):1500-6. doi: 10.1212/WNL.0b013e3182553c5b. Epub 2012 Apr 25. PMID: 22539566; PMCID: PMC3345617.
Aljarallah S, Alkhawajah N, Aldosari O, Alhuqbani M, Alqifari F, Alkhuwaitir B, Aldawood A, Alshenawy O, BaHammam AS. Restless leg syndrome in multiple sclerosis: a case-control study. Front Neurol. 2023 Jun 19;14:1194212. doi: 10.3389/fneur.2023.1194212. PMID: 37404942; PMCID: PMC10315471.
Koch M, Mostert J, Heersema D, De Keyser J. Tremor in multiple sclerosis. J Neurol. 2007 Feb;254(2):133-45. doi: 10.1007/s00415-006-0296-7. Epub 2007 Feb 21. PMID: 17318714; PMCID: PMC1915650.
Pourmohammadi A, Riahi R, Hosseini SM, Adibi I. Pharmacological treatment of tremor in multiple sclerosis; a systematic review. Mult Scler Relat Disord. 2022 Apr;60:103722. doi: 10.1016/j.msard.2022.103722. Epub 2022 Mar 10. PMID: 35339007.
Etoom M, Khraiwesh Y, Lena F, Hawamdeh M, Hawamdeh Z, Centonze D, Foti C. Effectiveness of Physiotherapy Interventions on Spasticity in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis. Am J Phys Med Rehabil. 2018 Nov;97(11):793-807. doi: 10.1097/PHM.0000000000000970. PMID: 29794531.
Guillermo Izquierdo (2017) Multiple Sclerosis Symptoms and Spasticity Management: New Data, Neurodegenerative Disease Management, 7:sup6, 7-11, DOI:10.2217/nmt-2017-0034
Hughes C, Howard IM. Spasticity management in multiple sclerosis. Phys Med Rehabil Clin N Am. 2013 Nov;24(4):593-604. doi: 10.1016/j.pmr.2013.07.003. PMID: 24314678.
Flachenecker P, Henze T, Zettl UK. Spasticity in patients with multiple sclerosis—clinical characteristics, treatment and quality of life. Acta Neurol Scand. 2014 Mar;129(3):154-62. doi:10.1111/ane.12202. Epub 2013 Nov 20. PMID: 24256407.
Vecchio M, Chiaramonte R, DI Benedetto P. Management of bladder dysfunction in multiple sclerosis: a systematic review and meta-analysis of studies regarding bladder rehabilitation. Eur J Phys Rehabil Med. 2022 Jun;58(3):387-396. doi: 10.23736/S1973-9087.22.07217-3. Epub 2022 Feb 1.
Bir LS. Multipl sklerozda belirtilere yönelik sağaltım. Türkiye Klinikleri Nöroloji Özel (Multiple Skleroz Özel Sayısı). 2020. p.94-100.
Yang CC. Bladder management in multiple sclerosis. Phys Med Rehabil Clin N Am. 2013 Nov;24(4):673-86. doi: 10.1016/j.pmr.2013.06.004. Epub 2013 Aug 27. PMID: 24314685.
Tota V, Briganti G, Ris L. Algorithms for the first-line management of bladder, bowel and sexual dysfunction in multiple sclerosis: Present and future. Mult Scler Relat Disord. 2024 Nov;91:105884.
