Letter From the Editor - Volume 25, Issue 4 - July 2023

M. ALISSA WILLIS, MD

Severe thunderstorms swept through my area as I wrote the first draft of this editorial. Many local and regional events were disrupted by intense rain, power outages, and structural damage. Such storms are a common prelude to the Atlantic hurricane season (June to November). Warmer temperatures and early rains resulting from El Niño conditions this year have made this season particularly volatile already. As I cleared debris and waited for power to be restored, I reflected on how dangerous these storms and the aftermath can be for people with multiple sclerosis (MS) and other health conditions. Hsieh and colleagues from Miami, Florida, outline these potential challenges and provide a checklist for preparing people with MS for climate-related disasters. Although their focus is hurricane preparedness, their advice is also good for other severe weather events.

Even without storms, sleep disruptions and sleep disorders are common in MS. Scherder and colleagues used actigraphy to assess rest-activity rhythm—an indirect measure of sleep rhythm—in a group of patients with pain and other symptoms. The association of mood, pain, and physical disability with sleep variability in their study suggests that treating these symptoms may improve sleep consistency.

Treatment of multiple interrelated symptoms often leads to polypharmacy. In a short report from Greece, Bakirtzis and colleagues remind us of the prevalence of this problem. Commonly prescribed medications other than disease-modifying therapies include antispasticity agents, fampridine, antihypertensives, antidepressants, and anxiolytics. Although the intent is to improve quality of life by addressing symptoms, polypharmacy poses many risks, including sedation and increased risk of falls, particularly in aging patients.

Anticholinergic agents are frequently prescribed for bladder dysfunction in MS after first-line interventions (ie, fluid management, pelvic floor therapy, scheduled voiding) fail. Risk of adverse events with these agents is high in older individuals and those taking multiple medications. These medications may also worsen comorbid bowel problems. Thys and Sasse describe the safety and potential benefits of a nonpharmacologic approach, percutaneous sacral neuromodulation. Fortunately, newer devices are fully MRI compatible, making this treatment an option for patients still requiring radiographic monitoring.

Bowel and bladder dysfunction in MS can lead to avoidance of activities. Mobility challenges also lead to decreased community participation. Giroux and colleagues show that this avoidance begins before the need for an assistive device. They noted avoidance of certain ambient conditions (ie, hot, snow, dark) and crossing a busy street even with mild and moderate gait impairment. Those with more severe gait impairment avoid heavy manual doors, postural transitions, and crowded places due to a concern with falling.

Given the limitations in activity with even mild gait impairment, improving mobility is often a primary concern of patients and care providers. The benefits of exercise and physical therapy in MS are clearly established. Weigel and colleagues remind us about an underappreciated modality for improving fine motor skills, mobility, fatigue, and overall quality of life. Music therapy is not widely available but it can be a valuable intervention alone or as an adjunct to physical therapy or psychotherapy. The authors include a list of virtual exercise providers that I found to be helpful for use outside of an MS center.

Finally, our continuing education paper by Davis and colleagues from Glasgow shares evidence for dance in MS. Dance incorporates physical activity with social interaction which may lead to improvement in mobility, depression, and anxiety. More work needs to be done to understand the influence of tempo and genre on various symptoms.

The music and weather themes in this issue remind me of a line from one of my favorite songs: “You can dance in a hurricane, but only if you’re standing in the eye.” I wish everyone a safe and fun summer.