Finding Solutions for the Advanced Care Needs of People with MS
While researchers are working to identify new and better strategies to stop MS, restore function and end MS forever, people whose MS has become more disabling—and their family members and friends—need information right now about how to manage the challenges they face. With these goals in mind, the National MS Society convened a group of key stakeholders – including people with MS, support partners, Society staff and clinicians from the fields of neurology, primary care, rehabilitation medicine, psychology, nursing, physical therapy and speech pathology– to help inform the Society’s role in finding solutions for individuals and families who are facing advanced care needs.
“At the Society, when we face a challenge, we get the brightest minds together and put the problems on the table,” said Cyndi Zagieboylo, President & CEO of the National MS Society. “We need to pursue every opportunity to support people with advanced MS in living their best lives.”
What It’s Like
People living with MS lent a vital voice to the process. “It’s going to be very important as you think about this that you understand our lived experience,” urged Lisa Iezzoni, MD, a health services researcher who has MS. “It takes me about 10 times longer to do the most basic task.”
Karen Jackson, who lives with primary progressive MS, agreed. “Having advanced MS means I have lost the ability to be spontaneous,” she said. “I am forced to plan every minute of every day. The only thing more exhausting than planning my day, is not planning. It takes an annoying sequence of action steps to achieve even the smallest goal, like buying gas or parking the car.”
Resilience, however, rang through despite the challenges of advanced care needs, which for both of these women includes wheeled mobility. “When people ask me how I feel about my MS, I tell them that I’m not sick,” insisted Dr. Iezzoni. “I just can’t walk.” Ms. Jackson added, “Explain to people what your needs are. They want to help.” It’s worth the effort, she says. “Not participating in life is not an option.”
If I Have to Use a Wheelchair…
Getting a wheelchair was noted to be a “line in the sand” for many people living with MS, who often view the choice to use one as a loss of independence. Meanwhile, by trying to stay on their feet, people might be curtailing activities because of increased fatigue, or concerns about stumbling or falling.
“One of our challenges is that the wheelchair is used to symbolize disability,” said physical therapist Jean Minkel (Independence Care System. New York). “The wheelchair should not be considered a failure of therapy.”
Dr. Iezzoni heartily agrees. “When I finally started using a wheelchair 14 years after my first MS symptom, it was like spring after a housebound winter,” she said. “Silliness – that I was afraid people wouldn’t think I was strong because I was using a wheelchair.” Ms. Jackson agreed. “I’m learning to navigate a new normal,” she said. “My goal when I meet you is to have my chair disappear in 10 minutes, so that you only see me!”
Evaluating the home environment is key to determining the type of mobility device needed. “A picture is worth a thousand words and a home visit is a narrative,” said Ms. Minkel. “To understand the need, we need to see the environment. For example, show me what the front door looks like.”
The wheeled device is not the only crucial factor – so is choosing the proper cushion to sit on. Some cushions can relieve pressure, thus preventing pressure sores (sites of damaged skin that can cause serious infections). “Thirty percent of our clients are at risk for pressure sores,” said Minkel. “Only two percent get them because they have pressure-relieving wheelchair cushions.”
Participants considered other key issues related to the advanced care needs of people with MS, naming some difficult problems and suggesting solutions.
- Breathing easier — “Respiratory dysfunction begins very early in the disease process,” noted physical therapist Donna Fry, PhD (University of Michigan-Flint). But, she said, respiratory exercises can improve strength in respiratory muscles even late in the disease. Dr. Fry’s team has shown these improvements using “threshold inspiratory muscle trainers,” inexpensive devices that can help breathing muscles to get stronger. “Most clinicians are not aware of the potential early involvement of the respiratory system in people with MS and of accessible, inexpensive equipment that can enhance muscle strength,” she added.
- Muscle spasticity — “Quite a few people with MS are experiencing significant problems from spasticity,” said neurologist Francois Bethoux, MD (Cleveland Clinic). Spasticity may be as mild as the feeling of tightness of muscles or may be so severe as to produce painful, uncontrollable spasms in the extremities, usually the legs. Dr. Bethoux believes spasticity can often be managed without specialized care. “Optimal care would involve an early diagnosis, setting realistic goals, and re-evaluation,” he said. Plus, stretching is vital, even if mobility is impaired
- Swallowing — “We all swallow 400-500 times a day, often without knowing,” said speech-language pathologist Alex Burnham (The Boston Home). “But 30-40% of people with MS can have problems with swallowing.” The consequences can be serious – breathing in food or fluids, choking, malnutrition, dehydration, and not taking medicine. Especially later in the disease, says Mr. Burnham, swallowing and feeding issues can have dramatic effects on quality of life, especially if it limits enjoying a meal with friends and family or prevents someone from eating favorite, culturally-significant foods. Mr. Burnham advocated for screening for these problems during regular visits. “Ask patients, have you had any trouble eating? Swallowing your pills?” Burnham also mentioned novel therapies that may prove helpful, such as the “free water protocol,” in which patients are allowed to have water by itself to improve hydration. Another method is neuromuscular electrical stimulation, applied in low doses to the neck
- Speech — Swallowing disorders can occur hand-in-hand with speech difficulties. “It’s never too early to start thinking about assistive technology, especially for people with a wide fluctuation of symptoms,” noted Mr. Burnham. “They might be fine in the morning, but then if they don’t get a nap, fatigue makes it hard for them to speak intelligibly later in the day.” Give people with MS an opportunity to use as many different modes of communication as possible, he advised. “Miscommunication can lead to frustration, social isolation, and a loss of independence,” said Mr. Burnham. “Maintaining any form of communication is critical for empowerment, relationships, and appropriate disease management.” , including the use of smartphone applications.
- Thinking and mood problems – “Cognitive changes are among the most prevalent reasons that people with MS are admitted to nursing homes,” said Rosalind Kalb, PhD, Vice President, Healthcare Information and Resources at the Society. “We need to be providing strategies to help people compensate for cognitive changes, and we need to speak to family members, since families may help to pick these changes up earlier.” With mood, it’s vital to understand that although depression in common in MS, some mood changes may be a natural consequence of the process of an advancing chronic disease. “People may be grieving over changes,” said Dr. Kalb. “We need to treat depression when it is present and also be respectful and comfortable with talking with people who are not depressed about how they want to live the rest of their lives.”
Achieving Optimal Care
The group discussed how to achieve optimal care for people with advanced MS. Nicholas LaRocca, PhD, Vice President of Healthcare Delivery and Policy at the Society, noted that health care concerns are changing as the MS population gets older. “The average age of people with MS has increased by over 30 years since 1984,” he said. “Coexisting conditions, such as hypertension, increase with age and appear to be increasing in MS. Furthermore, people with MS who have some of these conditions at diagnosis reach the most severe level of mobility impairment faster than those who don’t.”
The group agreed that education is needed on both ends of this spectrum. Primary care providers need to be educated about MS so that they can distinguish MS symptoms from conditions that require primary care. And people with MS need to be educated about the importance of watching out for their own health. “A person with a disability still needs their cholesterol checked,” said Ms. Minkel. ”They still need their blood pressure checked.” Neurologists and primary care providers need to communicate, collaborate and coordinate their care of a person with MS.
Early and ongoing evaluation of symptoms also is key. “We need to educate people with MS and their caregivers about advocating for chronic care issues,” said Ruth Whitham, MD (Oregon Health& Science University). “Perhaps we can develop an advanced MS care checklist that would include symptoms to think about and what to do if you notice them.” The goal is to help people with MS to advocate for early and ongoing assessment, and for healthcare providers to ask routinely about changes that may be occurring throughout all bodily systems.
Importantly, people with MS need to know they have the right to advocate for care, regardless of how advanced their MS. “We don’t ever want a person to hear, ‘There’s nothing more we can do for you,’” added Dr. Kalb.
Caring for Caregivers
Speakers paid careful attention to how advanced care needs can affect caregivers.
“Families can become isolated,” said psychologist David Rintel, EdD, whose father lived with MS. “You feel pretty different from everyone else, and that isolation is harmful to your physical and mental health.” He advised that healthcare providers should see the caregiver occasionally along with the patient, if the patient grants permission, to get their perspective, and also see how the caregiver themselves are doing. “We need to learn the signs of burnout, such as depression, and increased use of alcohol,” he said. “Caregiver burden is real.”
There also is much that a caregiver needs to learn – navigating the healthcare system, how to transfer people safely, and management of bladder and bowel problems. “Dealing with bowel/bladder issues is actually a leading cause of caregiver burnout,” added nurse Cindy Walsh (The Boston Home).
“Families have to learn how to ask for help,” said Dr. Rintel. “They have to ask in a way where they say what, where, when and how long. Most people would help if they understood specifically what you need.”
The group identified the highest priority research questions that need to be answered concerning the care and support of people with advanced care needs and their families, pinpointing questions in the areas of assistive technology; comorbidities and primary care; health care system issues (e.g., insurance coverage); long-term care; symptoms and complications; skin care; speech, swallowing, and pulmonary functions; and the benefits of wellness/lifestyle interventions. They are now formulating a prioritized list of these questions to help inform the Society’s next steps.
A white paper describing the meeting’s discussion highlights and recommendations regarding the Society’s response to the needs of those affected by advanced MS will be posted on the Society’s web site, and a similar paper will be submitted for publication in a peer-reviewed journal.
Help is Available Now
Individuals nationwide may contact the Society’s MS Navigator® program via the Society’s toll-free help line 1-800-344-4867 (1-800-FIGHT MS) or via email (contactusNMSS@nmss.org). The MS Navigator Program connects people to resources,, helps people access optimal healthcare and understand benefits such as health insurance, face financial challenges and planning for the future, and find support when MS progresses.
Right now, MS activists are engaged on a number of fronts to improve quality of life and access to care. Among these is advancing home modification tax credit legislation, to provide financial relief for home modifications to promote safety and mobility.
The National MS Society provides support to people living with advanced MS, including care guides for families, information about symptom management, a guide to financial planning, and information on advanced directives. Read more
The Society also provides support for healthcare professionals who are seeking to help people with MS obtain care at home, in nursing homes, assisted living facilities, or adult day homes. Read more