Multiple Sclerosis GP Role Dr James Douglas Tweeddale Medical Practice Fort William

GP Role in MS First symptoms and diagnosis Epidemiology and sub types GP role in chronic disease management Disease trajectories Further Information and clinical pathways

MS is an auto immune disease where the myelin nerve sheath becomes damaged and interferes with the transmission of motor and sensory nerve impulses

MS is a disease of the Central Nervous System

What do we know about MS? More common the further north we live in the world Genetic suscepability and environment Auto Immune disease Is it a virus ? Is it about Vit D and sunlight? In Tweeddale we have 13 Patients with MS

First symptoms Motor weakness Sensory disturbance Visual disturbance ( optic neuritis) Ataxia and walking difficulty Mental symptoms Lhermittes phenomenon - tingling in legs with neck flexion Utoffs Phenomenon – worsening of neurological symptoms with heat or exercise ( warm bath)

Dread disease in 10 minutes Consultation Skills ( Ideas ,Concerns, Expectations) Open questions What is your worst fear? What is going through your mind? What have you found out about this on the internet? Do you know anybody else with these sorts of symptoms?

Dread disease in 10 minutes Listening and pattern matching Shared understanding and a plan Yes, it could be , but we will have to: - see how things go and review - only make such a serious diagnosis with more tests and a specialist opinion

Pros and Cons of early diagnosis in any dread disease Starting an early treatment to reduce disability eg RA Reducing anxiety with certainty A label to get services and support Cons Blissful ignorance if no effective disease modifying treatment Life / sickness insurance and date of first knowledge Wrong data label applied

What else can it be? A neurology text book! Poly neuropathies Motor neurone disease Huntingdon's Chorea Lyme Disease Anxiety causes hyperesthesia lots of people present with “pins and needles” GP has to find the pin in the hay stack!

MS Diagnosis Must have relapsing and remitting nature Time to be certain – later anger Neurological examination Magnetic Resonance Imaging Lumbar Puncture Visual Evoked Potential

Emotional Adjustment to any serious disease Bereavement sequence Denial Frustration , emotional upset Anger/guilt/depression. Understanding and acceptance of loss Emotional adjustment to new role/situation

MS sub types Benign MS ( after 10 -15 years with not much problem) Relapsing and Remitting MS ( remission and recovery) Secondary Progressive MS ( follow on form relapsing and remitting) Primary Progressive ( no clear remission 10 -15% >40 years onset )

GP MS Annual Review

Disease Trajectories

Summary of GP role Diagnosis Prescribing and co morbidities Working with specialist team The long term relationship The family The clinical record /coding / decision points NHS Highland MS guidelines on intranet

MS Society UK and Scotland www.mssociety.org.uk

Patient with MS for 30 years Life story with video editing “Stoory pints” Sailing > family seperation Fund raising in Caol for a wheelchair