Brain, Vol. 125, No. 3, 683-684,
March 2002
© 2002 Guarantors of Brain
Book Review |
MULTIPLE SCLEROSIS: THE GUIDE TO TREATMENT AND MANAGEMENT
University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK
MULTIPLE SCLEROSIS: THE GUIDE TO TREATMENT AND MANAGEMENT.
By Chris H. Polman, Alan J. Thompson, T. Jock Murray and W. Ian McDonald.
2001. New York: Demos Medical Publishing.
Price $24.95. Pp. 137. ISBN 1-88879-954-4..
This is the fifth edition of what used to be called ‘Therapeutic Claims in Multiple Sclerosis’. It is a concise but comprehensive and up-to-date overview of multiple sclerosis treatments, which would be well-placed on any clinical neurologist’s shelf. It is written with the aim of being accessible to people with multiple sclerosis, their families, carers and health professionals.
The authors are four experienced multiple sclerosis neurologists and the text has been reviewed by the members of the Multiple Sclerosis International Federation Medical Management Committee to ensure a balanced and representative medical opinion. Advice is based on scientific evidence when available and the extensive clinical experience shared by the authors and committee.
The book is well set out and is divided into four main sections covering the treatment of acute exacerbations, disease-modifying therapies, symptomatic treatments and rehabilitation, and an overview of alternative therapies. The modes of action for the treatments are given and concluding statements for each treatment are made by the panel, along with the original data backing these judgements. Each section ends with a reading list including a brief summary of these references.
The introduction advertises the use of the MSIF’s website to encourage the user to gain up-to-date information in between the printed versions of this book. MRI is briefly mentioned and its sensitivity to disease activity is outlined. Because of the poor relationship so far demonstrated between conventional MRI and disability, the importance of clinical outcomes in treatment trials is emphasized.
Individual symptoms are addressed and include, when known, the anatomical location of the problem and the frequency with which the symptom is experienced. The multiplicity and diversity of symptoms, the—often only partial—recovery and recurrence of symptoms and the progression occurring in the majority of patients is explained. It is always a concern that unnecessary anxiety may be caused when information on potential problems is offered to patients. However, the present climate of heath care is to empower patients by informing and educating in order to promote autonomy.
The aims and usefulness of neurological rehabilitation are discussed. Evaluation of the effects of rehabilitation on disability, handicap and quality of life, the length of the effectiveness and the assessment of service delivery is also covered. The authors view multiple sclerosis as being ideally suited to the philosophy of rehabilitation, which emphasizes patient education and self-management.
A short overview of the immunological mechanisms thought to play a role in multiple sclerosis is well communicated in layman’s terms and sets the scene for the disease-modifying treatment section. This section makes clear which drugs are not specifically approved for treatment of multiple sclerosis and which are still under development.
There are many issues around the treatment of multiple sclerosis that are poorly understood by patients leading to difficulties in management. These are clearly explained and the care of many patients might be improved through patient access to such a text. The limitations of many treatments due to partial efficacy and side-effect risks, such as with corticosteroid treatment, are covered. Different levels of evidence, the problems with anecdote, especially in a fluctuating disease, and how this may lead to false claims is set out. Additionally, outlining the symptoms that can be effectively managed will encourage patients to seek help if they encounter such problems. In many cases, the patients, their families, GPs and other health professionals have a nihilistic view of the usefulness of reassessment by a neurologist or rehabilitationist and miss out on available treatment. Jargon used in trials and many other medical terms are defined; however, many patients may struggle with some of the terminology, especially if cognitively impaired.
Oral corticosteroids as a treatment for acute relapses are perhaps unfairly dismissed. The authors conclude that intravenous corticosteroids are the treatment of choice and are less convinced that oral steroids have a role. Type II errors are quoted as making equivalence in the UK study unproven, and concern is expressed regarding side-effects of longer treatment regimes often given with oral doses. However, there is no evidence that either regime is superior in this respect. The Danish efficacy study of high dose oral corticosteroid treatment that shows a doubling of patients improving at 2 months compared with placebo is mentioned, but not the comparative study of Alam et al. (1993
). This showed no difference between equivalent dosage regime when given orally or intravenously, and was powered to show a 25% or greater difference. It is clear that oral corticosteroids have an effect on acute relapses and that if there is a difference compared with intravenous therapy, it is not large. Many patients prefer outpatient treatment, and many neurologists have limited access to inpatient beds. Even day-case intravenous treatment utilizes inpatient resources, is expensive and is an inconvenience to many patients. Additionally, the lack of proven long-term efficacy makes a small difference between the different modes of administration less medically important.
The alternative therapies section is comprehensive in the range of treatments covered. Having searched on the internet and having been presented with internet printouts by patients, I found most therapies included. This section lists the commonly used therapies and types of therapists consulted, and details more specific treatments including hyperbaric oxygen therapy, magnotherapy, various diets and vitamin/trace element/enzyme administrations, snake and bee-sting venom treatment, mercury amalgam filling replacement and, interestingly, thalamotomy. Each treatment is described, the rationale for its use is given and details of evaluation of efficacy are outlined (usually poor in this group of therapies). The risks and costs are quoted and a conclusion reached. Patients are advised to obtain information on any alternative therapy they are interested in, to assess whether the claims are substantiated and to beware of incurring costs that they cannot afford. The authors also suggest patients inform their doctors of any unconventional treatments they are receiving, although the paucity of information available on these makes advice on interactions difficult.
Overall, the authors have a fairly conservative view on the multiple sclerosis treatments, and this is helpful to counterbalance the false hopes raised by those promoting the treatments. It is a responsible text with clear contents and index sections and the format has most definitely resulted, as stated, in an ‘easy-to-use’ guide on current multiple sclerosis therapies. I have already started recommending this book to my patients.
References
Alam SM, Kyriakides T, Lawden M, Newman PK. Methylprednisolone in multiple sclerosis: a comparison of oral with intravenous therapy at equivalent high dose. J Neurol Neurosurg Psychiatry 1993; 56: 1219–20.
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