Complications of MS are physical or mental disorders directly caused by the disease. These conditions have a direct impact on the course and outcomes in MS, and, if serious, they can can be lethal. Prompt recognition and treatment can improve the course of MS, but it also improves the overall well-being and quality of life of the patient. Mood disorders and sleep problems were already reviewed among symptoms of MS, so in this article we will focus on osteoporosis, fractures and urinary tract infections. Pressure ulcers, albeit less frequent in MS populations, will also be reviewed.
Osteoporosis and Fractures
Osteoporosis results in decreased bone density and increases the risk of fractures. Both osteoporosis and fractures are important possible complications of MS. Research has shown that the presence of osteoporosis in MS patients is much higher than in the general population. Research also found increased risk of fractures, particularly in female MS patients. The most common were fractures of the hip, pelvis, back and shoulder bone.
Decreased physical activity stemming from neurological impairment (often present in MS) that leads to decreased mechanical stimuli important for bone formation is the major factor. Other contributing factors include low vitamin D levels, smoking, use of certain medications (such as pain medications and long-term steroids) and possibly inflammatory activity present in MS.
Diagnosis of osteoporosis is established using a special type of X-ray called a DXA scan that measures bone density at different bone areas. Results are compared to population standards, and if they’re significantly different from normal, osteoporosis is diagnosed. While there are no specific guidelines for MS patients regarding the diagnosis or treatment of osteoporosis, a DXA scan is recommended for postmenopausal women and men over age 40 who require an assistive device for walking (this signifies a certain level of disability). In patients who are able to walk without a cane or walker, a DXA scan is recommended for those with other risk factors, such as a history of frequent falls, recent fracture or prolonged steroid treatment. Vitamin D supplementation in deficient patients, smoking cessation and resistance training are recommended for all patients. Additional medications used to treat osteoporosis are usually managed by different specialists, such as endocrinologists.
Urinary Tract Infections
Multiple sclerosis commonly causes impairment of bladder function. As discussed previously, two main changes are present: urgency and frequency, or hesitancy and incomplete bladder emptying. Impairment of bladder function significantly increases the risk of urinary tract infections (UTIs), which in turn worsen quality of life and increase the risk of MS relapses.
During the disease progression bladder function tends to further deteriorate, and patients with significant neurological impairment usually require catheterization — either intermittent or permanent — to improve bladder management. This in combination with decreased mobility further increases the risk of infections, both urinary tract and systemic. It is the systemic infection, or sepsis, that has life-threatening capacity, mainly for elders.
Apart from increasing the risk of new relapse, UTIs and infections in general can also cause transient worsening of previously experienced neurological symptoms. This event, called pseudo-relapse (meaning relapse-like), should always be thought of as being in the presence of infection and fever. If unrecognized and untreated with antibiotics, the use of steroids (the usual medication for new relapse) can worsen the infection and prolong the treatment time.
Simple UTIs are usually treated with a short course of antibiotics. Increased fluid intake and medication that increases the acidity of urine and prevents bacteria growth are also recommended as preventative measure for MS patients. More complex infections, such as kidney infections and systemic infections, usually require hospitalization and antibiotics.
Pressure ulcers (PU) are described as a local skin injury on areas where skin closely covers bone and is also exposed to prolonged pressure, such as on the low back, buttocks and heels. Skin breakage on these areas happens after sustained mechanical pressure further impairs blood supply and decreases the viability of skin.
The primary risk factors causative in this MS complication are decreased mobility and prolonged bed rest or wheelchair use without frequent position change. Impaired sensory functioning, often present in MS patients, further increases the risk for PU. Additional risk factors are associated diseases, such as diabetes, and specific skin conditions, such as increased moisture of skin.
Pressure ulcers often cause pain, worsen spasticity and significantly worsen quality of life in already-impaired patients. More importantly, broken skin is an easy target for bacteria, which can cause first local infection, but often also systemic infection (sepsis). As discussed before, sepsis is often a life-threatening complication in MS patients.
In patients with decreased mobility, the skin should be checked routinely for skin breakage or PUs. Since prevention is easier than treatment, frequent repositioning, weight shifting and cushioning is recommended. Treatment of PU requires specialists in wound healing and sometimes surgeons.