Multiple sclerosis involves multiple areas of the central nervous system and therefore can produce a diverse range of symptoms, from visual loss to pain, fatigue, and paraparesis. In the initial stages of the condition, the symptoms are often isolated, relating to a single area of inflammation, although multiple areas may be involved (e.g., optic nerve and spinal cord). Symptoms usually are transient, but even in these early stages recovery may be less than complete, leaving residual disturbance, which is either constant or re-emerges with exercise (e.g., Uhthoff’s phenomenon). There are some people in whom the initial presentation, usually a mild spastic paraparesis (spasticity and weakness that leads to difficulty in walking), progressively worsens without any remission (primary progressive MS [PPMS]).

In time, the majority of patients develop an increasing range of symptoms, many of which worsen slowly and result in progressive and complex disability. This poses particular problems in terms of management, in that the symptoms tend to interact with each other, and it may be inappropriate to treat one symptom in isolation. For example, the carrying out of clean, intermittent self-catheterization to manage bladder control must take into account the patient’s cognitive ability, upper limb dexterity, and lower limb mobility (in relation to spasticity, etc.). It is also important to appreciate that the treatment of one symptom may worsen another, such as the effects of anti-spasticity or antidepressant agents in people already suffering from severe fatigue. This is, at least in part, the rationale behind the need for goal-orientated multidisciplinary rehabilitation.

This chapter discusses the treatment of individual symptoms followed by rehabilitation and service provision. In contrast to the previous section, which was able to call upon evidence from randomized control trials, there is a paucity of such data available in symptomatic management and rehabilitation. The studies that have been carried out have tended to be small and poorly designed. To address this deficit, two important initiatives were set up—the Multiple Sclerosis Council for Clinical Practice Guidelines (MSCCPG) (which has since been disbanded) and the establishment of the Cochrane Collaboration for Multiple Sclerosis.

The MSCCPG was a collaboration of a number of key organizations involved in MS, including the Consortium of Multiple Sclerosis Centres (North America), Rehabilitation in Multiple Sclerosis (RIMS – A European Organization of MS Centres), and the Multiple Sclerosis International Federation (MSIF). The MSCCPG has published guidelines on fatigue, bladder management, and spasticity. The Cochrane Collaboration has carried out systematic reviews on symptomatic management and multidisciplinary rehabilitation in MS.
In the United Kingdom, the National Institute for Clinical Excellence has produced detailed guidance on the management of MS, incorporating all available supporting evidence, which is a valuable resource (NICE 2003 – www.nice.org.uk). Most recently the World Health Organisation has produced an overview of the global impact of neurological disorders which has included MS, a condition with a relatively low prevalence but high economic burden. Importantly it emphasises the importance of Rehabilitation as a key area of development and dissemination world-wide.