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Hypoxic-Anoxic Brain Injury

Introduction & Definition

Oxygen is required for normal brain functioning. Hypoxic-anoxic injuries result when there is a substantial (partial, or hypoxic) or a complete (total, or anoxic) lack of oxygen supplied to the brain.

This diminished oxygen supply to the brain may produce profound cognitive (thinking), physical (movement), and affective (emotional) impairments which may be slow to recover. As a result, hypoxic-anoxic injury (HAI) can have a catastrophic impact, both in terms of functional (what a person can do) deficits as well as the costs involved in treatment and the disruption it can cause among associated families.

One of the problems that has plagued affected individuals and their families is the relative lack of easy-to-read, accessible information to answer their questions.

This fact sheet will help answer some of these questions.

Causes of Hypoxic-anoxic Injury (Etiology)

Why is oxygen important?

The brain consumes about 20% of the body's total oxygen. 90% of the brain's total energy is used to send electrochemical impulses and maintain the neurons' ability to send these impulses. Much like the base of a pyramid on which everything else rests, oxygen is necessary to metabolize glucose which is used to provide the energy for all living cells.

If oxygen is not available, a cascade-effect of problems occurs. Oxygen and glucose are responsible, either directly or indirectly, for a variety of chemical reactions which are involved in the production of important chemical-like brain neurotransmitters (e.g., dopamine, norepinephrine, and serotonin).

Such neurotransmitters act to regulate the brain's many complex functions. One particular neurotransmitter, acetylcholine (Ach), seems to play a direct role in memory. HAI can be caused by a variety of disease processes and injuries. Although there are several possible reasons for anoxic injury, hypoxic-ischemic injury (HII) is the most common.

Anoxic anoxia--not enough oxygen is in the air to be absorbed by the body and used (high-altitude sickness). Unless the person has just climbed Mount Everest or is a jet pilot, this is an uncommon cause. Anemic anoxia--basically, not enough blood or hemoglobin, which is a chemical in red blood cells that carry oxygen throughout the body.

Acute hemorrhage, chronic anemia, carbon monoxide poisoning are common causes of this type of injury. Acute hemorrhages (bleeding) can occur due to gunshot wounds.

Chronic anemia occurs when there are persistent low red blood cells or hemoglobin. Carbon monoxide poisoning is seen in suicide attempts using the exhaust of automobiles, but can also occur in home or industrial accidents (e.g., malfunctioning furnace, cleaning oil tanks, working with machinery in poorly ventilated areas).

Carbon monoxide poisoning also appears to selectively damage particular areas of the brain (such as the basal ganglia, caudate nucleus, putamen, globus pallidus, and central white matter). These brain areas are important for the control of movement.

Stagnant (ischemic) anoxia (also called hypoxic-ischemic injury, or HII)--not enough cerebral blood flow to carry blood to the brain. Injury can be localized (such as ischemic strokes) or generalized (circulatory collapse secondary to cardiac arrhythmias or cardiac arrest). This type of injury causes general, diffuse damage to the cerebral cortex and cerebellum.

Areas of the brain that are very sensitive to lack of oxygen include the hippocampus (a region critical for memory), borderzone areas of the cerebral cortex (the parieto-occipital and frontoparietal regions), cerebellum, basal ganglia, and spinal cord (thoracic region).

Below is a summary of the more frequent causes of cardiac arrest, perhaps the most common cause of ischemic anoxia:

Anesthesia accidents--32%
Atheroscl cardiovascular disease ("hardening of the arteries")--29%
Asphyxia (drowning and suicide attempts)--16%
Chest trauma--about 10%
Electrocution--about 6.5%
Severe bronchial asthma--3%
Barbiturate poisoning--3%

(Source: Groswaser, Ze'ev, Cohen, & Costeff, 1989.)

Symptoms

The symptoms of hypoxic-ischemic injury (HII) are related to the areas of the brain and spinal cord that are damaged. A brief summary of the types of symptoms and regions of the brain responsible are described below.

Symptoms will be divided into cognitive and physical deficits:

Cognitive deficits. The cognitive symptoms observed from most to least common are:

Short-term memory loss. This is by far the most common, virtually universal, symptom of HII. The reason is that one portion of the brain believed to be critical for learning new information (called the hippocampus) has neurons which are highly sensitive to changes in chemistry or trauma.

Executive functioning (reasoning/judgment, initiation, perseveration, and impulsivity). Word-finding difficulties (also called anomia).

Visual disturbances. A person may have difficulty processing incoming visual information. In rare instances, a disorder called cortical blindness (Anton's Syndrome) may be observed in HII. In this case, the area of the brain responsible for vision becomes disconnected from the rest of the brain.

Because the brain cannot tell that this part of the brain is damaged or disconnected, a person may act as though he/she can see, even though he/she shows no ability to identify or discriminate objects, shapes, or colors.

Physical deficits

Commons symptoms may include:

Ataxia (incoordination). These symptoms are similar to those seen in alcohol-intoxicated individuals. Areas of the brain that may be affected are the cerebellum, basal ganglia, and putamen.

Apraxia (inability to follow a sequence of commands).

Spasticity, rigidity, myoclonus.

Abnormal movements.

Quadriparesis (weakness of all four extremities), paresis (weakness) or paralysis (inability to move). This can also occur due to spinal cord damage.

Predicting Outcome (Will the person recover?)

Why is the recovery of from HAI different from traumatic brain injuries or strokes? Recovery is thought to occur for a variety of reasons. One theory is that there exists a neuronal reserve which is used to compensate for lost nerve cells. Because an anoxic injury is diffuse and widespread, this may deplete the reserve capacity substantially.

Predicting outcome is much like estimating how high a rocket will go up. There are some general factors at the start of the launch which will be helpful, but the actual course of the rocket will also point out future progress. In other words, past and current changes will predict future recovery.

Below is a list of these factors.

Coma duration--as might be expected, the longer a person is in a coma, the less promising the outcome. One study suggested that if coma is less than 12 hours, there is no or little transient damage. If coma is greater than 12 hours, recovery may be slow and incomplete (lasting deficits). If coma is 24 hours or more, the person is at a greater chance of dying. Another study showed that 21% of HAI patients who remained in coma four weeks or less had a good recovery, and 79% had a poor recovery. 100% of those patients who remained in coma more than four weeks had a poor recovery. Also, the patients whose coma durations were greater than four weeks tended to show minimal recovery (functional gains) after the first four months. If a person does not "wake up" from a coma, then significant damage to the cerebral cortex, called laminar necrosis may have occurred. Like wood-paneling, the cerebral cortex is made up of a number of layers. If these cells die, the layers become separated from each other. This results in neocortical death while lower brain functions continue to operate (called a persistent vegetative state).

Pupillary reactivity--when both eyes have "fixed", or dilated pupils, this points to a very poor prognosis. Even survival is highly questionable as such signs point to brainstem damage, which is a brain area responsible for keeping the body regulated (like breathing, heart-rate, etc.).

brain stem reflexes--one of the brain's many reflexes that can be tested by a neurologist. If these are not present, it suggests lower brain-stem damage.

Age--Some studies suggest that patients 25 years and younger have a better rate of recovery than those who are older.

Cause of injury--there have been several studies which suggest that functional recovery is unrelated to the cause of the cardiopulmonary arrest. Imaging studies (CT/MRI scans)--These imaging techniques typically fail to find any recent (acute) damage. If an imaging study is done several months later, damage may include brain matter loss (atrophy) with resulting enlargement of the ventricles. EEGs/Evoked Potentials (EPs)--If EEGs show cortical activity, then it is a positive prognostic sign. EEGs/EPs may also be used to determine brain death through the lack of cortical electrical activity.

Treatment and Course of Injury

Unfortunately, direct treatment of the anoxia is limited. Some studies have suggested the use of barbiturates, which slow down the brain's activity, may be helpful in the first 2-3 days of injury onset.

Otherwise, the general medical approach is one of maintaining the body's general status. Once a person becomes medically stable, the next question is to what capacity can he/she recover/participate?

Rehabilitation efforts may be attempted anywhere along the several stages of recovery:

Coma--a condition in which the person appears to be sleeping, but is unable to be aroused

Persistent vegetative state (PVS)--"wakeful unresponsiveness"; a person who is neither in a coma nor conscious.

Conscious--a person is awake and able to interact with his/her environment.

Coma/PVS rehabilitation

In the 1980s and early 1990s, coma or sensory stimulation was thought to help speed the person from coma or persistent vegetative state (PVS). However, there have been a number of studies which, to date, do not support these earlier claims.

Acute/sub-acute rehabilitation

If the person is conscious, then active attempts will be made to assist the patient to improve cognitive and functional skills. Course of treatment may be very long. During rehabilitation, the individual and family may interact with a variety of professionals as the need for constant medical attention (and hence for physician involvement) diminishes. Such professionals may include a physical therapist (who aids in improving walking/movement), an occupational therapist (who assists in retraining/relearning previously known daily living skills), a speech therapist (who helps with swallowing, speech or cognitive problems), and a neuropsychologist (who may assess the level and kind of cognitive impairment, collaborate on cognitive retraining and assist both the individual and family with behavioral and emotional issues).

As recovery may take months to years, rapport and a good working relationship with the rehabilitation specialists are very important. Because of extended contact, both the person in rehabilitation and his/her family may experience a variety of emotions as they learn to cope and adapt to a constantly changing condition.

Because expectations may not always match the person's current level of progress, the potential for disappointment and/or conflict may be high. Therefore, it is important to discuss such issues both early in the course of treatment as well as throughout the course of recovery.

Finally, predicting long-term recovery from hypoxic-anoxic brain injury can be difficult. Full rehabilitation potential is not always apparent early on. Often, depending on the nature and extent of the injury, rehabilitation and improvement can continue over a period of months or years.

Families should stay informed and involved. It is important that the person's family work with the rehabilitation team to help ask and answer questions about the person, monitor care, and provide support. Working together is one way to help maximize the person's potential and ensure that the person can continue to live in the least restrictive environment.

Credits

Caronna, J. (1979).Diagnosis, prognosis, and treatment of hypoxic coma.

Advances in Neurology, 26, 1-15. Gibson, G.E., Pulsinelli, W., Blass, J.P., Duffy, T.E. (1981).

Brain dysfunction in mild to moderate hypoxia. American Journal of Medicine, 70, 1247-1254. Groswasser, Ze'ev, Cohen, M., & Costeff, H. (1989).

Rehabilitation outcome after anoxic brain damage. Archives of Physical Medicine & Rehabilitation, 70, 186-188. Myer, R.E. (1979). A unitary theory of causation of anoxic and hypoxic brain pathology.

Advances in Neurology, 26, 195-213.

Brain Injury/Head Injury

Definition

Brain injury, also known as traumatic brain injury, is an injury that results in damage to the brain. Brain injury may occur in one of two ways: A closed head injury occurs when the moving head is rapidly stopped, as when hitting a windshield, or when it is hit by a blunt object causing the brain to smash into the hard bony surface inside the skull.

Closed head injury may also occur without direct external trauma to the head if the brain undergoes a rapid forward or backward movement, such as when a person experiences whiplash. A penetrating head injury occurs when a fast moving object such as a bullet pierces the skull. Both closed and penetrating head injuries may result in localized and widespread, or diffuse, damage to the brain.

Facts

Each year, an estimated 2 million people sustain a head injury. About 500,000 to 750,000 head injuries each year are severe enough to require hospitalization.

Head injury is most common among males between the ages of 15-24, but can strike, unexpectedly, at any age. Many head injuries are mild, and symptoms usually disappear over time with proper attention. Others are more severe and may result in permanent disability.

Consequences

Cognitive Deficits-Shortened attention span, short-term memory problems, problem solving or judgment deficits, inability to understand abstract concepts. Loss of sense of time and space, identity of self and others. There may also be an inability to accept more than one- or two-step commands simultaneously.

Motor Deficits-Paralysis, poor balance, lower endurance, reduction in the ability to plan motor movements and poor coordination.

Perceptual Deficits-Possible changes in hearing, vision, taste, smell and touch, loss of sensation of body parts, left or right side of body neglect. The individual may have difficulty understanding where limbs are in relation to body.

Speech Deficits -Speech that is not clear as a result of poor control of the speech muscles (lips, tongue, teeth, etc.) and poor breathing patterns.

Language Deficits-Difficulty expressing thoughts and understanding others. This may include problems identifying objects and their function as well as problems with reading, writing, and ability to work with numbers. It is important to note that although pronunciation may be normal, what is being said may be inappropriate. Speech therapy may be necessary to work with the language problems.

Social Difficulties-Impaired social capacity resulting in self-centered behavior in which both empathy and self-critical attitudes are greatly diminished.

Regulatory Disturbances-Fatigue and/or changes in sleep patterns. Also loss of bowel and bladder control.

Personality Changes-Apathy and decreased motivation. Emotional lability, irritability, depression. Disinhibition which may result in temper flare-ups, aggression, cursing, lowered frustration tolerance, and inappropriate behavior.

Traumatic Epilepsy Epilepsy occurs in 2 to 5 percent of all people who sustain head injury, but it is much more common with severe or penetrating injuries.

While most seizures occur immediately after the injury or within the first year. It is also possible for epilepsy to surface years later. Epilepsy includes both major or generalized seizures and minor or partial seizures.

Generalized Seizures, also called "Grand Mal" are the most dramatic type of seizure. The person falls unconscious to the ground. His or her body stiffens, then jerks convulsively. The mouth, eyes, legs and arms move. Incontinence of urine is common. After several minutes, the jerking movements slow and the seizure ends. The person will likely be drowsy afterwards and may not remember the seizure.

Partial (also known as focal) Seizures may be simple (during which the person is conscious, but temporarily loses control of movements or senses. The person may uncontrollably jerk an arm or leg) or complex (in which the person appears to be in a trance and may have uncontrollable movements, such as lip smacking or picking at their clothes).

Most seizures (about 75%) are partial although many of these seizures may eventually generalize. Prognosis The extent of an individual's enduring problems after a head injury depend on many factors. Prompt and proper diagnosis and treatment can help minimize some consequences of head injury.

However, it is usually difficult to predict the outcome of a traumatic brain injury in the first hours, days, or weeks. In fact, the outcome may remain unknown for many months or years.

Treatment

Rehabilitation of the individual with a brain injury begins immediately. The initial life-saving treatment may be provided by an EMT, emergency physician, neurosurgeon or neurologist.

As the person improves, a team of specialists may be used to evaluate and treat the problems that result. This team may include experts in rehabilitation medicine (physiatrist), psychiatry, nursing, neuropsychology, social work, nutrition, special education, occupation, physical, speech and language therapies, cognitive retraining, pastoral support, activity therapy, and vocational rehabilitation.

The individual and his/her family are the most important members of the team, and should be included in the rehabilitation and treatment to the greatest extent possible. There are a variety of treatment programs along the continuum of care, including: acute rehabilitation, long-term rehabilitation, coma treatment centers, late rehabilitation, extended intensive rehabilitation, transitional living programs, behavior management programs, life-long residential, day treatment programs, independent living programs, and Traumatic Brain Injury programs within community colleges.

Credits

National Institute of Neurological Disorders and Stroke, February, 1989, Inter-Agency Head Injury Task Force Report, Bethesda, MD. Soren, S. and Kraus, J.F., 1991.

Occurrence, Severity and Outcomes of Brain Injury, Journal of Head Trauma Rehabilitation, 6(2), 1-10. Resources Family Caregiver Alliance Website: http://www.caregiver.org

Brain Tumor

Definition

A tumor is an abnormal mass of tissue which results from the excessive multiplication of cells. A tumor that originates in the brain is called a "primary" brain tumor. Primary brain tumors may be either benign or malignant. These tumors very rarely, if ever, metastasize (spread to other parts of the body). Metastatic brain tumors begin as a cancer elsewhere in the body then spread to the brain.

Facts According to the American Brain Tumor Association, the estimated number of new cases of primary brain tumors diagnosed each year is approximately 20,000. An additional 20,000 individuals are diagnosed with metastatic brain tumors. Brain tumors are usually classified by cell types. Certain types of primary brain tumors most commonly occur in children while others occur more frequently in adults.

Adult brain tumors have their highest incidence between the ages of 40 and 60 years, with a slight preponderance in men.

Symptoms

Symptoms may vary by type and location of the brain tumor. They can include: severe headaches, seizures, visual disturbances, motor weakness, sensory disturbances, language disorders, short term memory loss, personality changes, mood swings, intellectual impairment, and endocrinological disturbances.

Diagnosis

Diagnosis of a brain tumor occasionally is difficult because symptoms may be similar to those caused by other disorders. However, early detection is important as early treatment may limit the extent of damage to physical and mental functions. Making the diagnosis of a brain tumor has been greatly simplified since the advent of CT scans and MRI scans.

Occasionally other techniques like an arterio-gram (shows the blood vessels in the brain) or sometimes an electroencephalogram (measures the electrical activity of the brain) may be used in order to obtain more information about a lesion seen on a CT or MRI scan.

For certain types of brain tumors, it is also important to analyze cerebrospinal fluid, obtained by a lumbar puncture, for the presence of tumor cells.

Treatment

Various forms of treatment are available:

1.Surgery

The first treatment for most brain tumors is either surgery to remove the tumor or a biopsy to obtain a small sample of tumor. The tumor tissue that is removed is used to determine the exact type of tumor.

Additional treatment depends on the tumor type and amount of tumor removed. Side effects of surgery include the risks of infection, blood clotting, seizures and, in some cases, increased neurological deficit that may be temporary or permanent.

2.Radiation Therapy

Conventional radiation therapy uses external beams of either x or gamma rays aimed at the tumor. The therapy is given over a period of several weeks. Other types of radiation also are available. One of these is interstitial radiation_implanting radioactive seeds directly into a tumor. Stereotactic radiosurgery delivers a high, single dose of radiation to a small, well-defined area. Another technique is photodynamic therapy. A light sensitive drug is given through a vein and concentrates in the tumor. Then, during a surgical procedure, a special light activities the drug. Hyperthermia uses heat to kill tumor cells.

Also available are other forms of radiation energy, dosages, and schedules. Side effects of radiation therapy may include hair loss, skin irritation, fatigue and, rarely, increase of preexisting neurologic deficits.

3.Chemotherapy

Certain chemotherapeutic drugs have proven to be effective in controlling the growth of a tumor for shorter or longer periods of time. Research continues to develop new drugs, new combinations of drugs and new ways of delivering drugs. Side effects of chemotherapeutic drugs include nausea or vomiting, disruption of the production of blood cells in the bone marrow, occasionally soreness of the mouth or mouth ulcers and skin rash. These side effects are usually reversible and may vary with each individual.

4.Immunotherapy

This is a form of therapy aimed at activating the patient's own immune system in order to kill tumor cells. This group of substances includes the interferons, interleukins, growth factors and others. These forms of therapy are still experimental and only used in strictly controlled protocols at certain treatment centers.

Steroids Drugs such as prednisone and dexamethasone are being used throughout the treatment of patients with brain tumors in order to reduce the swelling around the tumor. Side effects are increased appetite and therefore weight gain, swelling of face and feet, nervousness or restlessness, trouble sleeping, blood sugar and hormonal disturbances, and weakening of bones and muscles.

Recommended Readings

Navigating Through A Strange Land. A Book For Brain Tumor Patients and Their Families, Patricia Ann Roloff (Ed), 1995, Indigo Press, 109 Walnut St., San Francisco, CA 94118.

Coping With a Brain Tumor Part I: From Diagnosis to Treatment and Part II: During and After Treatment, American Brain Tumor Association, 2720 River Road, Ste. 146, Des Plaines, IL 60018.

A Primer on Brain Tumors, Sixth Edition, Gail Segal, 1996, available from the American Brain Tumor Association, 2720 River Road, Ste. 146, Des Plaines, IL 60018.

Love, Medicine and Miracles, Bernie Siegel, 1986, Harper Perennial, New York, NY, (800) 242-7737.

Brain Tumors: A Guide, the National Brain Tumor Foundation, 1993, 785 Market St., #1600, San Francisco, CA 94103-2003.

Multiple Sclerosis

Definition

Multiple Sclerosis (MS) is one of the most commonly encountered neurological diseases, yet its cause is unknown and its course unpredictable.

MS is a disorder of the brain and spinal cord which results from a scattered loss of myelin, a fatty substance that surrounds the nerve cells. Myelin is considered important for separating nerve pathways from each other, so that impulses can travel from one location in the nervous system to another.

"Multiple" comes from the multiple sites where the disease is scattered in the brain and spinal cord. "Sclerosis" refers to "sclera" or scar tissue which can obstruct or distort the flow of messages between nerves and to muscles.

Facts

About 350,000 people nationwide have MS. MS affects people of all ages, but is most likely to begin between the ages of 20 and 40. Women are twice as likely as men to develop MS. MS differs markedly from one patient to another.

Prognosis It is often very difficult to predict the course of MS. The great variability of this disorder must be considered in each individual case.

Some studies have shown that the degree of disability present at five years after the onset of symptoms is a good predictor of disability at 10 or 15 years after onset, and many neurologists use this "five year" rule in predicting a person's course.

Other studies suggest that sensory problems (e.g., loss of feeling on the skin's surface, "pins and needles," or increased sensitivity to pain) are associated with a good prognosis, that is, a relatively benign course. Early onset of cerebellar findings, (e.g., tremor, coordination problems and slurred speech) tend to be linked to a more progressive disease course. MS tends to take one of four clinical courses. Some people have the benign sensory form, where attacks are characterized by sensory symptoms and/or optic neuritis. These individuals generally do not have severe long-term disability.

Many people with MS have a relapsing/remitting course characterized by periodic, unpredictable exacerbations where existing symptoms worsen or new symptoms appear. Remission from such flare-ups may be complete or partial. When remission is partial, the course may be referred to as relapsing/remitting turned progressive. Such individuals sometimes develop a progressive form.

A minority of people with MS have a severe, progressive form of the disease from onset, where symptoms generally do not remit, but tend to be progressive from the onset. Research is currently going on to try and identify more precise prognostic indicators of disease activity.

Symptoms

The most prominent symptoms are:

Visual Problems--Ranging from blurred vision to more serious visual impairment, often a symptom which disappears later. Blindness in MS is rare.

Ataxia--Difficulties in controlling the strength and precision of movements, so that holding things is a problem; balance and coordination may be impaired.

Sensory Problems--Numbness, tingling and sensitivity to heat or cold.

Bladder--Control problems and urinary tract infections.

Mood Swings--Ranging from depression to euphoria.

Fatigue--Mild to severe fatigue and weakness.

Cognitive Problems

Most people with MS do not show any evidence of intellectual deficits. However, it is estimated that about 40 percent of people with MS have mild cognitive dysfunction and another 10 percent have moderate to severe cognitive impairment.

Among those individuals affected by cognitive impairment, the most common problems include: Memory recall, particularly remembering recent events. Slowness in learning and processing new information. Difficulty with abstract reasoning, such as analyzing a situation, planning a course of action, and following through. Poor judgment. Impaired verbal fluency, such as slowed speech or difficulty coming up with a word during conversation.

Cognitive problems associated with MS are not related to a person's level of physical disability and can potentially affect people with few physical symptoms of MS. In addition, cognitive problems can develop rapidly during an exacerbation of the disease. In these cases, the cognitive deficits can improve as the person comes to a remission. It is important to stress that cognitive impairment in MS bears little resemblance to the intellectual decline in Alzheimer's disease.

People with MS virtually never experience severe, progressive cognitive decline. Cognitive impairment in MS is typically mild and may stabilize at any time. Individuals with MS and their families should be aware of potential cognitive problems.

Recognizing and learning about certain deficits can dispel misunderstandings about a person's apparent forgetfulness, carelessness, or seeming indifference. Families can be supportive and help the person compensate. Understanding deficits can alleviate fears about losing one's capacities. If cognitive impairment is suspected, this topic should be discussed with the person's doctor. In some cases, depression or medications can mimic cognitive problems. These can be treated separately.

A neurologist can perform a brief evaluation to test for pronounced (severe) cognitive deficits. However, a neuropsychologist (preferably one with experience with MS) may be recommended to perform a more complete evaluation to test for subtle cognitive changes. If deficits are found, the neuropsychologist can follow up to help individuals and their families cope with cognitive problems and to work on cognitive rehabilitation. There are a number of compensatory strategies individuals can use to cope with mild cognitive problems.

These include memory aides such as writing down all appointments, making check lists, or using memory "tricks" (e.g., visual images or rhymes) to help remember. Practicing concentration and focus when listening will also minimize distractions and help the person retain new information.

Diagnosis

There is no single test available to clearly identify MS, although Magnetic Resonance Imaging (MRI) is currently the most sensitive diagnostic test. The diagnostic process usually takes a period of time and is based on cumulative symptoms and tests and a good patient medical history.

Treatment In May 1996, the U.S. Food and Drug Administration (FDA) approved Avonex (Interferon beta-1a) for its ability to slow progression of physical disability and reduce the number of relapses, or flare-ups, in people with relapsing forms of MS. This joined Betaseron (Interferon beta-1b), which was approved in 1993 for reducing the number and severity of relapses in people with relapsing/remitting MS.

Other treatment is targeted to help patients function at their best level on a day-to-day basis. Some evidence indicates that steroid-type drugs such as ACTH or prednisone will reduce the severity of an attack. This varies, however, from individual to individual. Medications are available for symptomatic treatment. Muscle relaxers aid in reducing spasms. Bowel and urinary distress are treated with management programs. Some people benefit from intermittent catherization.

A urologist or neurologist can help determine if this option is suitable. Rehabilitation programs are helpful in some cases to increase muscle strength or improve walking ability. Getting Support It is important for both individuals and family members to get support when dealing with MS.

Support groups are often available for both individuals and family caregivers. Counseling also may be helpful for individuals or couples learning to cope with chronic illness or periodic health crises. Caregivers with constant care responsibilities should schedule some time off from care giving

Respite care can be arranged through family members, friends, volunteer services, independent living centers, or home care agencies.

Recommended Readings

Multiple Sclerosis: A Guide for Patients and Their Families, 2nd ed., Louis J. and Shelley Ross, 1992, Fireside Press, Simon & Schuster, Inc., 1230 Avenue of the Americas, New York, NY 10020.

Mastering Multiple Sclerosis: A Guide to Management, 2nd ed., John K. Wolf, 1996, Academy Books, Box 757, Rutland, VT 05701.

MS Fact Book, Richard Lechtenberg, 1995, F. A. Davis Company, 1915 Arch St., Philadelphia, PA 19103.

The Other Victim: How Caregivers Survive a Loved One's Chronic Illness, Alan Drattell, 1996, Seven Locks Press, P.O. Box 25689, Santa Ana, CA 92799.

Resources

Family Caregiver Alliance supports and assists caregivers of brain-impaired adults through education, research, services and advocacy.

FCA's information Clearinghouse covers current medical, social, public policy and caregiving issues related to brain impairments.

For residents of the greater San Francisco Bay Area, FCA provides direct family support services for caregivers of those with Alzheimer's disease, stroke, head injury, Parkinson's, MS and other debilitating brain disorders that strike adults.

National Multiple Sclerosis Society
733 Third Ave., 6th Floor
New York, NY 10017
(212) 986-3240 (800) FIGHT-MS (rings to nearest chapter office)

The National Multiple Sclerosis Society provides individual and family counseling visits, telephone reassurance, social services, advocacy, durable medical equipment, water exercise, transportation, education and recreational programs. There are eight MS Society Chapters throughout California. The coalition of California chapters is called MS-CAN.

American Academy of Physical Medicine and Rehabilitation
IBM Plaza, Suite 2500
Chicago, IL 60611-3604
(312) 464-9700

American Board of Clinical Neuropsychology
Department of Pychiatry c/o Linus Bieliasukas
University of Michigan Medical Center
1500 E. Medical Center Drive
Ann Arbor, MI 48109-0704
(313) 936-8269

4220 Montgomery Lane
P.O. Box 31220
Bethesda, MD 20824-1220
(301) 652-2682

Independent Living Research Utilization Program
2323 Shepard, Suite 1000
Houston, TX 77019
(713) 520-0232

National Association for Continence
P.O. Box 8310
Spartanburg, SC 29305-8301
(800) BLADDER (864) 579-7900

Well Spouse Foundation
610 Lexington Ave., Suite 814
New York, NY 10022
(212) 644-1241 (800) 838-0879