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Multiple Sclerosis DIAGNOSED IN 2000
Multiple SclerosisBY DEBR A FR ANKEL, MS, OTR WITH HETTIE JAMES Debra Frankel, MS, OTR is Vice President of Healthcare Access Initiatives for the Advocacy, Services and Research Department at the National MS Society. Hettie Jones is a professional writer.
Reviewed by: Pat Bednarik, MS, CCC-SLP, MSCS; Adrienne Boissy, MD; James Bowen, MD; Sharon Dodge, MS activist; George Garmany, MD; Barbara Giesser, MD; and Pat Kennedy, RN, CNP, MSCN 2015 National MS Society. All rights reserved. IntroductionIf this book has made it into your hands, the words "multiple sclerosis" (MS) may have been recently spoken by your physician. These words can be incredibly scary whether you have never heard of MS before or have some personal experience with MS in friends or family. This guide is designed to help ease some of those fears and educate you about what MS is and what MS is not. Keep in mind that each individual's experience with MS is unique, and that having MS today is different from what it was like in the past. Today there are a number of effective treatments for the disease — with more in the pipeline. Be sure to educate yourself, and don't succumb to myths and Clearing up misconceptionsMultiple sclerosis isn't entirely understood yet, so there are many misconceptions about it. Here are some myths you may have heard already: "MS is fatal."Life expectancy for people with MS has increased over time. We believe this is due to treatment breakthroughs, improved healthcare and lifestyle changes. Recent research, however, indicates that people with MS may live an average of about seven years less than the general population because of disease complications or other medical conditions. Many of these complications are preventable or manageable. Attention to overall health and wellness can help reduce the risk of other medical conditions, such as heart disease and stroke, that can contribute to a shortened life expectancy. In some rare instances, there are cases of MS that progress rapidly from disease onset and can be fatal. "Everyone with MS will be in a wheelchair sooner or later."Not true. Many people living with MS remain able to walk without help. And, with the increased availability and use of disease-modifying therapies and other treatments, more people are remaining mobile longer. People who are able to walk may choose to use a wheelchair, cane, scooter or other device to conserve energy or prevent injury from falls. In a National MS Society 2 large-scale study of people with MS, 32% reported using a mobility device, 12% of respondents used a wheelchair or scooter for mobility, and 19% reported using a cane or other mobility device to walk. (Harris Interactive on behalf of Acorda Therapeutics, Inc. and the National MS Society) "Life in a wheelchair is a half-life."People who use wheelchairs work, drive cars, travel, participate in sports, maintain meaningful family and social lives, contribute to the community, and pursue their dreams with as much passion as people who don't use wheelchairs.
"You should stop working. The stress is harmful."There is no scientific evidence that the normal stress of working has any effect on MS. But symptoms such as fatigue and cognitive problems can cause problems on the job. A recent Society-funded study indicated that about 44% of people with MS are currently in the workforce. That number could be higher; the National MS Society is working to influence the attitudes of employees and employers alike, as well as help them understand their rights and responsibilities in the workplace.
"You shouldn't have children."Studies have demonstrated that the risk of an MS relapse (also called an attack or exacerbation) is reduced during pregnancy, particularly during the second and third trimester, compared to the relapse rate prior to pregnancy. The risk of an attack then rises somewhat in the first six months after delivery. Overall, however, pregnancy and childbirth have no long-term effect on MS progression. MS is not directly inherited, but genetics play an important role in who gets the disease. Those who fear passing on the disease to their children should know that the risk is actually very small — somewhere between 1 and 5%. So the news for prospective parents is good all around. However, one hallmark of MS is its unpredictability, so planning ahead as much as possible is helpful during pregnancy and beyond.
"Diet can cure MS."No specific diet has been found to treat MS or slow disease progression. While efforts to study the impact of various dietary strategies continue, people with MS are strongly advised to limit sugar and processed foods (particularly those high in sugar, salt and sodium), increase fruits and vegetables, choose lean sources of protein, choose healthy fats, and consume adequate amounts of fiber and fluids.
"MS is the same as muscular dystrophy."Muscular dystrophy (or MD) is a disease of the skeletal or voluntary muscles that control movement. Multiple sclerosis (or MS) is a disease of the central nervous system. The two diseases are completely unrelated to each other. MS damages the nerves that control muscles, not the muscles themselves.
National MS Society 4 What is multiple sclerosis?MS is thought to be an immune-mediated disease that primarily affects the central nervous system (CNS). The CNS consists of the brain, spinal cord and the optic nerves. Surrounding and protecting the nerve fibers of the CNS is a fatty tissue called myelin, which helps nerve fibers conduct electrical impulses.
In MS, myelin is lost in multiple areas, leaving scar tissue called sclerosis. These damaged areas are also known as plaques or lesions. The nerve fiber itself (called the axon) can also be damaged or broken.
Myelin not only protects nerve fibers, it makes their job possible. When myelin and/or the nerve fibers are destroyed or damaged, the ability of the fibers to conduct electrical impulses in the brain and spinal cord is disrupted, and this produces the various symptoms of MS.
MS is not contagious; no one in your family will catch it What causes this disease?While the exact cause of MS is unknown, most researchers believe that the damage to myelin results from an abnormal response by the body's immune system. Normally, the immune system defends the body against foreign invaders such as viruses or bacteria. In MS, the immune system attacks the body's own healthy tissue — the myelin in the CNS.
Scientists do not yet know what triggers the immune system to do this. Most agree that several factors are involved, including a genetic predisposition that may make someone more susceptible to whatever stimuli or agent(s) in the environment cause the MS to become active.
symptoms of MS?Symptoms depend on which areas of the CNS have been attacked. Symptoms are not only different for different people, but different in the same person from time to time.
Symptoms may range from mild to severe. They may go away on their own or they may not. A person with MS will usually experience more than one symptom, but not all of them.
National MS Society 6 Symptoms include weakness, tingling, numbness or impaired sensation, poor coordination, fatigue, problems with balance, visual disturbances such as blurred or distorted vision or involuntary rapid eye movement (also called nystagmus), tremors, spasticity or muscle stiffness, problems with speech or swallowing, bowel or bladder problems, unstable walking, problems with sexual function, sensitivity to heat, moodiness or irritability, increased susceptibility to clinical depression, and problems with memory, judgment or reasoning (cognitive problems).
In severe cases, MS can cause partial or complete paralysis. Remember, the majority of people with MS do not have all these symptoms and many have only a few of these How is MS diagnosed?Because no single test can diagnose MS, several tests and procedures are commonly used to diagnose MS, including: n A medical history, in which the physician will look for evidence of past neurological signs and symptoms.
n A thorough neurological exam.
n MRI (magnetic resonance imaging), a noninvasive form of imaging that produces detailed pictures of the brain and spinal cord.
n Blood tests that can test for certain uncommon illnesses that can occasionally resemble MS (e.g. lupus, vitamin B12 deficiency and others).
Other tests that may be helpful where diagnosis is unclear are: n Lumbar puncture (or spinal tap), to look at the composition of the fluid that surrounds the spinal cord (cerebrospinal fluid or CSF) for signs of problems in the immune system.
n Studies called "visual evoked potentials" (VEP) and somatosen- sory evoked potentials (SEPs) that measure the response of the CNS to visual or sensory stimuli.
What about a second opinion?If you've seen only one doctor, it's certainly reasonable to get a second opinion. Your original doctor should not be insulted or hurt because you want to confirm your diagnosis. You might ask your family doctor or call the National MS Society for a referral to a physician that specializes in MS in your area.
National MS Society 8 What will happen next with my MS?No one can know with certainty. You and your doctor should talk over your particular situation. The words you will hear most often are "unpredictable" and "variable." Living with this unpredictability is part of living with MS.
Many people go through days or weeks when new symptoms appear or existing symptoms become more severe. These are called relapses or exacerbations. Exacerbations are usually followed by remissions, which may bring you back to your pre-relapse level or may leave you with some remaining disability. This form of MS is called relapsing-remitting MS.
Some people never have attacks but instead experience slow and steady worsening of symptoms and disability over time. When this pattern exists from the outset, it is called primary-progressive MS. When this steady pattern follows an earlier period of relapsing-remitting MS, it is called secondary-progressive MS.
MS may stabilize at any time, regardless of pattern. Your MS healthcare provider may have additional insights about your situation.
Is MS inherited?MS is not directly inherited, although studies do reveal a family predisposition. This means that siblings or other close relatives are somewhat more likely to develop the disease. However, the majority of people with MS do not have a close relative with MS.
Who gets MS?Women develop MS at a rate at least three times that of men. More than 2.3 million people are affected by MS worldwide. Because it isn't contagious, the reporting of cases is not required. So the actual number of people with MS can only be estimated.
MS is more common in those areas farthest from the equator. However, some ethnic groups, such as the Inuit, aborigines and Maoris, have few, if any, documented cases of MS regardless of where they live. This suggests that geography, ethnicity, genetics and other factors interact in some complex way that scientists have not yet fully determined.
MS occurs in most ethnic groups, including African- Americans, Asians and Hispanics/Latinos, but is more common in Caucasians of northern European ancestry. National MS Society 10 There is also accumulating evidence that the disease may be more severe in African-Americans than in other ethnic groups. The variation in severity and type of MS among different populations is an area of increasing research interest.
Are there treatments for MS?Yes, there are many treatments, which fall into two general groups. The first group — the Food and Drug Administration (FDA)-approved disease-modifying medications — works to slow or alter the disease process itself. The second group includes medications and techniques to improve or alleviate symptoms. Symptom management is vitally important for living well with MS. We've provided a brief introduction on page 13, but there are many additional strategies.
Because treatment for MS is changing so rapidly, it's a good idea to be in contact with your doctor for the most current information. The National MS Society is also a source of information on new developments. Call 1-800-344-4867 or check our web site often at nationalMSsociety.org. For
a useful tool to help people with MS and their healthcare providers discuss the benefits and risks of newly emerging 11 Living with MS What therapies help manage the disease?Today there are many therapies approved in the United States by the FDA to reduce the frequency of attacks in relapsing forms of MS, delay the progression of disability, and reduce the signs of new injury within the brain and spinal cord as seen on MRI scans. The Society's publication, "Disease-Modifying Therapies for Multiple Sclerosis," includes more information about each therapy including how each is administered, side effects and more. Visit nationalMSsociety.org/DMT or call to request.
The Multiple Sclerosis Coalition released a consensus paper
about the disease-modifying therapies, which summarizes the research showing that early and ongoing treatment with a disease-modifying therapy (DMT) is the best way to reduce MS disease activity and improve quality of life for people with MS. Experts agree that treatment with one of these medications should be considered as soon as possible following a confirmed diagnosis of MS with a relapsing course. http://ntl.ms/coalitionDMTsummary
Treatment may be recommended even before an individual
is definitely diagnosed, if the person has experienced one episode of neurologic symptoms (also called an attack, relapse or exacerbation) and has lesions on MRI scanning National MS Society 12 that are similar to those seen in MS. Several of the DMTs are given by injection, some are taken orally, and others are delivered by infusion. Other medications are in various stages of clinical trials or are under review by the FDA, and researchers are hopeful that more treatments will be available in the near future. Keep up to date on these new treatments; visit nationalMSsociety.org/meds.
Decisions about taking a DMT are best made through
discussions with your MS healthcare provider, carefully considering and weighing such factors as side effects, risks and benefits, lifestyle and cost. None of the DMTs is approved for use by women who are pregnant, trying to become pregnant, or breastfeeding.
relieve symptoms?Something can be done to moderate almost every MS symptom, but identifying the option(s) that are most effective for you with the fewest side effects often takes time and patience. Good communication with your healthcare team is the key. And there is more to managing MS symptoms than taking medication. Healthy living habits, stress management, spiritual life and psychological support all play a part in living well with MS.
13 Living with MS n Corticosteroids, such as methylprednisolone (Solu-Medrol®), or prednisone, are used to shorten attacks (also called relapses, exacerbations or flares) and the discomfort resulting from the symptoms that occur during attacks.
n Spasticity or stiffness in the muscles can be managed with stretching exercises and medications including baclofen (Lioresal®), tizanidine (Zanaflex®), dantrolene (Dantrium®) and onabotulinumtoxinA (Botox®), among others.
n Walking speed may be increased by a medication called fampridine (Ampyra®), which helps to enhance conduction of nerve signals in nerve fibers on which the insulating myelin coating has been damaged.
n Fatigue may improve with aerobic exercise, energy-management strategies, and medications including amantadine (Symmetrel®), modafinil (Provigil®) and armodafinil (Nuvigil®).
n Certain bladder problems respond to medication, including oral medications such as tolterodine tartrate (Detrol®), oxybutynin (Ditropan®), mirabegron (Myrbetriq®), trospium chloride (Sanctura®), fesoterodine (Toviaz®), and solifenacin succinate (Vesicare®), among others, as well as onabotulinumtoxin A (Botox®) injections. Sometimes techniques such as self-catheterization or pelvic floor physical therapy (Kegel exercises) are recommended. Prompt treatment of urinary tract infections and adequate intake of fluids are important to help prevent bladder complications. An evaluation by a urologist is important for determining the appropriate treatment strategies.
n Bowel problems (such as constipation or loss of control) are not uncommon. They are managed with diet changes, lifestyle modifications, fluid changes, suppositories or medications.
National MS Society 14 n Burning, painful or unusual sensations (called paresthesias) may respond to medication, including carbamazepine (Tegretol®), amitriptyline (Elavil®), gabapentin (Neurontin®), pregabalin (Lyrica®), duloxetine hydrochloride (Cymbalta®) or others.
n Cognitive problems may be managed with rehabilitation and training.
n Speech and swallowing changes can be managed through rehabilitation and use of compensatory strategies.
n Mood changes, including moodiness, anxiety and depression, are best treated with a combination of talk therapy and medication. Significant mood swings generally respond well to a mood-stabilizing medication like divalproex sodium (Depakote®). Antidepressant medications are very effective, but it often takes time to find the optimal medication and dose for each person. Uncontrollable episodes of crying and/or laughing that are unrelated to a person's mood or circumstances — a relatively uncommon condition called pseudobulbar affect — can be treated with a medication called Nuedexta®, which is a combination of dextromethorphan and quinidine.
* NOTE: The information above was current at the time of publication. Please visit our website, nationalMSsociety.org/meds for updates about medications.
15 Living with MS What can rehabilitation offer?Rehabilitation cannot alter the course of MS itself, but may improve fitness, mobility, safety, and cognition, and enhance independence and quality of life.
Physical therapy (PT) can help strengthen muscles weakened by disuse and improve balance and mobility. A PT regimen might include range-of-motion exercises, stretching, strengthening and balance exercise, help with walking, and training in the use of canes, walkers or other assistive devices. PT can also include exercises to maintain or increase overall function, endurance and stamina, transfer training (for example, learning how to move safely from a wheelchair to a bed or toilet) and recommendations for a regular fitness program.
Occupational therapy improves independence in daily living. An occupational therapist (OT) can help people with MS attain maximum levels of independence and optimal functioning. OTs are specialists in energy conservation to combat fatigue and can teach techniques for dressing, grooming, eating and driving. They can provide exercises for coordination and strength, and recommend low- and high-tech equipment and strategies to adapt the home or workplace to increase safety, productivity and independence.
National MS Society 16 Speech therapy addresses problems for those who experience changes in speaking or chewing and swallowing due to weakness or poor coordination. Techniques used by speech-language pathologists might include oral exercises, voice training and special communications devices for speech problems, and diet modification and altered positioning while eating for problems related to swallowing.
Cognitive rehabilitation offers strategies to help improve memory, attention, information processing and problem- solving, which may be impaired due to inflammation and loss of myelin in the brain. A neuropsychologist, speech-language pathologist or OT can teach methods to compensate for cognitive problems including memory strategies, time management techniques, organization methods and the use of computers.
Does exercise help?More and more research is suggesting the benefit of exercise and other rehabilitation strategies in improving safety, quality of life, mobility and independence. Exercise alone cannot alter MS, but it can improve overall health and may prevent many complications that stem from inactivity. Because exercise contributes to a feeling of well-being and helps to regulate sleep patterns, appetite, and bowel and bladder function, there are psychological as well as physical benefits. Furthermore, an exercise program can help reduce 17 Living with MS your risk of falling, maximize your safety and improve your confidence as you move about at home and in your community. Yoga, swimming, tai chi and other forms of movement and body work may also be helpful.
You and your doctor or physical therapist can work out a program that will benefit you the most.
What do employers need to know?It's up to you whether or not to disclose your diagnosis to co-workers and your employer. Legally, you're not required to reveal this information. You can access an online tool to help you with employment disclosure decisions at Keep in mind that it's not a good idea to make major decisions about employment while you're in the midst of a crisis — either right after diagnosis, or during an attack of symptoms. Give yourself time to recover from immediate problems. Then gather information that will help you understand your options. MS varies from person to person, and so will its impact on work situations.
If you are interviewing for a new job, you are not required to disclose your diagnosis, and it is illegal for the potential employer to inquire about your health. A medical examination may be performed only after an offer National MS Society 18 of employment is made. If physicals are conducted, they must be conducted on all employees in that job category. The medical information must be kept separate from the personnel file.
If you need any accommodations such as flextime, a modified telephone or other equipment to do your job, you must disclose to your employer that you have a disability (you are not required to disclose your diagnosis). The Americans with Disabilities Act (ADA) requires most employers to provide "reasonable" accommodations.
The ADA contains many other provisions to protect you. Be informed before you do anything. Call the National MS Society for more information on your rights as a person Does MS affect sexuality?Everything connected to MS — from its physical symptoms to its emotional impact — can affect sexual expression. But this doesn't mean that sexual problems can't be managed successfully. People with MS can and do have fulfilling sex lives. Please consider these suggestions: n Work at sharing feelings honestly with your partner. Communication is a key factor for a satisfying sex life.
n Be flexible about sexual expression.
19 Living with MS n Seek medical treatment for physical symptoms that may interfere with sexual activity, such as fatigue, spasticity, impotence or bladder problems.
n For non-physical problems, consider consulting a psychotherapist or counselor.
Is depression common in MS?It's certainly common — and normal — to feel fear, confusion, loss of control, anger or grief at a diagnosis or worsening of MS. Beyond that, more than half of people with MS experience what doctors define as moderate to severe "clinical" depression. Many others experience milder forms of depression. In fact, depression is one of the most common symptoms of MS. It can be a direct result of MS damage within the brain, changes in the immune system, a side effect of some medications, or triggered by loss or life changes. Depression, whatever the cause, can be treated with medication and counseling. If you feel hopeless, sad, and/or lose interest or pleasure in usual activities, and these feelings persist over several weeks, this may indicate clinical depression. Other symptoms of depression include irritability, changes in appetite or weight, sleep problems, fatigue, feelings of worthlessness or guilt, inability to concentrate, restlessness, and recurrent thoughts of suicide, violence or death. If you are experiencing these symptoms, you should find a qualified professional who can help.
National MS Society 20 If you feel depressed or overwhelmed, remember that asking for help is not a weakness, but a strength. The Society or your doctor can refer you to a knowledgeable professional.
What resources are available to help a person with a recent diagnosis? No one needs to feel alone in dealing with a diagnosis of MS. The National MS Society offers education programs, and self-help groups and social networking opportunities where people can meet others who are living with and managing the challenges of MS. Start by calling 1-800-344- 4867 to speak with an MS Navigator who can answer your questions and point you toward any resources you might need. You can also sign up to receive Knowledge Is Power
— a free, at-home educational series about MS — which is available in print and online.
21 Living with MS Can family counseling help?The whole family lives with MS. It may change family routines for work, play — almost everything — and everyone is affected. Counseling may help the whole family to adjust. Call 1-800-344-4867 for information or for referral to counselors or support groups.
What's the best way to talk to children about MS?Young children easily sense when something is wrong. They need clear, age-appropriate explanations. Discussing issues, rather than hiding them, benefits children of any age. Usually they're more resilient and better able to accept challenging realities than their parents assume. Children do need to be consistently reassured that their parent will be there to take care of them and that they will be safe and loved regardless of what MS may bring.
The National MS Society offers a number of programs, brochures and special newsletters for children and teens of a parent with MS. Call 1-800-344-4867 or visit nationalMSsociety.org/family for more information.
National MS Society 22 Does stress make MS worse?The relationship between stress and MS isn't clear. Although there is no evidence that stress causes MS, some research suggests that stress may play a role in MS exacerbations. Given that stress is part of everyday life, and having a chronic illness is stressful in itself, efforts to rid one's life of stress entirely are generally unsuccessful. The best strategy is to learn to manage the stresses of everyday life as comfortably as possible. MS specialists recommend: n Keep as active as possible mentally and physically.
n Manage time to conserve energy.
n Simplify life — set priorities.
n Practice relaxation or meditation techniques.
n Make time for fun and cultivate your sense of humor.
n Set realistic goals and expectations.
n Work on accepting what cannot be changed.
n Ask for help if and when you need it.
23 Living with MS drinking affect MS?Recent studies have suggested that smokers are more likely to develop MS than non-smokers, and smoking has been shown to accelerate disease progression. The good news is that stopping smoking slows disability progression.
Smoking harms your health in general, which could add to disability. And because of weakness and poor coordination, people with MS who smoke may be at increased risk of injury. Drinking in excess causes poor coordination, poor balance and slurred speech. It also impairs judgment and alters behavior. All this can add to existing symptoms, although there's no evidence that alcohol makes MS worse.
National MS Society 24 How does heat affect MS?Heat doesn't make MS worse permanently, but many people with MS find that hot, humid weather, a hot bath or shower, or a fever can temporarily make their symptoms worse. Although this temporary worsening (known as a pseudo-exacerbation) may feel like a real MS attack, the symptoms will improve as the body's temperature returns to normal. It's a good idea to avoid heat in the middle of the day and to bathe in warm rather than hot water.
Many people with MS find that cooling off with ice packs, iced drinks, cooling garments (such as vests, suits, hats, and neck, ankle or leg wraps) and cool baths helps to reduce symptoms and improve stamina in hot environments.
If you find you are heat sensitive, an air conditioner may be an essential piece of equipment and is usually tax- deductible if your healthcare provider writes a prescription 25 Living with MS What about vaccination against the flu?You should discuss your individual situation with your doctor. The seasonal influenza vaccine is safe for people with MS, including people who are taking a disease- modifying therapy. However, people with MS should only receive the seasonal injectable vaccine containing inactivated or "killed" virus and avoid the nasal spray vaccine containing live or attenuated flu virus. The new, extra strength flu vaccine for people over age 65 has not been tested in people with MS. What about vitamin D?In the past, it was assumed that most people maintained adequate vitamin D levels from their diet and exposure to the sun. Today, there is a growing concern that most children and adults have insufficient levels of this important vitamin. In addition to its effects on calcium absorption and bone health, vitamin D exerts important actions on many other body systems, including the immune system. We know that adequate levels help prevent bone loss from reduced mobility, and there is some evidence to suggest that vitamin D may play a role in reducing a person's National MS Society 26 risk of developing MS and in slowing disease progression in someone who has MS. Much additional research on vitamin D is needed. In the meantime, people with MS should discuss their situation with their healthcare provider to determine an appropriate vitamin D strategy.
Will complementary or alternative therapies help?While complementary (used in conjunction with prescribed treatments) and alternative (used instead of prescribed treatments) therapies such as acupuncture, dietary supplements, massage, meditation and hypnosis have not shown a proven effect on MS, people sometimes find that these therapies help them reduce stress, manage symptoms and feel better. But before deciding to pursue one of these therapies, investigate all potential risks, benefits and costs, and discuss them with your healthcare provider. And keep in mind that no complementary or alternative strategies
have been shown to be as effective in treating MS as the disease-modifying therapies that are available today.
Most alternative and complementary health practitioners are not MS specialists and cannot provide diagnoses. It is important to discuss new symptoms with your doctor and keep him/her informed about all treatments or regimens you may decide to use.
27 Living with MS What's the bottom line?Your MS is unique to you, but it is not your identity. You are still the same person you were, but a diagnosis of MS may require you to make adaptations to your life and lifestyle. Here are some general tips on living well: n Take care of yourself. Eat well, exercise and get enough rest. Listen to your body, and say no when you need to conserve energy.
n Take control of your emotional well-being. Find people with whom you can talk and share feelings, and who will offer support. Seek professional help if you consistently feel sad or hopeless or experience uncomfortable levels of anxiety.
n Try to act as a partner with your physician and other healthcare professionals to manage your disease. Learn about your options and discuss them with your healthcare providers.
n Connect with others who have the disease as you feel comfortable. Sharing tips, information and feelings about coping with MS with others can be reassuring and helpful; the National MS Society can help you make that connection.
n Examine your priorities. Try to make sense of MS within your own worldview, according to your personal values and insights. You might wish to seek support from clergy, spiritual organizations or counselors.
n MS poses uncertainties about the future. At some point, you need to examine your financial plans, insurance coverage, housing needs and other practical issues and to build a network of informed advisors who can help you and your family with long-term life planning.
n Call the National MS Society for information, referral and support.
National MS Society 28 Ampyra® is a registered trademark of Acorda Therapeutics, Inc. Botox® is a registered trademark of Allergen, Inc.
Cymbalta® is a registered trademark of Eli Lilly and Co.
Dantrium® is a registered trademark of JHP Pharmaceuticals, LLC. Depakote® is a registered trademark of Sanofi-Aventis Corp. Detrol® is a registered trademark of Pfizer.
Ditropan® is a registered trademark of Alza Corp. Elavil® is a registered trademark of Zeneca, Inc. Lioresal® is a registered trademark of Medtronic Inc.
Lyrica® is a registered trademark of C.P. Pharmaceuticals international C.V. Myrbetriq® is a registered trademark of Astellas Pharma Inc.
Neurontin® is a registered trademark of Warner-Lambert Co.
Nuedexta® is a registered trademark of Avanir Pharmaceuticals, Inc. Nuvigil® is a registered trademark of Cephalon, Inc.
Provigil® is a registered trademark of Cephalon, Inc. Sanctura® is a registered trademark of Allergan, Inc.
Solu Medrol® is a registered trademark of Pharmacia & Upjohn Co. Symmetrel® is a registered trademark of Endo Pharmaceuticals. Tegretol® is a registered trademark of Novartis Corp.
TOUCH® is a registered trademark of Elan Pharmaceuticals. Inc.
Toviaz® is a registered trademark of Pfizer, Inc.
Vesicare® is a registered trademark of Astellas Pharma.
Zanaflex® is a registered trademark of Elan Pharmaceuticals Inc.
29 Living with MS National MS Society 30 31 Living with MS The National Multiple Sclerosis Society ("Society") is proud to be a source of information on multiple sclerosis related topics. The information provided is based on professional advice, published experience, and expert opinion, but does not constitute medical or legal advice. For specific medical advice, consult a qualified physician. For specific legal advice, consult a qualified attorney.
The Society does not endorse products, services or manufacturers. Such names appear here solely because they are considered helpful information. The Society assumes no liability for the recipient's use of any product or service mentioned. The Society does not independently verify whether the information provided by each service provider is accurate. The Society undertakes no responsibility to verify whether the service provider is appropriately licensed and certified and has applicable insurance coverage.
Early and ongoing treatment with an FDA-approved therapy can make
a difference for people with multiple sclerosis. Learn about your options
by talking to your healthcare professional and contacting the National
MS Society at nationalMSsociety.org or 1-800-344-4867.
The Society publishes many other resources about various
aspects of MS. Visit nationalMSsociety.org/brochures or
call 1-800-344-4867.
Other popular resources include: n Clear Thinking About Alternative Therapies n Depression and Multiple Sclerosis n Fatigue: What You Should Know n Disease-Modifying Therapies for Multiple Sclerosis n Preventive Care Recommendations for Adults with MS n Should I Work: Information for Employees n Taming Stress in Multiple Sclerosis The Win-Win Approach to Reasonable Aational MS Society Enhancing Productivity on Your Job


The National MS Society mobilizes people and resources
so that everyone affected by MS can live their best lives
as we stop MS in its tracks, restore what has been lost and
end MS forever. To fulfill this mission, the Society funds
cutting-edge research, drives change through advocacy,
facilitates professional education, collaborates with MS
organizations around the world, and provides programs
and services designed to help people with MS and their
families move their lives forward.

l rights reserved.

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Microsoft word - 2016 ah65 preferred rx individual formulary - update 9.16--final

AmeriHealth 65® Preferred Rx HMO 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN FID 16215, Version 21 This formulary was updated on 9/01/16. For more recent information or other questions, please contact AmeriHealth 65 Preferred Rx at 1-866-569-5190 or, for TTY/TDD users, 711, seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail. Or visit www.amerihealthmedicare.com.

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Indian J Med Res 130, December 2009, pp 681-688 Cardiovascular effects of sexual activity Xiaojun Chen, Qingying Zhang* & Xuerui Tan Department of Cardiology, The First Affiliated Hospital of Shantou University Medical College & *Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong, China Received June 11, 2008 Sexuality is a major way of intimacy in human being and it is very important in gender relationship,