Preventing the risks to a person with progressive MS of an acute hospital admission.

A Pathway.

For the past few months, we have been working on a ‘pathway’ to help protect people with progressive MS when they are admitted to hospital with an acute illness ( such as infection) . We know that when people with progressive MS have an unplanned hospital stay ( due to becoming unwell – obviously all problems are not caused by being in hospital ), they often take a step up in disability, and sometimes this can be permanent.

Once someone is in hospital, all kinds of helpful aids and routines, like their own electric wheelchair, intermittent catheters or bowel irrigation can be stripped away, causing problems and complications, but that shouldn’t be the case. Once a person is in bed, they are also at risk of the complications of immobility, such as increased spasticity, pressure areas and constipation.

We based our work on issues and stories that came from people with progressive MS, with a view to helping to improve education and finally, care, and with a final aim to help people get home again as safely, and as quickly as possible.

We have created a ‘pathway’ on one A4 sheet, which can be adapted for use in any locality, to be laminated and kept on the ward, and act as a prompt for the key actions that should be taken when a person with progressive MS is admitted to hospital. If these actions are taken, then the hospital stay itself should not be contributing to any worsening, and should be able to play its therapeutic part.

This is the Pathway:

Pathway for progressive MS in acute admission

And this is the poster which both introduces and shows the pathway, with references.

Progressive MS Poster

Our aim is to introduce this into our local hospital along with some training, to raise awareness for front line staff in the needs of a person with progressive or advanced MS.

C53CC87D-2E6D-4987-8ABD-FED2AE6D724D367B97D4-5B98-4CC5-8EF9-A7C378A1E4D9

 

 

 

 

 

 

 

Yesterday,  I presented this at the MS Trust annual conference, and it was received very positively by the MS specialists attending; lots came to the poster display to take away a paper copy. It was great to get positive feedback from colleagues, and also from Stuart Nixon MBE, MS ambassador and his wife, who pointed out immediate tweaks we need to make ( like ensuring we consistently use the word Person rather than Patient – good call!)

This pathway has been part of a wider project undertaken by the Beds and Northants MS Therapy Centre, funded by Central Bedfordshire Council, to improve quality of life for people with long term conditions. We are also running 3 hour interactive sessions for both family and professional carers, ‘Caring for the Person with Advanced MS’, which have been very warmly received and positively reviewed. We intend to develop this training for hospital staff, to go along with the launch of the pathway.

This is a work in progress so if you have suggestions for improvement, please get in touch! msnursemiranda.olding@gmail.com. We also had assistance from Sanofi Genzyme with putting the Pathway into VISIO format, so Thankyou to you guys and hope you like what we’re doing with it!

All the best, Miranda ( Olding)  and Emma (Matthews)

 

 

 

 

 

Sex and MS

Just as in anyone’s life, sex with MS can be fun, intense, routine, boring, passionate, flirty, dirty, easy, comforting, fraught with difficulties, or all of the above!

Sexuality and sensuality is an integral part of being human and, depending on the individuals involved, has varying degrees of importance at different times in a relationship.

For this article, I’m leaning heavily on an excellent publication for healthcare professionals, ‘MS, Sex, Sexuality and Intimacy’; link at the end of the article.

Screenshot 2018-11-03 14.37.09

The chance to discuss issues with sexual function is an important part of your MS Nurse appointment, and if you have a concern, always raise the subject.

Problems with sex that can affect people with MS are divided into:

Primary problems, which occur as a direct result of MS lesions, and can include numbess in the genital area, and problems with orgasm, erections, or vaginal lubrication.

First of all, both partners should understand that mutually expressing sensuality, through loving touch, with affection and humour, can still be deeply rewarding, even if  sex does not necessarily end in orgasm.

Then, it’s worth checking that problems aren’t being caused by one of the commonly used in MS medications that can cause problems in libido, erection/lubrication, or achieving orgasm, which include:

  • Amitriptyline, Carbamazepine, Gabapentin, Pregabalin, and Baclofen as well as opiod painkillers, antidepressants, blood pressure drugs, statins, and cannabis.

This is not an exhaustive list! If therefore, you can find a way to decrease the need for these medications, that’s ideal.

medication

For problems with erection, men with MS qualify for the medications Viagra, Cialis, Levitra and Spedra on the NHS, and if they are not suitable, ask to be referred to  the local erectile dysfunction clinic, where different options like implants, creams, injections, and vacuum pumps can be discussed. Pumps can also be bought privately, and work well for many men.

To help achieve orgasm, and for numbness, exploring the use of sex toys can be helpful. These include vibrators for both sexes and different sexual areas, and vibrating rings; ‘sleeves’, or artificial vaginas, which can also be during foreplay instead of hands for stimulation, and stimulant lubricants (‘play gels’) which can strengthen sensation, amongst others, and are available via tasteful online shops like lovehoney.co.uk, beecourse.com and emotionalbliss.co.uk.

For problems with ejaculation, there are no specifically licensed medications, however,  in 158 men with spinal injuries; 65% did achieve ejaculation when taking midodrine.

champagne

The NHS choices website mentions that Baclofen can cause delayed ejaculation, and that Amantadine, bupoprion and yohimbine are suggested are suggested when this problem is caused by SSRIs. Pseudoephedrine has also shown promise but hasn’t been licensed for this use. Interestingly, Amantadine is also used for fatigue in MS.

Secondary sexual problems describes when MS symptoms interfere with sex; for instance, bladder, pain, spasticity or fatigue.

These problems can often be got round with a bit of planning. The most common problem I hear in clinic from people with relapsing remitting MS is fatigue. When tired, libido can be the first thing to go, but where sex is important to your partner, try to plan for it: is it possible to have morning sex, at least on the weekends, a nap in the day, or a super early night together..?

dreamstime_s_31163319 couple

With pain and spasm, timing medications to get the most relief at the right time, taking an extra (agreed with your prescriber) muscle relaxant, or using CBD oil for instance, can help.

If you have more advanced MS, with disability, thinking about positioning may be important. You may want to use pillows to raise hips or get comfy. Spokz.co.uk is a disability equipment site that includes sex products, including a gripper, for when hand function is an issue, and sex furniture – swings and swinging chairs, that sound exotic, but take the effort out of sexual moves, and can make positioning easier.

If you have a catheter, adding a flipflow valve means the bag can be removed, and this can be taped out of the way underneath nice underwear. Absorbant bed pads can be placed underneath if you’re worried about bypassing.

Tertiary sexual problems refers to cultural, emotional, psychological and social aspects; for example, inhibitions due to beliefs, or losing confidence.

Keeping the channels of communication open is probably the most important factor here, and has a direct effect both on successful sex, and on maintaining intimacy. After spinal injury, the important factors in maintaining a positive and satisfying sexual relationship were found to be “emotional factors such as honesty, trust,
closeness, mutual respect, communication, caring and appreciation”

A fulfilling sexual relationship is about more than intercourse or orgasms, and a fulfilling relationship is about more than sex. There are many couples whose relationship does not involve sex at all, but who maintain a high level of intimacy, with warmth, and fulfilment on both sides, and many others whose sexual relationship involves creative solutions and may not culminate for both partners in orgasm, but is still a deeply enjoyable expression of love and care for each other and each other’s needs. 

 

 

 

 

The document below has a full list of resources for support with sexual and relationship difficulties including the excellent booklets for both sexes by the MS Trust, downloadable from www.mstrust.org.uk; sexual and relationship counselling, books, films and organisations.

https://www.mstrust.org.uk/sites/default/files/MS%20%26%20Sex%20Guide%20INTERACTIVE.pdf

 

MS bowel problems and what to do about them!

Now I have your attention with this picture of Fake poo – Bowels! Trouble with the bowel can be the bane of your life, so here we’re going to have a look at what can go wrong and what you can do to prevent or rectify things!

For the bowel to work perfectly, there must be intact nerve pathways from the inner and outer anal sphincters, all the way up the spinal cord, and down again. Any interruption to these messages can cause problems.

picture from Aliexpress.com

Let’s start with constipation. As well as changes to the nervous system, reduced ability to exercise, difficulty getting into a good position, reducing fluid intake because of urinary urgency, and medication, can all contribute to this problem.

Of course we always start by looking at diet and fluids, adding plant-based fibre, fruit, vegetables, pulses and seeds. Some old school wisdom that can be very effective include: 1 ripe pear daily, figs, prunes, and adding linseeds to cereal or porridge. Cold pressed flax-seed oil can have a 2 fold role as it’s the highest source of omega 3s, strongly anti-inflammatory, and for some, has a loosening effect.

 

 

 

 

 

However, in MS, sometimes, you can be doing everything just perfectly re diet and fluids, and still have a serious problem with constipation.  If you need to use laxatives, it’s important to understand how they work. The longer the stool stays in the bowel, the more your body draws water out, causing a hard, dry stool.

There are four types of laxative; bulk-forming, osmotic, stimulant, and stool softening. If you have enough dietary fibre, bulk-forming shouldn’t be necessary, and we hope to prevent the hard dry stools that stool-softeners treat.

In my experience, an osmotic, ‘macrogol ‘ product, like Movicol or Laxido, which contains indigestible plastic molecules to stop your body from absorbing water from the stool, is often helpful, but do find the daily dose that works, rather than first getting constipated and then taking it, as this can cause the opposite problem.

Senna or Bisacodyl are stimulant laxatives, increasing the luscular action of the bowel, and can also be used to add ‘oomph’, but if taken on their own, may just give you cramps. Try taking them at night, with the aim to catch the time that the bowel is most active naturally; after the first hot drink in the morning…

Some people find suppositories helpful; these can be glycerin, a simple oily substance that can loosen dry stool, or bisacodyl, to stimulate the bowel.

Constipation that has not responded to these measures may be treated with mini-enemas, (eg Fleet) which can reach a little higher.

 

Did you know that the natural position for humans to poop is in squatting? There’s a brilliant demonstration in this video, https://youtu.be/YbYWhdLO43Q advertising the ‘Squatty Potty’, a peice of bathroom furniture that helps get you more in that sort of position. Of course you can make your own position support system, and there is more than position at play in bowel problems in MS; however, it’s a good start.

For intractable constipation, one of the irrigation systems, discussed below, may help.

 

 

 

Bowel urgency and accidents

Sometimes, the nerve damage in MS can mean that it’s not possible to ‘hold on’, and for some people, constipation alternates with bowel urgency or incontinence. Sometimes, just solving constipation and getting into a routine can be enough to prevent accidents, but sometimes it’s not enough. Nothing can be more upsetting than having a bowel accident, but luckily, there are now very effective products available on prescription, which can help to prevent this happening.

For occasional looseness, Loperamide ( Immodium) can be used, either in tablet or liquid form. However, it’s not advisable for long term, especially if you also get constipation.

For longer term problems, trans-anal irrigation systems provide some people with MS with a life-changing solution. These are basically kits for pumping some body-temperature tap water into your lower bowel, using a soft, disposable rectal catheter or cone, whilst you sit on the toilet.

 

Once you remove the catheter or cone, the water is also released, and any stool that was sitting in the descending colon, is washed out. The action of the water can also stimulate a bowel movement within the next 10-15 minutes.

Once you’ve used the irrigation system, you know that the descending colon is clear, and that it would be very unlikely to need to go for the next 8 hours, unless you have a problem with diarrhoea or loose stools.

Peristeen:  https://www.coloplast.co.uk/peristeen-anal-irrigation-system-en-gb.aspx

Qufora: http://www.macgregorhealthcare.com/index.html

For people who would find hand-pumping impossible, there are motorised systems, including the ‘Navina’ by Wellspect, and the Irypump by B-Braun.

Speak to your continence nurse or MS Nurse to discuss your problems and be referred.

Qufora also has a bed system, that can be used for people who can’t sit on a toilet,

and a mini pump, which is very handy for people who just cannot get started, or can’t seem to finish off properly.

Posterior tibial nerve stimulation (PTNS)

PTNS is a drug-free electrical treatment for both bowel and bladder urgency and incontinence, which involves having several weeks of weekly, tapering down to less frequent, sessions, sitting with a tiny, ( hairs breadth ) needle attached to an electrical current, inserted at the back of your ankle.  From here the current travels to the sacral nerve plexus. It has about an 80% success rate. I recently had the chance to experience this and me and my colleague Emma, got to stick needles in each other, as Alison from Cogentix ‘Urgent-pc’ came to demonstrate. It didn’t hurt… very much at all! – and many people, ( including Emma)  don’t even feel it! It’s not currently available in our area on the NHS at present, although Bedford, Luton and Northmampton hospitals all have business plans to introduce it. It is available in some NHS hospitals, and also in many private clinics, and I have previously had someone referred for it for bowel incontinence, who did very well.

See http://www.cogentixmedical.com/patients/products/urgent-pc

 

 

 

 

 

 

 

 

Bowel accidents due to loose stools, is a different type of problem. Medical problems need to be excluded by seeing your GP, and you may also need to explore whether items in your diet are upsetting your digestion. The sugar Lactose in milk is a common suspect, and some people have a problem with almost all the simple sugars in foods, and have to follow a very strict diet which eliminates ‘FODMAP’s; see:

https://www.nhs.uk/Conditions/Irritable-bowel-syndrome/Pages/Treatment.aspx,

If absolutely nothing else works, and you are still being plagued with problems, then there are surgical options, including elective colostomy.

There are now so many options to help with bowel problems in MS , so ask for help,  and if you’re not getting anywhere, ask to be referred to a specialist bowel clinic.

 

 

 

 

Urine infections in MS – an integrated approach to prevention & treatment.

I always discuss the need to stay one step ahead of the bladder in MS with my patients, as having a urinary tract infection (UTI) can mimic a relapse and cause real setbacks.

Explain this to your GP, request they prescribe antibiotics at the first sign of infection, and that NICE guidelines recommend a longer (5–10-day) course for these ‘neurogenic’ UTIs.  It’s also worth taking at least a prescription away with you on holiday to prevent losing days trying to see a doctor.

Check! Whenever you experience new or worse symptoms of MS, always check for a silent UTI. Aswell as  visiting your surgery or MS nurse, you can also buy urinalysis dipsticks for home use. A change of colour to Leukocytes or Nitrites may indicate infection, which should be treated.

dipsticks

If you take antibiotics, top up with probiotics (good bacteria), during and afterwards, to prevent digestive problems and thrush, and boost your health and resistance to future UTIs. Lactose-free capsules or powder are better than sweet probiotic drinks. In fact looking after the good bacteria in your gut is a huge and important topic for all of us, and particularly if you have an auto-immune condition, and there’s lots of ways you can do this.

bacteria (1)

Also drink plenty of water, pee frequently, and cut out sugar to help your immune system fight back.

Causes.

One cause of UTIs with MS is the bladder not emptying fully, because the muscles involved are not working together properly. Struggling to start passing urine, feeling there’s some left, urgency, and UTIs can all be signs of incomplete emptying. This needs to be identified by ultrasound scan, generally with the continence service.

bladder ultrasound

Try peeing twice every time, but if a residual (left over) volume of 100mls or more is found, you may need to learn how to use intermittent self-catheterisation with small, lubricated, disposable catheters, to empty fully.

ISC can be liberating, but also potentially cause infection; technique and catheter type are important, so stay in touch with your advisor.

ISC

Prevention and natural treatments

If you seem to keep getting urine infections one after the other, it’s quite likely that you are just not completely throwing off one infection.

It’s a very dispiriting situation, However –  there are lots of things you can do to shake off and help prevent recurrent UTIs.

The most common bacteria causing UTIs is E coli, which can cause recurrent UTIs, as it can burrow into the bladder wall, and release spores after antibiotics are finished. However, it’s important that your urine goes to the lab, as rarer bugs are also possible, including from candida, which we’re not covering here today. GPs are recommended not to prescribe low dose daily antibiotics, but they sometimes help as a last resort.

e-coli bacteria

Sometimes antibiotic treatment no longer seems to work, or some people prefer to try herbal remedies with antibiotic properties. Stopping the bacteria from sticking to the bladder wall and flushing it out when it does is the aim of these natural agents. There are many, with varying degrees of research to back them, but the ones that I have seen most success with are: (Nb I don’t get any benefit from these companies!)

For prevention:

  • Concentrated cranberry tablets,  eg Cysticlean

http://www.cysticlean.co.uk/main/index.phpcysticlean 2

For prevention ( low dose) and/or treatment ( full dose)

  • D-Mannose; a simple sugar that e-coli latches on to and can be flushed out on, and is now being tried by consultants at the national hospital for neurology and neurosurgery.  https://www.waterfall-d-mannose.com/dmannose-options.html

d-mannose

  • SOS advance; a colloidal solution of antibiotic herbs that can be used preventatively or at times of infection.

http://www.sosessentials.com/s/

sos-advance

For recurrent UTIs with an indwelling catheter

If after a catheter changes, with symptoms, ask District Nurses to test from the port after 48 hours, and have an antibiotic at the ready; test again 48 hours after completion.

The ‘Bardex IC’ ( infection control) silver tipped catheter has been shown to reduce UTIs, (reports infections 3.7 x more common in those catheterised with a normal catheter vs a sliver tipped one) as it prevents a biofilm forming. It becomes effective after around 3 months ( and has to be changed regularly like all indwelling catheters), so don’t give up too soon.

Uro.13.BardexIC2way.0165SI (1)

If all else fails, ask for a referral to urology, to check for bladder stones, and possibly for bladder washout, and to discuss possible treatments.

See a doctor if you have a fever, chills, pain in the flank area, nausea or vomiting, and always check any natural/herbal remedies are safe to take with your condition and medications.

UPDATE: – I thought this comment from Jenny was important enough to update the blog with:

“I thought I’d let you know about some other treatments for UTIs that are being tried on me that no-one seems to know about (not even doctors in Oxford, nor the MS specialist nurses – I’m keeping them posted too)..

So one is Uromune, supposedly a vaccination against four strains of UTI including e-coli. It’s inactivated bacteria taken in pineapple juice under the tongue once a day for 3 or 6 months. They’re doing a trial in Reading and there are details here http://www.readingurologypartnership.com/uti-vaccine/4594063839 – you can’t get on the trial if you self-catheterise but can pay privately for it (not cheap – including seeing the consultant it was about £600 for me).

And the other is iAluRil, a GAG layer replacement, which you stick inside directly with a catheter, to replenish the non-stick lining of the bladder, and keep in for as long as poss (I do it at night and sleep with it in – it’s only 50mls). There are apparently two places in the UK which don’t do this and Oxford is one, so I go to the Royal Berks for that, on the NHS. Info here http://ialuril.co.uk/

Apologies if you knew all this and that just took up time that you’ll never get back! But I thought, if you don’t know about it, you’re the sort of person who will be interested and use the info to help people. (btw I have no financial links to any of the organisations – am just a person with MS and RUTIs who’s trying everything!). And also I should let you know that I’ve been on the Uromune for nearly 3 months now and just had an e-coli infection… hey ho.”

–Dear Jenny – this is fab; I’m going to post it up as an update so everyone can see, thankyou. I do have a patient who was on the immunisation trial but unfortunately it did not work for her. The aAlUril I have never heard of and am going to look into. Thanks again for your most useful comments!
all the best, Miranda

 

 

Assistive technology for loss of hand function

The hardest part of being an MS Nurse, for me, (and I know I have Nothing to grumble about!!)  is when someone with advanced MS tells me that  they are losing hand function.

I’ve compiled a list of useful resources to help live life as fully and independently as possible, in this situation. Here’s the list so far, but it’s only a beginning, I’d like a more comprehensive resource so please do contribute the things that you know.

This is where technology is absolutely your friend.

I’m loving this round up of the best assistive tech for 2017 from the makers of TECLA: https://gettecla.com/blogs/news/the-best-wheelchair-tech-accessories-of-2018?customer_posted=true#contact_form

They also have useful blogs on choosing smartphones, DIY assistive tech and more; see https://gettecla.com/

1) Abilitynet are an excellent charity that provide information and even home visiting assistance to help people with disabilities get the most from their computer, tablet and smartphone, including using voice controls.

https://www.abilitynet.org.uk/homepage

The home visit service:

https://www.abilitynet.org.uk/at-home/IT-support-for-disabled-people

 

2) Environmental controls/Assistive technology (AT)

(AT) is any item, piece of equipment, software program, or product system that is used to increase, maintain, or improve the functional capabilities of persons with disabilities. Put simply, it allows you to control things around you – from doors and curtains to TV, phone, wheelchair and more, without the normal use of your hands.

Counties will vary, but in Bedfordshire, if only one item is requested, the community OT department sort it, but for more than one, you can request a referral to the Acquired Brain Injury (ABI) team, for a specialist assessment.

3) Another place you can learn about AT is http://www.livingmadeeasy.org.uk/ which has impartial advice and information  about daily living equipment, developed by the Disabled Living Foundation (DLF)Their AT advice is here:

http://www.livingmadeeasy.org.uk/telecare/environmental-controls-2393/

 

Sometimes, what you need, is absolutely bespoke to you. When that’s the case, the wonderful experts are the charity

 

4) Remap http://www.remap.org.uk/  Remap are

retired engineers work with disabled people to try to make things to solve their individual problems; my experience of them has been fantastic.

Photo courtesy of Remap.

 

5) Independent electric wheelchair control can still be possible for people who have completely lost hand function, using ‘sip and puff’ / ‘suck and blow’ , or ‘tongue drive technology. Discuss with wheelchair services. You can see an example of it here, but it’s just an example, I don’t particularly recommend or endorse it.

 

https://smilesmart-tech.com/assistive-technology-products/wheelchair-controls/suck-and-blow-switch/

6) Suck and blow/sip and puff technology can also be used to use a computer, turn pages, or other commands.

 

http://www.livingmadeeasy.org.uk/search.php?cx=005018225405928271468%3Appdewqx27cq&ie=UTF-8&q=suck+and+blow

7) Neater eater

This is a lovely piece of kit that has been around for a long time; like a robotic arm that can help people with limited hand function to eat independently; i also see that they have systems for drinking too.

http://www.neater.co.uk/


I have many patients who continue to lead rich, full and busy lives, even with minimal function and maximum disability, and that, I guess, is the power of the human spirit.

Emma ( my colleague and the other MS Nurse at the MS Therapy centre) has just recently been at ECTRIMS in Paris, and we are both going to be at the MS Trust Annual conference next week, so hope to report back soon,

All the very best!  Miranda

human spirit

Trials you can take part in: Statins in progressive MS, and Biotin in progressive MS

biotin 2

There’s a lot to think about if you’re considering being part of a clinical trial.

Some trials are more risky than others. These two are probably less risky, but you still need to ask:

What are the potential risks?

How many people/ what percentage have these risks

What are the potential side-effects?

How many people /what percentage get these?

What can be done if I do have a side effect or risk? Is it reversible?

What are the potential benefits?

What percentage have had these benefits?

How much of these had similar condition at a similar stage to me?

How long do they last?

Is more treatment necessary?

How much does it cost?

Will you give information either to me or to my doctor about what therapy I have undergone?

How will I be monitored? Eg scans, bloodtests etc

How often will I have to return for follow up? Is there a charge?

Will they pay my travel expenses?

How will I know if it’s worked? What’s the timescale for improvement?

Is there a placebo ( dummy drug) group? If I’m in the placebo group, and the real treatment group benefit, will I have the chance to change to the treatment group?

If I have the treatment during the trial, and benefit from it, will I be able to carry on with it long term?

Biotin

I’ve posted before about biotin in MS. A medical preparation of it has been given the name MD1003, and it is now being trialled to see its effect on people with progressive MS.  If you’re interested, here are the contacts. Don’t forget to ask those questions!

Trial Location(s)
Southern General Hospital
Glasgow
Scotland
G51 4TF
Musculoskeletal Department; Freeman Hospital
Newcastle upon Tyne
NE7 7DN
Clinical Trials Unit; Main Hospital; Salford Rooyal NHS Foundation Trust
Salford
M6 8HD
Barts and The London Hospital
London
E1 2AT
University College of London, Institute of Neurology
London
WC1N 3BG
Edinburgh
EH16 4SB
Trial Contact(s)
Primary Trial Contact
abdelkarim Bendarraz

Statins

statins

UPDATE November 2018:

  1. Researcher believe that benefits are NOT all just about the lower cholesterol in the blood, but that there are other effects on the cells and the immune system
  2. The next phase of Statins research is recruiting, and to get involved, visit http://www.ms-stat2.info

It may be that this becomes the treatment for progressive MS of the future.

 

 

I’ve also posted a long time ago about statins.

My personal suspicion is that the beneficial effects are from lowering the bad fats in the blood, and that a safer and more healthy way to do this would be to adjust lifestyle factors; primarily diet, along the lines of the advice at http://www.overcomingms.org…. However, there may be some other mode of action, or radical lifestyle change may not be possible for you, in which case, you can register your interest for the trials, so that somebody will contact you when they start recruiting, which should be very soon ( summer of 2017), here:

https://www.mssociety.org.uk/forms/ms-stat2-information

Its’ been a long gap –  hope to post again much sooner this time,

all the best

Miranda

 

Panic attacks – an integrated approach.

This blog is an article in the last issue of the excellent New Pathways MS magazine, which they have kindly allowed me to share on my blog, too!

Hello and thanks for inviting me to do a regular column with New Pathways. As an MS Nurse with an interest in integrative medicine/ holistic health, when I explore a topic here, I will generally move from the conventional advice to exploring some of the more natural approaches that may also help.

Recent interactions with one of my very young patients, got me focussing on anxiety and PANIC ATTACKS! So here goesthe-scream

Panic attacks are intensely frightening events that happen when our systems are overloaded with stress hormones, causing a dry mouth, pounding heart, feeling of shortness of breath, dizziness, shaking, and sometimes, tingling ( as we hyperventilate) and chest pain. It can feel as if you’re about to die – which of course, increases the anxiety!  After a nasty experience with a panic attack, it can be easy to develop a fear of having another one.

Starting with the conventional, tell your GP what’s happening.  The NICE guidelines for the medical management of panic attacks recommend firstly, education and monitoring, secondly, Cognitive behavioural therapy (CBT) or relaxation therapy, and only in extreme cases that do not resolve, an anti-depressant medication, such as sertraline ( which can have the dangerous side effect of causing suicidal thoughts in a minority of people)

The NHS Website has a handy self-help guide: http://www.nhs.uk/Conditions/Panic-disorder/Pages/self%20help.aspx

I had my own experiences with panic attacks as a teenager, living abroad and drinking way too much coffee for my system, so all these suggestions come from an amalgamation of personal experience, nursing experience and learning!.

So let’s have a look at both immediate and long term strategies for mastering this problem.

If you feel one coming on:

Remember: Panic attacks aren’t dangerous. Remind yourself that it’s happening because of anxiety; your body is OK, and the very worst that could happen it that you could become dizzy from breathing too fast , and pass out, after which, your body will regulate itself again, and you’ll go back to normal. If you’re driving, pull over.

Change your focus from scary sensations, to something else that’s tangible – a sound, a feeling, a smell – part of being ‘mindful’ I found that focussing on something else – squeezing my toes and calf muscles, for instance, could distract me. Even searching for a specific item in a supermarket, or counting.  Having someone chatting to you, perhaps, squeezing or massaging hands, also helps.keep-calm

Regulate your breathing. Slow your breathing and count it in and out, starting with a count of three, and slowing if you can, to a count of five.

Rescue Remedy is a homeopathically diluted ( meaning that it works on an energy level, rather XX UNLIKE than like herbal or conventional medicine, and is safe to take whatever other tablets you may be on) Bach flower remedy, that many people find effective for times of crisis. See  http://www.nelsonsnaturalworld.com/en-gb/uk/our-brands/rescue-remedy/the-rescue-story.There is also a spray, and pastilles; use when you feel at risk of panic attack.

rescue-drops

rescue-spray

 

 

 

 

 

 

Preventing further panic attacks.

Gaining mastery over our states of mind is a lifelong learning process, and something we will probably never completely perfect. However, there are ways to prevent complete overwhelm from ruling us.

Anxiety and panic attacks can be very isolating.hug Connecting with others and having their support defuses this feeling, so tell other people who care about you, and let them know how they can help you through.

lists

 

 

 

 

 

In healthcare, we have a tendency to medicalise everything, and by doing this, we sometimes miss the obvious. It’s worth taking some time to think about the practical issues that may be causing feelings of anxiety and panic, and to ask – are there are any practical actions that can be take to make things easier? If something feels overwhelming, is there any help you can get? Can deadlines be extended? Can you get workplace support? Do you have to do things in the same way or can changes be made? Can a charity be approached to help fund an item that would help, but that you can’t afford? I often use www.Turntous.org for this. Getting organised, setting realistic goals, getting help, and taking small steps and deciding on future steps can help to restore a sense of equilibrium.

come on girls!

Because the hormones caused by stress are ‘burned up’ by exercise, making exercise, as much as you can, a regular part of your routine, is a powerful assistance in prevention.

Unstable blood sugar can also contribute to panic attacks, so coming off sugar and eating whole foods is helps. Coffee can cause anxiety and panic symptoms all by itself in susceptible individuals, so cut caffeinated coffee out completely.

Herbalists often recommend ‘adaptogens’ – herbs with the ability to lower stress hormones or increase resilience to stress. You can learn more at: http://nourishholisticnutrition.com/what-are-adaptogens-and-how-do-they-work/

One of the most powerful tools to become more resilient to stress and prevent anxiety and panic attacks that I have found ( through personal experience) is something called HeartMath. This is a very simple technique where you breathe in a rhythm of 5 (seconds) in, 5 out, in one continuous flow, whilst focussing on heart felt positive emotions, in the heart area. Technology can be added to allow teaching or self-monitoring using gadgets, or a sensor connected to heart rate variability display, but the basic technique is as free and as old as the hills; however, done regularly, it has the most profound effect on resilience to stress and mental, emotional and physical health. See https://mirandasmsblog.com/category/heartmath/ for my study in people with MS, and http://www.heartmath.com for more information.

heartmath-waves

 

 

 

 

 

Likewise, anything that helps to restore a connection to a sense of inner peace – meditation-and-the-brain

meditation, deep relaxation, helps to prevent overwhelm and retain balance. You don’t need technology to meditate, but there are loads of apps available now for phones, like http://www.headspace.com. These type of things need to be done daily to build resilience to stress, to be effective.

 

Moving into the world of energy and its flow, certain positions help to ‘ground’ us and defuse overwhelming feelings of panic. There’s a wealth of yoga exercises that strengthen and ground, but also some quick tricks, like ‘Cook’s Hook-ups’ from Educational Kinesiology: watch this video, and do try this at home!
https://www.youtube.com/watch?v=W8Ns-2yENgccooks_hookup_fullsize

pic (c) Maryam Webster http://maryamwebster.com/stressrelief/

It’s not always possible to take up a strange position, especially if you’re at work or on the tube for instance! But Mudras, or hand-yoga is often possible!. Mudras change the flow of energy around the body, affecting physical and mental states, and are a part of the Indian system of medicine called Ayurveda. Here’s a link to the mudras for anxiety and depression https://youtu.be/X8OgsX9b3JA.

mudra

image from http://www.stylecraze.com/articles/8-yoga-mudras-to-overcome-any-ailments/#gref

In summary, panic attacks can be caused by many factors, so having a multi-factorial approach, with patience, to achieve the goal of mastering them, makes sense. I hope these resources are useful, and if you have your own personal tips, please do share them by commenting.

All the best, Miranda