Immunotherapy for MS is an important measure for many patients, but it is not the only strategy we use. Although immunotherapies are particularly important therapeutic measures in the early stages of the disease, this (apparent) hierarchy does not apply to every stage of the disease and not to every age group. Rehabilitation with its wide range of symptomatic therapies is probably more important in later stages of the disease than immunotherapy, especially when it comes to immediate improvement of the individual situation.
I would like to give you a small example. A patient I saw some time ago had been suffering from MS for years, which had already led to significant neurological impairments. The presentation was made with the desire for a highly efficient drug therapy – “something must finally be done”, was strongly advocated by her relatives. Since no relapses had occurred for years and the MRI also showed no further changes, I saw no real reason for a change in drug therapy. On the other hand, it turned out that no rehabilitation had been carried out for years, that physiotherapy was carried out weekly, but only in the form of massages, and physical activity and movement were foreign words. No speech therapy treatment had ever been considered for a pronounced speech and associated breathing disorder. Therefore, I made it clear that in this case I would first want to see the optimisation of a symptomatic therapy before any immunotherapy, especially because of the severe breathing disorder. I recommended intensive speech therapy and inpatient rehabilitation. In addition, I tried to convey to the relatives the importance of physiotherapy, occupational therapy and speech therapy in the late stages of the disease. Despite the severe disability, I emphasised the importance of physical activity. However, I definitely failed to convey this message – I subsequently received a disappointed letter: “I didn’t take the situation seriously, I didn’t do anything and withheld life-saving medication from her…”
This case is very similar to another case. Here too, there was no obvious inflammatory activity, which is why I did not recommend immunotherapy. Here too, the focus was on rehabilitation. In this particular case, we paid special attention to the speech and swallowing situation, which was significantly improved by intensive therapy, thereby enhancing the patient’s quality of life. I think that even though we did not pursue an immunotherapeutic approach here either, the patient was helped considerably.
So, I resist the view that one is doing nothing if one does not prescribe an MS drug. Rehabilitation and symptomatic treatment approaches can significantly improve quality of life, particularly in later stages of the disease, and deserve to be considered as equivalent measures. It is probably time – especially as efforts are now being made to identify suitable immunotherapies for late stages of the disease – for rehabilitation strategies to be implemented earlier in the course of the disease, in order to build up body and movement competence as early as possible. This too is a kind of prophylactic therapy.
