Neurology

WHO WE ARE

The Department of Neurology provides expert care to thousands of adults each year, many with rare and complex conditions. The team at UHCW is dedicated to promoting the highest quality patient-centred care, training medical students and neurology registrars and conducts research to advance the science of neurology to provide meaningful therapies for our patients.

Our areas of focus are general neurological conditions and also specialist care in Parkinson’s Disease, Multiple Sclerosis and other neuroinflammatory disorders, Epilepsy and headaches.

WHAT WE DO

Adult Epilepsy Service

The epilepsy team provide a comprehensive epilepsy service for people over the age of 16 with established and suspected epilepsy/seizures living in Coventry and Warwickshire as well as bordering parts of some surrounding counties.

The team consists of two consultant neurologists with special interest in epilepsy, one consultant clinical neurophysiologist with interest in epilepsy, one part-time general practitioner with interest in epilepsy and two hospital-based Clinical Nurse Specialists (CNS) in epilepsy supported by the neurophysiology/EEG team.

Multiple Sclerosis and Neuroinflammation

A specialised multidisciplinary team including MS consultants, specialist nurses, neurophysiotherapists, continence specialists and occupational therapists provide diagnostics, treatment and support services to patients with MS and other related neuroinflammatory disorders.

The team is also involved in clinical research and education and a member of the MS registries and trials consortium. More than 2,500 patients are regularly seen in our clinics. The neurology clinics provide a one stop diagnostic clinic, rapid access relapse management service, disease modifying therapies, symptom management, neurorehabilitation.

Multiple Sclerosis (MS) is the most common neurological disease to affect young adults, with most people diagnosed in their 20s and 30s. Approximately 130,000 people in the UK have MS which is a lifelong condition. Females are affected three times more than males. It is an autoimmune disease which affects the central nervous system (brain and spinal cord).

The exact physiology remains unclear, however in MS the coating that protects your nerves (Myelin) is damaged. The immune system which normally helps fight off infections, mistakes myelin for a foreign body and attacks it. This affects how messages are transmitted between the brain and the rest of the body.

What are the symptoms of MS?

The central nervous system connects everything your body does, therefore MS can cause many symptoms. The disease is unpredictable and the specific symptoms depend on which part of your central nervous system is affected. Common symptoms include visual disturbance, poor co-ordination and balance, tremor, bladder, bowel and sexual dysfunction, cognitive issues, sensory disturbance, fatigue, mobility problems.

Relapsing/remitting MS

Relapsing-remitting type of MS is when you have flare-ups of the disease, or relapses. Between these flare-ups, you have periods of recovery, or remissions. A relapse is a relatively sudden (over hours or days) episode of new symptoms or the reappearance of, or significant increase in, old symptoms. To be considered a new relapse it must:

last at least 24 hours, but usually lasts anything from a few days to a number of weeks or months
occur at least 30 days after the start of a previous relapse.
There must be no other explanation for the onset of symptoms such as an infection or a rise in body temperature.

Secondary progressive

Many people who are initially diagnosed with relapsing remitting MS find that, over time, their MS changes so that there are fewer or no relapses but disability is increasing. This is called secondary progressive MS (often abbreviated to SPMS). It is called 'secondary' because the progressive phase happens second, after the relapsing remitting stage. 'Progressive' is the word used to describe the change towards more disability. However, a small number of people will be diagnosed with secondary progressive MS from the very beginning. In hindsight, they may have experienced relapses in the past but these may have been mild or their significance was missed.

Primary progressive

In this type of MS it is very rare to have any relapses (periods where symptoms flare up) and remissions (periods of good or complete recovery). Instead symptoms gradually worsen from the outset (progression). This is why it is called 'primary' – because progression happens first, rather than having a relapsing remitting phase which can be followed by a progressive phase called secondary progressive MS. 'Progressive' is the word used to describe the change towards more disability in MS.

Why do people develop MS?

The cause of multiple sclerosis is unknown. It is considered an autoimmune disease in which the body's immune system attacks its own tissues. In the case of MS, this immune system malfunction destroys the fatty substance that coats and protects nerve fibers in the brain and spinal cord (myelin). Myelin can be compared to the insulation coating on electrical wires. When the protective myelin is damaged and the nerve fiber is exposed, the messages that travel along that nerve fiber may be slowed or blocked. It isn't clear why MS develops in some people and not others.

A combination of genetics and environmental factors appears to be responsible. These factors may increase your risk of developing multiple sclerosis:

Age. MS can occur at any age, but onset usually occurs around 20 and 40 years of age. However, younger and older people can be affected.
Sex. Women are more than two to three times as likely as men are to have relapsing-remitting MS.
Family history. If one of your parents or siblings has had MS, you are at higher risk of developing the disease.
Certain infections. A variety of viruses have been linked to MS, including Epstein-Barr, the virus that causes infectious mononucleosis.
Race. White people, particularly those of Northern European descent, are at highest risk of developing MS. People of Asian, African or Native American descent have the lowest risk.
Climate. MS is far more common in countries with temperate climates, including Canada, the northern United States, New Zealand, southeastern Australia and Europe.
Vitamin D. Having low levels of vitamin D and low exposure to sunlight is associated with a greater risk of MS.
Certain autoimmune diseases. You have a slightly higher risk of developing MS if you have other autoimmune disorders such as thyroid disease, pernicious anemia, psoriasis, type 1 diabetes or inflammatory bowel disease.
Smoking. Smokers who experience an initial event of symptoms that may signal MS are more likely than nonsmokers to develop a second event that confirms relapsing-remitting MS.

Diagnosis of MS

Multiple sclerosis (MS) can be hard to diagnose because some of the symptoms are similar to those of other conditions. Consultant neurologists specialise in the brain and nervous system. Only a consultant neurologist can diagnose MS, after carefully assessing your symptoms or circumstances. Even if you have had an MRI scan that suggests you have MS, you still need to see a consultant neurologist who will look at the results of all of your tests before making a diagnosis. If your symptoms and circumstances don't match the criteria for how MS usually appears over a specific period of time, but your consultant neurologist still thinks MS is a possibility, they will plan a review appointment. They will tell you when the appointment will take place and who to contact if your symptoms get worse or you get any new symptoms in the meantime. If it's possible that you have MS, you will also be given information about support groups and national charities.

Living with MS

Fatigue management

Many people with MS have fatigue. This is not ordinary tiredness, but a feeling of utter exhaustion that is not related to how much you have been doing. The fatigue can be brought on by heat, overexerting yourself or stress. Sometimes it can be related to the time of day. If you have problems with fatigue, your GP will first make sure that nothing else could be causing it, such as anxiety, depression, difficulty in sleeping or medical problems such as anaemia or thyroid disease. If you have any of these conditions you will be offered treatment for them first. If your fatigue is caused by your MS, a drug called amantadine could help with this.

Training in mindfulness (paying attention to your present thoughts and feelings), cognitive behavioural therapy (a type of talking therapy that helps you change the way you think and behave) or special techniques to help you manage your fatigue may also help. Aerobic, balance and stretching exercises such as yoga may also help ease MS-related fatigue.

Mobility

If you are having problems with mobility you will be fully assessed so that you and your healthcare professional (usually a rehabilitation specialist or a physiotherapist with expertise in MS) can set some goals and plan how you can achieve them.

Taking part in a supervised exercise class that combines some aerobic and strength training may help if you have problems with mobility or fatigue.

Spasticity

Spasticity is a condition that affects the muscles, making them more stiff and rigid than usual. Other conditions can make spasticity worse such as constipation or an infection and these should be assessed and treated. You may need to try several different drugs for spasticity taken at various doses until the right one is found for you. The drugs could include baclofen, gabapentin, tizanidine, dantrolene, and benzodiazepines. You may even need to try a combination of drugs. Drugs that don't work for you should be stopped. Once the right drug and dose has been prescribed, your neurologist will set up an appointment to review your treatment at least once a year. You will also be encouraged to manage your own spasticity by varying the drug dose you take within agreed limits.

Pain

You may have neuropathic pain. This happens when the nerves don't work properly and send the wrong signals to the brain. It can feel like stabbing, an electric shock, burning, tingling, prickling, itching, or a sensation of pins and needles anywhere in the body. If you have this, you will be offered treatment in line with NICE's guideline on neuropathic pain. You might also get pain in your muscles, joints and bone, and this is usually caused by problems with mobility or posture. If you have this type of pain your doctor will assess your symptoms and offer treatment or referral.

Diet

For most people with MS, the best diet is a healthy, varied one. Some people with MS say that following a specific diet has made a difference to how they feel, but there’s no conclusive evidence to support excluding specific foods from your diet to treat MS. Eating nutritionally balanced meals helps the body to work to its full potential – particularly useful when living with a long-term condition.

You can ask for a referral to a dietitian, who can help if you have any particular nutritional or energy needs – for example, if you have a constant tremor, you’re underweight, or if you have another health condition which might affect your diet. A dietitian can help you plan your meals so that you’re getting all the nutrients you need.

Mental health

If you have problems with your memory or thinking, or if you have anxiety, depression or difficulty in sleeping, you may be referred to mental health team members to assess your symptoms and offer you treatment. They may suggest you see an occupational therapist or neuropsychologist (a psychologist who specialises conditions that affect the nervous system). You may also be referred to a memory clinic if your problems relate to memory or thinking.

Pregnancy

Fortunately, pregnancy does not appear to speed up the course or worsen the effects of MS. However, if you have unrecognized MS you may be more likely to start having symptoms during pregnancy. Some studies have found that MS symptoms decrease in pregnancy and increase after delivery. The disabling effects of the disease may make it physically hard to carry a pregnancy. Muscle weakness and coordination problems may increase the likelihood for falls. Fatigue may worsen. Wheelchair dependence may increase the risk for urinary tract infections.

There is no evidence that MS causes infertility.

Studies have shown that pregnancy, delivery, and rate of birth defects are not significantly different in women with MS compared with those without MS. During pregnancy, you will need close monitoring to keep track of the disease and the health of the foetus. You may need more frequent prenatal visits. There is no established treatment that alters the course of MS. But, you may be given medicines such as steroids and anti-inflammatory drugs. A procedure called plasmapheresis (a method for removing toxic elements from the blood) has been used in trials for treatment of MS. Consult your doctor for more information.

Supportive treatment and rehabilitation for MS are especially important during pregnancy. Rehabilitation varies depending on your symptoms but may help with doing normal activities of daily living (ADLs), maintaining independence, using assistive devices (for example, canes, braces, and walkers), setting an appropriate exercise program to promote muscle strength, endurance, and control, re-establishing motor skills, improving communication skills if you have trouble speaking because of weakness or lack of coordination of face and tongue muscles, managing bowel or bladder incontinence, providing cognitive retraining, adapting the home environment for safety and usability. During labour, you may not have pelvic sensation and may not feel pain with contractions. This may also make it hard to tell when labour starts. Delivery of the baby may be more difficult if you have MS. While labour itself is not affected, MS can affect the muscles and nerves needed for pushing. For this reason, you may need Caesarean delivery, or delivery with the help of forceps or vacuum.

Sarcoidosis

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Parkinson's Disease

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Neurology Research

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DELIVERING YOUR CARE

Adult Epilepsy Service

The following clinics/services are provided: General epilepsy clinics, daily first seizure clinics, adolescent transition epilepsy clinic, Clinical Nurse Specialist [CNS] pre conceptual counselling epilepsy clinic, CNS pregnancy monitoring epilepsy clinic, CNS buccal midazolam training clinic, CNS Telephone advice for non-urgent calls.

Clinics are held at the main University Hospital site and the City of Coventry Health Centre.

Patients with suspected and established epilepsy/seizures have access to the following investigations: Modern 3 tesla MRI with dedicated epilepsy protocol, standard and sleep deprived EEG (electroencephalogram/brain wave testing), ambulatory home video telemetry (monitoring of brain waves and simultaneous video recording of suspected seizures in the patient's own home) and inpatient video telemetry (monitoring of brain waves and simultaneous video recording of suspected seizures in a dedicated side room on the neurology ward). The EEG tests are provided by a team of specialists within the department of Clinical Neurophysiology based on the main hospital site. The epilepsy team works closely with colleagues at the West Midlands Complex Epilepsy Surgery Centre at the University Hospital in Birmingham when surgical procedures for certain forms of epilepsy are being considered (such as temporal lobe surgery or vagal nerve stimulator insertion).

Multiple Sclerosis and Neuroinflammation

Our MS services include:

i) Multiple Sclerosis Clinic

Information about MS for newly diagnosed patients or for those who are experiencing a change in their MS, transition to secondary progressive multiple sclerosis or pregnancy.
Education about first or second-line therapies

Follow-up nurse-led clinics can be face to face, by telephone or virtual (These clinics focus on:

Update of clinical tests such as blood tests and vital signs
Follow up assessments to assess how treatment in going

ii) Relapse clinic

The Relapse Clinic is led by one of MS specialists. It is a rapid access clinic from the onset of symptoms. Patients go either to the Day Care Unit and receive medication via an intravenous drip or treatment can be given as tablets which can be collected from the hospital pharmacy or their GP.

iii) Symptom management clinic

iv) Neurophysiotherapy

MS physiotherapists support patients through:

Assessing difficulties patients may be having with movement, strength, mobility and balance
Giving advice about ways to improve or maintain functional ability
Giving advice on what exercises may be of benefit to help guide self-management techniques
Giving advice on any equipment that may be of help, such as splints and walking aids
Exploring options for on-going physiotherapy and exercise as required
Making referrals to other health professionals, if required

v) Occupational therapy

Occupational therapists support individuals to achieve participation in daily activities that are relevant and meaningful to them. This includes:

Analysing how well patients can perform everyday tasks
Assisting individual patients to adapt the way an activity is done
Identifying environmental modifications and equipment
Educating and advising on appropriate alternative activities or occupations
Assisting an individual to resume their daily routine following a relapse
Referring to external agencies such as social services, the Access to Work scheme, wheelchair services or local rehabilitation teams.

vi) Continence clinics

Bladder symptoms are very common in MS patients and tend to be problems with storage and/or emptying. They are often easily treated or at least manageable following the right assessment, treatment and advice.

The Continence team are able to fully assess any symptoms and suggest an appropriate, individually tailored treatment course. This may involve:

Lifestyle changes, such as alteration to fluid intake
Non-pharmacological treatments, such as the learning of intermittent self-catheterization, bladder retraining or pelvic floor exercises or use of medications, such as anti-muscarinics that relax the bladder.

vii) Mindfulness

HOW TO ACCESS OUR SERVICES

Access to our AES is generally via choose and book following referrals from general practitioners or through referrals from general neurologists and other specialists in our and neighbouring hospitals. Please note that patients need to be under the care of a neurology consultant to access the Clinical Nurse Specialist service.