Multiple Sclerosis (MS)
Multiple sclerosis (MS), also known as disseminated sclerosis or encephalomyelitis disseminata, is an inflammatory disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged. This damage disrupts the ability of parts of the nervous system to communicate, resulting in a wide range of signs and symptoms, including physical, mental, and sometimes psychiatric problems. MS takes several forms, with new symptoms either occurring in isolated attacks (relapsing forms) or building up over time (progressive forms). Between attacks, symptoms may disappear completely; however, permanent neurological problems often occur, especially as the disease advances.
While the cause is not clear, the underlying mechanism is thought to be either destruction by the immune system or failure of the myelin-producing cells. Proposed causes for this include genetics and environmental factors such as infections. MS is usually diagnosed based on the presenting signs and symptoms and the results of supporting medical tests.
There is no known cure for multiple sclerosis. Treatments attempt to improve function after an attack and prevent new attacks. Medications used to treat MS while modestly effective can have adverse effects and be poorly tolerated. Many people pursue alternative treatments, despite a lack of evidence. The long-term outcome is difficult to predict, with good outcomes more often seen in women, those who develop the disease early in life, those with a relapsing course, and those who initially experienced few attacks. Life expectancy is on average 5 to 10 years lower than that of an unaffected population.
Multiple sclerosis is the most common autoimmune disorder affecting the central nervous system. As of 2008, between 2 and 2.5 million people are affected globally with rates varying widely in different regions of the world and among different populations. The disease usually begins between the ages of 20 and 50 and is twice as common in women as in men. The name multiple sclerosis refers to scars (sclerae—better known as plaques or lesions) in particular in the white matter of the brain and spinal cord. MS was first described in 1868 by Jean-Martin Charcot. A number of new treatments and diagnostic methods are under development.
Multiple sclerosis (MS) is a disease in which your immune system attacks the protective sheath (myelin) that covers your nerves. Myelin damage disrupts communication between your brain and the rest of your body. Ultimately, the nerves themselves may deteriorate, a process that's currently irreversible.
Signs and symptoms vary widely, depending on the amount of damage and which nerves are affected. Some people with severe MS may lose the ability to walk independently or at all, while others experience long periods of remission during which they develop no new symptoms.
There's no cure for multiple sclerosis. However, treatments can help speed recovery from attacks, modify the course of the disease and manage symptoms.
Signs and symptoms of multiple sclerosis vary, depending on the location of affected nerve fibers. MS signs and symptoms may include:
- Numbness or weakness in one or more limbs that typically occurs on one side of your body at a time, or the legs and trunk
- Partial or complete loss of vision, usually in one eye at a time, often with pain during eye movement
- Double vision or blurring of vision
- Tingling or pain in parts of your body
- Electric-shock sensations that occur with certain neck movements, especially bending the neck forward
- Tremor, lack of coordination or unsteady gait
- Slurred speech
- Problems with bowel and bladder function
Most people with MS have a relapsing-remitting course, with new symptoms (relapse) that develop over days or weeks and usually improve partially or completely, followed by a quiet period (remission) that can last months or even years. Small increases in body temperature can temporarily worsen signs and symptoms of MS, but that type of event isn't a relapse.
About 60 to 70 percent of people with relapsing-remitting MS eventually develop a steady progression of symptoms, with or without periods of remission (secondary-progressive MS). The worsening symptoms usually include problems with gait. The rate of progression varies greatly among people with secondary-progressive MS.
Some people with MS experience a gradual onset and steady progression of signs and symptoms with no relapses (primary-progressive MS).
The cause of multiple sclerosis is unknown. It's believed to be an autoimmune disease, in which the body's immune system attacks its own tissues. In MS, this process destroys myelin — the fatty substance that coats and protects nerve fibers in the brain and spinal cord.
Myelin can be compared to the insulation on electrical wires. When myelin is damaged, the messages that travel along that nerve may be slowed or blocked.
It isn't clear why MS develops in some people and not others. A combination of factors, ranging from genetics to childhood infections, may play a role.
These factors may increase your risk of developing multiple sclerosis:
- Age. MS can occur at any age, but most commonly affects people between the ages of 15 and 60.
- Sex. Women are about twice as likely as men are to develop 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 southern Canada, northern United States, New Zealand, southeastern Australia and Europe.
- Certain autoimmune diseases. You have a slightly higher risk of developing MS if you have thyroid disease, 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.
People with multiple sclerosis also may develop:
- Muscle stiffness or spasms
- Paralysis, typically in the legs
- Problems with bladder, bowel or sexual function
- Mental changes, such as forgetfulness or mood swings
You may be referred to a doctor who specializes in disorders of the brain and nervous system (neurologist).
What you can do
- Write down your symptoms, including any that may seem unrelated to the reason why you scheduled the appointment.
- Make a list of all your medications, vitamins and supplements.
- Write down your key medical information, including other conditions.
- Write down key personal information, including any recent changes or stressors in your life.
- Write down questions to ask your doctor.
- Ask a relative or friend to accompany you, to help you remember what the doctor says.
Questions to ask your doctor
- What's the most likely cause of my symptoms?
- What kinds of tests do I need? Do they require any special preparation?
- Is my condition likely temporary or chronic?
- Will my condition progress?
- What treatments are available?
- I have these other health conditions. How can I best manage them together?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions during your appointment.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may make time to go over points you want to spend more time on. You may be asked:
- When did you begin experiencing symptoms?
- Have your symptoms been continuous or occasional?
- How severe are your symptoms?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
- Does anyone in your family have multiple sclerosis?
There are no specific tests for MS. The diagnosis relies on ruling out other conditions that might produce similar signs and symptoms.
Your doctor is likely to start with a thorough medical history and examination. Your doctor may then recommend:
- Blood tests, to help rule out infectious or inflammatory diseases with symptoms similar to MS.
- Spinal tap (lumbar puncture), in which a small sample of fluid is removed from your spinal canal for laboratory analysis. This sample can show abnormalities in white blood cells or antibodies that are associated with MS. Spinal tap can also help rule out viral infections and other conditions with symptoms similar to MS.
- MRI, which can reveal areas of MS (lesions) on your brain and spinal cord. You may receive an intravenous dye to highlight lesions that indicate your disease is in an active phase.
- Evoked potential tests - These tests record the electrical signals produced by your nervous system in response to stimuli. An evoked potential test may use visual stimuli or electrical stimuli, in which you watch a moving visual pattern or short electrical impulses are applied to nerves in your legs or arms. Electrodes measure how quickly the information travels down your nerve pathways.
There is no cure for multiple sclerosis. Treatment typically focuses on speeding recovery from attacks, slowing the progression of the disease and managing symptoms. Some people have such mild symptoms that no treatment is necessary.
Treatments for attacks
- Corticosteroids, such as oral prednisone and intravenous methylprednisolone, are prescribed to reduce nerve inflammation. Side effects may include insomnia, increased blood pressure, mood swings and fluid retention.
- Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is removed and separated from your blood cells. The blood cells are then mixed with a protein solution (albumin) and put back into your body. Plasma exchange may be used if your symptoms are severe and haven't responded to steroids.
Treatments to modify progression
- No therapies have shown benefit for slowing the progression of primary-progressive MS. For relapsing-remitting MS, certain medications can lower the relapse rate and reduce the rate of formation of new lesions, particularly early in the disease course.
- The options include:
- Beta interferons. These medications, which are injected under the skin or into muscle, can reduce the frequency and severity of relapses. Beta interferons can cause side effects such as flu-like symptoms and injection-site reactions. You'll need blood tests to monitor your liver enzymes.
- Glatiramer acetate (Copaxone). This medication may help block your immune system's attack on myelin. The medication must be injected beneath the skin. Side effects may include skin irritation at the injection site.
- Dimethyl fumarate (Tecfidera). This twice-daily oral medication can reduce relapses. Side effects may include flushing, diarrhea, nausea and lowered white blood cell count.
- Fingolimod (Gilenya). This once-daily oral medication reduces relapse rate. You'll need to have your heart rate monitored for six hours after the first dose because your heartbeat may be slowed. Other side effects include high blood pressure and blurred vision.
- Teriflunomide (Aubagio). This once-daily medication can reduce relapse rate. Teriflunomide can cause liver damage, hair loss and other side effects. It is also known to be harmful to a developing fetus.
- Natalizumab (Tysabri). This medication is designed to block the movement of potentially damaging immune cells from your bloodstream to your brain and spinal cord. The medication increases the risk of a viral infection of the brain called progressive multifocal leukoencephalopathy. It is generally given to people who have more severe or active MS, or who do not respond to or can't tolerate other treatments.
- Mitoxantrone (Novantrone). This immunosuppressant drug can be harmful to the heart and is associated with development of blood cancers. Mitoxantrone is usually used only to treat severe, advanced MS.
Treatments for signs and symptoms
- Physical therapy. A physical or occupational therapist can teach you stretching and strengthening exercises, and show you how to use devices that can make it easier to perform daily tasks.
- Muscle relaxants. You may experience painful or uncontrollable muscle stiffness or spasms, particularly in your legs. Muscle relaxants such as baclofen (Lioresal, Gablofen) and tizanidine (Zanaflex) may help.
- Medications to reduce fatigue.
- Other medications. Medications may also be prescribed for depression, pain, and bladder or bowel control problems that are associated with MS.
- To help relieve the signs and symptoms of MS, try to:
- Get plenty of rest.
- Exercise. If you have mild to moderate MS, regular exercise can help improve your strength, muscle tone, balance and coordination. Swimming or other water exercises are good options if you're bothered by heat. Other types of mild to moderate exercise recommended for MS include walking, stretching, low-impact aerobics, stationary bicycling, yoga and tai chi.
- Cool down. MS symptoms often worsen when your body temperature rises. Avoiding exposure to heat and using devices such as cooling scarves or vests can be helpful.
- Eat a balanced diet. Results of small studies suggest that a diet low in saturated fat but high in omega-3 fatty acids, such as those found in olive and fish oils, may be beneficial. But further research is needed. Studies also suggest that vitamin D may have potential benefit for MS.
- Relieve stress. Stress may trigger or worsen your signs and symptoms. Yoga, tai chi, massage, meditation or deep breathing may help.
Living with any chronic illness can be difficult. To manage the stress of living with MS, consider these suggestions:
- Maintain normal daily activities as best you can.
- Stay connected to friends and family.
- Continue to pursue hobbies that you enjoy and are able to do.
- Contact a support group, for yourself or for family members.
- Discuss your feelings and concerns about living with MS with your doctor or a counselor.
Multiple sclerosis (MS) affects the brain and spinal cord. Early MS symptoms include weakness, tingling, numbness, and blurred vision. Other signs are muscle stiffness, thinking problems, and urinary problems. Treatment can relieve MS symptoms and delay disease progression.