Multiple Sclerosis: Defined

OVERVIEW

An estimated 400,000 people in the United States live with multiple sclerosis (MS). MS is a condition in which the body’s own immune system damages the fatty layer (myelin sheath) around the nerve cells in the brain and spinal cord. This damage results in the slowing or stopping of nerve signals along the affected nerves and can lead to serious disability.

drawing of the myelin sheath renderingWhile the exact cause of MS is unknown, genetic, environmental and viral factors may all play a role. The disease most commonly follows a relapsing-remitting course, meaning patients will have acute flare-ups or attacks of symptoms followed by periods of remission (reduction or disappearance of symptoms). Almost every neurological system can be affected by MS.

SYMPTOMS

Most people with MS show their first symptoms between 20 and 40 years of age. In many cases, the first symptom of MS involves vision; patients may experience blurred or double vision, red-green color distortion or even blindness in one eye.

Most MS patients have muscle weakness in their limbs and problems with coordination and balance. These symptoms can make it difficult for patients to walk or even stand. At its worst, MS can lead to partial or complete paralysis. Most MS patients also tend to have paresthesia — sensations of numbness, tingling, prickling, burning or “pins and needles.”

About half of all people with MS have cognitive problems such as difficulty concentrating and paying attention, memory issues and poor judgement. These symptoms, however, are typically mild.

Other symptoms of MS include pain, speech difficulties, tremors and dizziness. In some cases, MS patients experience hearing loss. Many people with MS are affected by depression as well.

DIAGNOSIS

There is no single test that can diagnose multiple sclerosis on its own. An MS diagnosis is usually made using a combination of tools, including a medical history, neurological exams, eye exams, spinal tap and MRI.

Medical History

A patient’s medical history may provide enough evidence alone for a doctor to suspect multiple sclerosis, but it still is not enough for a definitive diagnosis. A careful physical exam — including tests of reflexes, eye movements, balance and walking — also can point the doctor in the right direction.

Evoked Potential Test

An evoked potential test measures the brain’s electrical activity in response to visual or electrical stimulation. This test can spot the slowing of electrical signals caused by damage to the myelin sheath. As such, it can help doctors make a diagnosis even if a patient isn’t showing symptoms of nerve damage.

Magnetic Resonance Imaging (MRI)

MRI is used to create detailed images of the brain, spinal cord and other areas of the body. It is the preferred imaging tool for making an MS diagnosis and to track the course of the disease.

MRI can reveal lesions caused by damage to the myelin sheath. These lesions, however, are not always the result of MS; they may also be caused by other conditions, such as lupus, diabetes or migraines. For this reason, an MRI cannot provide all the information needed to make a definitive diagnosis.

Spinal Tap (lumbar puncture)

A lumbar puncture — more commonly known as a “spinal tap” — is used to draw cerebrospinal fluid from the spinal cord. This fluid can provide clues for the diagnosis of many nervous system diseases, including MS.

During a spinal tap, a doctor or nurse inserts a long, thin, hollow needle between two bones in the lower spine and into the area where cerebrospinal fluid circulates.

Like the other tests used in the diagnosis of MS, an analysis cerebrospinal fluid provide an MS diagnosis on its own; rather, it must be part of the whole bag of tools used to diagnose MS.

TREATMENTS

There is no cure for multiple sclerosis, but there are treatments to control the disease. Medications are used to slow disease progress, treat MS attacks — or exacerbations — and manage symptoms. While some patients with mild symptoms may not need treatment, others will require these medications.

Slowing progress of MS

drugs on a shelfOver time, MS can lead to debilitating nerve damage, which cannot be reversed. Fortunately, there are medications that can change the course of disease. These medications include the following:

  • Beta interferons: These medications — which include Avonex (interferon beta-1a), Betaseron (interferon beta-1b), Extavia (interferon beta-1b) and Rebif (interferon beta-1a) —are used to slow the progress of MS, reduce the number of MS attacks and to reduce the severity of attacks. While interferons can cause side effects like liver damage and reactions at the injection site, serious and permanent side effects are rare.
  • Copaxone (glatiramer acetate): This medication appears to block immune system T-cells from damaging myelin. Research has shown that glatiramer acetate may reduce the number of MS attacks. Glatiramer acetate is injected under the skin either once a day or three times a week. Side effects usually resolve on their own and do not require medical attention unless they last for several weeks. Such side effects may include injection-site reactions — such as swelling, formation of a hardened lump, redness, warmth of the skin and itching — as well as runny nose, tremor, tiredness or weakness and weight gain.
  • Gilenya (fingolimod): Scientists believe that fingolimod works by keeping certain white blood cells — called lymphocytes — trapped in the lymph nodes, which may reduce the number of MS attacks and short-term disability. Fingolimod is a capsule taken orally once a day. This medication may cause a patient’s heart rate to slow down. Therefore, patients must have their heart rate monitored in the six hours after taking their first dose. Before taking fingolimod, patients must be immune to chickenpox. Other possible side effects include headache, flu, diarrhea, back pain, liver issues and cough.
  • Tysabri (natalizumab): This medication may reduce the number of MS attacks and lower the risk of worsening disability. Because natalizumab raises the risk for a serious brain infection known as progressive multifocal leukoencephalopathy (PML), natalizumab is usually recommended for patients who have not responded well to other treatments. Other possible side effects include liver damage, allergic reactions and several infections.
  • Novantrone (mitoxantrone): Before being approved for use in MS, mitoxantrone was used to treat certain kinds of cancer. In patients with MS, mitoxantrone works by blocking immune system cells that are thought to play a role in the attack on the myelin sheath. This medication has been linked to heart troubles and blood cancers such as leukemia. Mitoxantrone is mainly used to treat severe and advanced multiple sclerosis.
  • Aubagio (teriflunomide): This oral medication blocks the function of certain immune cells that are thought to play a role in MS. Terflunomide may reduce attacks and lesions in people with MS. Since teriflunomide can cause serious liver damage, doctors use blood tests to monitor liver function in patients taking this medication. Teriflunomide also may cause birth defects if used by women during pregnancy. Other possible side effects include diarrhea, nausea, influenza and alopecia (hair thinning).
Treating attacks
  • Corticoteroids: Neurologists often recommend corticosteroids for severe attacks (relapses) of MS. Such attacks can involve vision loss, severe weakness and poor balance. These symptoms and others can limit a patient’s mobility and overall ability to function. Corticosteroids are used to reduce inflammation during these attacks, and are most commonly prescribed in high-doses for three to five days. Examples of corticosteroids used to treat MS include oral prednisone and intravenous (injected) methylprednisolone (Solu-Medrol). Side effects may include weight gain, mood swings, seizures and increased infection risk.
  • Plasma exchange (plasmapheresis): For this procedure, a doctor takes blood from the patient’s body and mechanically separates blood cells from the plasma (the liquid part of blood). Then the doctor replaces the plasma with another solution, mixes that solution with blood cells and returns the blood to the patient’s body. Plasma exchange is typically used in MS patients who haven’t responded well to steroid treatment.
Treating symptoms

A wide array of medications are used to treat the many symptoms of MS. There are dozens of medications to treat bladder problems, bowel dysfunction, depression, dizziness and vertigo, emotional issues, fatigue, itching, pain, sexual problems, spasticity (stiff or rigid muscles), tremors and walking difficulties. Tell your doctor or neurologist if you need more help managing these symptoms.

Physical therapy is also used to manage symptoms of MS. Physical and occupational therapists can walk MS patients through stretching and strengthening exercises. They can also teach patients how to properly use assistive devices.

CAUSES

Research has shown that multiple sclerosis is an autoimmune disease, meaning it is triggered by the body’s immune system mistakenly attacking its own healthy tissues. The exact cause of multiple sclerosis is not known, but scientists have found evidence that points to several factors that may be involved: immunologic factors (of the body’s immune system), environmental factors, infectious factors and genetics.

The following factors may increase the risk of developing MS:

  • Age: People can develop MS at any age. However, the disease usually develops at 20 to 40 years of age.
  • Gender: Women are approximately two times more likely than men to develop MS.
  • Family history: People with parents or siblings who have MS have a higher risk of developing the disease than the general population. However, research on identical twins has shown that genetics cannot be the only factor involved in MS. If genetics were the only factor, then identical twins would have the same MS risk, but the research has shown the do not share the same risk.
  • Ethnicity: MS risk is highest in white people, especially those with a northern European family background. MS risk is lowest in people of Asian, African or Native American descent.
  • Certain infections: MS may be linked to many viruses, such as Epstein-Barr virus.
  • Geographic location: MS is much more common in regions farther from the equator. Research has shown that if a child moves from a high-risk region to a low-risk region, or the other way around, that child tends to take on the MS risk associated with the new home region. However, if that move happens after the child has hit puberty, then that child typically maintains the risk of the first home region.

GETTING HELP

Living with multiple sclerosis can involve many emotional ups and downs. For this reason, multiple sclerosis patients often need coping strategies. Such strategies may involve support groups, staying close to friends and family and simple reminders to stay strong.

If you have MS, it’s important to maintain your normal daily activities to the best of your abilities. Continue doing the hobbies that you enjoy, and stay connected with your friends and family.

If multiple sclerosis makes it difficult for you to do what you enjoy, talk to your doctor about possible ways to overcome these roadblocks.

If the daily struggles of living with multiple sclerosis start to affect your mental health, consider seeking the help of a counselor or therapist. These mental health professionals can help give you perspective, provide coping strategies and teach you relaxation techniques.

Some multiple sclerosis patients find that support groups give them a comfortable place to express their feelings and share their experiences living with multiple sclerosis. Ask your health care provider if there are multiple sclerosis support groups in your area.

RELATED INFORMATION

Multiple sclerosis isn’t the only disease that attacks the myelin (layer covering nerve fibers) of the central nervous system. Here are some of the conditions related to MS.

Acute Disseminated Encephalomyelitis

Acute disseminated encephalomyelitis (ADEM) is an intense yet brief attack of inflammation, or swelling, in the brain, spinal cord, and in some cases, the optic nerves. This inflammation causes damage to the myelin. ADEM is also referred to as post-infectious encephalomyelitis and immune-mediated encephalomyelitis.

In some cases, it can be hard to tell the difference between ADEM and multiple sclerosis, as they both can have symptoms like vision loss, weakness, numbness and loss of balance.

Balo’s Disease

Balo’s disease is a rare disorder that, like multiple sclerosis, damages the myelin layer covering nerve fibers. Even though many experts consider Balo’s disease to be distinct disorder from MS and similar diseases, most specialists see it as a rare form of MS.

Clinically Isolated Syndrome

Clinically isolated syndrome (CIS) is a first and single episode of inflammation or myelin damage in the central nervous system (brain and spinal cord). This episode can involve just one area or multiple areas of the central nervous system. While CIS may not be an early sign of multiple sclerosis, people who have a second episode are considered to have clinically definite MS.

HTLV-1 Associated Myelopathy

HTLV-1 associated myelopathy (HAM) is a chronic disease of the spinal cord that slowly progresses over time. The condition develops in some people infected with the HTLV-1 virus. HAM leads to painful stiffness and weakness of the legs.

Neuromyelitis Optica

Neuromyelitis optica (NMO) is also referred to as Devic’s disease. NMO is a disorder in which the immune system mistakenly attacks myelin in the optic nerves and spinal cord. This immune system attack can damage the optic nerves and spinal cord. This damage may lead to swelling and inflammation that can cause pain and vision loss, weakness or paralysis of arms and legs, loss of feeling and bladder and bowel control problems.

Schilder’s Disease

Schilder’s disease is a very rare disorder that, like multiple sclerosis, damages the myelin sheath over time. The disorder is even thought to be a variant of MS. As Schilder’s disease worsens, it can affect motor movement, speech, personality, hearing and vision. Eventually, the condition can affect respiratory function, heart rate and blood pressure.

Transverse Myelitis

Transverse myelitis is caused by inflammation and swelling on both sides of one part of the spinal cord. This inflammation may damage the myelin layer covering nerve fibers, which can disrupt nerve signals between the spinal cord and the rest of the body.

People who experience transverse myelitis usually have just one attack. However, a small number of patients may experience more than one attack. Transverse myelitis may be the first sign of conditions like multiple sclerosis or neuromeylitis optica.

LIVING WITH

Medical treatment is only part of managing multiple sclerosis. MS patients also must make MS_poster_woman lifting small weights with help of physician behind herMS management a part of their daily lives. Here are some steps that may ease some symptoms of MS:

  • Get active: Exercising on a regular basis may be beneficial to patients with mild to moderate MS. Activities such as walking, swimming and weightlifting, among others, can boost strength, muscle tone, balance and coordination, bladder control and bowel control. Physical activity also may reduce depression and fatigue.
  • Rest up: Fatigue is common in people with MS. Getting plenty of rest may help MS patients feel less tired.
  • Stay cool: Symptoms of MS can get worse when body temperature rises. Finding ways to cool down may improve symptoms. Some patients cool off by running cold water on their wrists, staying in areas with air conditioning, taking a dip in a cool pool or sipping on a cold drink.
  • Eat a healthy diet: A healthy diet can help MS patients stay at a healthy weight, maintain a strong immune system and maintain strong bones.
  • Ease stress: Research has shown that MS symptoms may flare up or worsen with stress. Yoga, tai chi, massage, meditation and deep breathing are all ways that may help reduce stress. If you have MS, find what activities lowers stress best for you.