Multiple sclerosis

Definition

Multiple sclerosis is an autoimmune disease that affects the central nervous system (the brain and spinal cord). 

Causes, incidence, and risk factors

Multiple sclerosis (MS) usually affects woman more than men. The disorder most commonly begins between ages 20 and 40, but can strike at any age.

The exact cause is not known, but MS is believed to result from damage to the myelin sheath, the protective material which surrounds nerve cells. It is a progressive disease, meaning the damage gets worse over time. Inflammation destroys the myelin, leaving multiple areas of scar tissue (sclerosis). The inflammation occurs when the body's own immune cells attack the nervous system.

The inflammation causes nerve impulses to slow down or become blocked, leading to the symptoms of MS. Repeated episodes, or flare ups, of inflammation can occur along any area of the brain and spinal cord.

Symptoms vary because the location and extent of each attack varies. Usually episodes that last days, weeks, or months alternate with times of reduced or no symptoms (remission).

Recurrence (relapse) is common although non-stop progression without periods of remission may also occur.

Researchers are not sure what triggers an attack. Patients with MS typically have a higher number of immune cells than a healthy person, which suggests that an immune response might play a role. The most common theories point to a virus or genetic defect, or a combination of both. There also appears to be a genetic link to the disease. MS is more likely to occur in northern Europe, the northern United States, southern Australia, and New Zealand than in other areas. Geographic studies indicate there may be an environmental factor involved.

People with a family history of MS and those who live in a geographical area with a higher incidence rate for MS have a higher risk of the disease.

Symptoms

• weakness of one or more extremities
• paralysis of one or more extremities
• tremor of one or more extremities
• muscle spasticity (uncontrollable spasm of muscle groups)
• muscle atrophy
• movement, dysfunctional - slowly progressive; beginning in the legs
• numbness or abnormal sensation in any area
• tingling
• facial pain
• extremity pain
• loss of vision -- usually affects one eye at a time
• double vision
• eye discomfort
• uncontrollable rapid eye movements
• eye symptoms worsen on movement of the eyes
• decreased coordination
• loss of balance
• decreased ability to control small or intricate movements
• walking/gait abnormalities
• muscle spasms (especially in the legs)
• dizziness
• vertigo
• urinary hesitancy, difficult to begin urinating
• strong urge to urinate (urinary urgency)
• frequent need to urinate (urinary frequency)
• incontinence (leakage of urine, loss of control over urination)
• decreased memory
• decreased spontaneity
• decreased judgment
• loss of ability to think abstractly
• loss of ability to generalize
• depression
• decreased attention span
• slurred speech
• difficulty speaking or understanding speech
• fatigue, tired easily

• constipation
• hearing loss
• positive Babinski's reflex

Signs and tests

Symptoms of MS may mimic many other neurologic disorders. Diagnosis is made by ruling out other conditions.

A history of at least two attacks separated by a period of reduced or no symptoms may indicate one pattern of attack/remission seen in MS (known as relapsing-remitting pattern). If there are observable decreases in any functions of the central nervous system (such as abnormal reflexes), the diagnosis of MS may be suspected.

Examination by the health care provider may show focal neurologic deficits (localized decreases in function). This may include decreased or abnormal sensation, decreased ability to move a part of the body, speech or vision changes, or other loss of neurologic functions. The type of neurologic deficits usually indicates the location of the damage to the nerves.

Eye examination may show abnormal pupil responses, changes in the visual fields or eye movements, nystagmus (rapid eye movements) triggered by movement of the eye, decreased visual acuity, or abnormal findings on a fundoscopy (an examination of the internal structures of the eye).

Tests that indicate or confirm multiple sclerosis include:

• head MRI scan that shows scarring or a new lesion
• spine MRI scan that shows scarring or a new lesion
• lumbar puncture (spinal tap)
• CSF oligoclonal banding
• CSF IgG index

Treatment

There is no known cure for multiple sclerosis at this time. However, there are promising therapies that may slow the disease. The goal of treatment is to control symptoms and maintain a normal quality of life. Types of treatment include:

• Immune modulators. Patients with a relapsing-remitting course of the disease are often placed on an immune modulating therapy. This requires injection under the skin or in the muscle once or several times a week. It may be in the form of interferon (such as Avonex, Betaseron, or Rebif) or another medicine called glatiramer acetate (Copaxone). They are all similar in their effectiveness and the decision on which to use depends on concerns about particular side effects.
• Steroids. Steroids are given to decrease the severity of attacks when they occur. These shut the immune system down to stop cells from causing inflammation.
• Lioresal (Baclofen), tizanidine (Zanaflex), or a benzodiazepine may be used to reduce muscle spasticity.
• Cholinergic medications to reduce urinary problems.
• Antidepressants for mood or behavior symptoms.
• Amantadine for fatigue.
• Physical therapy, speech therapy, occupational therapy, and support groups can help improve the person's outlook, reduce depression, maximize function, and improve coping skills.
• Exercise. A planned exercise program early in the course of the disorder can help maintain muscle tone.

A healthy lifestyle is encouraged, including good general nutrition. Adequate rest and relaxation can help maintain energy levels. Attempts should be made to avoid fatigue, stress, temperature extremes, and illness to reduce factors that may trigger an MS attack.

Support Groups

For additional information, see multiple sclerosis resources.

Expectations (prognosis)

The outcome is variable and unpredictable. Although the disorder is chronic and incurable, life expectancy can be normal or nearly so. Most people with MS continue to walk and function at work with minimal disability for 20 or more years.

The factors felt to best predict a relatively benign course are female gender, young age at onset (less than 30 years), infrequent attacks, a relapsing-remitting pattern, and low burden of disease on imaging studies.

The amount of disability and discomfort varies with the severity and frequency of attacks and the part of the central nervous system affected by each attack. Commonly, there is initially a return to normal or near-normal function between attacks. As the disorder progresses, there is progressive loss of function with less improvement between attacks.

Complications

• progressive disability
• urinary tract infections
• side effects of medications used to treat the disorder

Calling your health care provider

Call your health care provider if you develop any symptoms of MS, as he or she is the only one who can distinguish multiple sclerosis from other serious disorders such as stroke or infection.

Call your health care provider if symptoms progressively worsen despite treatment.

Call your health care provider if the condition deteriorates to the point where home care is no longer possible.

References

Hafler DA. Multiple sclerosis. J Clin Invest. 2004 Mar 15; 113(6): 788-794.

Goetz, CG, ed. Multiple Sclerosis. In: Textbook of Clinical Neurology. 2nd ed. Saunders. Philadelphia, PA: 2003;1060-1076

National Multiple Sclerosis Society. Available at: http://www.nmss.org/. Accessed June 6, 2005.

Illustrations

Multiple sclerosis

MRI of the brain

Nerve supply to the pelvis

Central nervous system

Myelin and nerve structure

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