Multiple Sclerosis (MS)

Inflammatory and Immune System, Neurological

Multiple Sclerosis (MS) is a neurologic disorder that occurs when the immune system attacks the nerves of the central nervous system (CNS) that consists of the brain and spinal cord1. In MS, the immune system breaks down the myelin sheath, a protective layer that encapsulates the nerves of the body’s nervous system. Nerves send electrical signals to and from the brain through the spinal cord. Myelin allows these signals to travel rapidly and efficiently along the pathway of nerve cells. Unfortunately, when the myelin sheath is attacked by the immune system, the signals are weakened or blocked completely causing abnormal functioning of the brain and spinal cord. A person with MS will initially experience numbness or tingling in the limbs, generalized weakness, bladder or bowel problems, and visual disturbances. MS usually occurs in adults between the ages of 30-50 and women are diagnosed two to three times more often than men.

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Symptoms

Multiple sclerosis means hardening of scar tissue in multiple areas of the body. The immune system’s attack on the myelin sheath surrounding nerve cells causes inflammation that leads to scar tissue formation. This scar tissue, called plaques or lesions by physicians, affects multiple areas of the nervous system including2.

  • optic nerves
  • the cerebellum (controls balance and coordination of movement)
  • spinal cord
  • white matter in a few regions of the brain
  • brain stem

The development of lesions breaks down the nerve fibers and slows down the action of electrical impulses. The degeneration of nerve cells greatly affects the ability of the body to carry out important functions and causes a variety of symptoms:

  • Bladder problems –Loss of bladder control is an early sign of MS
  • Bowel problems –Constipation and bowel incontinence
  • Dizziness and vertigo
  • Emotional changes and depression
  • Fatigue
  • Learning and memory problems – Difficulties in concentration, learning, and planning
  • Lhermitte’s sign – A sudden sensation (similar to an electric shock) that travels down the back of the neck and into the spine that can radiate out into the arms and legs.
  • Motor difficulties
  • Muscle weakness
  • Pain – Neuropathic pain caused by nerve damage and muscle pain caused by weakness and stiffness
  • Sexual dysfunction
  • Muscle spasms – Nhis is an early sign of MS due to the damage of nerve fibers along the spinal cord that can cause painful muscle spasms throughout the body
  • Tremor
  • Vision problems

Types

According to the National MS Society Advisory Committee on Clinical Trials in MS, there are four main types of multiple sclerosis.3These types are classified according to the phase and the severity of disease progression.4

  1. Clinically isolated syndrome (CIS). CIS is the first clinical presentation of MS-like symptoms caused by nerve inflammation and demyelination that lasts longer than 24 hours. In these cases, patients may present with vision problems, numbness or tingling in their limbs, or difficulty with balance and/or walking. Some patients diagnosed with CIS may not experience any other episodes of symptoms or they may progress into multiple sclerosis in time.
  1. Relapsing-remitting MS (RRMS). RRMS is defined by the return of MS symptoms for the second time or the appearance of new symptoms. Because the disease has progressed, patients experience symptoms in different areas of the body dependent on where the inflammatory attacks are occurring. These attacks are often followed by periods of recovery (remissions) that are partial or complete.
  1. Secondary progressive MS (SPMS). Patients diagnosed with SPMS have a history of worsening symptoms with a clear progression of nervous system damage. In SPMS, there may be times of remission or lessening of symptoms or times when the disease is active or not active.
  1. Primary progressive MS (PPMS). PPMS is characterized by little to no periods of remission and progressively worsening symptoms. These symptoms are caused by nerve damage as opposed to inflammation of the nerve fibers.

Risk Factors

  • Sex – women are two to three times more likely to have multiple sclerosis (RRMS) than men.
  • Smoking – smokers are at increased risk of developing MS and rapidly progress to worse stages.
  • Vitamin D deficiency – low levels of Vitamin D have been associated with a higher risk of MS.
  • Genetics – close relatives of people with MS have an increased risk of developing the disease.
  • Viral infections – viruses like Epstein-Barr, mononucleosis, and herpes type viruses have been linked to MS.
  • Climate – people living in New Zealand, Northern United States, Canada, and Northern Europe show an increased tendency of getting MS.
  • Co-existing conditions – people with auto-immune diseases like type 1 diabetes, thyroid disease, and psoriasis have a small increased risk of developing MS.

Diagnosis

The signs and symptoms of MS mimic a host of other conditions, including Lyme disease, syphilis, and hereditary diseases. Your healthcare provider will rule out these conditions that “look like” MS using a differential diagnosis. After taking a complete medical history and thorough physical examination, your physician will run the following tests to confirm the diagnosis6.

Blood tests

There are no specific blood tests for MS. Instead, your physician will order a blood panel to eliminate other diseases or imbalances in your body that are causing MS-like symptoms.

Lumbar puncture

A diagnostic lumbar puncture is advised in all patients who are suspected of having MS. In this test, your healthcare provider will take a small sample of cerebrospinal fluid out of your spinal cord using a needle. You may be worried about the pain involved. Thankfully, you will be first given a local anesthetic and you will feel the pressure sensation of the needle going in as well as a sting. The procedure takes between 30-45 minutes. The signs of MS that your physician is looking for are elevated antibodies related to MS.

Magnetic resonance imaging (MRI)

MRIs can show scar tissue or lesions that are on your brain and the spinal cord or rule out other causes for MS-like symptoms.

Evoked potential tests

These tests record electrical signals that the nervous system generates when responding to a visual or electrical stimulus. Electrodes are applied to your body to measure the speed that electrical impulses are traveling. Remember that the breakdown of myelin and/or inflammation of the nerve fibers causes the impulses to slow down or not travel at all. The evoked potential tests will show whether or not these impulses are being affected by inflamed or scarred nerve fibers.

Treatments

The cure for multiple sclerosis is currently being researched. Until the cure is found, people with MS are finding relief for symptoms as well as a delay of progression with medical treatments such as immunosuppressant drugs, corticosteroids, and plasmapheresis.  Your physician may also prescribe drugs that help to target the symptoms caused by damage to the central nervous system6.

Symptomatic Treatments

  • Anticholinergics –Helps with bladder dysfunction
  • Trycyclic antidepressants and gabapentin or derivatives –Treats neuropathic pain
  • Muscle relaxants –Treats spasticity and uncontrollable muscle stiffness
  • Famribidine or dalfampridine –Improves walking ability
  • Sleep aides –Treats anxiety, depression, and fatigue caused by sleep deprivation
  • Physical therapy – Assist MS patients in keeping mobility and reducing pain through stretching and strengthening exercises

Treatment for MS Attacks

  • Plasmapheresis (plasma exchange) –This procedure involves the removal of blood plasma from a patient with MS. During plasma exchange, small amounts of blood are removed and placed in a machine that separates the plasma from other blood components using a process called centrifugation – or spinning at a high speed – and filtration. The unhealthy plasma is thrown away and replaced with healthy plasma from a donor.
  • Corticosteroids – These drugs help to relieve pain and other MS-related symptoms by reducing nerve inflammation. You may be prescribed an oral corticosteroid like prednisone or receive it intravenously via methylprednisolone. Unfortunately, there are side effects including insomnia, mood swings, fluid retention, high blood pressure, and high glucose levels. These side effects usually occur after prolonged usage and your physician will help you find alternatives if the side effects are remarkably unpleasant.

Disease-modifying treatments

Disease-modifying treatments are therapies that help to slow the progression of MS7. (Mayo Clinic Staff, 2020) Physicians may prescribe drugs that suppress the immune system, especially in the early stages of the disease to slow progression. There are several disease-modifying therapies for people who have relapsing-remitting MS (RRMS) including:

  • Interferon-beta medications
  • Glatiramer acetate
  • Fingolimod
  • Dimethyl fumarate
  • Diroximel fumarate
  • Teriflunomide
  • Siponimod
  • Cladribine
  • Ocrelizumab
  • Natalizumab
  • Alemtuzumab

For PPMS (primary-progressive MS), the only FDA-approved drug is ocrelizumab.

Alternative Treatments and Home Remedies

Alternative treatments for Multiple Sclerosis should be used to help you manage your symptoms and increase your quality of life. Talk to your physician about any new activity, supplement, or diet you are trying to keep you safe and your doctor informed.

  • Exercise – Muscle weakness and pain improve with a regular exercise routine. Dance or yoga are wonderful outlets to relieve stress, help to build strength, and relax the mind.
  • Relaxation techniques and meditation – Helps to improve anxiety and calm the body
  • Massage therapy – Relieves pain and tension caused by stiff muscles along the spine and in the arms and legs
  • Nutritional therapy and supplements – Studies suggest that dairy and gluten can contribute to MS symptoms and some physicians advise taking both out of the diet if you have MS. Oral cannabis extract may improve muscle spasticity and pain. Vitamin D3 has been a recommended supplement for MS patients as well.
  • Support resources – Living with multiple sclerosis is physically and emotionally demanding. You must stay connected with friends and family. Do not hesitate to reach out to mental health professionals to help develop coping strategies that are healthy and supportive of your medical treatments. There are support groups available in your community.

References

  1. National Multiple Sclerosis Society(2020, December). Definition of MS. Retrieved from National Multiple SclerosisSociety: https://www.nationalmssociety.org/What-is-MS/Definition-of-MS
  2. Brazier, Y. (2019, May 29). Multiple sclerosis: What you need to know. Retrieved from Medical News Today: https://www.medicalnewstoday.com/articles/37556
  3. Multiple Sclerosis News Today. (2020, December 21). Types of MS. Retrieved from Multiple Sclerosis News Today: http://multiplesclerosisnewstoday.com/4-types-ms
  4. Lublin, F., Reingold, S. C., Cohen, J. A., Cutter, G. R., Sorensen, P., &Thompson, A. (2014, July 15). Defining the clinical course of multiple sclerosis. Retrieved from PubMed Central: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117366/
  5. 5.Wood, T. R., Sverdrup, U., Ragnarsdóttir, K. V., & Sverdrup, H. (2012). Investigating the root causes of multiple sclerosis using systems analysis and dynamics, developing an integrated treatment strategy. Proceedings of the 30th International Conference of the Systems Dynamics Society. (p. 1). St. Gallen. Retrieved from System Dynamics: https://proceedings.systemdynamics.org/2012/proceed/papers/P1183.pdf
  6. Dobson, R., &Giovannoni, G. (2018, October 09). Multiple sclerosis – a review. European Journal of Neurology, 26(1). DOI: https://doi.org/10.1111/ene.13819
  7. Mayo Clinic Staff. (2020, December 22). Multiple sclerosis. Retrieved from Mayo Clinic:https://www.mayoclinic.org/diseases-conditions/multiple-sclerosis/diagnosis-treatment/drc-20350274
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