Multiple Sclerosis
What is Multiple Sclerosis?
Multiple sclerosis (MS) is a potentially disabling chronic disease affecting the central nervous system namely the brain and spinal cord. It can cause serious disability and the life expectancy of patients is reduced. Diagnosis is usually made between 20-50 years of age and its 2-3 times more common in women than men.
In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers which protects them. Myelin also helps the nerves conduct electrical signals quickly and efficiently. In MS, the myelin sheath disappears in multiple areas, leaving a scar or sclerosis thus the name multiple sclerosis. Eventually, the disease can cause the nerves themselves to deteriorate or become permanently damaged. In such cases, the electrical impulses from the brain do not flow smoothly to the target nerve.
Signs and symptoms of MS vary widely and depend on the amount of nerve damage and which nerves are affected. It can affect one's vision, limb movement and coordination, sensation or balance.
There's currently no cure for multiple sclerosis. However, treatments can help manage symptoms, hasten recovery from attacks and modify the course of the disease.
There's no cure for multiple sclerosis. However, treatments can help speed recovery from attacks, modify the course of the disease and manage 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.
Multiple sclerosis (MS) is a potentially disabling chronic disease affecting the central nervous system namely the brain and spinal cord. It can cause serious disability and the life expectancy of patients is reduced. Diagnosis is usually made between 20-50 years of age and its 2-3 times more common in women than men.
In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers which protects them. Myelin also helps the nerves conduct electrical signals quickly and efficiently. In MS, the myelin sheath disappears in multiple areas, leaving a scar or sclerosis thus the name multiple sclerosis. Eventually, the disease can cause the nerves themselves to deteriorate or become permanently damaged. In such cases, the electrical impulses from the brain do not flow smoothly to the target nerve.
Signs and symptoms of MS vary widely and depend on the amount of nerve damage and which nerves are affected. It can affect one's vision, limb movement and coordination, sensation or balance.
There's currently no cure for multiple sclerosis. However, treatments can help manage symptoms, hasten recovery from attacks and modify the course of the disease.
There's no cure for multiple sclerosis. However, treatments can help speed recovery from attacks, modify the course of the disease and manage 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.
Four types of Multiple Sclerosis
1. Clinically isolated syndrome: This is a single, first episode, with symptoms lasting at least 1 day.
2. Relapse-remitting MS: This is the most common form, affecting approximately 85% of MS patients and involving attacks of new or worsening symptoms (relapses) between periods of remission. Relapses often occur without warning, but are sometimes associated with a period of illness or stress. Around 50% of them with relapsing remitting MS will develop secondary progressive MS within 15-20 years, and the risk increases the longer you have the disease.
3. Primary progressive MS: Symptoms worsen progressively with time, without early relapses or remissions. Around 15 percent of cases belong to this group.
4. Secondary progressive MS: After initial episodes or relapse and remission, the disease progresses steadily.
1. Clinically isolated syndrome: This is a single, first episode, with symptoms lasting at least 1 day.
2. Relapse-remitting MS: This is the most common form, affecting approximately 85% of MS patients and involving attacks of new or worsening symptoms (relapses) between periods of remission. Relapses often occur without warning, but are sometimes associated with a period of illness or stress. Around 50% of them with relapsing remitting MS will develop secondary progressive MS within 15-20 years, and the risk increases the longer you have the disease.
3. Primary progressive MS: Symptoms worsen progressively with time, without early relapses or remissions. Around 15 percent of cases belong to this group.
4. Secondary progressive MS: After initial episodes or relapse and remission, the disease progresses steadily.
What causes Multiple Sclerosis?
The exact cause of MS is unknown. It is considered an autoimmune disorder in which the body's immune system attacks its own tissues. In MS, the immune system malfunction and destroys myelin which coats and protects nerve fibers in the brain and spinal cord. When the protective myelin is damaged and nerve fiber is exposed, the nerve is damaged and its signal is disrupted from travelling along that nerve. A combination of genetics and environmental factors could play a role in the cause.
The exact cause of MS is unknown. It is considered an autoimmune disorder in which the body's immune system attacks its own tissues. In MS, the immune system malfunction and destroys myelin which coats and protects nerve fibers in the brain and spinal cord. When the protective myelin is damaged and nerve fiber is exposed, the nerve is damaged and its signal is disrupted from travelling along that nerve. A combination of genetics and environmental factors could play a role in the cause.
Risk factors of developing multiple sclerosis:
- Age. MS can occur at any age, but most commonly affects people between 20 and 50.
- Sex. Women are twice as likely as men to develop MS.
- Family history. If one of your parents or siblings has had MS, then you are at higher risk.
- Race. White people, particularly those of Northern European descent, are at highest risk of developing MS.
- Climate. MS is far more common in countries with temperate climates, including Canada, the northern United States, New Zealand, Australia and Europe.
- Certain infections. A variety of viruses like Epstein-Barr have been linked to MS
- Smoking. Smokers are more likely than non-smokers to develop relapsing-remitting MS.
- Certain autoimmune diseases. If you have other autoimmune diseases like thyroid disease, type 1 diabetes or inflammatory bowel disease then you have a higher risk of developing MS.
Symptoms of Multiple Sclerosis
The signs and symptoms may vary from person to person and over the course of the disease depending on the location of affected nerve fibers. It can affect any part of the body. Symptoms include:
The signs and symptoms may vary from person to person and over the course of the disease depending on the location of affected nerve fibers. It can affect any part of the body. Symptoms include:
- Neurological : Numbness or weakness in one or more limbs that typically on one side of your body at a time, or the legs and trunk. Tingling or pain in parts of your body
- Muscle Spasticity and spasms: Damaged nerve fibers in the spinal cord and brain can cause painful muscle spasms. This can result in muscle stiffness and spasticity.
- Vision: Partial or complete loss of vision, usually in one eye at a time associated with pain during eye movement due to optic nerve inflammation. Prolonged double vision. Red-green color distortion.
- Lhermitte sign: Electric-shock sensations that occur with certain neck movements, especially when bending the neck forward
- Tremor
- Imbalance and Gait change: lack of coordination, clumsiness or unsteady gait because of muscle weakness.
- Speech: Slurred
- Fatigue: affecting 90% of patients. It can affect daily life activities and work.
- Dizziness and vertigo: associated with balance difficulties
- Problems with bowel function: Constipation can lead to fecal impaction and subsequent bowel incontinence
- Problems with bladder function: Incomplete bladder emptying, frequent urination and and urge incontinence
- Sexual dysfunction: decrease interest
- Emotional changes and depression: As MS is a disabling disorder with no cure, it can cause emotional changes and has been linked to depression.
- Disability in functioning: problems with thinking, learning and planning
Complications of Multiple Sclerosis:
- Muscle stiffness or spasms
- Paralysis especially in the legs
- Bladder and bowel dysfunction
- Mental changes : mood changes
- Sexual dysfunction
- Psychiatric disorder: Depression
- Neurological : Epilepsy
Diagnosis of Multiple Sclerosis
If you develop similar symptoms mentioned above, do seek medical consult with a neurologist. The doctor will take a thorough medical history and conduct a medical examination on you. The doctor will look for any abnormalities in your limbs' strength, imbalance or in-coordination, changes in speech and reflexes and abnormality in your vision and eye movements.
There are no specific tests for MS and diagnosis of multiple sclerosis often relies on ruling out other differential diagnosis. It may also not be possible to confirm a diagnosis if you only had one episode of MS-like symptoms or those with unusual symptoms. In patients with relapsing-remitting MS, the diagnosis is more straightforward based on the pattern of symptoms consistent with the disease and it is confirmed by brain imaging MRI scan.
In unspecific cases, further testing with spinal fluid analysis, evoked potentials and MRI imaging may be needed for diagnosis.
Diagnostic tests for confirmation of Multiple Sclerosis
1. Blood tests : to rule out other diseases like infections, vitamin deficiencies, syphilis.
2. Lumbar puncture: A needle is inserted into your lower back and a small sample of spinal fluid which surrounds the brain and spinal cord is withdrawn from your spinal canal for laboratory analysis. This septic procedure is done under local anesthesia. This sample can show abnormalities in antibodies that are associated with MS. It can also rule out infections and other conditions with symptoms similar to MS. Side effect post procedure is headache that could last a few days.
3. MRI: Magnetic Resonance imaging uses strong magnetic field to image the brain which can reveal areas of MS (lesions), damage or scarring of the myelin sheath in your brain and spinal cord. An intravenous injection of a contrast maybe injected into you vein to highlight lesions that indicate your disease is in an active phase. Patients who has claustrophobia can be sedated during the scan.
4. Evoked potential tests: It is a painless procedure whereby sticky patches called electrodes placed on your head. Then it records the electrical signals produced by your nervous system in response to a stimulus such as 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 then measure how quickly the information travels through the neurons to the brain.
If you develop similar symptoms mentioned above, do seek medical consult with a neurologist. The doctor will take a thorough medical history and conduct a medical examination on you. The doctor will look for any abnormalities in your limbs' strength, imbalance or in-coordination, changes in speech and reflexes and abnormality in your vision and eye movements.
There are no specific tests for MS and diagnosis of multiple sclerosis often relies on ruling out other differential diagnosis. It may also not be possible to confirm a diagnosis if you only had one episode of MS-like symptoms or those with unusual symptoms. In patients with relapsing-remitting MS, the diagnosis is more straightforward based on the pattern of symptoms consistent with the disease and it is confirmed by brain imaging MRI scan.
In unspecific cases, further testing with spinal fluid analysis, evoked potentials and MRI imaging may be needed for diagnosis.
Diagnostic tests for confirmation of Multiple Sclerosis
1. Blood tests : to rule out other diseases like infections, vitamin deficiencies, syphilis.
2. Lumbar puncture: A needle is inserted into your lower back and a small sample of spinal fluid which surrounds the brain and spinal cord is withdrawn from your spinal canal for laboratory analysis. This septic procedure is done under local anesthesia. This sample can show abnormalities in antibodies that are associated with MS. It can also rule out infections and other conditions with symptoms similar to MS. Side effect post procedure is headache that could last a few days.
3. MRI: Magnetic Resonance imaging uses strong magnetic field to image the brain which can reveal areas of MS (lesions), damage or scarring of the myelin sheath in your brain and spinal cord. An intravenous injection of a contrast maybe injected into you vein to highlight lesions that indicate your disease is in an active phase. Patients who has claustrophobia can be sedated during the scan.
4. Evoked potential tests: It is a painless procedure whereby sticky patches called electrodes placed on your head. Then it records the electrical signals produced by your nervous system in response to a stimulus such as 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 then measure how quickly the information travels through the neurons to the brain.
Treatment for Multiple Sclerosis
There is currently no cure for MS, so treatment focuses on suppressing the autoimmune response, managing attacks and symptoms. A team consisting of neurologist, opthalmologist, a physiotherapist, a speech and language therapist and nurse clinician will be managing the patient together.
Medications:
1. Corticosteroids: oral prednisone and intravenous methylprednisolone over 5 days are prescribed to reduce nerve inflammation and to suppress immune system. These are prescribed during acute flares. Side effects may include insomnia, increased blood pressure, increased blood sugar level, gastritis, mood swings and fluid retention.
2. Interferon Beta 1a or 1b: These injectable medications reduce the frequency, slow disease progression and severity of relapses.Side effects may include flu-like symptoms and injection-site reactions. But they can cause liver toxicity and liver function tests should be monitored.
3. Ocrelizumab (Ocrevus). This humanized immunoglobulin antibody is given as an intravenous infusion to treat both the relapse-remitting and primary progressive forms of MS. Side effects are irritation at the injection site, low blood pressure, fever and nausea. Ocrevus may also increase the risk of cancer, particularly breast cancer.
4. Copaxone: This injectable once daily medication aims to stop the immune system from attacking myelin. Side effects include flushing and shortness of breath, skin irritation may occur after the injection.
5. Tysabri : It is designed to block the movement of potentially damaging immune cells from your bloodstream to your brain and spinal cord. This is used for patients who either cannot tolerate or did not benefit from other treatments. However it increases the risk of developing multifocal leukoencephalopathy.
6. Mitoxantrone: This immuno-suppressant is used only in the later stages of the disease.It can help slow down the progression of disability. However it is cardio-toxic.
7. Aubagio: This is a once-daily tablet for patients with relapsing forms of MS. Side effects are liver toxicity, hair loss and harmful to a developing fetus in pregnant woman.
8. Tecfidera: This twice-daily oral medication can reduce relapses. Side effects may include flushing, diarrhea, nausea and lowered white blood cell count.
9. Fingolimod: Taken once-daily oral , may help to reduce relapse rate. It may reduce your heart rate thus vital signs should be monitored for six hours after the first dose. Other side effects include headache, high blood pressure and blurred vision.
There is currently no cure for MS, so treatment focuses on suppressing the autoimmune response, managing attacks and symptoms. A team consisting of neurologist, opthalmologist, a physiotherapist, a speech and language therapist and nurse clinician will be managing the patient together.
Medications:
1. Corticosteroids: oral prednisone and intravenous methylprednisolone over 5 days are prescribed to reduce nerve inflammation and to suppress immune system. These are prescribed during acute flares. Side effects may include insomnia, increased blood pressure, increased blood sugar level, gastritis, mood swings and fluid retention.
2. Interferon Beta 1a or 1b: These injectable medications reduce the frequency, slow disease progression and severity of relapses.Side effects may include flu-like symptoms and injection-site reactions. But they can cause liver toxicity and liver function tests should be monitored.
3. Ocrelizumab (Ocrevus). This humanized immunoglobulin antibody is given as an intravenous infusion to treat both the relapse-remitting and primary progressive forms of MS. Side effects are irritation at the injection site, low blood pressure, fever and nausea. Ocrevus may also increase the risk of cancer, particularly breast cancer.
4. Copaxone: This injectable once daily medication aims to stop the immune system from attacking myelin. Side effects include flushing and shortness of breath, skin irritation may occur after the injection.
5. Tysabri : It is designed to block the movement of potentially damaging immune cells from your bloodstream to your brain and spinal cord. This is used for patients who either cannot tolerate or did not benefit from other treatments. However it increases the risk of developing multifocal leukoencephalopathy.
6. Mitoxantrone: This immuno-suppressant is used only in the later stages of the disease.It can help slow down the progression of disability. However it is cardio-toxic.
7. Aubagio: This is a once-daily tablet for patients with relapsing forms of MS. Side effects are liver toxicity, hair loss and harmful to a developing fetus in pregnant woman.
8. Tecfidera: This twice-daily oral medication can reduce relapses. Side effects may include flushing, diarrhea, nausea and lowered white blood cell count.
9. Fingolimod: Taken once-daily oral , may help to reduce relapse rate. It may reduce your heart rate thus vital signs should be monitored for six hours after the first dose. Other side effects include headache, high blood pressure and blurred vision.
Plasma exchange (plasmapheresis): The plasma of your blood is removed and separated from your blood cells so as to remove the antibodies that attack the mylein. The blood cells are then mixed with albumin (new plasma) and put back into your body. Plasma exchange is tried if your symptoms are new, severe and did not respond to steroids.
Dealing with fatigue
- Regular sleeping pattern with enough rest
- Exercise
- Meditation
- Avoid medications that cause drowsiness
- Cognitive Behavioral Therapy (CBT)
Dealing with Muscle stiffness and spasms
- Physiotherapy to stretch and strengthen muscles
- Occupational therapy to cope with daily life activities
- Exercise
- Medications like baclofen or gabapentin
Psychiatry medical conditions
- Consult psychiatrists for cognitive behavioral therapy and anti-depressants if necessary
- Psychologists to provide counselling and support
- Group and family support
Bladder and sexual problems
- to consult urologist
- For overactive bladders: medications like Oxybutynin and Tolterodine may be prescribed
- For those who has urinary retention, catheterisation may be offered
- For sexual dysfunction: medications like viagra, cialis may be prescribed
Bowel problems
- For those with constipation, laxatives and enemas may be prescribed
- For those with diarrhea, anti-diarrhea medications and pelvic floor exercise are helpful
Speech and swallowing problems
- Consult a speech therapist
- Change of diet's consistency for easier swallowing
- Strengthen muscles to aid speech and swallowing
- In those who has difficulty to swallow with increased risk of choking and aspiration pneumonia, a feeding tube may be inserted
Supplements
Vitamin D and Omega 3 supplements may help patients with Multiple sclerosis. However more research is needed to prove its' effectiveness.
Vitamin D and Omega 3 supplements may help patients with Multiple sclerosis. However more research is needed to prove its' effectiveness.
