Everything You Need to Know About Multiple Sclerosis

Overview

Multiple sclerosis (MS) is a chronic, potentially progressive, disease of the central nervous system (CNS). The brain and spinal cord compose the CNS. It is considered a demyelinating disease, meaning that it destroys the myelin sheath that surrounds and protects nerve cells, or neurons.

The National MS Society estimates that close to one million Americans are living with the disease.

Signs and Symptoms

The first signs and symptoms of MS most commonly occur between the ages of 20 and 40. Because MS attacks the myelin sheath that protects neurons, it will eventually begin to disrupt the flow of nervous signals from your CNS to the rest of the body and vice versa. This disruption is what gives rise to the signs and symptoms of MS.

Take note that the signs and symptoms of MS may differ greatly from one person to another depending on the particular nerve that is being affected.

Common Signs and Symptoms

Some of the early common signs and symptoms of MS include:

Muscle weakness;
Tingling and numbness;
Fatigue;
Visual disturbances;
Dizziness, and;
Vertigo.

Additional symptoms of MS may include:

Sexual dysfunction;
Problems with the bowel and bladder;
Muscle stiffness and spasm;
Thinking and memory problems, and;
Emotional changes.

Less Common Sign and Symptoms

Less common symptoms of MS may include:

Speech disturbances;
Tremors;
Hearing loss;
Swallowing problems, and;
Seizures or epilepsy.

Other Signs and Symptoms

There are a few other symptoms of MS deserve special mention.

One is Lhermitte’s sign. It is a brief shock-like sensation starting in the back of the neck and traveling down the spine into the arms and/or legs. The sign is most commonly triggered by bending the neck forward.

Another is the nerve disorder referred to as trigeminal neuralgia. Also known as tic douloureux, those affected experience excruciating facial pain that can be concentrated in the jaw.

The last notable symptom is referred to as the “MS hug.” Many describe it as a pressure-like sensation around the chest or abdomen.

Risk Factors

No one really knows the exact cause of MS, but there are a host of possible risk factors. These risk factors are:

Age: Although MS is most commonly diagnosed between the age of 20 and 40, it can occur at any age.
Sex: Women are two times more likely to be affected than men; this suggests that female hormones may have a major role in determining the disease.
Smoking: If you smoke, you are two times more likely to develop MS.
Certain Infections: In particular, Epstein-Barr virus and Mycoplasma pneumoniae have been linked to MS.
Genetics: If you have a first-degree relative with MS, you are at increased risk for developing the disease.
Race/Ethnicity: Caucasians — especially those of Northern European ancestry — are at higher risk for developing MS as compared to those of Asian, African, and Native American ancestry.
Where You Live: MS is more common in temperate regions as you go away from the equator, including Canada, northern Europe, northern United States, New Zealand, and southern Australia.
Vitamin D Deficiency: Inadequate exposure to sunlight, the main cause of vitamin D deficiency, has been linked to an increased risk of developing MS.
Vitamin B12 Deficiency: Vitamin B12 is an important component of the myelin sheath and a deficiency may increase your risk of developing MS.
Certain Autoimmune Diseases: Your risk of developing MS is increased if you have been diagnosed with an autoimmune disease, such as inflammatory bowel disease, thyroid disease, or type 1 diabetes.

Screening and Prevention

Currently, there are no medical guidelines that recommend routine screening for MS. Furthermore, the medical establishment has not yet discovered a way to prevent MS. However, you can decrease your risk of developing MS by:

Quitting Smoking: Today, smoking cessation can be achieved with several treatments. This includes over-the-counter nicotine replacement with patches, gums, and lozenges as well as prescription medications such as bupropion (Zyban) and varenicline (Chantix).
Getting Some Sun: Anywhere from 10 to 30 minutes of midday sun will provide your day’s supply of vitamin D. Just don’t forget to wear sunscreen with at least 30 SPF.

Recently, there have been interesting studies that have given insight into possibilities for the prevention of MS, including:

A 2016 study published in Cell Reports concluded fasting (“3 days every 7 days”) helped decrease the symptoms in mice with the relapsing-remitting form of MS;
A 2016 research paper published in the Journal of Neurology, Neurosurgery, & Psychiatry concluded that high consumption of coffee (a little less than four cups) may decrease the risk of developing MS.
A 2017 study published in Molecular Neurobiology concluded that resveratrol, a potent anti-inflammatory agent found in red wine, promoted the renewal of the myelin sheaths in mice with MS.

When to See a Doctor

If you have MS, damage to your CNS may occur even before the onset of any symptoms. If you are concerned that you may be experiencing the early symptoms of MS, you should make an appointment to see a doctor.

If you are diagnosed with MS, there are many treatments that have the potential to ease symptoms. Therefore, early diagnosis and treatment of MS is imperative, as it provides the best chances of slowing the progression of the disease and preventing disability.

Diagnosis

Unfortunately, there is no single test or examination that can provide a definitive diagnosis of MS.

You will probably start the process in the office of your primary care doctor. They will review your medical history, perform a thorough physical examination (with particular attention to your nervous system), and possibly take some preliminary blood tests.

Based on these, your doctor may refer you to a neurologist, a doctor who specializes in diagnosing and treating diseases of the nervous system. Your neurologist will perform an in-depth examination of your nervous system and pose many questions in order to make the most accurate diagnosis, as there are diseases that mimic MS.

You may be asked the following questions by your neurologist:

What are your symptoms and when did they begin?
Are your symptoms constant or intermittent?
What makes your symptoms worse and what makes them better?
Is there a history of MS in your family?
Do you have any other medical conditions, and if so, what medications do you take?

After this, your neurologist will employ a variety of strategies to arrive at the correct diagnosis, including:

Magnetic resonance imaging (MRI) of the brain and spinal cord to look for the lesions/scars of MS;
Spinal tap — known clinically as a lumbar puncture — to extract a sample of spinal fluid for analysis, and;
Evoked potential tests, which records the time it takes for nerves to respond to stimulation.

If any of the above are abnormal, it still does not establish a definitive diagnosis of MS. For the definitive diagnosis of the disease, the following must also be present:

Evidence of nerve damage in at least two areas of the CNS, and;
At least two episodes — also referred to as relapses — causing damage at different points in time.

Types

Now that you have a definitive diagnosis of MS, your neurologist will need to categorize the particular type of the disease that you are afflicted with. At present, there are a total of four types of MS that are clinically recognized.

1. Clinically Isolated Syndrome (CIS)

CIS represents the first episode of CNS symptoms lasting more than 24 hours, which is followed by partial or complete recovery.

A brain MRI at this juncture is crucial, as it may or may not reveal lesions. If lesions are present, the National MS Society estimates that you have a high risk (60 to 80 percent) of developing full-blown MS at some time in the next few years. If no lesions are present on brain MRI, the estimate is that you have a low risk (approximately 20 percent) of developing full-blown MS in the next few years.

2. Relapsing-Remitting MS (RRMS)

RRMS is the most common type of MS, representing 85 percent of all initial MS diagnoses. This type of MS is characterized by well-defined episodes consisting of new symptoms or an increase in pre-existing symptoms. They are followed by partial or complete recovery.

Furthermore, according to the National MS Society, “RRMS can be further characterized as either active (with relapses and/or evidence of new MRI activity) or not active, as well as worsening (a confirmed increase in disability over a specified period of time following a relapse) or not worsening.”

3. Secondary Progressive MS (SPMS)

An SPMS diagnosis typically follows an initial diagnosis of RRMS. SPMS is characterized by a steady, gradual worsening of symptoms with or without relapses and remissions.

Prior to the approval of today’s MS treatments by the FDA, it was thought that individuals diagnosed with RRMS would progress to SPMS at some point in time. In fact, 50 percent within 10 years and 90 percent within 25 years.

In addition to being further characterized as either active or not active, SPMS can be considered “with progression (evidence of disease worsening on an objective measure of change over time, with or without relapses) or without progression.”

4. Primary Progressive MS (PPMS)

PPMS is not as common as other types of MS. In fact, it accounts for approximately 15 percent of cases.

PPMS is characterized by a gradual worsening of symptoms from the time of diagnosis, without clearly defined relapses or remissions. It’s not uncommon for patients to report the onset of symptoms to begin between the ages of 35 and 39.

Like SPMS, PPMS can be categorized as active, not active, with progression, or without progression.

As of 2013, progressive-relapsing MS (PRMS) was no longer considered a primary type of MS. At the time, it accounted for approximately five percent of cases. As a result, patients with a diagnosis of PRMS were reclassified as having PPMS.

Complications

Even with proper treatment and follow-up, you may be at risk for complications from MS.

Complications are issues resulting from the accumulation of damage as the disease progresses. In fact, many of the symptoms of MS can also be considered complications.

Common Complications

Some of the more common complications of MS that deserve mention include:

Sensory problems, such as dysesthesia and the “MS hug”;
Visual problems, such as optic neuritis, double vision, color blindness, uncontrollable eye movements, and internuclear ophthalmoplegia;
Muscular problems, such as foot drop, loss of mobility, tremors, and spasticity;
Bladder problems, such as diarrhea, constipation, and incontinence;
Bowel problems, such as urinary tract infections, hesitancy, nocturia, retention, and incontinence.
Mood problems, such as depression and bipolar disorder, and;
Cognitive problems, such as memory loss and troubles with concentration and problem-solving.

Steroids

Although steroids are no longer used in the primary treatment of MS, they may have short-term and long-term complications. The complications that steroids cause for MS patients are:

High blood pressure;
Fluid retention;
Weight gain;
High blood sugar;
Osteoporosis;
Cataracts, and;
Increased susceptibility to infections.

Blood Clots

MS patients are at an increased risk for the development of blood clots in the lower leg. Clinically referred to as venous thromboembolism (VTE), blood clots can be potentially life-threatening by giving rise to pulmonary embolism.

A recent study concluded that MS patients were 2.6 times more likely to develop VTE as compared with the general population.

Treatments

Unfortunately, there is no cure for MS. If you have mild MS symptoms, you may choose not to take medications, as the benefits may outweigh the potential risks.

If you do choose treatment, the goals of management for MS include:

Assistance coping with and relieving symptoms;
Slowing the progression of the disease, and;
Maintaining an acceptable quality of life.

This can be accomplished through a combination of medicines and physical therapy (PT), occupational therapy (OT), and speech therapy.

Medication

The first-line treatment of MS consists of “disease-modifying” drugs that can be taken via the oral, injectable, and infusion routes.

Before taking any medication, make sure to discuss your options with your doctor. This will help you obtain a transparent view of your risks and benefits as they pertain to the management of your MS.

Oral Medications

Oral medications for MS approved by the FDA include:

Fingolimod (Gilenya);
Teriflunomide (Aubagio);
Cladribine (Mavenclad);
Siponimod (Mayzent), and;
Dimethyl fumarate (Tecfidera).

The oral medications may have side effects such as:

Flushing;
GI intolerance;
high blood pressure, and;
Liver toxicity.

Injectable Medications

Injectable medications for MS include beta interferons and glatiramer acetate.

Out of the two, beta interferons are among the most widely used medications to treat MS. Examples of beta (β) interferons include interferon β-1a (Avonex, Rebif, and Plegridy) and interferon β-1b (Betaseron and Extavia).

Potential side effects of injectable medications may include:

Injection site reactions;
Flu-like symptoms;
Localized loss of fat tissue;
Systemic reactions after injection, and;
Liver toxicity.

Infusion Medications

Infusion medications for MS include:

Alemtuzumab (Lemtrada);
Mitoxantrone (Novantrone);
Ocrelizumab (Ocrevus), and;
Natalizumab (Tysabri).

The infusion medications may have side effects like:

Infusion reactions;
Thyroid gland toxicity;
Liver toxicity, and;
An increased risk of infection and malignancy.

Other Medications

There is a whole host of medications used to treat symptom-specific aspects of MS including:

Steroids may be used in the short-term to decrease adverse effects of MS;
Tolterodine (Detrol) and oxybutynin (Ditropan) for bladder symptoms/complications;
Venlafaxine (Effexor), paroxetine (Paxil), and citalopram (Celexa) for depression;
Amantadine, modafinil (Provigil), and armodafinil (Nuvigil) for fatigue;
Dantrolene (Dantrium), baclofen (Lioresal), tizanidine (Zanaflex), and gabapentin (Neurontin) for muscle spasticity;
Tadalafil (Cialis), sildenafil (Viagra), and alprostadil (Caverject) for erectile dysfunction.

Therapy

PT and OT, along with mobility aids and speech therapy, can be very helpful with the gait difficulties and speech difficulties that often complicate MS.

Complementary and Alternative Medicine

As of late, there has been an increased interest in complementary and alternative medicine (CAM) therapies for MS. CAM therapies are considered non-conventional treatments, which are not regulated by the FDA.

They include:

Herbs or dietary supplements, such as ginkgo biloba and fish oil;
Mind-body medicine, such as mindfulness, yoga, and reflexology, and;
Chinese traditional medicine like acupuncture.

It should be kept in mind that there is little scientific evidence for the efficacy of CAM therapies in the treatment of MS.

Living with Multiple Sclerosis

Living with MS is no walk in the park. It is both physically and emotionally taxing.

In an effort to cope with this chronic, potentially progressive disease, you will have to make some lifestyle changes. PT and OT may become an ever-present part of your life as you battle to regain or maintain function. In order to remain independent, you may have to significantly alter the design of your home.

Some lifestyle tips to help you in your fight are:

Regular Exercise: Staying active has a multitude of benefits for MS, including improving your strength, balance, mobility, and even mood.
Sensible Diet: Although no diet has been proven as disease-modifying for MS, eating a heart-healthy, high-fiber, low-fat diet is recommended.
Rest and Stress Management: Adequate rest and de-stressing will assure that your immune system is at its peak and will help with the fatigue of MS.
Avoid Overheating: Overheating has the potential to trigger or aggravate MS symptoms, so find solace in a cool bath or shower and air conditioning.
Get Support: Sources of encouragement and support include your family, friends, community, doctors, counselors, and support groups.

Outlook

Today, the outlook for MS is quite bright. The progression of the disease differs from person to person. As such, most MS patients will not experience severe disability as a result of the disease.

Additionally, over the last few decades, research into MS has provided significant advancements in its treatment, yielding safer and more effective therapies. These advances have the potential to slow the progression of the disease and, in the future, perhaps even a cure may be realized.

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