Multiple Sclerosis

Definition
Multiple sclerosis (MS) is a chronic, potentially debilitating disease that affects your
central nervous system, which is made up of your brain and spinal cord. Multiple
sclerosis is widely believed to be an autoimmune disease, a condition in which your
immune system attacks components of your body as if they're foreign.

In multiple sclerosis, the body mistakenly directs antibodies and white blood cells
against proteins in the myelin sheath, a fatty substance that insulates nerve fibers in
your brain and spinal cord. This results in inflammation and injury to the sheath and
ultimately to the nerves that it surrounds. The result may be multiple areas of scarring
(sclerosis). Eventually, this damage can slow or block the nerve signals that control
muscle coordination, strength, sensation and vision.

Multiple sclerosis affects an estimated 300,000 people in the United States and
probably more than 1 million people around the world — including twice as many
women as men. Most people experience their first signs or symptoms between ages 20
and 40.

Multiple sclerosis is unpredictable and varies in severity. In some people, multiple

sclerosis is a mild illness, but it can lead to permanent disability in others. Treatments
can modify the course of the disease and relieve symptoms.

Symptoms
Signs and symptoms of multiple sclerosis vary widely, depending on the location of
affected nerve fibers. Multiple sclerosis symptoms may include:

 Numbness or weakness in one or more limbs, which typically occurs on one

side of your body at a time or the bottom half of your body
 Partial or complete loss of vision, usually in one eye at a time, often with pain
during eye movement
 Double vision or blurring of vision
 Tingling or pain in parts of your body
 Electric-shock sensations that occur with certain head movements
 Tremor, lack of coordination or unsteady gait
 Fatigue
 Dizziness

In some cases, people with multiple sclerosis may also develop muscle stiffness or
spasticity, slurred speech, paralysis, or problems with bladder, bowel or sexual
function. Mental changes, such as forgetfulness or difficulties with concentration, also
may occur.

Causes
Your central nervous system contains millions of nerve cells that send their electrical
signals to and from your brain along wire-like extensions of the cells called axons, or
nerve fibers. Myelin is the fatty substance that coats and protects these fibers, similar
to the way insulation shields electrical wires.

In people with multiple sclerosis, the immune system mistakenly destroys the cells
that produce the myelin sheath. As a result, myelin becomes inflamed and swollen
and detaches from the nerve fibers. The detached myelin may eventually be
destroyed. Firm or hardened (sclerosed) patches of scar tissue form over the fibers.
When nerve impulses reach a damaged area, some impulses are blocked or delayed
from traveling to or from your brain. Ultimately, this process leads to degeneration of
the nerves themselves, which likely accounts for the permanent disabilities that may
develop in MS.

Doctors and researchers don't understand what causes this autoimmune reaction.
Something seems to trigger the condition in susceptible people.

Genetic factors may make certain people more susceptible to multiple sclerosis. But
genetic susceptibility is only part of the explanation. A number of researchers believe
the disorder is related to a protein that mimics the myelin protein, which may be
introduced into the body by a virus. Other researchers believe that the immune system
overreacts toward myelin proteins in people with MS, which leads to an abnormal
tendency to develop autoimmune disease.

A period of disease activity (exacerbation) may be triggered by a viral infection, such

as a cold or flu, or by changes in the immune system during the first six months
following a pregnancy.

Patterns of MS
Whatever the multiple sclerosis cause or trigger, the disease occurs in four main
patterns:
  Relapsing remitting. This type of multiple sclerosis is characterized by clearly defined flare-
ups, followed by periods of remission. The flare-ups typically appear suddenly, last a few
weeks or months, and then gradually disappear. Most people with MS have this form at the
time of diagnosis.
 Primary progressive. People with this less common form of multiple sclerosis experience a
gradual decline, without periods of remission. People with this form of MS are usually older
than 40 when signs or symptoms begin.
 Secondary progressive. More than half the people with relapsing remitting MS eventually
enter a stage of continuous deterioration referred to as secondary progressive MS. Sudden
relapses may occur, superimposed upon the continuous deterioration that characterizes this
type of multiple sclerosis.
 Progressive relapsing. This is primary progressive MS with the addition of sudden episodes
of new symptoms or worsened existing ones. This form is relatively uncommon.

Risk factors
These factors may increase your risk of developing multiple sclerosis:

 Heredity. Multiple sclerosis is more common in people of Northern European

descent. There also appears to be a genetic component to the condition,
although the risk to children of people affected by MS is less than 5 percent
over their lifetime. Researchers suspect that the tendency to develop multiple
sclerosis is inherited, but the disease manifests only when environmental
triggers are present.
 Environmental factors. Environmental factors have some influence on
multiple sclerosis. Many viruses and bacteria have been suspected of causing
MS, most recently the Epstein-Barr virus, known also for causing infectious
mononucleosis. Some studies have suggested that developing infection at a
critical period of exposure may lead to conditions conducive to the
development of MS a decade or more later.
 Geographical factors. Multiple sclerosis is more common in countries with
temperate climates, including Europe, southern Canada, northern United
States, and southeastern Australia. The reason is unknown.

When to seek medical advice

One of the early indications of multiple sclerosis is numbness and tingling in your
arms, legs or elsewhere in your body. Although numbness most often doesn't indicate
MS, it's important to see your doctor if you experience numbness or tingling that
persists for days or weeks — especially if it spreads to involve large parts of your
body. Your doctor can determine whether MS or another neurological disorder may
be the cause. Also see your doctor if you experience persistent double vision,
persistent loss of balance or visual loss.

Tests and diagnosis

Multiple sclerosis can be difficult to diagnose. Many other conditions may produce
symptoms similar to multiple sclerosis, but with a different prognosis and treatment.
There are no specific tests for multiple sclerosis. Ultimately, the diagnosis relies on a
determination that the clinical symptoms, radiological studies and laboratory studies
suggest MS, and that no other condition provides a better explanation for them. Your
doctor may base a multiple sclerosis diagnosis on the following:

 Medical history. Your doctor reviews your signs and symptoms and their
pattern.
 Neurological examination. This examination systematically tests various
parts of your nervous system, including your reflexes, muscle strength, muscle
tone, and sensations of pain, heat, touch and vibration. Your doctor may also
observe your gait, posture, coordination and balance, and ask you questions to
help determine the clarity of your thinking, judgment and memory.
 Magnetic resonance imaging (MRI) scan. The cylinder-shaped MRI scanner
creates tissue-slice images on a computer from data generated by a powerful
magnetic field and radio waves. Your doctor can view these images from any
direction or plane.

This imaging technique may reveal MS lesions, which are caused by myelin
loss. An intravenous dye, gadolinium, will highlight "active" lesions that have
developed within the past two months and this may help doctors know
whether the MS is in an active phase, even if no symptoms are present
indicating an attack of MS. Newer MRI techniques can provide even greater
detail about the degree of nerve fiber injury or permanent myelin loss and
recovery.

 Spinal tap (lumbar puncture). In this procedure, a doctor or nurse removes a

small sample of cerebrospinal fluid from within your spinal canal for
laboratory analysis. This sample can show abnormalities associated with
multiple sclerosis, such as abnormal levels of white blood cells or proteins.
This procedure can also help rule out viral infections and other conditions that
can cause neurological symptoms similar to those of MS.
 Evoked potential test. This test measures the electrical signals sent by your
brain in response to stimuli. An evoked potential test may use visual stimuli or
electrical stimuli, in which short electrical impulses are applied to your legs or
arms.

Treatments and drugs

If your attacks are mild or infrequent, your doctor may advise a wait-and-see
approach, with counseling and observation.

Medications for relapsing MS

If you have a relapsing form of the disease, your doctor may recommend treatment
with disease-modifying medications early in the course of disease. You can't take
these medications if you're pregnant or may become pregnant. These medications for
multiple sclerosis treatment include:

 Beta interferons. Interferon beta-1b (Betaseron) and interferon beta-1a

(Avonex, Rebif) are genetically engineered copies of proteins that occur
 naturally in your body. They help fight viral infection and regulate your
immune system.

If you use Betaseron, you inject yourself under your skin (subcutaneously)
every other day. If you use Rebif, you inject yourself subcutaneously three
times a week. You self-inject Avonex into your muscle (intramuscularly) once
a week. These medications reduce but don't eliminate flare-ups of multiple
sclerosis. It's uncertain which of their many actions lead to a reduction in
disease activity and what their long-term benefits are. Beta interferons aren't
used in combination with one another; only one of these medications is used at
a time.

The Food and Drug Administration (FDA) has approved beta interferons only
for people with relapsing forms of MS who can still walk. Beta interferons
don't reverse damage and haven't been proved to significantly alter long-term
development of permanent disability. Some people develop antibodies to beta
interferons, which may make them less effective. Other people can't tolerate
the side effects, which may include symptoms similar to those of the flu
(influenza).

Doctors generally recommend beta interferons for people who have more than
one attack of MS a year and for those who don't recover well from flare-ups.
The treatment may also be used for people who have a significant buildup of
new lesions as seen on an MRI scan, even when there may not be major new
symptoms of disease activity.

The FDA has approved the use of several beta interferons for people who've
experienced a single attack that suggests multiple sclerosis, and who may be at
risk of future attacks and developing definite MS. Risk of MS may also be
suggested when an MRI scan of the brain shows lesions that predict a high risk
of conversion to definite MS. Controversy exists as to whether these people
should take these expensive and often inconvenient drugs for indefinite
periods, especially because some people do well both in the short term and
long term without therapy. Some doctors prefer to observe people at high risk
with follow-up examinations and MRI scans to document any ongoing
inflammatory disease activity before recommending long-term therapies such
as beta interferon.

 Glatiramer (Copaxone). This medication is an alternative to beta interferons

if you have relapsing remitting MS. Doctors believe that glatiramer works by
blocking your immune system's attack on myelin. You must inject glatiramer
subcutaneously once daily. Side effects may include flushing and shortness of
breath after injection.
 Natalizumab (Tysabri). This drug is administered intravenously once a
month. It works by blocking the attachment of immune cells to brain blood
vessels — a necessary step for immune cells to cross into the brain — thus
reducing the immune cells' inflammatory action on brain nerve cells.

During clinical trials, this drug was shown to significantly reduce the
frequency of attacks in people with relapsing MS. After receiving FDA
 approval, however, the drug was withdrawn from the market because of
reports from three people who developed a rare, often fatal, brain disorder
called progressive multifocal leukoencephalopathy.

In 2006, after reconsideration of the drug's benefits for people with multiple
sclerosis, the FDA agreed to allow the drug to be marketed again under
specific conditions. Chief among these conditions is the requirement that
doctors, pharmacists and patients be involved in a special distribution program
known as TOUCH in order to prescribe, dispense or receive the drug. Because
of the drug's risks, it's generally recommended only for people whose
condition hasn't responded to other forms of MS therapy. Furthermore, there
has been no study direct comparing natalizumab to existing treatments to
prove whether it's superior to existing treatments.

 Other medications. Mitoxantrone (Novantrone) is a chemotherapy drug used

for many cancers. This drug is also FDA-approved for treatment of aggressive
forms of relapsing remitting MS, as well as certain forms of progressive MS.
It's given intravenously, typically every three months.

Mitoxantrone may cause serious side effects, such as heart damage, after long-
term use, so it's typically not used for longer than two to three years. And it's
typically reserved for people with severe attacks or rapidly advancing disease
who don't respond to other treatments. Close monitoring is critical for anyone
on this medication.

Some doctors are also prescribing other chemotherapy drugs, such as

cyclophosphamide (Cytoxan), for people with severe, rapidly progressing MS.
However, these medications aren't FDA-approved for treatment of MS.

Medications for progressive MS

Some medications may relieve symptoms of progressive MS. They include:

 Corticosteroids. Doctors most often prescribe short courses of oral or

intravenous corticosteroids to reduce inflammation in nerve tissue and to
shorten the duration of flare-ups. Prolonged use of these medications,
however, may cause side effects, such as osteoporosis and high blood pressure
(hypertension), and the benefit of long-term therapy in multiple sclerosis isn't
established.
 Muscle relaxants. Baclofen (Lioresal) and tizanidine (Zanaflex) are oral
treatments for muscle spasticity. If you have multiple sclerosis, you may
experience muscle stiffening or spasms, particularly in your legs, which can be
painful and uncontrollable. This typically occurs in people with persisting or
progressive weakness of their legs. Baclofen may temporarily increase
weakness in your legs. Tizanidine controls muscle spasms without causing
your legs to feel weak, but can be associated with drowsiness or a dry mouth.
 Medications to reduce fatigue. To help combat fatigue, your doctor may
prescribe an antidepressant medication, the antiviral drug amantadine
(Symmetrel) or a medication for narcolepsy called modafinil (Provigil). All
drugs prescribed for this purpose appear to work because of their stimulant
properties. One study has showed that aspirin treatment may be effective in
 controlling MS-related fatigue; further research is planned to address the
benefits of aspirin on fatigue.
 Other medications. Many medications are used for the muscle stiffness,
depression, pain and bladder control problems associated with multiple
sclerosis. Drugs for arthritis and medications that suppress the immune system
may slow MS in some cases.

MS treatments other than medications

In addition to medications, these treatments also may be helpful:

 Physical and occupational therapy. A physical or occupational therapist can

teach you strengthening exercises and show you how to use devices that can
ease the performance of daily tasks. Therapists are usually supervised by
doctors (physiatrists) who advise and coordinate the therapy that you might
receive. Therapists can assist you in finding optimal mobility assistance
devices such as canes, wheelchairs and motorized scooters. These devices and
exercises can help preserve your independence.
 Counseling. Individual or group therapy may help you cope with multiple
sclerosis and relieve emotional stress. Your family members or caregivers also
may benefit from seeing a counselor.
 Plasma exchange (plasmapheresis). Plasma exchange may help restore
neurological function in people with sudden severe attacks of MS-related
disability who don't respond to high doses of steroid treatment. This procedure
involves removing some of your blood and mechanically separating the blood
cells from the fluid (plasma). Your blood cells then are mixed with a
replacement solution, typically albumin, or a synthetic fluid with properties
like plasma. The solution with your blood is then returned to your body.

Replacing your plasma may dilute the activity of the destructive factors in
your immune system, including antibodies that attack myelin, and help you to
recover. Plasma exchange has no proven benefit beyond three months from the
onset of the neurological symptoms.

Lifestyle and home remedies

These steps may help relieve some symptoms of multiple sclerosis:

 Get enough rest. Fatigue is a common symptom of multiple sclerosis, and

getting your rest may make you feel less tired.
 Exercise. Regular aerobic exercise may offer some benefits if you have mild
to moderate MS. Benefits include improved strength, muscle tone, balance and
coordination, and help with depression. Swimming is a good option for people
with MS who are bothered by heat.
 Be careful with heat. Extreme heat may cause extreme muscle weakness.
Although some people with multiple sclerosis aren't bothered by heat and may
enjoy warm baths and showers, be very careful before exposing yourself to
extreme heat until you know how you'll react. Don't get into a hot tub or sauna
unless there's someone nearby who can pull you out if necessary. If you do
 experience heat-related worsening of signs or symptoms, cooling down for a
few hours usually will return you to your normal state.
 Cool down. Many people with multiple sclerosis experience heat-related
worsening of MS symptoms. If you live in a hot and humid area, consider
having air conditioning in your home. Tepid or cool baths also may provide
some relief.
 Eat a well-balanced diet. Eating a healthy, well-balanced diet can help keep
your immune system strong.

Coping and support

As is true with other chronic diseases, living with multiple sclerosis can place you on
a roller coaster of emotions. Here are some suggestions to help you even out the ups
and downs:

 Maintain normal daily activities as best you can.

 Stay connected with friends and family.
 Continue to pursue hobbies that you enjoy and are able to do.

If multiple sclerosis impairs your ability to do things you enjoy, talk with your doctor
about possible ways to get around the obstacles.

Remember that your physical health can directly impact your mental health. Denial,
anger and frustration are not uncommon when you learn life has dealt you something
painful and unexpected. Professionals such as therapists or behavioral psychologists
may help you put things in perspective. They can also teach you coping skills and
relaxation techniques that may be helpful.

Sometimes, joining a support group, where you can share experiences and feelings
with other people, is a good approach. Ask your doctor what support groups are
available in your community.

Many chronic illnesses, including multiple sclerosis, are associated with an increased
risk of depression. This isn't a failure to cope. Rather, depression may indicate a
disruption in the body's neurochemistry that can be helped with appropriate medical
treatment.

If you have a chronic illness, such as MS, there's no denying that it affects your life.
But how much you allow it to determine the quality of your life depends, to some
extent, on the way you choose to live day to day.