Understanding Multiple Sclerosis: English Version

MODULE 1
Understanding
Multiple Sclerosis
English Version
CME Module Title
Understanding Multiple Sclerosis
Learning Objectives Disclosure of Unlabelled Use

After completing this activity, the participant should be better able to: This educational activity may contain discussion of published and/or investigational uses
of agents that are not indicated by the EMEA or local regulatory authorities. The RCN, ICN,
• A
ppreciate the importance of understanding the pathophysiology of MS as a foundation
for making decisions concerning the management of MS. EANN, EMSP, RIMS, IOMSN, SCI, and Novartis do not recommend the use of any agent
outside of the labelled indications.
• Identify the various types of MS and know their natural history and progression.
The opinions expressed in the educational activity are those of the faculty and do not
• S
tate the genetic, race, gender and environmental factors which affect the incidence necessarily represent the views of RCN, ICN, EANN, EMSP, RIMS, IOMSN, SCI and Novartis.
of MS.
Please refer to the official prescribing information in your own country for each product for
• D
escribe the structure of the nervous system and how its function is altered discussion of approved indications, contraindications, and warnings.
by MS.
• Explain the function of the immune system and how its role is disrupted by MS.
• D
escribe the underlying pathophysiological causes of the most common symptoms Method of Participation
associated with MS.
There are no fees for participating and receiving CME credit for this activity. During the
• R
ecognise that central to this is the inflammation and demyelination of axons which period of TBC, 2013, through TBC, 2015, participants must; (1) read the learning objectives
disrupts neural conduction.
and faculty disclosures, (2) participate in the entire educational activity, consisting of 5 core
• A
ppreciate that cortical pathology, that is, inflammatory focal lesions (cortical lesions) modules, (3) complete the post-test for each module by recording the best answer to
and atrophy (cortical thickness), may determine cognitive disability in MS. each question, and (4) complete the online evaluation form for each module. Upon successful
completion of all 5 post-tests (75% or better) and online evaluation forms, you will be
provided with a statement of credit which you can download, save and print.
Target Audience
This activity has been developed to meet the educational needs of nurses who have an
interest in optimising the management of people with MS. Disclaimer
Participants have an implied responsibility to use the newly acquired information to enhance
patient outcomes and their own professional development. The information presented in
Accreditation this activity is not meant to serve as a guideline for patient management. Any procedures,
medications, or other courses of diagnosis or treatment discussed or suggested in this
This e-learning training curriculum is accredited by the Royal College of Nursing Accreditation activity should not be used by nurses without evaluation of their patient’s conditions and
for the award of continuing professional development credits. possible contraindications on dangers in use, review of any applicable manufacturer’s
This continuing education activity has been approved by the International Council of Nurses product information, and comparison with recommendations of other authorities.
(ICN) for the award of International Continuing Nursing Education Credits (ICNECs).
Grant Statement
Credit Designation
This activity is supported by an educational grant from Novartis Pharma AG
The Royal College of Nursing and the International Council of Nursing designates this module
of the e-learning training curriculum for a maximum of 5 credits. On completion of the course
(i.e. all 5 modules) you will be able to download a Virtual College certificate.
Estimated time to complete this module: 5 hours

Table of Contents: Module 1
Understanding Multiple Sclerosis
1.0 Introduction 3.5 Immune System Function
2.0 MS Demographics 3.5.1 Innate & Adaptive Immunity
2.1 Learning Objectives 3.5.2 Innate Immunity
2.2 Overview of MS 3.5.3 Adaptive Immunity
2.3 Definition and Classification 3.5.4 Summary
2.3.1 Relapsing-remitting 3.6 Pathophysiology
2.3.2 Secondary-progressive 3.6.1 Lesions
2.3.3 Primary-progressive 3.6.2 Inflammation & Neurodegeneration
2.3.4 Progressive-relapsing 3.6.3 Cellular Involvement
2.4 Clinical Course 3.6.4 Summary
2.5 Contributing Factors 4.0 Symptoms and Pathophysiology
2.5.1 Race 4.1 Learning Objectives
2.5.2 Age 4.2 Introduction
2.5.3 Gender 4.3 Heat Sensitivity
2.5.4 Genetics 4.4 Fatigue
2.5.5 Vitamin D 4.5 Optic Neuritis
2.5.6 Stress 4.6 Positive Symptoms
2.5.7 Smoking 4.7 Psychiatric Disorders
2.5.8 Infection 4.8 Cognitive Impairment
2.6 Summary 4.9 Bowel Dysfunction
3.0 Understanding the Causes of MS 4.10 Bladder Symptoms
3.1 Introduction 4.11 Summary
3.2 Recommended Reading
3.3 Learning Objectives Summary of Module

Recommended Reading
3.4 Nervous System Structure
Full References
3.4.1 Spinal Cord
3.4.2 Summary
4 Understanding multiple sclerosis Understanding multiple sclerosis 5

2 MS Demographics
MODULE 1:
Understanding Multiple Sclerosis 2.1 Learning Objectives
After review of this section, you should be better able to:
• A
ppreciate the importance of understanding the pathophysiology of MS as a
foundation for making decisions concerning the management of MS.
• Identify the various types of MS and know their natural history and progression.
• S
tate the genetic, race, gender and environmental factors which affect the
incidence of MS.
2.2 Overview of MS
The distribution of MS varies throughout the world and appears to be related to geographical
location and genetic background. Worldwide, it is estimated that up to
2.5 million people are affected by MS and it is more common in cooler climates1. Globally,
the median estimated incidence of MS is 2.5 per 100,000 (with a range of 1.1–4)2. Regionally,
the median estimated incidence of MS is greatest in Europe (3.8 per 100,000), followed by
the Eastern Mediterranean (2), the Americas (1.5), the Western Pacific (0.9) and Africa (0.1).
Twice as many women are affected with the disease than men (lifetime risk of MS: 2.5% for
women and 1.4% for men)3. The incidence appears to be highest between the ages of 35 and
64 years4.
1 Why Understanding the Pathophysiology of

Multiple Sclerosis (MS) Will Improve Patient Care The mean European MS incidence rate is estimated to be 4 cases per 100,000
population per year, with twice as many women with the disease than men.
It is important for MS Nurses to have an appreciation of the pathophysiology
contributing to the development of MS. This will provide the essential concepts and 80O 80O
information required to answer patients’ questions about what causes their disease
and how the disease will affect their future life. This education and counselling will
help patients, their family and carers to develop a realistic picture of disease
progression, assess the benefits of treatment and set appropriate expectations 60O 60O
related to its management.

45O 45O
40O 40O
The pathophysiology also helps to explain the multiple symptoms that people
20O 20O
with MS typically experience, and it underpins the identification of therapeutic
targets and the optimisation of current and emerging therapies. In addition, an High risk
0O 0O
understanding of the pathophysiology of MS may help to anticipate the way a Probable high risk
Low risk
person with MS will respond to treatment. It will also provide a valuable insight into 20O
Probable low risk
20O
identifying and managing possible side effects that might arise from therapies. North-South gradient risk
Other risk
40O 40O
45O 45O
Figure 1 – The geography of multiple sclerosis

European countries reporting the highest estimated incidence of MS include Croatia (29 MS can cause an unpredictable and diverse range of neurological impairments that are
per 100,000), Iceland (10), Hungary (9.8), Slovakia (7.5), United Kingdom (6), Lithuania (6), unique to each individual. Since neurological damage can affect any part of the CNS, MS
Denmark (5.9), Norway (5.5) and Switzerland (5) (Figures 2 and 3)2. can cause a variety of distressing symptoms, including fatigue, visual impairment, urinary
and bowel incontinence, mobility problems, spasticity, tremor, pain, sexual dysfunction,
depression and cognitive dysfunction. Many people with MS experience multiple symptoms
concurrently and 90% of people with MS experience these at an early stage. The majority
will go on to develop progressive disability8. It is this diversity of symptoms, and the
unpredictable nature of MS, that makes it one of the most difficult neurological diseases
with which to cope.
Reported survival times among people with MS have varied considerably in the past, but
more recent studies have demonstrated some reproducible statistics. For instance, British
people with MS were recently reported to have a 3.5-fold increase in mortality compared
with the general population10. Smoking and respiratory diseases were reported as the
major factors associated with the increased mortality. In a Norwegian study, the median
survival time from onset of MS was 41 years compared with 49 years in the corresponding
population, and mortality was increased 2.5 fold11. Median survival times were longer
amongst relapsing-remitting MS (43 years) than in patients with primary-progressive (PP)
disease (49 years), and the relative mortality risk (RMR) was higher in PPMS (RMR = 1.55).
According to death certificates, 57% died from MS. Similarly, a large Canadian study
Figure 2 – Incidence of MS in Western Europe involving 6,917 patients with MS found an overall standardised mortality ratio of 2.89 in
people with MS and MS patients survived approximately 6 years less than expected relative
to the general population12.
MS is the most common serious, chronic neurological disorder in young adults.

Men often have a later onset of disease and a worse prognosis. MS can cause an
unpredictable and diverse range of neurological impairments that are unique to
each individual.
Reflective learning point

How will my ability to discuss MS with my patients be improved through a better
appreciation of the underlying causes?
Figure 3 – Incidence of MS in Eastern Europe
MS is the most common serious, chronic neurological disorder in young adults5. It is a

progressive, autoimmune, degenerative disease, and is characterised by neuro inflammation
of the central nervous system (CNS), mainly of the white matter, which results from a mix of
clinical, pathological and immunological components, together with an interaction between
genes and the environment6. The disease usually begins between the ages of 20 and 40
years and is more common in young females than males. However, men often have a later
onset of disease and a worse prognosis7. In either gender, it is often diagnosed at a time
when family and job responsibilities are at their most demanding and this results in a serious
socioeconomic impact on the family8,9.

2.3 Definition and Classification of Multiple Sclerosis PPMS is diagnosed in ~10–15% of the MS population.
In clinical practice it can be difficult to identify a particular disease category or classification,
as MS shows considerable individual variability. As a consequence, it is essential to take care
when discussing disease patterns and to ensure that patients realise that their type of MS
2.3.4 Progressive-relapsing (PRMS)
will have a lifetime course that is unique to them. Moreover, not all people with MS will reach
the same level of disability, and there can be wide variations in prognosis and functional PRMS accounts for ~5% of MS. Like those with PPMS, patients with PRMS experience a
difficulties between individuals. There are several well defined stages and types of MS which steady deterioration in their condition from disease onset, but like those with SPMS, they
are described below. experience occasional acute attacks superimposed upon their progressive course.
Ensure that patients realise that their type of MS will have a lifetime course that is PRMS accounts for ~5% of MS.
unique to them.
Disease severity varies considerably between people with MS, no matter the type of disease
The four categories of disease courses are briefly defined below13. They are described in ascribed to them at the time of diagnosis15.
greater detail in Module 2. Briefly, the categories are classified as:
2.3.1 Relapsing-remitting MS (RRMS) 2.4 The Clinical Course of MS Over Time
RRMS is the most common form of MS and accounts for 85% of MS cases at onset14. It is Despite the unpredictable nature of MS, results of cohort studies have provided general
characterised by clearly defined relapses (a period in which a person with MS experiences prognostic markers.
an acute worsening of function that lasts for at least 24 hours, usually lasting for several days
or weeks, followed by an improvement that lasts for at least one month) that generally evolve
over days to weeks, followed either by complete remission or with some residual deficit (i) Factors pointing to a more favourable prognosis include:
following recovery. • younger age at onset.
• female gender.
RRMS is the most common form of MS and accounts for 85% of MS cases • monosymptomatic presentation (particularly optic or sensory presentation).
at onset. • complete recovery between relapses.
• long intervals between relapses and a low number of relapses.
2.3.2 Secondary-progressive MS (SPMS)

(ii) Factors pointing to a poor prognosis include:
SPMS is the long-term outcome of RRMS, occurring when the clinical course of RRMS • male gender.
changes so the patient experiences a steady decline in function; the period between relapses
becomes progressively longer and there is a steady deterioration in function1. • older at disease onset (>40 years).
• motor, cerebellar or sphincter symptoms at presentation.
• polysymptomatic presentation.
2.3.3 Primary-progressive MS (PPMS)
• frequent attacks in the first 5 years.
PPMS is diagnosed in ~10–15% of the MS population. In contrast to RRMS, in both genders
• short interval between the first two attacks.
with this form of MS, symptoms develop faster and the disease is progressive from the
outset without any discernible relapses or remissions. • short time to reach an Expanded Disability Status Scale (EDSS) of 4.
Please see Module 2, Section 6 for more detailed information about prognosis of MS.

2.5 Factors Contributing to MS Europe, Northern USA, Southern Canada, Southern Australia or New Zealand) but moves to a
low risk area (e.g. Asia, Latin America, Middle East) before the age of 15 years, he or she will
Both environmental and genetic factors contribute to the aetiology of MS, and genetic assume the low risk potential. Equally, people of Japanese origin living in the USA are more
factors also contribute to MS susceptibility. MS is particularly prevalent in populations from likely to develop MS than those living in Japan21.
Northern Europe and their descendants, including those living in Australia, New Zealand and
North America. It has been suggested that MS is more frequent in areas settled by Vikings Some ethnic groups show disproportionately low frequencies of MS, e.g. Maltese, Innuits,
and Goths, and that migrants from these areas took this susceptibility throughout Europe, Lapps, Siberians, Hungarian Gypsies and Central Asians15.
the New World, South Africa, Australia and New Zealand16. Other prevalence rates are as
follows17,18:
MS affects Caucasians more than other races. The potential for developing MS
• United Kingdom: 80–250 per 100,000.
may be established in early life.
• Scandinavia: 32–93 per 100,000.
• Northern United States (above 37°N): 69 per 100,000.
• Asia, Africa, South America: 5 per 100,000. 2.5.2 Age
• Canada: 150–200 per 100,000. Although MS can occur at any age, the average age at diagnosis is approximately 30
years worldwide. Childhood MS is uncommon (~5% of cases), and paediatric presentation
• O
rkney and Shetland Islands, and South East Scotland:
250 per 100,000 population – this is the highest prevalence rate in the world. is generally one of relapses of sensory symptoms. More than 90% of the paediatric MS
population have RRMS. Disease course is usually slower than in adults, but significant
disability may still occur by early adulthood. It is not clear at the onset of symptoms which
The prevalence of MS significantly increases for each degree of northern latitude, by 1.5% in children will go on to develop MS22.
men (p = 0.013) and 1% in women (p = 0.015). Equatorial countries are usually the areas of
low risk, while the northernmost and southernmost countries tend to be areas of high risk7.
The average age at diagnosis is approximately 30 years worldwide.
Both environmental and genetic factors contribute to the aetiology of MS, and
genetic factors also contribute to MS susceptibility.
2.5.3 Gender
People will often enquire why they have MS. There is no one cause and the disease is
Like the majority of other autoimmune diseases, MS predominately affects women. The ratio
multifactorial – including genetic susceptibility, environmental factors, viral exposure and
of women to men with MS is approximately 2:1. This is consistent with the phenomenon that
possibly hormonal interplay.
women, especially during childbearing years, are more likely to have autoimmune diseases.
MS nurses need to have an understanding of the current concepts of MS etiology and the Women in high risk areas have a lifetime risk of 1 in 20023. Moreover, MS symptoms are
pathological changes that are characteristic of the disease, so that they are better able to affected by the normal ebb and flow of hormones during the menstrual cycle24. The only
address the concerns of their patients and their families. exception to this is PPMS, in which the female preponderance is absent. However, when
present, MS tends to be more severe in men and the male gender is typically associated
with a poor prognosis25.
2.5.1 Race
MS affects Caucasians more than other races19. MS was virtually unknown among black MS tends to be more severe in men and the male gender is typically associated
Africans, although, of late, there are increasing reports amongst these races. Indeed, while with a poor prognosis.
MS has a higher incidence in Caucasian Americans than in African Americans, the latter may
have a more aggressive disease course and experience greater disability20. Migration studies
are particularly interesting when studying the cause of MS. The potential for developing MS
may be established in early life. Thus, if a person is born in a high risk area (e.g. Northern

Sex hormones are known to play a central role as modulators of the immune response in One of the most common questions a newly diagnosed person with MS will ask is “Is MS
autoimmune diseases. Use of hormone replacement therapy may be associated with a inherited?” When counselling people with MS and their relatives it should be explained that
lower risk of MS – suggesting that sex hormones may have a role in the decrease in relapse the risk for first-degree relatives of people with MS is greater than the risk for second-degree
rates observed during pregnancy and the increase seen following delivery. More studies relatives. Overall, siblings have the highest age-adjusted risk, followed by parents, then
are needed to determine the precise relationship between MS and hormonal imbalances. children, then uncles, aunts and cousins26 (Figure 4).
2.5.4 Genetics
Some of the geographic variation of this disease may result from genetic predisposition.
Family studies and twin studies have shown that there is a strong genetic component
underlying the etiology of multiple sclerosis. The rate of MS among family members of
an individual affected by the disease is higher than would be expected by chance. The
prevalence of this disease among first-degree relatives of affected individuals is 20 to 40
times higher than the overall population26. However, this cannot be entirely attributed to
genetics, as most family members share a similar environment and lifestyle.
20% of people with MS have a positive family history.
Figure 4 – Incidence of MS in Eastern Europe
Twin studies “Is MS inherited?”
In theory, if genes were solely responsible for determining the risk of the development of MS, then it would follow that if One UK study examined the risks of developing MS in both first- and second-degree relatives of an MS patient and
one monozygotic twin were diagnosed with MS, then there would be a 100% chance of the other twin also developing reported the following figures27
the disease. In fact, this is not the case. In a Canadian study of twin pairs, Sadovnick and colleagues followed up their
• Sister = 4.4%
study group for 7.5 years30. They discovered the concordance rate is approximately 30% in monozygotic twins, which
contrasts with the rate in dizygotic twins of approximately 4.7%. The rate in the latter group is roughly the same risk as • Brother = 3.2%
in non-twin siblings.
• Parent = 2.1%
Recent studies have highlighted the fact that monozygotic twins might not actually be genetically or epigenetically
identical31. Baranzini and colleagues sequenced the genome from a pair of monozygotic twins discordant for multiple • Child = 1.8%
sclerosis, and also examined DNA methylation and gene expression across the genome32. No consistent difference in
Where both parents have MS, the risk to their children is higher, approaching 20%.
DNA sequence, DNA methylation or gene expression was found between affected and unaffected twins. This result
suggests that the environment is the key driver of twin discordance.
This has led to the conclusion that up to 75% of MS cases must be due to non-genetic factors33,34.

2.5.5 Vitamin D
The risk for first-degree relatives of people with MS is greater than the risk for
second-degree relatives. Another factor believed to contribute to MS is dietary and sunlight-activated vitamin D in
the body35. Geographical gradients have been observed repeatedly in MS, with disease
Some specific gene markers have been identified as possible causative genes in MS, prevalence rates increasing at higher latitudes – i.e. with increasing distance from the
although their consistency across the MS population has yet to be established. Patients equator.
may ask for genetic counselling if they are planning a family, but because of the complexity
of genetics and the interplay of genetic and environmental factors, genetic screening or The hygiene hypothesis – the idea that our modern, ultra-clean living conditions induce
counselling is difficult. There is currently no genetic testing for MS available. There is an hyper-reactivity of the immune system – may also play a role, since the geographical
association with certain human leukocyte antigen (HLA) alleles, such as HLA-DR2, and the distribution also coincides with the location of the ‘first-world’ countries37.
development of MS28. Other non-HLA genes may also play a role in MS susceptibility.
MS is not an exclusively inherited disease as shown by twin data. The higher concordance 2.5.6 The Role of Stress in MS
rate for monozygotic twins (25–34%) than for dizygotic twins (2–5%) indicates a high
The concept that stress might trigger MS relapses dates back a long time and has been
heritability. Various genetic studies have examined the risk of the disease to family members
borne out in more recent studies. For instance, in patients living in a war zone there was a
of an affected individual. Thus, those genetically identical (monozygotic twins) have the
significant increase in MS relapses38.
highest risk (~25–34%), and those genetically unrelated (general population) have the
lowest risk (~0.1–0.2% in high risk areas). Adoptees have a comparable risk to the general
population indicating that living with an affected individual has little or no effect on one’s
susceptibility in the absence of biological relatedness7,26.Researchers have concluded that 2.5.7 Smoking and MS
both genetic susceptibility and environmental influences affect the development and clinical
manifestations of MS29. Smoking has been observed to play a contributory role in MS. Epidemiology studies have
shown smoking increases the risk of MS by 40–80%39. Children exposed to cigarette smoke
(i.e. passive smoking) are also at an increased risk of developing MS – and the longer the
exposure, the higher the risk39. There are conflicting data as to whether cigarette smoking is
Genetic susceptibility and environmental influences affect the development and
a risk factor for transforming RRMS to SPMS.
clinical manifestations of MS.
Among people with MS, smoking is associated with higher levels of disability, greater number
of enhancing T2 and T1 lesions, greater lesion volume and more brain atrophy40.
Because there are no tests to evaluate the genetic susceptibility of people to MS, it is
difficult to counsel patients who want to know their chances of passing the disease on to
their children. The best we can do is to evaluate the family history and be empathetic.
2.5.8 Viral Factors
Several studies suggest that MS and its accompanying exacerbations are associated with
viral or microbial infections41. For instance, a relapse may be triggered following a viral
infection such as an upper respiratory infection42. Many viral triggers have been cited, for
example paramyxo virus, coronavirus, Epstein-Barr virus, herpes zoster, herpes simplex
Twin data
virus, human herpes virus, measles and rubella43.
In theory, if genes were solely responsible for determining the risk of the development of MS, then it would follow that if
one monozygotic twin were diagnosed with MS, then there would be a 100% chance of the other twin also developing
the disease. In fact, this is not the case. In a Canadian study of twin pairs, Sadovnick and colleagues followed up their
study group for 7.5 years30. They discovered the concordance rate is approximately 30% in monozygotic twins, which
contrasts with the rate in dizygotic twins of approximately 4.7%. The rate in the latter group is roughly the same risk as
in non-twin siblings.
Recent studies have highlighted the fact that monozygotic twins might not actually be genetically or epigenetically
identical31. Baranzini and colleagues sequenced the genome from a pair of monozygotic twins discordant for multiple Vitamin D
sclerosis, and also examined DNA methylation and gene expression across the genome32. No consistent difference in
DNA sequence, DNA methylation or gene expression was found between affected and unaffected twins. This result The effects of vitamin D on the immune system and in the CNS are increasingly understood, as are the underlying effects
suggests that the environment is the key driver of twin discordance. of vitamin D in MS. Experimental studies have shown that the biologically active metabolite of vitamin D is able to skew
the composition of T cells into a more anti-inflammatory and regulated state36. The geographical distribution of MS may
This has led to the conclusion that up to 75% of MS cases must be due to non-genetic factors33,34. thus be explained by the vitamin D hypothesis.

2.6 Summary
Nursing tip • MS is the most common chronic neurological disorder in young adults.
ow might you describe some of the current theories about causes of MS to

H • It tends to be most common in countries furthest from the equator.
someone who is just diagnosed? • R
ace, gender, genetics and environmental factors can influence the incidence of
the disease.
How would you check the person has understood the information you have
• W
hile MS is typically classified into four main types (RRMS, SPMS, PPMS and
given them? PRMS), the prognosis can vary considerably between patients.
There are several theories about what causes MS and newly diagnosed patients often
want to know “How did I get this disease?” This is important to explain because without
a clear understanding they often deny they have the disease and may choose not to treat
with disease modifying therapies. Both environmental and genetic factors contribute to the
aetiology of MS, and genetic factors also contribute to MS susceptibility. MS is particularly
How does knowing about the factors contributing to MS link to my competencies
prevalent in populations from Northern Europe and their descendants. There is no one
as an MS Nurse?
cause and the disease is multifactorial – including genetic susceptibility, environmental
factors, viral exposure and possibly hormonal interplay.
MS affects Caucasians more than other races. The potential for developing MS may be
established in early life. Persons born in a high risk area (e.g. Northern Europe, Northern
USA,) but moves to a low risk area (e.g. Asia, Latin America, Middle East) before the age
of 15 years, he or she will assume the low risk potential. Although MS can occur at any
age, the average age at diagnosis is approximately 30 years worldwide. It can be seen
in children and the elderly also. Like the majority of other autoimmune diseases, MS
predominately affects women.
Some of the geographic variation of this disease may result from genetic predisposition.
The prevalence of this disease among first-degree relatives of affected individuals is 20 to
40 times higher than the overall population. However, this cannot be entirely attributed to
genetics, as most family members share a similar environment and lifestyle. Some specific
gene markers have been identified as possible causative genes in MS, although their
consistency across the MS population has yet to be established.
Another factor believed to contribute to MS is dietary and sunlight-activated vitamin D

in the body. Geographical gradients have been observed repeatedly in MS, with disease
prevalence rates increasing at higher latitudes – i.e. with increasing distance from the
equator. Smoking has been observed to play a contributory role in MS. Epidemiology
studies have shown smoking increases the risk of MS by 40–80%. Several studies
suggest that MS and its accompanying exacerbations are associated with viral or
microbial infections.
Nurses should review the information with the patient and their families. Particular
attention should be paid to any specific questions they may have such as a history of MS
in the family. All of this information can be reviewed when a discussion about disease
modifying therapies is held. Patients can also be asked to repeat in their own words their
understanding of the causes.

3 Understanding the causes of MS 3.4 Overall Structure of the Healthy Nervous System
The nervous system is divided into essentially two components:
3.1 Recommended Reading for this Section
• the central nervous system (CNS).
Marieb EN. Essentials of Human Anatomy and Physiology. 8th Edition. San • the peripheral nervous system (PNS): which consists of nerves outside the brain
Francisco, CA: Pearson Benjamin Cummings; 2006. and spinal cord.
Herlihy B. Nervous system: nervous tissue and brain. In: Herlihy B. (ed.), The
Human Body in Health and Illness. 3rd ed. Philadelphia, PA: W B Saunders; 2007. The CNS consists of the brain and the spinal cord, plus the optic nerve. It is the body’s
primary command and coordination system, receiving and processing incoming data and
Hauser SL (ed.). Harrison’s Neurology in Clinical Medicine. New York, NY: McGraw
instructing responses. The brain comprises of four main regions:
Hill; 2006.
The cerebral hemispheres which are responsible for higher functions of the brain i.e.,
speech, memory, logic, emotions, consciousness, interpretation and processing of sensation
3.2 Introduction and voluntary movement. The cell bodies of neurons which are involved in these higher
functions are located in the outermost non-myelinated, grey matter of the brain, called
A sound knowledge of the pathophysiology of MS is important to the MS Nurse as the cerebral cortex. This consists of several hundreds of billions of neurons and is where
one of the most common questions asked by people with MS is ‘What causes this information processing takes place. The myelinated white matter comprises of densely
disease?.’ It is therefore important to be able to provide a clear answer that helps packed bundles of nerve fibres carrying electrical impulses to the cortex. The white matter
patients gain greater insight into their condition and provides a foundation for their provides the communication between different areas of grey matter and between the grey
understanding the rationale of their treatment, both in terms of their prescribed matter and the rest of the body (see Figures 5 and 6).
medication and the all-important self-management that they will be recommended
to undertake.
A sound knowledge of the pathophysiology of MS is important to the MS Nurse

as one of the most common questions asked by people with MS is “What causes
this disease?”
The pathophysiology of MS also includes the mechanisms underlying the inflammation

and degeneration of the nervous system that typically occurs in MS. This has practical
implications for the use of the currently available disease-modifying therapies, and ongoing
and future research efforts. This knowledge provides a framework for rational treatment
selection, helps to anticipate response and aids the understanding of adverse events, should
they occur.
3.3 Learning Objectives

• D
escribe the structure of the nervous system and how its function is altered
by MS.
• Explain the function of the immune system and how its role is disrupted by MS.
Figure 5 – The functional areas of the left hemisphere

Figure 6 – The cerebral cortex
The diencephalon which is located at the top of the brain stem is enclosed by the cerebral
hemispheres. It contains the:
• thalamus, a relay station for sensory impulses passing into the sensory cortex;
• hypothalamus, which regulates body temperature, water balance and
metabolism. Figure 7 – The brain stem, cerebrum and cerebellum
The epithalamus, which contains the pineal body and the choroid plexus- a knot of
capillaries from which the cerebrospinal fluid is derived
The brain stem, which controls, among others, essential bodily functions such as breathing,
blood pressure, swallowing and vomiting
The cerebellum, which co-ordinates skeletal muscle activity and controls balance and
equilibrium (See Figure 7).

A neuron is comprised of the soma, or the main body of the cell, which contains the nucleus
and other cell structures and is the metabolic centre of the cell (see Figure 8). From the cell
there are arm-like processes or fibres that can be as long as one metre in length. There fibres
are of two types:
• Dendrites which receive electrical signals from neighbouring cells.
• Axons which generate, transmit and propagate the signals onto the next neuron.
Figure 9 – The nerve impulse
Figure 8 – Diagram of a neuron

Arrival of the nerve impulse at the termination of an axon stimulates the release of
neurotransmitters into the synaptic cleft between the two neurons. The neurotransmitters
then diffuse across the synaptic cleft, bind to the receptors, and stimulate the dendrites
Information is conveyed along a neuron by electrical signals (see Figure 9). These signals of the second neuron. Hence a nerve signal is propagated by both electrical and chemical
involve a series of events (primarily the movement of ions, particularly sodium (Na+) and means, within and between cells.
potassium (K+) which cause the electrical charge inside the cell to move from its positive
depolarised state back to its negative resting state again. The resultant waves of electrical
activity are known as action potentials.

A nerve signal is propagated by both electrical and chemical means, within and The brain and the nervous system are protected from potentially toxic chemicals
between cells. and organisms by the blood–brain barrier.
Axons are insulated by myelin sheaths like the plastic coating that surrounds a metal core
in an electrical cable. It prevents dissipation of the electrical signal along the length of the
axon. These sheaths are formed by cells exclusive to the CNS called the oligodendrocytes
which coil round multiple axons – up to 60 different axons at a time. The myelin sheaths are
interrupted by a series of gaps along each axon called the Nodes of Ranvier, where myelin is
absent. The Nodes of Ranvier are the means by which electrical nerve impulses are rapidly
conducted through an axon – they allow action potentials to jump from node to node at an
accelerated rate.
Myelin is a glycoprotein (a protein that has carbohydrate molecules attached), and as such is
recognised by components of the immune system. In MS, myelin is attacked by the patient’s
own immune system and compromised, resulting in hardened plaques called scleroses.
The myelin sheath is thus damaged and electrical signalling is short-circuited. Initially, the
myelin sheath is repaired (accounting for remission in early stages of some types of MS), but
eventually the myelin sheath breaks down and axons themselves come under attack and are Figure 10 – Diagram of a blood vessel in the CNS forming the blood–brain barrier
severed. This is associated with increasing disability.
Only water, glucose, essential amino acids, lipids and lipid-soluble molecules can pass
In MS, myelin is attacked by the patient’s own immune system and compromised, through the membranes of these capillaries; thus, hormones do not normally cross this
resulting in hardened plaques called scleroses. barrier but lipid soluble compounds such as alcohol, anaesthetics and certain drugs can
cross the blood–brain barrier.
The different types of cells surrounding the neurons are known as glial cells.
The brain and the nervous system are protected from potentially toxic chemicals (including
some drugs) and organisms by the blood–brain barrier. This is composed of the least
permeable capillaries found in the body, lined with endothelial cells that are more tightly
packed together than in the rest of the body, forming tight junctions. In addition, on the CNS
side of the barrier, the endothelial cells are covered by a thin basement membrane of cells
called pericytes and the ‘feet’ of the astrocytes (see Figure 10).
The glial cells comprise:
Astrocytes
The cells provide bracing and anchorage between neurons and blood capillaries. They also play a role in making
exchanges between the neurons and capillaries and are a buffer that protects the delicate neuron from toxic substances
in the blood
Microglia
These cells play a phagocytic (cell-engulfing) role and are immunocompetent. They are implicated in the progression of
several demyelinating diseases including MS.
Ependymal cells
Glial cells that line the cavities of the brain and spinal cord, and help to circulate fluid which forms a protective cushion
around the CNS

3.4.1 Structure of the Spinal Cord 3.5 The Overall Function of the Healthy Immune System
The spinal cord is the long extension of the brain stem that provides two-way communication The immune system is highly specialised and comprises many different cell types, and many
between the body and the brain. In humans, there are 31 pairs of spinal nerves which enter complex mechanisms. It evolved as a means to protect the body against specific threats,
the spinal cord by penetrating the vertebral column from the surrounding body. including microorganisms, certain molecules, such as toxins, and internal threats such as
malignancies. The immune system:
The spinal cord comprises grey and white matter. Grey matter surrounds the central canal
of the cord, which is filled with cerebrospinal fluid, and is shaped into horns - dorsal and • Is antigen specific – it recognises proteins or glycoproteins on an invading
ventral. Nerves enter the spinal cords by dorsal and ventral root ganglia, while motor neurons cell’s membrane.
enter via the ventral root ganglion. White matter is located in posterior, lateral and anterior • Is systemic – the components are found in the systemic circulation.
columns, surrounding the horns of grey matter (see Figure 11).
• Has memory – once the body recognises an antigen, it retains the capacity
to raise an immune response against that antigen should it appear in the
body again.
The immune system protects the body against specific threats, including
microorganisms, certain molecules, such as toxins, and internal threats such
as malignancies.
3.5.1 Innate and Adaptive Immunity
The immune system has two distinct functions which interact to protect the body against
dangerous organisms and compounds that enter the body:
• t he more primitive innate immune system (the first line of non-specific defense
against infection by other organisms)
• t he adaptive immune system composed of highly specialised, systemic cells
and processes that eliminate or prevent pathogenic growth. It provides the ability
to recognise and remember specific pathogens (to generate immunity), and to
mount stronger attacks each time the pathogen is encountered.
All immune system cells derive from stem cells in the bone marrow. After proliferating as non-
specialised stem cells, they begin to specialise into lymphoid and myeloid cell types.
Figure 11 – Diagram of the structure of the spinal cord
3.4.2 Summary
The nervous system is divided onto components – the central nervous system
(CNS) and the peripheral nervous system (PNS). Together they relay both physical
and cognitive information about macro and microenvironments in and around the
body, using electrical impulses as the signally device.
The sheath that surrounds an axon fibre is made of myelin and this is vital for the
generation and propagation of electrical signals along the axon fibre. In MS, this
myelin sheath is attacked by a person’s own immune system and destroyed.

Lymphoid cells (T and B lymphocytes) are very specific in their actions and are part of the Lymphocytes that recognise ‘self’ are normally rapidly and effectively destroyed as soon as
adaptive immune response. they emerge. This process fails in the case of autoimmune disease.
Lymphoid cells differentiate into either B cells or T cells, depending on whether they are
produced in the marrow (B cells) or are produced in the marrow and migrate to the thymus,
where they mature (T cells). They each display a unique type of receptor on their surfaces and
so only recognise one specific type of antigen (see Figure 12).
T cells (cont’d)
• Killer T cells (kill cells expressing antigens for which they are specific)
• Helper T cells (stimulate T and B cells)
• Regulatory T cells (inhibit T and B cells and wind down the immune response once the attack is completed)
• Memory T cells (remember antigens for future encounters)
Figure 12 – The humoral immune response
B cells
B-cells migrate to the spleen, lymph nodes and mucosal-associated lymphoid tissue (MALT). They are responsible for
producing and secreting antibodies. They can differentiate into plasma B cells, which produce antibodies in response
to antigen challenges and memory B cells (which carry antibody or receptor for a specific antigen, formed after its first
exposure to that antigen). When stimulated by a second exposure to the antigen, memory B cells mount a more rapid
and effective immune response than a B-cell that has not been previously exposed.
T cells
T cells mature in the thymus and then concentrate in secondary lymphoid organs where they differentiate into cytotoxic
T cells (also known as CD8+T cells) or Helper T cells (also known as CD4+ T cells). T cells are stimulated by macrophages
that have engulfed invading cells or viruses, partially digested them and then presented various parts of the invader
on their cell surface together with a cell marker of their own from the major histocompatibility complex (MHC). This
stimulates cytotoxic T cells to react by releasing toxic chemicals to kill the infected cells. Cytotoxic T cells also stimulate
T cells to differentiate into: Figure 13 – The cellular immune response

3.5.2 Innate Immunity
Myeloid cells respond early and non-specifically to infection and form the innate immune
response.
Nursing tip
The innate immune system is a genetically determined, non-specific defence mechanism
that provides an immediate barrier to infection. It lacks specificity and memory, and does not
confer long-lasting or protective immunity. However, it does play a vital role in activating the In what way would you describe the function of the immune system to a person
adaptive immune system through the process of antigen presentation. with MS?
The cellular mediators of the innate immune system are phagocytes (monocytes,
macrophages, dendritic cells and granulocytes) and natural killer (NK) cells; the soluble A sound knowledge of the pathophysiology of MS is important as one of the most common
components are complement proteins and cytokines, among others. questions asked by people with MS is ‘What causes this disease?”
3.5.3 Adaptive Immunity I normally begin by explaining about the nervous system and how it is divided into
essentially two components:
There are two types of specific adaptive immune response: the humoral immune responses
and the cellular response. T cells are the effective mediators of the cellular response, while • the central nervous system (CNS)
antibodies secreted by B cells are the effectors of the humoral response.
• the peripheral nervous system (PNS): which consists of nerves outside the
brain and spinal cord.
The CNS consists of the brain and the spinal cord, plus the optic nerve. It is the body’s
primary command and coordination system, receiving and processing incoming data and
instructing responses. The CNS is made up of many types of cells including the neurons.
Neurons are the cells that send messages from the brain to the body and back. Neurons
are made up of the cell body and the axon which is like a long tail. The axon is often
covered in a protective coating called myelin. In MS, myelin is attacked by the patient’s
own immune system and compromised, resulting in hardened plaques called scleroses.
When the myelin is damaged axons may also be destroyed. These areas of damage are
often seen on MRI scans and many produce symptoms of MS.
The immune system protects us from pathogens and responds to injury. The normal
immune system can recognise a wide variety of pathogens, leave its own tissue alone and
remember a previous exposure to a foreign pathogen. However, if the immune system
is abnormal, immune cells such as T and B cells will mistakenly damage a person’s own
tissues. This is the case in an autoimmune disease such as MS. Research suggests that
MS is a consequence of an abnormal autoimmune response to myelin that develops
after exposure to some environmental agent in genetically predisposed individuals.
Cellular or cell-mediated immunity The combined effects of this autoimmune response cause demyelination, axonal damage
This is where the white cells are engaged in immune activity. Principally lymphocytes are involved, some of which act and scarring, and account for the new brain and spinal lesions seen on the MRI of people
directly by destroying foreign cells, or indirectly by releasing chemical mediators that enhance the inflammatory response with MS.
or activate cells to destroy the invaders.
Humoral immunity
The immune system mainly works by producing antibodies against antigens. Antibodies are molecules produced by
B lymphocytes and they circulate in the blood and the lymph. They attach to antigens displayed by invading bacteria,
viruses or other organisms, and either inactivate them or facilitate their destruction by cells of the immune system.

3.5.4 Summary 3.6.1 The Multiple Sclerosis Lesion
• T
he immune system protects us from pathogens and responds to injury. It has The pathological hallmark of MS is the plaque45,46. Lesions are characterised histologically
several important characteristics: diversity, specificity, the ability to distinguish by hypercellularity, lymphocyte infiltration around blood vessels, loss of oligodendrocytes
self from non-self, and memory. and myelin, axonal damage and parenchymal oedema. Remyelination is seen occasionally.
• The normal immune system can recognise a wide variety of pathogens, leave Lesions can occur anywhere in the white and grey matter of the CNS; however, most are
its own tissue alone and remember a previous exposure to a foreign pathogen seen in deep white matter and in the spinal cord.
and responses.
• Some T and B cells also have the ability to react to self-antigens. A normally The pathological hallmark of MS is the plaque. Lesions can occur anywhere in
operating immune system keeps these autoreactive immune cells in check so the white and grey matter of the CNS; however, most are seen in deep white
that they do not provoke unwanted responses.
matter and in the spinal cord.
• However, if the immune system is dysregulated, tolerance to some self-antigens
may be disrupted and autoreactive T and B cells will mistakenly damage a
person’s own tissues. This is the case in an autoimmune disease such as MS. There is a preference for periarteriolar and perivenular lesion formation. Accordingly, lesions
are commonly found in areas with high vascularity, including the optic nerve, spinal cord, the
juxtacortical area and periventricular zone.
3.6 Pathophysiology of MS Thus, initial clinical symptoms are often associated with the brainstem, optic nerve, spinal
cord, or cerebellum lesions, causing optic neuritis, transverse myelitis or a brain-stem
The cause of MS is not known, but it appears that it occurs when the immune system is syndrome.
unable to distinguish self-antigens from foreign antigens. Research suggests that MS is a
consequence of an abnormal autoimmune response to myelin that develops after exposure
to some environmental agent in genetically predisposed individuals44.
3.6.2 The Main Pathological Processes: Inflammation and Neurodegeneration
Research suggests that MS is a consequence of an abnormal autoimmune The principle clinical expression of MS is relapses and disease progression leading to
progressive permanent disability.
response to myelin that develops after exposure to some environmental agent in
genetically predisposed individuals44. • Relapses are caused by acute inflammatory demyelination
When the immune response is triggered, there is peripheral activation of T cells and these • Progression reflects neurodegeneration, including axonal loss and gliosis
(sclerosis) with increasing brain atrophy47-50.
activated lymphocytes egress from the lymph nodes and migrate across the blood–brain
barrier (BBB) into the CNS. Once inside the CNS, these cells are reactivated and stimulate
production of inflammatory cytokines that damage the BBB and the components of
At one time it was thought that the pathological sequence was initial inflammation causing
the CNS.
demyelination leading to axonal loss later in the disease, secondary to repeated inflammatory
events. However, recent data suggest that the inflammation and neurodegeneration occur at,
The combined effects of this autoimmune response cause demyelination, axonal damage or near, the same time. This is supported by autopsy and MRI studies which have revealed
and scarring, and account for the newly evolving cranial and spinal lesions seen on the MRI that axonal damage occurs in the earliest phases of MS14, 47,50-52. Indeed, there are data that
of people with MS44. Axonal degeneration and axonal transection may lead to permanent show that axonal/neuronal damage in MS can occur largely independent of the inflammatory
neurological dysfunction and this may begin early in the disease course. This disruption of processes52.
conduction in nerves and nerve function causes the hallmark sensory, motor and cognitive
These data argue in favour of initiation of treatment in MS as early as possible, certainly
signs and symptoms of MS. In addition, brain atrophy may occur and is thought to reflect before permanent disability is apparent.
irreversible tissue damage.
• A genetic component is certain. Relapses are caused by acute inflammatory demyelination. Progression reflects
• Potential environmental risks have been proposed. neurodegeneration, including axonal loss. Data suggest that the inflammation and
neurodegeneration occur at, or near, the same time.
This disruption of conduction in nerves and nerve function causes the hallmark
sensory, motor and cognitive signs and symptoms of MS.

3.6.3 Cells Involved in the Pathogenesis of MS 3.6.4 Summary
The main cell types involved in MS are T cells and B cells. MS appears to be caused by • T
he pathophysiology of MS comprises of two components: inflammation and
activated myelin-specific T cells, which react with one or more antigens in myelin, leading to neurodegeneration.
formation of the typical inflammatory demyelinating lesions46,47,53.
• R
elapses are the clinical expression of acute inflammatory demyelination,
This is supported by animal data which have shown that auto reactive CD4+ or CD8+ T whereas progression reflects neurodegenerative processes, including axonal
cells cause CNS demyelination. Entry of these activated cells from the periphery into the loss, with increasing brain atrophy.
CNS results in disruption of the blood–brain barrier (BBB). In persons genetically disposed
to MS, this is presumably initiated by an environmental trigger, as alluded to above (e.g. • R
ecent research suggests that inflammation and neurodegeneration happen at,
an infectious agent)46,53. This initial event may up-regulate the adhesion molecule on or near, the same time.
brain and spinal cord endothelium (e.g. VCAM-1), allowing transmigration of circulating • These data argue in favour of the early initiation of treatment for MS.
lymphocytes46,53.
T cells must be activated to enter the CNS and this process and events involved in the BBB
penetration and subsequent tissue damage are complex, requiring adhesion and subsequent
reactivation after entry:
Although the focus of CNS injury in MS focuses on T cell-mediated pathogenesis,

mounting evidence suggests that humoral immunity also plays a role54-56. Elevated levels of
What is the significance of understanding the inflammatory and neurodegenerative
immunoglobulins in CSF have long been observed in people with MS54.
processes in MS to my role as an MS Nurse?
In recent years the potential for demyelination induced by the presence of immunoglobulins
has been suggested54,55. B cells have been reported in the meninges of many MS
patients, especially those with SPMS, which indicates that B cell maturation can be
sustained in the CNS56.
Complex
The first step is peripheral activation of T cells that recognise antigens in the CNS. For this to happen, the antigen
fragment must be presented to the T cell enfolded in the MHC which is presented on antigen-presenting cells (dendritic
cells, monocytes, macrophages, CNS microglial cells and B cells)44. The activated T cells adhere to the endothelial
cells of the BBB (step 2). Soluble proteins degrade the BBB which help the T cells invade the CNS, where they become
reactivated and injure the myelin.
Activated T cells differentiate into subsets known as helper cells, which include:
• Type 1 helper cells (Th-1): The cytokines produced include the damaging, proinflammatory IL 12, IL 23, INF γ, TNF α
• Type 2 helper cells (Th-2): The cytokines released include the anti-inflammatory / protective IL 4, IL 5 and IL 13, and
possibly IL 10.
In MS the balance is tipped towards a Th-1 response and modulating Th-1 and Th-2 responses is one target of MS
therapy44.
B cells have been reported in the meninges of many MS patients
Potential mechanisms by which the accumulation of B cells in the CNS may contribute to the pathogenesis of MS
include antigen presentation, production of proinflammatory cytokines, complement fixation and anti-idiotypic networks.
One theory is that memory B cells in the CSF from MS patients may amplify T cell responses in the CNS via presentation
of antigenic peptides.

4 Relating pathophysiology to MS symptoms Remissions are related to a recovery of function of the affected axons and
remyelination which restores conduction to demyelinated axons. Progression
4.1 Learning Objectives in MS is mainly related to “slow-burning” diffuse and chronic axonal loss in a
setting of inflammation.
• D
escribe the underlying pathophysiological causes of the most common Some symptoms in MS are so-called “positive” ones, arising from an acquired
symptoms associated with MS. hyperexcitability of demyelinated axons. These can occur either spontaneously
(e.g. paraesthesias) or mechanically.
• R
ecognise that central to this is the inflammation and demyelination of axons
which disrupts neural conduction.
• Appreciate that cortical pathology, that is, inflammatory focal lesions (cortical 4.3 Sensitivity of People with MS to Heat
lesions) and atrophy (cortical thickness), may determine cognitive disability
in MS. Recommended reading57: Flensner G, Ek A-C, Sőderhamn O, et al. Sensitivity to
heat in MS patients: a factor strongly influencing symptomology – an explorative
survey. BMC Neurol 2011; 11: 27.
4.2 Introduction
Between 60% and 80% of individuals diagnosed with MS have been reported as being
People with MS can exhibit an exceptionally wide variety of symptoms. This is sensitive to environmental heat58. Indeed, blurred vision, known as Uthoff’s phenomenon and
largely due to the semi-random distribution of the lesions in the central nervous first described in 1890, is caused by increased body temperature due to physical exercise
system (CNS). Most lesions occur in apparently “silent” areas in the brain, and or physical restraint59. In a multinational Internet-based survey of people with MS (n=2,529),
so cause no detectable symptoms. The disease is therefore much more active 70% reported that high temperatures worsened their MS (e.g. taking a hot shower or using
than clinical monitoring would suggest. Most symptoms are related to a loss of the hair drier); while drinking a glass of cold water could relief symptoms60.
function. During relapses, this is due to a failure of axonal conduction at the site
of the lesion(s). The conduction block is caused by the local demyelination
which prevents the saltatory conduction. It is also affected by inflammation which Between 60% and 80% of individuals diagnosed with MS have been reported as
contributes to neurological deficit by modifying the properties of gial cells, being sensitive to environmental heat.
particularly astrocytes and microglia. This can affect neurological function.
Remissions are related to a recovery of function of the affected axons and The heat reaction blocks the action potential/conduction block of the demyelinated
remyelination which restores conduction to demyelinated axons. There is also neuron59,61. The demyelination results in a slower nerve conduction velocity. Interestingly, very
resolution of inflammation. However, nerve conduction remains slower and small increases in temperature (due to both external conditions and exercise) can also block
less secure than normal, easily altered by changes such as increase in body action potentials61,62. Patients’ reports of temperature aberrations can vary greatly, indicating
temperature (Uhthoff’s phenomenon), and a recent history of conducting a large that the mechanisms may be multiple.
number of impulses. Remission is incomplete when the lesion has led to axonal
After normalisation of the temperature, signs and symptoms usually improve or disappear58,59.
transection and therefore axonal loss. Progression in MS is mainly related to
Heat sensitivity has been described as a significant correlate of the symptom of fatigue
“slow-burning” diffuse and chronic axonal loss in a setting of inflammation.
in MS63-65.
Recommended reading: Smith KJ. Pathophysiology of multiple sclerosis. Rev Prat

Very small increases in temperature can block action potentials. After
2006; 56(12): 1299–303.
normalisation of the temperature, signs and symptoms usually improve
or disappear.

4.4 Relationship of Fatigue to MS Pathophysiology 4.6 Positive Symptoms and MS
Recommended reading66: Pellicano C, Gallo A, Li X, et al. Relationship of fatigue to People with MS can experience a wide range of positive phenomena and recordings
MS pathophysiology. Arch Neurol. 2010; 67(4): 447–53. in experimentally demyelinated axons suggest that this is due to ectopic activity in
hyperexcitable demyelinated axons. This is manifested clinically as tingling in the trunk and
limbs. Some patients also report the presence of sensations provoked by body movements
Fatigue is a frequent symptom of patients with multiple sclerosis63. It has a severe effect on which distort areas of the nervous system containing demyelinated axons. For instance,
their quality of life67, but its pathophysiologic mechanisms remain incompletely understood. patients with cervical posterior column lesions can experience an ‘electric shock’ sensation
One explanation is that fatigue in MS could be due to impaired selecting and planning when they turn their head and, similarly, patients with demyelinating lesions in the optic nerve
of actions, as well as integrating different information, rather than the extent of physical can experience flashes of light on eye movement.
disability and motor impairment68-71. This is in line with a model proposed by Chaudhuri and
Pain is a common complaint in MS patients and it appears to have several origins. It seems
Behan, stating that there is, “failure to initiate and/or sustain attention task (mental fatigue)
that painful sensations will result from ectopic impulses generated in pain fibres. There is
and physical activities (physical fatigue) requiring self-motivation72.
evidence to suggest that some positive phenomena can be triggered by propagation of the
normal impulse traffic through the site of demyelination.
Fatigue in MS could be due to impaired selecting and planning of actions.
4.7 Psychiatric Disorders in People with MS
4.5 Optic Neuritis Recommended reading78: Fazzito MM, Jordy SS, Tilbery CP. Psychiatric disorders
in multiple sclerosis patients. Arq Neuropsiquiatr 2009; 67(3a): 664–7
Recommended reading73: Chu ER. Optic neuritis-more than a loss of vision.
Australian Family Physician 2009; 38(10): 789–93.
MS may be related to several psychiatric disorders which disturb mood, behaviour and
personality. Among those disorders, depression is the most frequently reported79.Psychiatric
Optic neuritis (ON) is caused by acute inflammation of the optic nerve that results in painful symptoms are commonly observed during disease evolution, but they are unusual as first
loss of vision. It is the most commonly encountered optic neuropathy in clinical practice74,75 symptoms and their occurrence is estimated at 1% of MS cases.
and is often associated with MS76. However, between attacks optic nerves can undergo
People with MS show psychiatric disorders secondary to demyelinating lesions at the
recovery of vision.
temporal lobe. The physiopathology of this observation is not fully understood80,81. The
temporal lobe functions are language, memory and emotion. Lesions at this brain location
Optic neuritis is caused by acute inflammation of the optic nerve that results in may cause hallucinations, mood and thought disorder, euphoria, irritability and cognitive
painful loss of vision. deficit. This brain location is especially associated with psychiatric alteration80.
ON may be due to demyelination and inflammation of the optic nerve and its lining, resulting
in inflammation of the extraocularrecti muscles that surround the optic nerve. Recti muscle 4.8 Cognitive Impairment in MS
involvement results in ocular pain, especially with eye movements. Regardless of etiology,
inflammatory cells surround the optic nerve resulting in swelling and fragmentation of Depending on the disease phase and type, 40–65% of people with MS develop various
the nerve tissue which are subsequently phagocytised by macrophages, resulting in further degrees of cognitive dysfunction. Pathological and MRI studies have failed to demonstrate
degeneration of the nerve and the signs of optic nerve dysfunction77. the existence of a strict relationship between cognitive impairment and subcortical white
matter pathology. The correlation is also poor when MRI metrics of whole brain (white plus
gray matter) atrophy are considered. Over the past decade, increasing observations have
provided evidence of a primary role of cortical pathology – that is, inflammatory focal lesions
(cortical lesions) and atrophy (cortical thickness) –in determining global and/or selective
cognitive disability in patients with MS. By applying a new technique, it has been observed
that specific cognitive deficits, such as memory impairment, attention deficits and reduced
mental processing speed, could be better explained by cortical structural abnormalities than
by subcortical white matter lesions. Therefore, MRI evaluation of cortical pathology should
be included in the routine examination of people with MS, especially those with initial signs/
symptoms of cognitive dysfunction.
It is estimated that 64–68% of patients with MS have increased daytime urinary urgency, The
Pathological and MRI studies have failed to demonstrate the existence of a strict
final pathway mediating bladder motor function is via the cholinergic pathways.MS can cause
relationship between cognitive impairment and subcortical white matter pathology.
a complex multi-level urinary tract dysfunction, which can progress. The urinary symptoms
MRI evaluation of cortical pathology should be included in the routine examination
increased with prolonged disease duration and involvement of the motor system. The
of people with MS.
anatomical lesions are usually on the spinal cord – but there may also be involvement
of the cortical centres.
These observations were borne out by a study by Calabrese and colleagues in which 24
patients with relapsing-remitting MS (34.3%) were classified as cognitively impaired82. The
study provided evidence that the burden of cortical lesions and tissue loss are among the 4.11 Summary
major structural changes associated with cognitive impairment in relapsing-remitting MS.
• T
he major cause of symptoms such as paralysis, blindness and numbness
is conduction block in the nerves. This is largely caused by demyelination
and inflammation.
4.9 Pathophysiological Bowel Dysfunction in MS • T
he sensitivity of these symptoms to changes in body temperature is well
recognised.
Recommended reading83: Wiesel PH, Norton C, Glickman S, et al. Pathophysiology
and management of bowel dysfunction in multiple sclerosis. Eur J Gastroenterol • S
ymptoms such as tingling are due to ectopic bursts of impulses and the
Hepatol 2001; 13(4): 441–8. triggering of other spurious impulses by the transmission of normal impulses
in the areas of demyelination.
• C
ognitive impairment is probably due to lesions associated with the cerebral
cortex.
MS can affect the extrinsic neurological control of gut and sphincter function.
Bowel function and continence depend on the integrity of bowel transit, pelvic floor muscle
function, anorectal sensation, the motivation to maintain bowel control, and the ability
to access the toilet. MS can affect the extrinsic neurological control of gut and sphincter
How does understanding the pathophysiology of MS symptoms link to the
function. This can occur at any level of the neural hierarchy. For example, emotional
successful management of your patients?
disturbance due to frontal lobe involvement can lead to behavioural disturbances which
can cause failure of pelvic floor relaxation or ignoring of the call to stool. Involvement of
cerebral centres of autonomic control may diminish colonic motor function.
There is also evidence for involvement of motor spinal pathways in people with MS
with bowel dysfunction. Other factors which could affect bowel function include muscle
weakness, spasticity, fatigue and poor mobility. Some medications affect visceral function,
for example, anticholinergics prescribed for bladder dysfunction, antidepressants or
antispastics.
4.10 Bladder Symptoms and MS

Recommended reading84: Nicholas R, Young C, and Friede T. Bladder symptoms in
multiple sclerosis: a review of pathophysiology and management. Expert Opin Drug
Saf 2010; 9(6): 905–15.

Summary of Module
• MS is the most common chronic neurological disorder in young adults. •
The major cause of symptoms such as paralysis, blindness and numbness
is conduction block in the nerves. This is largely caused by demyelination
• It tends to be most common in countries furthest from the equator. and inflammation.
• Race, gender, genetics and environmental factors can influence the •
The sensitivity of these symptoms to changes in body temperature is well
incidence of the disease. recognised.
•
While MS is typically classified into four main types, the prognosis can vary •
Symptoms such as tingling are due to ectopic bursts of impulses and
considerably between patients. the triggering of other spurious impulses by the transmission of normal
•
The nervous system is divided onto components – the central nervous impulses in the areas of demyelination.
system (CNS) and the peripheral nervous system (PNS). •
Cognitive impairment is probably due to lesions associated with the
•
Together they relay both physical and cognitive information about macro cerebral cortex.
and microenvironments in and around the body, using electrical impulses as
the signally device.
•
The sheath that surrounds an axon fibre is made of myelin and this is vital Recommended Reading
for the generation and propagation of electrical signals along the axon fibre.
<Selected references will follow>
•
In MS, this myelin sheath is attacked by a person’s own immune system
and destroyed.
•
The immune system protects us from pathogens and responds to injury.
It has several important characteristics: diversity, specificity, the ability to
distinguish self from non-self, and memory.
•
The normal immune system can recognise a wide variety of pathogens,
leave its own tissue alone and remember a previous exposure to a foreign
pathogen and response.
•
Some T and B cells also have the ability to react to self-antigens. A normally
operating immune system keeps these autoreactive immune cells in check
so that they do not provoke unwanted responses.
•
If the immune system is dysregulated, tolerance to some self-antigens
may be disrupted and autoreactive T and B cells will mistakenly damage a
person’s own tissues. This is the case in an autoimmune disease such
as MS.
•
The pathophysiology of MS comprises of two components: inflammation
and neurodegeneration.
•
Relapses are the clinical expression of acute inflammatory demyelination,
whereas progression reflects neurodegenerative processes, including
axonal loss, with increasing brain atrophy.
•
Recent research suggests that inflammation and neurodegeneration happen
at, or near, the same time.

References
1. Hauser SL and Goodin SC. Multiple sclerosis and other demyelinating diseases. In Fauci AS, Braunwald E, Karger DL 22. Absoud M, Cummins C, Chong WK, et al. Paediatric UK demyelinating disease longitudinal study (PUDDLS). BMC
et al. Harrison’s Principles of Internal Medicine. 17th edition. New York, NY: McGraw-Hill Medical; 2008: Chapter 375. Pediatr 2011; 11: 68.
2. World Health Organisation and Multiple Sclerosis International Federation. Atlas Multiple Sclerosis Resources in the 23. Ascherio A, Munger KL. Environmental risk factors for multiple sclerosis. Part I: the role of infection. Ann Neurol
World 2008. 2007; 61(4): 288–99.
3. Alonso A and Hernán MA. Temporal trends in the incidence of multiple sclerosis. A systematic review. Neurology 24. Willer CJ and Ebers GC. Susceptibility to multiple sclerosis: interplay between genes and environment. Curr Opin
2008; 71(2): 129–35. Neurol 2000: 13(3): 241–7.
4. P
ugliatti M, Rosati G, Carlton H, et al. The epidemiology of multiple sclerosis in Europe. Eur J Neurol 2006; 13(7): 25. Barnes D. Multiple sclerosis. Questions and answers. UK Merit Publishing International; 2000.
700–22.
26. Compston A and Coles A. Multiple sclerosis. Lancet 2002; 359(9313): 1221–31.
5. F
leming JO and Carrithers MD. Diagnosis and management of multiple sclerosis: A handful of patience. Neurology
2010; 74(11): 876–7. 27. Robertson NP, Fraser M, Deans J, et al. Age-adjusted recurrence risks for relatives of patients with multiple
sclerosis. Brain 1996; 119(Pt 2): 449–55.
6. G
old R, Linington C, Lassmann H. Understanding pathogenesis and therapy of multiple sclerosis via animal models:
70 years of merits and culprits in experimental autoimmune encephalomyelitis research. Brain 2006; 129(Pt 8): 28. de Jong BA, Huizinga TW, Zanelli E, et al. Evidence of additional genetic risk indicators of relapse-onset MS within
1953–71. the HLA region. Neurology 2002; 59(4): 549–55.
7. K
antarci O and Wingerchuck D. Epidemiology and natural history of multiple sclerosis: new insights. Curr Opin Neurol 29. Zuvich RL, McCauley JL, Pericak-Vance MA, et al. Genetics and Pathogenesis of Multiple Sclerosis. Semin Immunol
2006; 19(3): 248–54. 2009; 21(6): 328–33.
8. C
oleman J, Rath L, Carey J. Multiple Sclerosis and the role of the MS nurse consultant. Aust Nurs J 2001; 9(3): Suppl. 30. Sadovnick AD, Armstrong H, Rice GP, et al. A population-based study of multiple sclerosis in twins: update. Annals
1–4. of Neurology 1993; 33(3): 281–5.
9. H
opman WM, Coo H, Edgar CM, et al. Factors associated with health-related quality of life in multiple sclerosis. Can J 31. Bruder CE, Piotrowski A, Gijsber AA, et al. Phenotypically concordant and discordant monozygotic twins display
Neurol Sci 2007; 34(2):160–66. different DNA copy-number-variation profiles. Am J Hum Genet 2008; 82(3): 763–71.
10. L
almohamed A, Bazelier MT, Van Staa TP, et al. Causes of death in patients with multiple sclerosis and matched 32. Baranzini SE, Mudge J, van Velkinburgh JC, et al. Genome, epigenome and RNA sequences of monozygotic twins
referent subjects: A population-based cohort study. Eur J Neurol 2012; e pub ahead of print. discordant for multiple sclerosis. Nature 2010; 464(7293): 1351–6.
11. G
ryttenTorkildsen N, Lie SA, Aarseth JH, et al. Survival and cause of death in MS: results from a 50-year follow-up in 33. Willer CJ, Dyment DA, Risch NJ, et al. Twin concordance and sibling recurrence rates in multiple sclerosis. Proc Natl
Western Norway. Mult Scler 2008; 14(9): 1191–8. Acad Sci USA 2003; 100(22); 12877–82.
12. K
ingwell E, van de Kop M, Zhao Y, et al. Relative mortality and survival in multiple sclerosis: findings from British 34. Handunnetthi L, Handel AE, Ramagopalan SV. Contribution of genetic, epigenetic and transcriptomic differences to
Columbia, Canada. J Neurol Neurosurg Psychiatry 2012; 83(1): 61–6. twin discordance in multiple sclerosis. Expert Rev Neurother 2010; 10(9): 1379–81.
13. L
ublin FD and Reingold SC. Defining the clinical course of multiple sclerosis: results of an international survey. 35. Goodin DS. The causal cascade to multiple sclerosis: a model for MS pathogenesis, PLoS One 2009; 4(2): e4565.
National Multiple Sclerosis Society (USA) Advisory Committee on Clinical Trials of New Agents in Multiple Sclerosis.
36. Smolders J, Thewissen M, Peelen E, et al. Vitamin D status is positively correlated with regulatory T-cell function in
Neurology 1996; 46(4): 907–11.
patients with multiple sclerosis. PLoS One 2009; 4(8): e6635.
14. Murray TJ. Diagnosis and treatment of multiple sclerosis. BMJ 2006; 332(7540): 525–7.
37. Cantorna MT. Vitamin D and multiple sclerosis: an update. Nutr Rev 2008; 66(10 Suppl 2): S135–8.
15. Compston A. The basis for treatment in multiple sclerosis. Acta Neurol Scand Suppl 2006; 183: 41-7.
38. Golan D, Somer E, Dishon S, et al. Impact of exposure to war stress on exacerbations of multiple sclerosis. Ann
16. P
oser CM. Viking voyages: the origin of multiple sclerosis? An essay in medical history. Acta Neurol Scand Suppl. Neurol 2008; 64(2): 143–8.
1995; 161: 11-22.
39. Mikaeloff Y, Caridade G, Tardieu M, et al. KIDSEP study group. Parental smoking at home and the risk of childhood-
17. M
cAlpine D, Lumsden CE, Acheson ED (eds). Multiple sclerosis: a re-appraisal. Edinburgh; Churchill Livingstone; onset multiple sclerosis in children. Brain 2007; 130(Pt 10): 2589–95.
1972: 543–48.
40. Zivadinov R, Weinstock-Guttman B, Hashmi K, et al. Smoking is associated with increased lesion volumes and brain
18. K
urtzke JF. Epidemiology and etiology of multiple sclerosis. Phys Med Rehabil Clin N Am 2005; 16(2): 327-49. atrophy in MS. Neurology 2009; 73(7): 504–10.
19. Kurtzke JF. The epidemiology of multiple sclerosis. In: Multiple Sclerosis, Clinical and Pathogenic Basis. Rainew CS, 41. Buljevac D, Flach HZ, Hop WC, et al. Prospective study on the relationship between infections and multiple sclerosis
McFarland HF, Tourellotte WW, Eds. London: Chapman and Hall, 1997. exacerbations. Brain 2002; 125(Pt 5): 952–60.
20. Huang H, Hughes M, Mobley S, et al. APOE genotypes in African American female MS patients. Neurosci Lett 2007; 42. Kriesel JD, Sibley WA. The case for rhinoviruses in the pathogenesis of multiple sclerosis. Mult Scler 2005; 11(1):1–4.
414(1): 51–6.
43. Murray J. Infection as a cause of multiple sclerosis. BMJ 2002; 325(7373): 1128.
21. Detels R, Visscher BR, Malmgren RM, et al. Evidence for lower susceptibility to MS in Japanese-Americans. Am J
44. Bar-Or A. Immunology of multiple sclerosis. Neurol Clin 2005; 23(1): 149–75.
Epidemiol 1977; 105(4): 303–10.

References cont’d
45. Noseworthy JH, Lucchinetti C, Rodriguez M, et al. Multiple sclerosis. N Engl J Med 2000; 343(13): 938-52. 67. Janardhan V, Bakshi R. Quality of life in patients with multiple sclerosis: the impact of fatigue and depression. J
Neurol Sci 2002; 205(1): 51–8.
46. Frohman EM, Racke MK, Raine CS. Multiple sclerosis – the plaque and its pathogenesis. N Engl J Med 2006; 354(9):
942–55. 68. Tartaglia MC, Narayanan S, Arnold DL. Mental fatigue alters the pattern and increases the volume of cerebral
activation required for a motor task in multiple sclerosis patients with fatigue. Eur J Neurol 2008; 15(4): 413–9.
47. F
ox RJ, Bethoux F, Goldman MD, et al. Multiple sclerosis: Advances in understanding, diagnosing and treating the
underlying disease. Cleve Clin J Med 2006; 73(1): 91–102. 69. DeLuca J, Johnson SK, Natelson BH. Information processing efficiency in chronic fatigue syndrome and multiple
sclerosis. Arch Neurol 1993; 50(3): 301–4.
48. C
onfavreux C, Vukusic S, Moreau T, et al. Relapses and progression of disability in multiple sclerosis. N Engl J Med
2000; 343(20): 1430–8. 70. DeLuca J, Genova HM, Hillary FG, et al. Neural correlates of cognitive fatigue in multiple sclerosis using functional
MRI. J Neurol Sci 2008; 270(1–2): 28–39.
49. F
rohman EM. Multiple sclerosis. Med Clin North Am 2003; 87(4): 867–97.
71. Ford H, Trigwell P, Johnson M. The nature of fatigue in multiple sclerosis. J Psychosom Res 1998; 45(1): 33–8.
50. T
rapp BD, Petersen J, Ransohoff RM, et al, Axonal transaction in the lesions of multiple sclerosis. N Engl J Med
1998; 338(5): 278–85. 72. Chaudhuri A, Behan PO. Fatigue in neurological disorders. Lancet 2004; 363(9413): 978–88.
51. P
eterson LK, Fujinami RS. Inflammation, demyelination, neurodegeneration and neuroprotection in the pathogenesis 73. Chu ER and Chen CS. Optic neuritis - more than a loss of vision. Aust Fam Physician 2009; 38(10) 789-93.
of MS. J Neuroimmunol 2007; 184(1-2): 37–44.
74. Foroozan R, Buono LM, Savino PJ, et al. Acute demyelinating optic neuritis. Curr Opin Ophthalmol 2002; 13(6):
52. F
ilippi M, Bozzali M, Rovaris M, et al. Evidence for widespread axonal damage at the earliest clinical stage of 375–80.
multiple sclerosis. Brain 2003; 126(Pt 2): 433-7.
75. Balcer LJ. Clinical practice. Optic neuritis. N Engl J Med 2006; 354(12): 1273–80.
53. D
hib-Jalbut S. Pathogenesis of myelin/oligodendrocyte damage in multiple sclerosis. Neurology 2007; 68(22 Suppl
3): S13–21. 76. Boomer JA, Siatkowski RM. Optic neuritis in adults and children. Semin Ophthalmol 2003; 18(4): 174–80.
54. E
dwards JC, Cambridge G. B-cell targeting in rheumatoid arthritis and other autoimmune diseases. Nat Rev 77. Germann CA, Baumann MR, Hamzavi S. Ophthalmic diagnoses in the ED: Optic neuritis. Am J Emerg Med 2007;
Immunol 2006; 6(5): 394–403. 25(7): 834–7.
55. M
agliozzi R, Howell O, Vora A, et al. Meningeal B-cell follicles in secondary progressive multiple sclerosis associated 78. Fazzito MM, Jordy SS, Tilbery CP. Psychiatric disorders in multiple sclerosis patients. Arq Neuropsiquiatr 2009;
with early onset of disease and severe cortical pathology. Brain 2007; 130(Pt 4); 1089–104. 67(3a): 664–7.
56. Uccelli A, Aloisi F, Pistoia V. Unveiling the enigma of the CNS at a B-cell fostering environment. Trends Immunol 79. Feinstein A. Neuropsychiatric syndromes associated with multiple sclerosis. J Neurol 2007; 254(Suppl 2): II73–6.
2005; 26(5): 254–6.
80. G
udiene D, Burba B. Mental disorders and their relation to brain loca¬tion: diagnostic problems. Medicina (Kaunas)
57. F
lensner G, Ek A-C, Söderhamn O, et al. Sensitivity to heat in MS patients: a factor strongly influencing 2003; 39(2): 114–21.
symptomology – an explorative survey. BMC Neurol 2011; 11: 27.
81. Reiss JP, Sam D, Sareen J. Psychosis in multiple sclerosis associated with left temporal lobe lesions on serial MRI
58. S
yndulko K, Jafari M, Woldanski A, Baumhefner RW, Tourtellotte WW: Effects of Temperature in multiple sclerosis: a scans. J Clin Neurosci 2006; 13(2): 282–4.
review of the literature. Neurorehabil Neural Repair1996, 10:23-34.
82. Calabrese M, Agosta F, Rinaldi F, et al. Cortical lesions and atrophy associated with cognitive impairment in
59. G
uthrie TC, Nelson DA. Influence of temperature changes on multiple sclerosis: critical review of mechanisms and relapsing-remitting multiple sclerosis. Arch Neurol 2009; 66(9): 1144–50.
research potential. J Neurol Sci 1995, 129(1): 1–8.
83. Wiesel PH, Norton C, Glickman S, et al. Pathophysiology and management of bowel dysfunction in multiple
60. S
immons RD, Ponsonby AL, van der Mei I, et al. What affects your MS? Responses to an anonymous, Internet- sclerosis. Eur J Gastroenterol Hepatol 2001; 13(4): 441–8.
based epidemiological survey. Mult Scler 2004; 10(2): 202–11.
84. Nicholas R, Young C, and Friede T. Bladder symptoms in multiple sclerosis: a review of pathophysiology and
61. M
arino FE. Heat reactions in multiple sclerosis: An overlooked paradigm in the study of comparative fatigue. Int J management. Expert Opin Drug Saf 2010; 9(6): 905–15.
Hyperthermia 2009; 25(1): 34-40.
62. B
aker DG. Multiple sclerosis and thermoregulatory dysfunction. J Appl Physiol 2002, 92(5): 1779–80.
63. Freal JE, Kraft GH, Coryell JK. Symptomatic fatigue in multiple sclerosis. Arch Phys Med Rehab 1984; 65(3):135–8.
64. Krupp LB, Alvarez LA, LaRocca NG, et al. Fatigue in multiple sclerosis. Arch Neurol 1988; 45(4): 435–7.
65. Lerdal A, Celius EG, Krupp L, et al. A prospective study of fatigue in Multiple Sclerosis. Eur J Neurol 2007; 14(12):
1338–43.
66. P
ellicano C, Gallo A, Li X, et al. Relationship of cortial atrophy to fatigue in patients with MS. Arch Neurol 2010; 67(4):
447–53.

Led by the EMSP together with the IOMSN and RIMS
REHABILITATION IN
MULTIPLE SCLEROSIS
European network for best practice and research
Accredited by the RCN and ICN, in association with the EANN
English Version | Printed in September 2012 | www.msnursepro.org

Understanding Multiple Sclerosis: English Version

Uploaded by

Document Informationclick to expand document information

Copyright:

Available Formats

Understanding Multiple Sclerosis: English Version

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Understanding Multiple Sclerosis: English Version

Uploaded by

Copyright:

Available Formats

MODULE 1

Learning Objectives Disclosure of Unlabelled Use

Estimated time to complete this module: 5 hours

1.0 Introduction 3.5 Immune System Function

2.0 MS Demographics 3.5.1 Innate & Adaptive Immunity

2.1 Learning Objectives 3.5.2 Innate Immunity

2.2 Overview of MS 3.5.3 Adaptive Immunity

2.3 Definition and Classification 3.5.4 Summary

2.3.1 Relapsing-remitting 3.6 Pathophysiology

2.3.2 Secondary-progressive 3.6.1 Lesions

2.3.3 Primary-progressive 3.6.2 Inflammation & Neurodegeneration

2.3.4 Progressive-relapsing 3.6.3 Cellular Involvement

2.4 Clinical Course 3.6.4 Summary

2.5 Contributing Factors 4.0 Symptoms and Pathophysiology

2.5.1 Race 4.1 Learning Objectives

2.5.2 Age 4.2 Introduction

2.5.3 Gender 4.3 Heat Sensitivity

2.5.4 Genetics 4.4 Fatigue

2.5.5 Vitamin D 4.5 Optic Neuritis

2.5.6 Stress 4.6 Positive Symptoms

2.5.7 Smoking 4.7 Psychiatric Disorders

2.5.8 Infection 4.8 Cognitive Impairment

2.6 Summary 4.9 Bowel Dysfunction

3.0 Understanding the Causes of MS 4.10 Bladder Symptoms

3.1 Introduction 4.11 Summary

3.2 Recommended Reading

3.3 Learning Objectives Summary of Module

4 Understanding multiple sclerosis Understanding multiple sclerosis 5

1 Why Understanding the Pathophysiology of

related to its management.

Figure 1 – The geography of multiple sclerosis

6 Understanding multiple sclerosis Understanding multiple sclerosis 7

MS is the most common serious, chronic neurological disorder in young adults.

Reflective learning point

MS is the most common serious, chronic neurological disorder in young adults5. It is a

8 Understanding multiple sclerosis Understanding multiple sclerosis 9

2.3.1 Relapsing-remitting MS (RRMS) 2.4 The Clinical Course of MS Over Time

2.3.2 Secondary-progressive MS (SPMS)

10 Understanding multiple sclerosis Understanding multiple sclerosis 11

12 Understanding multiple sclerosis Understanding multiple sclerosis 13

20% of people with MS have a positive family history.

Figure 4 – Incidence of MS in Eastern Europe

Twin studies “Is MS inherited?”

14 Understanding multiple sclerosis Understanding multiple sclerosis 15

16 Understanding multiple sclerosis Understanding multiple sclerosis 17

 ow might you describe some of the current theories about causes of MS to

Another factor believed to contribute to MS is dietary and sunlight-activated vitamin D

18 Understanding multiple sclerosis Understanding multiple sclerosis 19

A sound knowledge of the pathophysiology of MS is important to the MS Nurse

The pathophysiology of MS also includes the mechanisms underlying the inflammation

3.3 Learning Objectives

Figure 5 – The functional areas of the left hemisphere

20 Understanding multiple sclerosis Understanding multiple sclerosis 21

22 Understanding multiple sclerosis Understanding multiple sclerosis 23

Figure 9 – The nerve impulse

Figure 8 – Diagram of a neuron

24 Understanding multiple sclerosis Understanding multiple sclerosis 25

Learning Objectives Disclosure of Unlabelled Use

1 Why Understanding the Pathophysiology of

ow might you describe some of the current theories about causes of MS to