History

Multiple sclerosis (MS) was first recognized in the late 1800s, but did not begin to be understood until the 1960s. The late 1960s was the time researchers began to correlate the inflammation process with the breakdown of the myelin sheath (a protective covering which surrounds the nerve fibers). This was also the time of the first clinical trials for MS, which eventually led to the development of the first anti-MS drug adrenocorticotropic hormone (ACTH), giving new hope to patients suffering from MS.

 

What we know today

Multiple sclerosis is a neuroinflammatory disease that affects myelin, the substance that makes up the myelin sheath. It is an autoimmune disorder and as with many autoimmune disorders, it affects women twice as often as men. Approximately 250,000 to 350,000 people in the United States have been diagnosed with MS, with 200-300 more diagnosed every week. Multiple sclerosis usually presents itself between the ages of 20 and 40, and although it can be quite debilitating, usually is not fatal on its own.

The term multiple sclerosis comes from the numerous plaque (sclerosis) that are visible in the white matter of patients with MS. White matter is made up of the myelinated axons or nerve bundles. Researchers have known for some time that the white matter is damaged by MS, but only recently they have learned that the nerve cell bodies in the grey matter are damaged as well. Plaque forms and axons are damaged when the inflammation process in the brain triggers the immune system. For reasons unknown, the immune system sees the myelin as a foreign body and attacks the myelin leaving the plaques. The plaques can be the size of a pinhead to the size of a ping pong ball. The plaques are most often seen on the brain stem, spinal cord, optic nerve, cerebellum, and around the ventricles of the brain.

 

Sign and Symptoms

Relapsing-remitting MS is the most common type of MS. It is referred to this because of its intermittent symptoms. When symptoms are present, it is referred to as an exacerbation or attack. When symptoms have ceased, it is referred to as remission. The severity of symptoms is determined by the severity of the attack. An attack can last for only a day or two or it can go on for months at a time. Multiple sclerosis attacks are usually mild with short duration in the beginning but become progressively worse as the disease develops.

Early signs and symptoms may include one or all of the following:

  • clumsiness

  • difficulty with balance (especially when walking)

  • blurred or double vision

  • optic neuritis

  • tingling and numbness in arms, legs, trunk, head, or face

  • muscle stiffness

  • muscle weakness

  • painful muscle spasms

  • loss of bladder control

  • persistent dizziness

Later symptoms may include any of the following:

  • depression

  • mood changes

  • inability to concentrate

  • mental fatigue

  • burning sensation in hands and legs

  • Lhermitte’s sign (feeling as if electricity is running down their spine)

  • trembling of the head or limbs

  • fatigue

  • chronic constipation

  • sexual problems

  • cognitive dysfunction (forgetfulness, difficulty learning new things, poor judgment)

  • transverse myelitis (temporary or partial paralysis)

 

Risk Factors

Although researchers have not identified the exact cause of MS, there are some factors that are seen more frequently in patients diagnosed with MS. Some frequently seen factors are:

  • Genetics – it is not believed that genetics alone determines if a patient will get MS; however, there are some gene variants that may make some people more likely to get MS

  • Smoking

  • Vitamin D deficiency

  • Infectious factors/viruses – especially those who had an exaggerated response to the Epstein-Barr virus in childhood

  • Other autoimmune diseases –  MS is very similar to other autoimmune diseases, having one (such as lupus) may predispose a person to MS.

Types

Relapsing-remitting is usually the first stage of MS, and is also the most common form of the disease. This form is characterized by periods of active symptoms and periods of remission. After a long period in this stage, patients may develop secondary progressive MS, which is defined by lack of remission periods and gradual worsening of symptoms. There is also primary progressive MS, which is indicated by gradual remission of the patient along with complete lack of active phases and remissions. Finally, there is progressive relapsing MS, which consists of gradual worsening of symptoms and more acute periods of symptoms, but is not preceded by relapsing-remitting MS.

 

Diagnosis

Multiple sclerosis is diagnosed using many tests, obtaining an accurate patient history, and physical examination.

An MRI scan is the most essential diagnostic imaging test, providing the neurologist with the most accurate information of the plaque formations. Determining the type of plaque formations is important in determining the type or variant of MS. Different variants are treated differently and therefore must be quickly identified.

 

Treatment

Treatment is typically high dose steroids by injection for 3-5 days. Sometimes a tapering dose of oral steroids will be given. The steroids are most effective if given as soon as an acute attack begins. The goal is to quickly shut down the immune system’s response and hopefully stop the inflammation. Clinical trials have shown shorter exacerbation times and faster recovery for the patient when given higher dose steroids.

There are many FDA approved therapies for MS that can alleviate the symptoms and in some cases slow disease progression. Some of these treatments are:

  • beta interferons-1a and 1b

  • glatiramer acetate

  • mitoxantrone (an immunosuppressant)

  • natalizumab (monoclonal antibody)

  • fingolimod

  • Ocrelizumab (most recently approved in March 2017)

Living with MS

Each individual person experiences MS in a different way. Symptoms, time between attacks, severity of attacks, and disease progression vary. Managing an individual’s symptoms is key in living a full and productive life. If a patient experiences depression, treatment with an antidepressant needs to be implemented. If a patient experiences a painful neuropathy, pain control needs to be discussed and if a patient’s loss of bladder control is preventing him or her from leaving the house, steps should be taken to alleviate the patient’s discomfort. Since MS itself cannot be treated at the current time, a nurse’s role in patient care should be treating the symptoms of the disease.

Patients may choose complimentary therapies to help them cope or alleviate pain and numbness. Therapies like acupuncture have had measurable effects on a patient’s mood and physical well being. Other complementary therapies include:

  • reflexology

  • massage therapy

  • meditation

  • aromatherapy

  • vitamin C infusions

  • ayurvedic medicine

  • touch therapy

  • biofeedback

  • tai chi

  • herbal supplements

  • yoga

  • energy therapy

These therapies all have beneficial effects for the patient and should be explored and encouraged in conjunction with medical therapies.  However, replacing medical treatment or using “alternative therapies” is not a decision to be taken lightly and should be discussed between the patient and their healthcare provider.

 

Prognosis

Multiple sclerosis may be diagnosed early in some patients but for others it may not be easily identified. For these patients, there may be many years of misdiagnosis and uncertainty. Most patients are mildly affected and live an average life expectancy. For others, MS can leave a person unable to walk, speak, or care for themselves. It is an unpredictable disease that can be manageable or devastating but treatments are more effective than ever before and new research continues to help us understand the disease.

 

 

References:

Multiple Sclerosis. Retrieved from https://www.ninds.nih.gov/. 

Multiple Sclerosis. Retrieved from https://medlineplus.gov/ency/article/000737.htm. 

Multiple Sclerosis. Retrieved from https://nccih.nih.gov/.