Multiple Sclerosis: Symptoms and Treatment

Multiple sclerosis is a chronic autoimmune disease that causes the immune system to erroneously attack the healthy tissue in the central nervous system. Ignatavicius and Workman describe that this autoimmune disease produces inflammation in the central nervous system, progressively destroying the myelin sheath, impairing the conduction pathway of neurons in the CNS, causing formation of plaque in the white and grey matter of the brain and spinal cord. This causes a variety of symptoms within the patient which vary greatly. Because of its unknown etiology it is difficult to identify an actual cause reducing the ability to cure and forcing medical personnel to focus on the treatment and reduction in symptoms.

Most individuals begin to experience symptoms of Multiple Sclerosis in their late 20s; however, most people are diagnosed between the ages of 30 and 35 and occurs nearly twice as often in women than men reports the National Institute of Health. With 3% – 5% of those diagnosed after the age of 50. The early signs as reported by Leonard, J, typically begin with mild vision changes including blurred vision, diplopia, color distortion in the red and green color spectrum, vision loss and “pain when looking up to the side”. This early symptom is seen as the optic nerve is often one of the first neurons to be attacked in MS. As the disease progresses, the immune system demyelinates the nerves of the spine resulting in muscle weakness and fatigue. Paresthesia (numbness and tingling) as afferent nerves from the can also be experienced in the arms, legs, body and face. This alteration in sensation can be mild and become more extreme as the disease worsens. These sensations can also come and go without the need for treatment.

Pain is also a common symptom, with 55% of Multiple Sclerosis sufferers reporting clinically significant pain at some in their life and nearly half of those that complain of chronic pain. Pain can be experiences as a stabbing pain in the face (trigeminal neuralgia), neuropathic pain which is described as a burning or sharp pain that is felt systematically, and Lhermitte’s sign, which is defined by Khare and Seth as “This sign is mostly described as an electric shock like condition by some patients of multiple sclerosis. This sensation occurs when the neck is moved in a wrong way or rather flexed. It can also travel down to the spine, arms, and legs, and sometimes the trunk.”

As lesions build up in the brain those with MS may experience vertigo (dizziness and the experience that the room is spinning), may feel faint, lightheaded, and nauseous which may result in vomiting if the sensation is severe enough. This can cause loss of balance, difficulty ambulating, and injuries from ground level falls.

80% of those diagnosed with MS report having some form of bladder dysfunction. As Multiple Sclerosis lesions interfere and delay the transmission of neurotransmitters through the central nervous system that control the bladder and urinary sphincter it can lead to an overactive bladder limiting the ability to hold the normal amount of urine, leading to urge incontinence. This can also cause the bladder to have an inefficient release system causing urinary retention which can further lead to urinary tract infections. This can be further demonstrated with a hesitant start in micturition, urinary frequency, and increased nocturia.

As sexual function is directly related to the health of the central nervous system, sexual dysfunction is also very common. Damage to the nerves interfere with the bodies ability to transmit signals to the sexual organ affecting the ability to obtain an erection, emotional and physical desire and the ability to orgasm. This is further compounded by the fatigue, and pain previously mentioned. The combination of these symptoms are reported as the leading cause of anxiety and depression.

In the latter stages of the disease more evidence shows a loss on cognitive ability and emotional changes. Amato, Zipoli and Portaccio reported in their 2006 journal that the “Prevalence estimates of cognitive impairment in multiple sclerosis (MS) range from 40% to 65%, depending on the research setting. Cognitive dysfunction virtually encompasses all the disease stages and types of clinical course, although it is generally less frequent in relapsing–remitting (RR) patients compared with secondary progressive (SP) patients, and tends to be less frequent in primary progressive (PP) patients.” This can further exacerbate the depression caused by the symptoms. The atrophy of cerebral tissue as well as damage to the nerve is evidenced by the inability to concentrate, demonstrate abstract thinking limiting the ability to recognize patterns, learn and adapt to new information, critically think or absorb complex data.

Other symptoms reported include difficulty breathing as the nerve conduction of the respiratory system are compromised, headaches, difficulty swallowing, and the most commonly known symptom of tremors and shaking.

Many people with Multiple Sclerosis have a relapse-remitting disease course in which new symptoms will appear over the course of days or weeks and then typically recover completely or partially. However, about “60-70% of people with Multiple Sclerosis will eventually develop secondary-progressive multiple sclerosis that involves a steady progression of symptoms without periods of remission”. Multiple sclerosis is an incurable disease in which treatment is typically directed at treating exacerbations, managing symptoms, improving and maintaining function, and slowing down the progress of the disease. Treatment of multiple sclerosis is often managed by a neurologist.

A large focus of treatment is speeding up the recovery from multiple sclerosis exacerbations. As inflammation of the central nervous system causes damage to the myelin sheath, it slows the transmission of nerve impulses, this can lead to exacerbations also known as relapses. Treatment of exacerbations aims at minimizing this inflammation to facilitate recovery. If the exacerbation is mild and does not interfere with mobility or activities of daily living, it can often be left untreated to improve on its own. For more severe exacerbations, short courses of high-dose corticosteroids may be used. The most common treatments are a three to five day course of intravenous methylprednisolone or oral prednisone. Plasmapheresis or plasma exchange may also be used if symptoms are not responding to steroid treatment or a patient is unable to tolerate steroids. In plasmapheresis, plasma is separated from blood cells, mixed with albumin and then put back into the body (Mayo Clinic, 2017).

A number of disease-modifying drugs are available in oral, injection, or intravenous form. These disease-modifying treatments have been proven effective in delaying the progress of the disease, as well as decreasing the number of relapses experienced. The most common disease-modifying drugs prescribed are beta interferons. Beta interferons are injected in the muscle or under the skin and may result in flu-like symptoms or injection-site reactions for some patients. Liver damage can also be a side effect of beta interferons, and patients need to have their liver enzymes closely monitored to ensure proper liver function during therapy. People taking beta interferons may also develop neutralizing antibodies, causing the drug to be less effective. Other disease-modifying drugs include; Copaxone, Ocrevus, Tecfidera, Gilenya, Aubagio, Tysabri, Lemtrada, and Novantrone. “The American Academy of Neurology (AAN) has developed guidelines for starting, switching and stopping disease modifying therapies for adults with clinically isolated syndrome, relapsing-remitting MS and progressive forms of MS”.

Many medications may be used to manage symptoms of multiple sclerosis such as medications to treat; bladder problems, bowel dysfunction, fatigue, itching, pain, sexual problems, spasticity, tremors, walking difficulty, dizziness and vertigo, emotional changes, and depression. Complementary and alternative therapies are also available and activities such as exercise, meditation, yoga, and healthier eating are encouraged to promote overall well-being, although there are currently few studies to back up their effectiveness in managing symptoms.

Rehabilitation is an essential component of treating multiple sclerosis and improving and maintaining function for the individual affected. It can include physical therapy, occupational therapy, cognitive rehabilitation, vocational rehabilitation, and speech-language pathology. Rehabilitation can address problems such as issues with mobility, dressing and hygiene care, driving, functioning at work and at home, and participating in leisure activities when symptoms of multiple sclerosis begin to interfere.

An often-debilitating disease such as multiple sclerosis can have a huge impact on a person’s psychosocial health so it is important to address these issues as well. It is vital to ensure that individuals diagnosed with multiple sclerosis have adequate coping and support. Resources for psychosocial support include mental health professionals such as social workers, psychologists, psychiatrists, and counselors. There are also MS support groups and MS advocacy organizations available.

Multiples sclerosis is a lifelong disease and there is still much research to be done on it. Most people living with multiple sclerosis are able to manage their symptoms and live their everyday life as normally as possible. Fortunately, research and awareness has come a long way and there are many knowledgeable physicians and resources available to those living with the debilitating disease.

References

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2. Mayo Clinic. (2017, August 4). Multiple sclerosis - Symptoms and causes. Retrieved from https://www.mayoclinic.org/diseases-conditions/multiple-sclerosis/symptoms-causes/syc-20350269
3. Mayo Clinic. (2017, August 4). Multiple sclerosis - Diagnosis and treatment -Retrieved from https://www.mayoclinic.org/diseases-conditions/multiple-sclerosis/diagnosis-treatment/drc-20350274
4. National Multiple Sclerosis Society. (n.d.). Comprehensive Care. Retrieved from https://www.nationalmssociety.org/Treating-MS/Comprehensive-Care
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8. Leonard, J. (2018, September 20). Early signs of MS: What to know. Retrieved December, 2018, from https://www.medicalnewstoday.com/articles/323130.php
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12. Amato, M. P., Zipoli, V., & Portaccio, E. (2006). Multiple sclerosis-related cognitive changes: A review of cross-sectional and longitudinal studies. Journal of the Neurological Sciences, 245(1-2), 41-46. doi:10.1016/j.jns.2005.08.019