Multiple Sclerosis (MS)

Original Editors -Sarah Demarest & Beth Niehbur from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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 Definition/Description

Multiple Sclerosis (MS) is an autoimmune disorder in which the body's immune cells attack the central nervous system (CNS), affecting the brain, spinal cord and optic nerve. MS is characterized by inflammation, demyelination and gliosis. An inflammatory response occurs when the body's immune cells attack the CNS, which leads to an increase in pressure and therefore disrupting the nerve conductivity. Demyelination is a process where a nerves protective covering, known as myelin, is damaged due to the autoimmune response leading to decreased nerve conduction velocity and early fatigue of the nerve. Gliosis occurs when demyelinated areas become fibrotic, which causes proliferation of neuroglial tissue in the CNS and leads to scarring of the tissue.

The course that MS can take will be different from one person to another as well as unpredictable. The disease can be divided into four clinical subytpes, which describe how the disease will progress as well as the corresponding characteristics that become evident for each subtype. Relapsing-remitting MS (RRMS) is the most commone subtype, affecting 85% of people with MS and is characterized by short attacks to the CNS followed by complete or partial return to normal functioning. Secondary-progressive MS (SPMS) is a subgroup that begins as a relapsing-remitting course accompanied by a steady decline in function and is often developed by patient. Primary-Progressive MS (PPMS) is a progression of the disease where a steady decline in function experienced from the onset of the disease. Progressive-Relapsing MS (PRMS) is similar to PPMS but has the additional characteristic of acute attacks.

Prevalence

It is estimated that in the United States there are 400,000 people being affected by MS and 2.1 million people globally. Females are 2 to 3 times more likely to have MS than males, which may indicate hormones play a role in acquiring the disease. The prevalence of MS has increased within the last 5 decades with the increase primarily being due to females. MS rarely occurs in children as well as adults over the age of 50 and will most commonly present between the ages of 20-40 years. The risk of being diagnosed with MS is increased in a person who has a sibling with MS by 3%, a fraternal twin by 5% and an identical twin by 25%.

MS can occur in many ethnics groups, with the most common populations being Caucasians with an ancestry from nothorn Europe, followed by African-Americans, latinos/hispanics and asians. It is rarely seen in ethnic populations such as, Australian Aborigines, New-Zealanders, Yakutes, Inuit, Hungarian Romani and Norwegian Lapps. There have been studies that show the prevalence of MS is higher in some geographical locations than in others, such as northern United States, norther Europe, southern Canada, New Zealand, Southern Australia and Scandinavian countries. Regions with a lower prevalence of MS tend to be closer to the equator, such as Asia, Africa, and South America.

Characteristics/Clinical Presentation

Multiple Sclerosis will present with varying symptoms because it depends on the location of the nerves being affected. Symptoms usually appear suddenly and rapidly over a period of minutes or hours but in more rare cases the symptoms may be insidious and take several weeks to months to develope. Numbness and weakness in one or several limbs progressing from parathesias, visual disturbances such as double vision and fatigue are typically the early symptoms that will present with MS. Other common symptoms presented with MS are:

• Pain: Headache, chronic neuropathic pain, paroxysmal limb pain
  
• Cognitive symptoms: Short-term memory dificits, diminished executive function, diminished attention/concentration
  
• Affective Symptoms: Depression, anxiety
  
• Motor symptoms: spasticity, spasms, ataxia, impaired balance and gait
  
• Speech and swallowing: dysarthria, dysphonia, dysphagia
  
• Bladder/Bowel symptoms: spastic or flaccid bladder, constipation, diarrhea and incontinence
  
• Sexual Symptoms: impotence, decreased libido, decreased ability to achieve orgasm

The pattern of symptoms will be different from person to person. The initial symptoms are typically acute and followed by a period of remission with complete or partial recovery. An increase in symptoms can occur with an increase in body temperature because many MS patients have a sensitivity to heat.

Associated Co-morbidities

Comorbidities are common among the aging population especially with added risk factors of a poor diet and obesity . As a result, comorbidities often lead to a decrease in functional status and quality of life. Knowing the prevalence and common types of comorbidities that exist in those living with chronic, degenerative diseases such as MS can help with disease management to maximize an individual’s overall physical well-being. Common comorbidities seen in patients with MS include  :
Autoimmune
• Inflammatory bowel disease
• Thyroid disease
• Uveitis
• Arthritis
• Systemic lupus erythematosus
Physical
• Hypertension
• Hyperlipidemia
• Heart disease
• Cancer
• Chronic lung disease
Behavioral
• Anxiety
• Depression
• Sleep disorders
• Alcohol use
• Obesity
Other less common comorbid conditions include: kidney disease, asthma, cancer, Sjogren’s syndrome, and liver disease .

Medications

Currently there is no cure for MS. However, treatments are available for initial attacks, reducing progression, and to help manage symptoms . Typically, a high dose of a corticosteroid, such as prednisone, is the first line of treatment against an attack of MS . Corticosteriods help to reduce and inflammation by suppressing the immune system, and when given intravenously can work quickly . Oral doses are often given as follow-up treatments during acute exacerbations . Side effects of corticosteroids may include: mood swings, seizures, weight gain, and can put the individual at an increased risk of infection due to immune system suppression . As a supplemental or secondary treatment to corticosteroids, plasma exchange (plasmapheresis) can be used in relapsing forms of MS to help control MS attacks . During the plasmapheresis procedure potentially harmful components of plasma are separated and removed from blood, then replacement plasma and blood cells are returned to the body . 

Diagnostic Tests/Lab Tests/Lab Values

Multiple Sclerosis is diagnosed by a neurologist by performing a detailed medical history, neurological exam as well as ordering supportive laboratory tests. The laboratory tests are used to diagnose as well as rule out other possible conditions that may present similarly.

Magnetic Resonance Imaging (MRI):

An MRI is a device in which powerful radio waves produce detailed images of the brain and spinal cord.An MRI is very sensitive in detecting MS plaques that are found in the white matter of the brain and spinal cord. The plaques that appear on the MRI may also be seen with conditions, such as Lupus, diabetes as well as migraines and therefore cannot be used to give difinitive reasoning to rule in MS.

Spinal Tap (Lumbar Puncture):

A spinal tap is a procedure in which a needle is inserted into the lumbar spine to remove a small amount of cerebral spinal fluid, which is then brought to a lab for analysis. The cerebral spinal fluid is tested for abnormal amount of white blood cells, proteins and other abnormalities that are secondary to MS.

Evoked Potential Test:

The evoked potential test measures electrical signals in the nerves sent from the brain in response to a stimuli. The stimulus may be visual or electrical in origin. This test helps detect whether there is a lesion to a nerve in the optic nerve, brainstem and spinal cord even though a person may not be presenting with any neurological signs of nerve damage.

Blood Tests:

A blood test is beneficial to perform to rule out other conditions that may present similar to MS, such as infectious or inflammatory diseases.

Etiology/Causes

The cause of MS is still unknown but there have been studies that show the interaction of several different factors, which could play a role in the etiology.

Immunologic factors: The body's own immune cells attack the CNS and ultimately destroy nerve conduction. Researchers have been able to identify what immune cells are attacking the CNS, the cause for their attack and some of the receptors on the attacking cells that make them attracted to myelin.

Environmental factors: MS appears to be more prevalent in areas farther from the equator in a colder climate. There is some evidence that shows Vitamin D may play an important role in that people who live in a warmer climate are exposed to the sun more and therefore their body naturally produces more Vitamin D. It is thought that larger amounts of naturally-produced Vitamin D may increase immune function and protect the body against autoimmune diseases.

Genetic factors: The risk of MS increases in a person who has a first degree family member with the disease, however MS is not considered to be hereditary. Studies have shown that in populations with higher rates of MS as well as in families where several members have MS there are similar genetic factors. The common genetic factors are continuing to be studied in the role they play for developing MS

Infectious factors: There is a possibility that viruses and other infectious agents may trigger the onset of MS. Many viral and bacterial infections are being investigated, however there is no definitive evidence that shows they may be the cause of MS.

Systemic Involvement

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Medical Management (current best evidence)

There are many medications used for MS to assist in managing acute relapses, progression of disease as well as presenting symptoms.

Physical Therapy Management (current best evidence)

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Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

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Case Reports/ Case Studies

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Resources

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Recent Related Research (from Pubmed)

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References

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