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Multiple sclerosis

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Dr. Sandeep Borse
Neurologist

verified

Multiple sclerosis (MS) is a chronic central nervous system (CNS) disease that affects the brain, spinal cord, and optic nerves. Even in the absence of symptoms, the disease is continuously active (causing brain damage) from the early stages of MS.

In recent times, MS prevalence rates in India have been revised from 1 case in every lakh to3 cases/100,000 people compared to USA where MS occurs in 1 per 1000 people. MS is anautoimmune disease because the MS patient’s immune system (body’s defence against infection) attacks a part of its own body – the nerve cell’s myelin sheath. The nervous system comprises billions of neurons (nerve cells) that relay messages in the brain and between the brain and other body parts. In a normal nervous system, nerves (bundles of nerve cells) pass messages amongst themselves at a superfast speed. The axon (long arm of a nerve cell) is covered by the myelin sheath (multi-layered bands) with small gaps in between. The nerve impulses, i.e. chemical signalsjump from gap-to-gap and rapidly spread the messages to the surrounding nerve cells.

MS is neurodegenerative because the damaged myelin sheath and oligodendrocytes (cells that produce myelin) delay communication between nerve cells, thus resulting in the inefficient functioning of multiple body systems. Demyelinating (without myelin sheath) nerve cells occurs in multiple areas of the brain and nervous system. The damaged portions of the axon undergo sclerosis (develop hardened scars). A noteworthy feature of MS is the remissions (remyelination with improved symptoms) and relapses (further demyelination with worsened symptoms) cycle that occur over time.

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Types

Multiple sclerosis is divided into four types.

Clinically isolated syndrome (CIS): In this type, the patient experiences varied neurological symptoms lasting for a duration of 24 h, and not all cases of CIS progress to MS.

Relapsing MS: In this type, which is called relapsing-remitting MS, patients experience symptom exacerbation (relapses) which then disappear (remission). These symptoms may be new or similar prior symptoms with varying intensity. In this type, the symptoms may exacerbate and then decrease for months to years before relapsing again.

Secondary progressive MS (SPMS): Usually, this type follows relapsing MS. It may occur after a prolonged duration of time after relapsing MS diagnosis. Usually, it is observed that individuals with relapsing MS will then progress to SPMS. 

Primary progressive MS (PPMS): In this type, rather than exacerbations and recovery, patients experience deteriorating symptoms with disability from the onset.

Symptoms

MS symptoms are variable, unpredictable, and appear in different patterns. Most common patterns are relapsing/remitting (symptoms come and go) and chronic progressive (symptoms continuously worsens).

Depending on which part of the nervous system develops demyelination, the condition affects corresponding body systems. The first MS symptom, in ~50% patients, appears as double or blurred vision because of optic neuritis (demyelination of nerves connected to the eyes). The loss of coordination (30% patients) and speech difficulties occur frequently. Other common symptoms include -


  • Numbness, tingling or pins-and-needles sensation

  • Tiredness and dizziness

  • Limb weakness and pain

  • Loss of touch and urinary control

  • Problems in memory and thinking ability

  • Hearing loss

  • Ataxia or imbalance

  • Trigeminal neuralgia (nerve pain in your face)

Causes And Risk Factors

Causes

MS does not result from any particular lifestyle choice and is not contagious. A link between MS and autoimmune diseases and smoking has been reported. Many other viral and bacterial infections, e.g., such as Epstein-Barr virus (EBV) infection and childhood mumps, are considered as MS triggers. Because Vitamin D is important for proper immune function, low levels of this vitamin are considered as a potential cause of MS. Environmentally, strong associations exist between MS and geography (temperate and cold zones) and demographics (age, sex, and ethnicity). Genetics play an important role in MS, though not hereditary, as there is increased risk of MS incidence among siblings. Scientists are investigating which genes are common within families affected by MS or in populations with high MS incidence rates. 

Risk Factors

MS may occur with or without the presence of risk factors; however, risk factors compound the susceptibility of an individual getting MS.


  • Infections - Certain viruses such as herpes, Epstein-Barr and human herpes virus-6 are considered to activate MS. 

  • Medical conditions - Individuals with optic neuritis (optic nerve swelling) pose a higher risk to MS.

  • Age- MS is mostly seen in individuals in the age group of 16-40 years.

  • Sex - Women are more vulnerable than men during the early years of life. Both women and men have the same risk during later years of life.

  • Genetics - Certain genes that are inherited may be linked to MS. Immune system disorders like systemic lupus erythematosus (SLE), which may be inherited, is another risk factor.

  • Ethnicity- European individuals tend to be more prone to MS.

  • Vitamin D - Low levels of vitamin D can increase our risk for MS.

  • Other factors - Smoking can increase an individual’s risk or MS.

Prevention

Adopting certain lifestyle modifications can help keep the symptoms of MS at bay.


  • Consumption of a healthy and balanced diet - A diet low in unhealthy fats, sugars and processed foods and high in vegetables, fruits, lean protein and healthy fats can help prevent MS. 

  • Regular exercise - Flexibility, aerobic exercises, and strength training exercises can help maintain strong muscles to counteract the muscle weakness and difficulty in walking, usually associated with MS.

  • Stress management - Yoga and meditation can help with stress management. This will ensure good sleep and reduced fatigue, which is usually associated with MS. 

  • Smoking cessation and limiting alcohol - Both smoking and alcohol are associated with the deterioration of MS symptoms. Thus, curbing these unhealthy habits can help maintain better health.

Diagnosis

High disease variability is a challenge for patients and neurologists

It is difficult to predict the development course of MS, which may be asymptomatic, mild or severe. In severe cases, the patients lose their ability to write, speak or walk, which drastically affects their daily lives.


  • Magnetic resonance imaging (MRI) scans of >90% of MS patients show the presence of lesions (demyelinated and scarred areas). MRI scans along with the patient’s medical history and neurological exam confirms MS diagnosis.

  • Lumbar puncture or spinal taps (check spinal fluid for abnormalities) and EEG (measures brain electrical activity) help exclude other autoimmune conditions or infections (HIV or Lyme disease).

  • Evoked responses — To verify which areas have been affected by MS, repeated stimulus is given. This test will assess how nerves respond to the stimulus. It considers the speed of the electrical response to the stimulus. 

  • Optical coherence tomography (OCT) - This test identifies the extent of MS progression to the eyes.

Treatment

The primary treatment of MS is to stop the flaring up and to reduce disease progression. Certain medications help in myelin sheath protection, which reduces disease progression. MS treatment options include disease-modifying drugs such as methylprednisolone, interferons (avonex, betaseron), copaxone and rebif, which provides symptomatic relief and slows down the disease progression to prevent relapses. Counselling, physical and occupational therapy, speech therapy and swallowing therapy help to cope with movement, behavioural and intake-related symptoms. Experimental treatment options such as stem cell transplant are being examined to produce new cells with an intact myelin sheath. MS is not fatal but there are complications arising from a weak immune system such as pneumonia or lower life expectancy by 10 years in MS patients.

Lifestyle/management

Certain lifestyle modifications can help reducing flaring up and reduction of symptoms of MS:


  • Regular exercise - Various exercises such as aerobic exercises and swimming can help reduce fatigue, muscle strengthening and improving balance.

  • Healthy diet - Diet rich in fibre can help prevent constipation. Fibre is reported in fruits, vegetables and whole grains. Limit foods that are fatty and high in sugars. Patients may take vitamin D pills after consultation with a physician. Drink sufficient water to prevent dehydration.

  • Stress management - Stress worsens the symptoms of MS. Include stress management techniques such as yoga, meditation, deep breathing and getting massages. Identifying a support group to help prevent depression can be beneficial.

  • Avoid overexposure to heat - Heat can worsen symptoms. Therefore, avoid areas that are too hot, avoid over-exercising, and hot showers. Drink plenty of water, and avoid sodas and sugary drinks because this can worsen dehydration. Remain in air-conditioned rooms when it is too hot to go outdoors. 

  • Smoking cessation - Smoking worsens MS symptoms. Options to stop smoking are self-help programs, medicines, and nicotine replacement items.

  • Rest adequately - Resting helps to reduce fatigue.

  • Preventing infections - Take necessary precautions to avoid infections. Avoid being in close contact with either sick or infected individuals.

Prognosis And Complications

Prognosis

Because of advances in technology and medicine, individuals with MS will continue to live productive and active lives. Lifestyle changes and modifications can ensure that individuals with MS can have an improved and effective outcome.

Complications

MS-related complications may include difficulty in walking because of a requirement or assistive devices such as cane or walker or even a wheelchair. Loss of vision may occur. Moreover, bladder or bowel control loss, problems with memory, sexual problems and loss of balance may occur. Because MS is a chronic condition, depression is often seen in individuals with MS.

Alternative Treatments

As MS is a chronic disease, most individuals turn to alternative treatment options.


  • Cognitive training - Ensures improvement in brain function to help with memory.

  • Exercising - Exercise can ensure relief of muscular symptoms and strengthening of muscles.

  • Pilates- It is a low weight-bearing exercise. This ensures strengthening of muscles and improvement in flexibility and posture. 

  • Yoga - This increases flexibility via poses and deep breathing techniques.

  • Tai Chi - It is a combination of movement and meditation and helps in symptomatic reduction.

  • Mindfulness practices can ensure improvement in overall quality of life.

  • Lipoic acid can be taken as a supplement and can help to slow down cell damage.

  • Ginseng- A type of plant, a constituent of sodas and teas; it can help in energy stimulation and improved brain function. 

  • Biotin- It is naturally produced by the body and can be added via a diet heavy in nuts, grains and egg yolks. This helps in symptom reduction. Biotin can be taken as a supplement.

  • Vitamin D - Helps in symptom reduction and slowing down the progression of the disease.

References


  1. Types of MS. Ms International Federation. Available at: https://www.msif.org/about-ms/types-of-ms/. (https://www.msif.org/about-ms/types-of-ms/.)

  2. Risk factors for multiple sclerosis. Winchester Hospital. Available at: https://www.winchesterhospital.org/health-library/article?id=20388.  (https://www.winchesterhospital.org/health-library/article?id=20388)

  3. Multiple Sclerosis. Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/diseases/17248-multiple-sclerosis. (https://my.clevelandclinic.org/health/diseases/17248-multiple-sclerosis)

  4. Diagnosis of multiple sclerosis. Winchester Hospital. Available at: https://www.winchesterhospital.org/health-library/article?id=20380. (https://www.winchesterhospital.org/health-library/article?id=20380)

  5.  Treatment of multiple sclerosis. Winchester Hospital. Available at: https://www.winchesterhospital.org/health-library/article?id=20385. (https://www.winchesterhospital.org/health-library/article?id=20385)

  6.  Lifestyle changes to manage multiple sclerosis. Winchester Hospital. Available at: https://www.winchesterhospital.org/health-library/article?id=20383#:~:text=drinks%20with%20caffeine.-,Ease%20Stress,for%20you%20and%20your%20family. (https://www.winchesterhospital.org/health-library/article?id=20383#:~:text=drinks%20with%20caffeine.-,Ease%20Stress,for%20you%20and%20your%20family)

  7. Multiple Sclerosis. Winchester Hospital. Available at https://www.winchesterhospital.org/health-library/article?id=21789. (https://www.winchesterhospital.org/health-library/article?id=21789)

  8. MS Symptoms. National Multiple Sclerosis Society. Available at: https://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms#section-1. (: https://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms#section-1)

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