What Is MS? What Is Multiple Sclerosis?

Multiple sclerosis, also known as MS, is a chronic disease that attacks the central nervous system, i.e. the brain, spinal cord and optic nerves. In severe cases the patient becomes paralyzed and/or blind, while in milder cases there may be numbness in the limbs.

Over 350,000 people have MS in the USA. The Cleveland Clinic says that MS-related health care costs are thought to be over $10 billion per year in the United States.

According to the National Health Service, UK, approximately 100,000 people live with multiple sclerosis in Great Britain. Symptoms usually appear initially between 15 and 45 years of age. Women are twice as likely to get MS than men.

The term Multiple Sclerosis comes from the Latin multus plus plica meaning "fold", and the Greek sklerosis meaning "hardening".

According to MediLexicon's medical dictionary, Multiple Sclerosis (MS) is:

"a common demyelinating disorder of the central nervous system, causing patches of sclerosis (plaques) in the brain and spinal cord; occurs primarily in young adults, and has protean clinical manifestations, depending on the location and size of the plaque; typical symptoms include visual loss, diplopia, nystagmus, dysarthria, weakness, paresthesias, bladder abnormalities, and mood alterations; characteristically, the plaques are "separated in time and space" and clinically the symptoms show exacerbations and remissions".

With MS the central nervous system (CNS) is attacked by the person's own immune system. That is why MS is known as an auto-immune disease.

Nerve fibers are surrounded by myelin, which protects them. Myelin also helps conduct electrical signals (impulses) - i.e. myelin facilitates a good flow of electricity along the nervous system from the brain. Myelin regulates a key protein involved in sending long-distant signals.

The myelin of a patient with MS disappears in multiple areas. This leaves a scar (sclerosis). Multiple Sclerosis means "Scar Tissue in Multiple Areas". The areas where there is either not enough or no myelin are called plaques or lesions. As the lesions get worse the nerve fiber can break or become damaged.

When a nerve fiber has less myelin the electrical impulses received from the brain do not flow smoothly to the target nerve - when there is no myelin the nerve fibers cannot conduct the electrical impulses at all. The electrical impulses are instructions from the brain to carry out actions, such as to move a muscle. With MS, you cannot get your body to do what your brain wants it to do.

Who Can Develop Multiple Sclerosis?

• MS can affect people of all ages.


• It is more common among people aged from 20 to 50 years.


• More women develop MS than men.


• People of European descent are more likely to develop MS, compared to other people. However, people of all ancestries can get it.


• You can inherit a greater susceptibility of getting MS from your parents.


• In 2007 the World Health Organization (WHO) estimated that approximately 2.5 million people had MS.


• Multiple sclerosis rates are higher the further away you live from the equator. This leads many to believe that exposure to sunlight impacts on MS risk.

What Are The Causes Of MS?

Although experts are still uncertain, most of them say that the person's own immune system attacks the myelin as if it were an undesirable foreign body - in the same way our immune system might attack a virus or bacteria.

Why might our immune system attack the myelin?

The reasons could be:

• Genetic - some studies have shown that the genes we inherit from our parents may, in part, impact on our risk of developing MS. If you have a parent, sibling, or grandparent who has/had MS, your risk of developing it yourself is greater than average.
  
  Several genes are most likely involved in influencing multiple sclerosis risk, experts say. Scientists believe that a set of gene variants we are born with, plus exposure to some environmental trigger(s), affect the immune system of some people which eventually leads to MS symptoms.
  
  We are probably not that far from identifying those gene variants. The largest MS genetic study ever undertaken, involving 250 scientists from around the world and led by the Universities of Cambridge and Oxford, reported in the journal Nature in August 2011 that over 50 genes had been identified and associated with MS.


• Environmental - MS prevalence varies according to geographical area and population groups. MS is much more common in northern Europe than southern Europe, northern USA than southern USA. It seems that the more exposure to sunlight we have, the lower our MS risk is. The more sunlight we are exposed to, the less likely we are to have low levels of vitamin D - therefore, long-term vitamin D levels probably play a role in MS risk.
  
  Italian scientists explained in July 2012 at the 22nd Meeting of the European Neurological Society (ENS) in Prague, Czech Republic, that people with high vitamin D levels are less likely to develop MS.
  
  In the USA, Caucasian people have a higher risk of developing MS than other racial groups; regardless of geographical location.
  
  Studies indicate that people who move from a higher-risk area to a lower-risk one only acquire the risk of the new area if they move before they reach adolescence. This means that there is something in the environment we are exposed to early in life which influences risk.
  
  Exposure to a toxic substance, such as a heavy metal or solvent has been suggested, but no clear conclusions have been reached.
  
  People with MS are less likely to suffer from gout. MS patients have lower-than-average levels of uric acid in their system, which leads scientists to believe that uric acid protects from MS.
  
  It is unlikely there is just one trigger, experts say, but rather MS is probably triggered by multiple factors.


• Infections - doctors and researchers have often mentioned viruses, such as Epstein-Barr (mononucleosis), varicella zoster, as possible MS triggers; however, this theory has not been backed up scientifically.


• Too much salt - too much salt may trigger the immune system, causing autoimmune diseases, researchers from the Massachusetts Institute of Technology reported in the journal Nature (March 2013 issue). The excessive consumption of salt might increase our risk of developing multiple sclerosis.

What Are The Signs And Symptoms Of MS?

MS affects the central nervous system, which controls all the actions in the body. When nerve fibers which carry messges to and from the brain are damaged, symptoms may occur in any part of the body.

In most cases, signs and symptoms generally appear between the ages of 20 and 40. For some patients, they are so mild that they do not notice anything until much later in the course of the disease. Others may be aware of them very early on

The most common symptoms are:

• Bladder problems - patients may have difficulty emptying their bladder completely, needing to go to the toilet more frequently. Urge incontinence (suddenly dying to go, or unintentional passing of urine), and Nocturia (needing to go frequently during the night) are also common symptoms.


• Bowel problems - half of all MS patients are frequently affected with constipation, which can sometimes be serious (fecal impaction). If the fecal impaction is not resolved, the problem may lead to bowel incontinence.


• Cognitive Function - according to the Multiple Sclerosis Resource Center, UK, about 50% of people with MS say they experience cognitive problems to some extent, increasing to 80% among the most severe cases. The most commonly reported cognitive abnormalities include problems with memory, abstraction, attention and word finding.
  
  In March 2012, researchers from the Kessler foundation reported on a study they carried out which showed that warmer weather has a negative effect on the cognitive performance of patients with MS.


• Depression - researchers from UCLA say MS patients have a 50% chance of developing depression. They add that depression among MS patients is not psychological, but linked to atrophy in part of the hippocampus.


• Emotional Changes - MS may have a profound emotional effect on the individual when a diagnosis is first made. It may be hard to adjust to the diagnosis of such an unpredictable disorder, which carries a risk of some level of physical disability. Also, demyelination and nerve fiber damage in the brain can cause emotional changes. In short, a person with MS may experience emotional changes for either psychological or physical reasons, or both.
  
  Researchers from the LSU Health Sciences Center New Orleans, USA, showed that stress management treatment reduced the formation of new brain lesions in people with MS considerably.


• Fatigue - this is one of the most common symptoms of MS, and affects approximately 80% of patients. The person's ability to function properly at work and at home may be seriously undermined by fatigue. It is the main reason MS patients leave their jobs.


• Dizziness and Vertigo - people with MS commonly experience dizziness and problems with balance. Vertigo is not the same as dizziness; it is a sensation that the room around you is moving or spinning.


• Head movements may cause electric-shock like sensations.


• Numbness or weakness - usually in one or more limbs, and typically affects just one side of the body at a time, or just the bottom half of the body.


• Pain or tingling in some parts of the body.


• Sexual Dysfunction - loss of interest in sex is common for people with MS. Males commonly find it difficult to reach or maintain an erection; they may also find it takes longer to ejaculate. Females may find achieving orgasm more difficult.


• Spasticity and muscle spasms - damaged nerve fibers in the spinal cord and brain can cause muscles to tightly and painfully contract (spasms). Muscles might get stiff and be resistant to movement (spasticity).


• Tremor - involuntary quivering movements


• Vision Problems - Double vision or blurring vision. There may be partial or total loss of vision, which usually affects one eye at a time. When the eye moves there is pain (optic neuritis, inflammation of the optic nerve)


• Gait - gait can be a problem for people with MS. Gait refers to the way you walk. MS can change the way people walk, because their muscles are weaker, they may have problems with balance and dizziness, plus fatigue.

These symptoms are less common, but also possible:

• Headache
• Hearing Loss
• Itching
• Respiration / Breathing Problems
• Seizures
• Speech Disorders
• Swallowing Problems
• Tremor

As the MS advances these symptoms may appear:

• Alterations in perception and thinking
• Fatigue
• Heat sensitivity
• Muscle spasm
• Sexual dysfunction

MS is an unpredictable disease. Each individual will experience it in different ways.. For some, MS starts with a subtle sensation, and it could take months and even years without any MS progression being noticed. For others, however, symptoms worsen much more rapidly - within weeks or months.

MS is very much an individual disease. People are encouraged not to compare what affects them against what other patients might experience.

The Four Courses Of Multiple Sclerosis

There are 4 courses of the disease. In each case, the MS may be mild, moderate or severe.

Relapsing-Remitting MS (RRMS): Over 80% of patients start off with this type.

• Relapsing - there are acute and unpredictable "exacerbations" (acute attacks, also called "flare-ups"). During this period symptoms get worse.
• Remitting - and then there are periods of full or partial recovery. Sometimes there is no recovery.
• The attacks may evolve over days or even weeks, and recovery can take weeks, or even months. In between the attacks there is calm, and symptoms do not worsen.

Primary-Progressive MS (PPMS): About 15% of patients have this type.

• There are no clear relapses or remissions.
• The progression of the disease is steady.
• It is the most common form of MS in those who develop the disease after 40 years of age.

Secondary-Progressive MS (SPMS):

• Starts off as a relapsing-remitting type of MS. Relapses and partial recoveries occur.
• However, in between cycles the disability does not go away.
• Eventually it becomes a progressive disease with no cycles.
• The progressive stage may start very early on, years, or even decades later.

Progressive-Relapsing MS (PRMS): The least common form.

• Symptoms worsen progressively, steadily
• There are acute attacks. Some recovery may follow, or may not.
• In the early stage, it seems the patient has primary progressive MS.

How Is MS Diagnosed?

It is still not yet possible to diagnose MS by sending samples to a lab or collecting physical findings.

The doctor needs to use several strategies to decide whether a patient meets the criteria for an MS diagnosis. To do this, other possible causes of the symptoms need to be ruled out.

The doctor will talk to the patient, carefully look at his/her medical history, carry out a neurolgic exam, order imaging scans, visual evoked potentials (VEP), spinal fluid analysis, and perhaps some further tests.

The health care professional needs to do the following before diagnosing MS:

• Detect evidence of damage in two or more separate parts of the CNS (central nervous system). The CNS includes the spinal cord, brain and optic nerves.
and

• Have proof that the CNS damage happened at least one month apart
and

• Eliminate other potential diagnoses

In 2001, the International Panel on the Diagnosis of Multiple Sclerosis revised the criteria to include precise instructions for using magnetic resonance imaging (MRI), visual evoked potentials (VEP) and cerebrospinal fluid analysis to hasten the diagnostic process. These tests can be used to look for a second area of damage in a person who has experienced only one episode of MS-like symptoms - referred to as a clinically-isolated syndrome (CIS). A person with CIS might not develop MS. The criteria were revised again in 2005 - it is now known as The Revised McDonald Criteria, and has improved the process.

Gauging MS progression through the patient's eyes

A person's multiple sclerosis progression can be determined by measuring how much their retina has thinned, researchers from Johns Hopkins MS Center reported in Neurology. The authors specified that a layer of the retina in the eyes thins when MS progresses.

The researchers wrote "This study suggests that retinal thinning, measured by in-office eye scans, called OCT, may occur at higher rates in people with earlier and more active MS."

What Are The Treatment Options For MS?

There is no cure for MS yet. Existing treatments focus on suppressing the autoimmune response and managing symptoms. Some MS patients do not need treatment because their symptoms are so mild, while others do.

The most common drugs used for treating MS; plus some new ones and a supplement that apparently does not help

• Corticosteroids - these drugs reduce inflammation. During a MS relapse inflammation can become problematic. Corticosteroids are the most commonly prescribed drugs for MS patients.
  
  Prednisone can be taken orally while methylprednisolone is administered intravenously.
  
  During a relapse there is a breakdown of the blood-brain-barrier (BBB) - harmful substances from the bloodstream might cross this barrier and make their way to the brain and spinal cord.
  
  Steroids stabilize the BBB and help prevent harmful substances leaking through. These drugs are also immunosuppressive - they help stop our body's immune system from attacking itself.


• Interferons - these medicines seem to slow down the progression of worsening MS symptoms. However, they must be used with care as they can also cause liver damage.
  
  Interferon alpha is used for treating some cancers, but has no effect on multiple sclerosis. Interferon gamma was also found to have no beneficial effect on multiple sclerosis. However, interferon beta has shown effectiveness as a multiple sclerosis treatment (A Canadian study contradicts this, see below). While the exact method by which interferon beta 1a achieves its beneficial effects in multiple sclerosis remains unknown, some researchers believe it may reduce inflammation. Studies looking at how interferon beta behaves in the lab suggest it may stop harmful cells from entering the brain. However, this is just a theory.
  
  Canadian scientists reported in JAMA in July 2012 that Interferon Beta may not slow long-term progression of MS. They had carried out a study with participants who had relapsing-remitting MS. They concluded that there was no clear evidence showing that Beta A had any measurable effect on the long-term disability progression of MS.


• Copaxone (Glatiramer) - this drug is aimed at stopping the immune system from attacking myelin. It is a combination of four amino acids (proteins). It is injected once a day, subcutaneously (under the skin). The patient may experience flushing and shortness of breath after receiving the injection.


• Tysabri (Natalizumab) - this drug is used on patients who either cannot tolerate other treatments or did not experience any benefits from them. It increases the patient's chances of developing multifocal leukoencephalopathy, a fatal brain infection. The drug is believed to work by reducing the ability of inflammatory immune cells to attach to and pass through the cell layers lining the intestines and blood-brain barriers.


• Mitoxantrone (Novantrone) - usually used only for patients with advanced MS. It is an immunosuppressant medication that can damage the heart.
  
  Novantrone was approved for the treatment of some cancer about 15 years ago. MS patients may find the idea of using chemotherapy cancer treatment disconcerting. In 2000 the Food and Drug Administration (FDA) approved Novantrone as the "only treatment for worsening MS". The recommended treatment schedule for Novantrone usage in MS is much less intensive than for cancer treatment.
  
  For MS patients whose illness is rapidly progressing and getting worse despite other therapies, Novantrone can help slow down the progression of disability and help preserve the patient's independence.


• Cannabis extract - a Phase III trial found that MS patients who took cannabis extract (tetrahydrocannabinol) had improvements in their symptoms of pain, muscle stiffness and insomnia.


• Aubagio (teriflunomide), a once-daily tablet for adults with relapsing forms of MS was approved by the FDA in September 2012. Clinical trials showed that those on Aubagio had relapse rates 30% lower compared to those on placebo.
• Do omega-3 fatty acid supplements help MS patients? - according to scientists at Haukeland University Hospital in Bergen, Norway, who carried out a double blind, placebo-control trial, omega-3 fatty acids do not help MS patients.

Rehabilitation

Rehabilitation is designed to help the MS patient improve or maintain his/her ability to perform effectively at home and at work. The focus is on general fitness and energy management, while at the same time dealing with the problems related to mobility and accessibility, speech and swallowing, memory, thinking and perception.

For an MS patient to achieve good quality health care, rehabilitation is usually a crucial component.

Rehabilitation programs generally include:

• Physical therapy (UK term is physiotherapy) - aims to provide people with the skills to maintain and restore maximum movement and functional ability.


• Occupational therapy - The therapeutic use of work, self-care, and play activities to increase development and prevent disability. It may include adaptation of task or environment to achieve maximum independence and to enhance the quality of life (American Occupational Therapy Association).


• Speech and swallowing therapy - professionals who are trained to assess speech and language development and to treat speech and language disorders are called Speech Language Pathologists, or Speech Therapists. They are also trained to help people with swallowing disorders.


• Cognitive rehabilitation - assists in the management of specific problems in thinking and perception. The patient learns and practices skills and strategies to improve function and/or make up for deficits that remain.


• Vocational rehabilitation - helps people with disabilities make career plans, learn job skills, get and keep a job.

Plasma exchange (plasmapheresis)

Plasmapheresis involves withdrawing whole blood from the patient. The plasma is removed from the blood and replaced with new plasma. Then the blood, with all its red and white blood cells is transfused back into the patient. This process is effective in treating patients with autoimmune diseases because it takes out the antibodies in the blood that are attacking parts of the patients body they should not be attacking.

However, whether plasmapheresis is of benefit to MS patients is unclear. Studies using plasmapheresis on patients with primary and secondary progressive MS have had mixed results.

Beware of fertility treatment - researchers from the Raúl Carrea Institute for Neurological Research in Buenos Aires, Argentina reported that females with MS who undergo ART (assisted reproduction technology) infertility treatment may risk increased disease activity.

Research Into Multiple Sclerosis

Over the last ten years, there has been a great deal of research into multiple sclerosis. Below are some examples:

Lemtrada (alemtuzumab), a medication used for the treatment of a type of leukemia, was shown to help MS patients in two Phase III trials. Lemtrada appears to "reboot" the immune system in MS cases that had not responded to first-line therapy; it reduced the risk of brain shrinkage and disability. Researchers from the University of Cambridge reported in the November 1, 2012, issue of The Lancet that alemtuzumab helped people with early MS who relapsed on previous treatments, as well as those who were treatment naïve (had not yet received any treatment).

Repairing Multiple Sclerosis Damage May be Possible - researchers at Oregon Health & Science University reported in Annals of Neurology (November 2012 issue) that they may be able to repair the damage to the central nervous system associated with multiple sclerosis by blocking an enzyme in the brain called hyaluronidase.

In animal experiments, the scientists blocked the activity of hyaluronidase in mice with MS-like disease, and found that myelin-forming cell differentiation was restored. In other words, remyelination (myelin repair) started to occur.

The authors added that the drug they used on the mice to block hyaluronidase activity would not work on humans, because of the serious side effects. However, they believe that creating one that is suitable for humans is feasible. Any therapy that promotes remyelination would completely change the lives of millions of MS sufferers around the world.

Nanoparticles to trick the immune system and protect the myelin sheath - researchers from Northwestern University Feinberg School of Medicine successfully used nanoparticles covered with proteins that tricked the immune systems of mice so that they stopped attacking myelin and halting MS progression. The mice had relapsing remitting MS.

The scientists say their breakthrough also has the potential for treatment for patients with type 1 diabetes, asthma, and other auto-immune diseases.

They reported in Nature Biotechnology (November 18th, 2012 issue) that MS relapses were prevented in mice for up to 100 days. In human terms, this is equivalent to several years.

The nanoparticles seem to be as effective as using the human body's own white blood cells to deliver the antigen. Phase I/II trials are currently underway on humans with MS. Nanoparticles are much cheaper and easier to use, the authors added.

BG-12 (dimethyl fumarate) - in September 2012, the results of two Phase III clinical trials that evaluated oral dimethyl fumarate, found that it may reduce relapses and disability progression in patients with relapsing-remitting MS.

Alzheimer's molecule reverses paralysis and inflammation - scientists from Stanford University School of Medicine found that a molecule known as the main culprit in Alzheimer's disease surprisingly reversed paralysis and inflammation in mice with multiple sclerosis.

Sodium accumulation - a French study revealed that sodium buildup is linked to MS disability. MRI scans detected the accumulation of sodium in certain parts of the brain among patients with early-stage MS, and throughout the entire brain in those with advanced MS. The scientists say sodium may be a biomarker for the degeneration of nerve cells that occurs in MS.

High Vitamin D levels protects mother but not baby from MS - pregnant women have a smaller risk of developing MS if their vitamin D levels are high. Scientists from Umeå University Hospital added that the developing fetus does not appear to receive the same protection if the mother's vitamin D levels are high. They reported their findings in the journal Neurology.

Jonatan Salzer, MD., neurologist and study author, said: "In our study, pregnant women and women in general had a lower risk for MS with higher levels of the vitamin, as expected. However, a mother's levels of vitamin D during early pregnancy did not have an effect on MS risk for her baby."

MS And Life Expectancy

The lifespan of a person with MS is usually about the same as a healthy person who does not have MS. In rare cases the MS may be so malignant that it is terminal.