Multiple Sclerosis

Multiple sclerosis (MS) is a chronic and often disabling disease of the central nervous system. Symptoms may be episodic and mild, such as numbness in a limb or a visual disturbance that resolves over time. Others can have more severe and lasting symptoms, including paralysis, incontinence, cognitive loss, or loss of vision. Each case of MS is unique depending on the nerves affected. An individual can have one, all, or any combination of symptoms. Symptoms can resolve totally, some or all symptoms can remain.

Nerves consist of a nerve body with many ‘branches.’ One of the branches is much longer than the others. This is called an axon. The entire nerve is covered in a myelin sheath to protect it and to help send messages from one nerve body to another. Myelin keeps the nerve impulse moving along. In multiple sclerosis, myelin becomes damaged. It starts to break down, leaving the nerve and especially the axon, unprotected (demyelination) which affects message transmission. Eventually, there is enough breakdown in the myelin that the nerve axon becomes damaged as well.

What happens in multiple sclerosis might be due to inflammation. Inflammation occurs when a person gets an infection. This can be seen on the skin with redness, swelling and heat production as white blood cells rush to fight the infection and other cells carry away damaged tissue. Inflammation also happens within the body which can affect all body systems, one of which is the nervous system. For some unknown reason, inflammation to the body organs and tissue can happen with or without a known infection. Inflammation in the body is thought to be a source of damage to myelin. This is thought to be the trigger for MS. Inflammation can leave plaques and damage injured myelin (sometimes called lesions).

Episodes of progression of multiple sclerosis occurs in phases called exacerbations. These are occurrences when symptoms appear or worsen for a minimum of 24 hours. Remission occurs when symptoms stabilize at the level of function of the individual after an exacerbation. When in remission, some people will return to their usual function, most will stabilize at their lower level of function after the exacerbation.

Multiple sclerosis can present in one of four classifications or types.

• Clinically Isolated Symptoms (CIS) are isolated symptoms of MS in a single event. These symptoms typically resolve in 24 hours. A CIS that does not resolve or is consistent with changes in the central nervous system is a criterion for diagnosis of MS. It is important to note that some people will have one CIS episode and therefore will not be diagnosed with MS. CIS symptoms might appear as:
  • Optic neuritis is the most common symptom of MS. This is an inflammation of the optic nerve. It usually appears in just one eye with blurry vision, decreased color values and pain when not moving the eye.
  • Numbness and tingling usually from your neck down your spine. However, numbness and tingling in the feet, legs, hands, arms or face can also appear.
• Relapsing Remitting MS consists of periods of exacerbation or increasing symptoms of MS followed by periods of stability or no increase in symptoms. In this classification, MS does not progress except during exacerbations. Of those who start with relapsing-remitting, more than half will develop secondary-progressive MS within ten years; 90 percent within 25 years. About 75 percent of people with MS begin with a relapsing-remitting course.
• Primary Progressive MS is a classification of MS where the disease continually progresses without periods of remission.
• Secondary Progressive MS begins as relapsing remitting with symptoms on and off but evolves into primary progressive or continual symptom changes.

Symptoms of Multiple Sclerosis

Symptoms occur depending on which nerve or nerves are affected. One person might have eye symptoms while another may have the first symptoms in leg function. Some people have only one symptom which is called a monofocal episode. Others might have a multifocal episode or a combination of a few or many symptoms.

Common onset symptoms of MS might include:

• Numbness or weakness in legs, arms or trunk, perhaps on just one side of the body
• Electric shocks sensations especially in with forward neck movement (Lhermitte sign)
• Tremor
• Tingling or pain in parts of your body
• Lack of coordination
• Unsteady gait
• Partial or complete loss of vision, usually in one eye at a time
• Pain when moving the eye
• Prolonged double vision or blurry vision
• Slurred speech
• Fatigue
• Dizziness
• Sexual, bowel and bladder dysfunction

Mental Health Issues in MS

Multiple sclerosis can affect an individual’s mental health and abilities. These symptoms can be impacted by fatigue and often are overlooked by the individual as temporary lapse. However, these symptoms should be noted for consistency. A person might not display all the cognitive challenges but more often will have one or two. These might include processing of information, attention, concentration, word finding or memory loss, higher level thinking, or perception and space challenges.

Some people might notice changes in their memory, ability to concentrate or remember as a first symptom of MS. Others might develop a challenge in controlling emotional responses such as laughing or crying inappropriately or not being able to stop when started. Judgement can become impaired with impulsive actions.

Physical Health Issues in MS

• Body changes due to MS can be a continuation of symptoms or new physical issues can develop.
• Either or both clinically isolated symptoms, optic neuritis and numbness and tingling in the body in more than one episode.
• Eye problems can also include nystagmus (jerking eye movement) or double vision from uncoordinated eye muscles.
• Speech difficulty usually begins with a nasal voice quality, pauses between words, or slurring.
• Swallowing problems typically appear later in the disease as throat muscles are affected.
• Dizziness, feeling like the room is spinning.
• Emotional changes and depression from affected nerves in the brain. You might react differently or more extremely in situations. Depression can be a result of MS or as a reaction to the disease.
• Thinking is affected by slowness, fuzzy memory or poor attention. MS does not affect the ability to read or have a conversation.
• Fatigue or tiredness especially in the late afternoon. The fatigue does not relate to over working or lack of sleep, although people with MS do not necessarily feel refreshed after sleeping.
• Walking differences such as clumsiness or lack of coordination, balance or changes in your gait (the way you walk). Walking difficulty from spasms, tremors, balance, numb feet and fatigue.
• Bladder and/or bowel symptoms include an increase need to empty your bladder or not being able to completely empty your bladder. Bowel constipation.
• Muscle spasms from stiffness to harsh spasms especially in the legs, are seen in about half of the individuals with MS especially with progressive MS.
• Tremors in the arms or legs which can make holding things difficult and affects walking.
• Unusual sensations (dysesthesia) that are nerve related such as burning, tingling, severe itching, burning, stabbing or tearing pains. A tightness around your ribs or stomach area which is known as the MS hug.
• Heat intolerance can increase symptoms. If you become too warm from exertion, you might notice an increase in symptoms but when your body cools, the symptoms resolve.
• Sexual dysfunction including vaginal dryness or erectile dysfunction, poor response to touch or inability to reach orgasm.

Tests to Diagnose MS

Like many neurological diseases, there is no specific test for MS. Instead, several assessments and tests are conducted. A standardized criterion used is the McDonald Criteria, 2017 edition which provides a guideline for diagnosis of MS. To diagnose MS, your healthcare provider will need to find evidence of the disease in at least two areas of your central nervous system (brain, spinal cord, optic nerve) that are from different time periods. It is also diagnosed by eliminating any other possible diseases.

A history and physical examination will be completed. It is important to describe all your symptoms to your healthcare provider if you think they are MS symptoms or not. This should include when symptoms occur, if there are any triggers for the symptoms, and if you had symptoms in the past which have now resolved.

Your provider will perform an extensive neurological examination which includes assessment of your central nervous system (CNS) as well as the nerves and muscles of your body.

A urodynamic study might be done. In this examination, performed by a urologist, your urinary system is completely studied for changes that could be related to MS. This is an important study to obtain your baseline functioning of your bladder system for treatment now and in the future.

MRI of the brain and spine including the optic nerve specifically to look for lesions and plaques of MS on the nerves in the central nervous system is only about 80% reliable. The amount of damage to the myelin will provide information about time periods of the episodes of demyelination.

Electrophoresis is a test of proteins in your cerebral spinal fluid. The cerebral spinal fluid is the fluid around the brain and spinal cord that cushions and protects the CNS. Cerebral spinal fluid is obtained by spinal tap or a needle carefully placed in the spinal canal (not spinal cord) and a little fluid is removed. It is them tested in a laboratory for protein and serum.

Evoked potential studies indicate how well the nerves are working in the body. A transponder is place on top of the skin over the nerves to measure their function.

Blood tests will be performed to assess inflammation within your body as well as monitoring your general state of health. Follow up blood work will provide assessment of the function of medications. Examples might include elevated live enzymes or decreased white blood cell count.

Treatment for MS

Medications are the most common treatment for MS. Treatments are based on the MS Clinical Practice Guideline written by the American Academy of Neurology, 2018.

Medication for MS is available only with the goal of preventing further disease. These medications are called disease modifying therapies (DMT). The goal is to delay further progression of the disease and thereby delay further functional issues. A medication to cure MS has not yet been formulated.

DMT is started based on many factors including the individual’s understanding of the diagnosis and situation, reduction of exacerbation episodes, and interactions with drugs taken for other symptoms. The person who prescribes your medication should clearly describe the benefits and side effects of recommended DMTs including management if you wish to change drugs.

Some medications in the following chart are FDA approved for MS, some are FDA approved for other diseases but used also to treat MS off label.  Other drugs listed are in clinical trials at various stages with FDA approval pending. Discuss treatment options with your personal healthcare professional as FDA approval is very close for some of these medications.

MS DMT (Disease Modifying Therapies)

Other medications are provided for specific symptoms. Common MS medicines include baclofen, tizanidine or diazepam to reduce muscle spasticity. Cholinergic medications may be helpful to reduce urinary problems. Bowel preparations assist with constipation or hemorrhoids. Antidepressant medications may be helpful for mood or behavior symptoms. Amantadine may be given for fatigue.

Other Treatments for MS

Some individuals during an MS exacerbation might have a treatment where the blood is cleansed of antibodies that might be attacking your immune system. This treatment is called plasmapheresis. The effectiveness of this therapy is unclear.

Cooling vest Some individuals find their body becomes warm with the slightest activity or they find the environment to be too warm to function. This increases fatigue which makes activity and thinking difficult. Therefore, a cooling vest or other equipment to help adjust their internal body temperature might be used.

Nonprescription Treatments for MS

Some individuals will elect to try additional treatments for MS symptoms, without prescription. Off label, alternative and over the counter medications and treatments should be openly discussed with your healthcare professional to ensure there is no interaction with prescribed medication or detriment to your individual health status. It is important to note that scientific research is in process to evaluate treatments.

Acupuncture and message are the most common nonprescription treatments sought by individuals with MS. Although they do not lessen disease progression, some individuals indicate reduction in symptoms such as spasticity.

Cannabis in different forms oral, spray, inhalation might be used for reduction of spasticity, neuropathic pain, urinary frequency and mental ability.

Gingko Biloba might be used to improve mental ability and fatigue.

A low-fat diet with fish oil might be used to decrease exacerbations, fatigue and quality of life.

Magnetic therapy might be used to reduce fatigue.

Therapy

An interdisciplinary approach to therapy using physical, speech and occupational therapies, either separately or together may maximize function, improve outlook, reduce depression, and enhance coping skills. A planned exercise program early in the course of MS helps to maintain muscle tone. Exercise and energy conservation are helpful therapies. Improvement or maintenance in breathing might be accomplished through respiratory or other therapies. Attempts should be made to avoid fatigue, stress, physical deterioration, temperature extremes, and illness to reduce factors that may trigger an MS attack.

A psychiatrist or mental health specialist is helpful in dealing with cognitive issues as well as depression associated with multiple sclerosis. This specialist can assist the patient with understanding and adaption techniques as well as with the family. Coping skills can be one focus of therapy.

Clinical Practice Guidelines for the treatment of MS are available:

The American Academy of Neurology (for professionals, fee required) https://www.aan.com/policy-and-guidelines/guidelines/

The International Organization of Multiple Sclerosis Nurses https://www.christopherreeve.org/wp-content/uploads/2024/04/AANN-ARN-IOMSN-MS-Guideline_FINAL.pdf

A Consensus Paper by the Multiple Sclerosis Coalition. The Use of Disease Modifying Therapies in Multiple Sclerosis: Principles and Current Evidence. MS Coalition. September, 2018. https://www.christopherreeve.org/wp-content/uploads/2024/04/DMT_Consensus_MS_Coalition.pdf

Historic Theories of MS Alternative Treatments

As there is no cure for MS, people have tried a variety of alternative treatments to cure the disease. Unfortunately, these have not been found to be effective. In fact, some have been demonstrated not only to be false but also dangerous due to allergic reactions, even death. There is no physiologic reasoning to assume these treatments can improve the course of the disease.

Bee stings do not improve the course of MS.

Removing amalgam fillings in the teeth does not improve the course of MS.

Research

Ongoing research of medications for drug modifying therapeutics and search for cure continue. New drugs are on the horizon as well as possible treatment with stem cell therapy.

Research of pediatric MS for diagnosis, treatment and outcomes is growing as it is estimated that 10% of new cases are in this population. There is some speculation that MS development begins at an early age even if symptoms are not seen until later in life.

The molecular cause, prevention and treatment are being studied to understand why and how MS develops. Researchers are using laboratory science to study the mechanisms of the source of MS including viruses, inflammation and other causes. When the cause is understood, treatments can be developed. Basic research extends into topics such as genetics, environment as well as by type of MS.

There are many studies underway by researchers from a variety of disciplines that are seeking to improve the quality of life of individuals with MS.

Transcranial direct current stimulation (tDCS) is a low-level current that is applied externally to the head to improve the electrical flow of the brain and sometimes the spinal cord. This research is being conducted in many diagnostic types of neurological disease including MS. It is being studied to assist with cognitive impairment and fatigue among other outcomes.

By wiping out the immune cells in a patient’s bone marrow with chemotherapy and then repopulating it with healthy mesenchymal stem cells, researchers hope the rebuilt immune system will stop attacking its own nerves. This concept is still understudy.

MS Facts and Figures

30 to 80 per 100,000 people are diagnosed with MS.

MS usually occurs in individuals between 20 and 50 years.

Children and the elderly have been diagnosed with MS but in much lesser numbers.

Women are twice as likely to be diagnosed with MS than men.

Individuals of Caucasian descent are most often diagnosed with MS.

The farther your live from the equator, the more MS is diagnosed.

About 15% of individuals appear to have a family tendency.

Fatigue, occurring in about 80 percent of people with MS, can significantly interfere with a person’s ability to work and function. It may be the most prominent symptom in a person who has otherwise been minimally affected by the disease.

Although MS is chronic and incurable, life expectancy is the same as for people without MS with a lifespan of 35 or more years after diagnosis. Most people with MS continue to walk and function at work with minimal disability for 20 or more years.

Resources for MS Education and Support

If you are looking for more information on multiple sclerosis or have a specific question, our information specialists are available business weekdays, Monday through Friday, toll-free at 800-539-7309 from 9am to 5pm ET.

Additionally, the Reeve Foundation maintains a fact sheet on MS with resources from trusted Reeve Foundation sources. Check out our repository of fact sheets on hundreds of topics ranging from state resources to secondary complications of paralysis.

We encourage you to also reach out to MS support groups and organizations, including:

• National Multiple Sclerosis Society – https://www.nationalmssociety.org
• National Institutes of Health (NIH) – https://www.nih.gov
• NIH division of the National Center for Complementary and Alternative Medicines – https://nccih.nih.gov
• Multiple Sclerosis Association of America – https://mymsaa.org
• Accelerated Cure Project for Multiple Sclerosis – https://mymsaa.org
• Multiple Sclerosis Foundation – https://msfocus.org/
• Multiple Sclerosis News Today – https://multiplesclerosisnewstoday.com
• Paralyzed Veterans of America – https://www.pva.org/research-resources/multiple-sclerosis/
• Multiple Sclerosis: A Guide for the Newly Diagnosed by T. Jock Murray, 2017. (book available from Amazon).

FURTHER READING

Introduction

Hecker M, Rüge A, Putscher E, Boxberger N, Rommer PS, Fitzner B, Zettla UK. Aberrant expression of alternative splicing variants in multiple sclerosis – A systematic review. Autoimmun Rev. 2019 May 3. pii: S1568-9972(19)30113-2. doi: 10.1016/j.autrev.2019.05.010. [Epub ahead of print]

Stadelmann C, Timmler S, Barrantes-Freer A, Simons M. Myelin in the Central Nervous System: Structure, Function, and Pathology. Physiol Rev. 2019 Jul 1;99(3):1381-1431. doi: 10.1152/physrev.00031.2018.

Mental Health Issues in MS section

Bakirtzis C, Ioannidis P, Messinis L, Nasios G, Konstantinopoulou E, Papathanasopoulos P, Grigoriadis N. The Rationale for Monitoring Cognitive Function in Multiple Sclerosis: Practical Issues for Clinicians. Open Neurol J. 2018 May 31;12:31-40. doi: 10.2174/1874205X01812010031. eCollection 2018.

Jongen PJ1, Ter Horst AT, Brands AM. Cognitive impairment in multiple sclerosis. Minerva Med. 2012 Apr;103(2):73-96.

Physical Issues in MS section

Katz Sand I. Classification, diagnosis, and differential diagnosis of multiple sclerosis. Curr Opin Neurol. 2015 Jun;28(3):193-205. doi: 10.1097/WCO.0000000000000206.

Tests to Diagnose MS section

Kamińska J, Koper OM, Piechal K, Kemona H. Multiple sclerosis – etiology and diagnostic potential. Postepy Hig Med Dosw (Online). 2017 Jun 30;71(0):551-563.

Carroll, WM. 2017 McDonald MS diagnostic criteria: Evidence-based revisions. Sage Publications. Volume: 24 issue: 2, page(s): 92-95. https://doi.org/10.1177/1352458517751861

Treatment for MS section

Floriana De Angelis, Nevin A John, Wallace J Brownlee. Disease-modifying therapies for multiple sclerosis. BMJ 2018;363:k4674. doi: https://doi.org/10.1136/bmj.k4674

Hegen H, Auer M, Deisenhammer F. Predictors of Response to Multiple Sclerosis Therapeutics in Individual Patients. Drugs. 2016 Oct;76(15):1421-1445. DOI: https://doi.org/10.1007/s40265-016-0639-3

Kaltsatou A, Flouris AD. Impact of pre-cooling therapy on the physical performance and functional capacity of multiple sclerosis patients: A systematic review. Mult Scler Relat Disord. 2019 Jan;27:419-423. doi: 10.1016/j.msard.2018.11.013. Epub 2018 Nov 13.

Therapy section

Dalgas U. Exercise therapy in multiple sclerosis and its effects on function and the brain. Neurodegener Dis Manag. 2017 Nov;7(6s):35-40. doi: 10.2217/nmt-2017-0040.

Halabchi F, Alizadeh Z, Sahraian MA, Abolhasani M. Exercise prescription for patients with multiple sclerosis; potential benefits and practical recommendations. BMC Neurol. 2017 Sep 16;17(1):185. doi: 10.1186/s12883-017-0960-9.

Non-prescription Treatments for MS section

Alphonsus KB, Su Y, D’Arcy C. The effect of exercise, yoga and physiotherapy on the quality of life of people with multiple sclerosis: Systematic review and meta-analysis. Complement Ther Med. 2019 Apr;43:188-195. doi: 10.1016/j.ctim.2019.02.010. Epub 2019 Feb 10.

Riccio P, Rossano R. Diet, Gut Microbiota, and Vitamins D + A in Multiple Sclerosis. Neurotherapeutics. 2018 Jan;15(1):75-91. doi: 10.1007/s13311-017-0581-4.

Kim S, Chang L, Weinstock-Guttman B, Gandhi S, Jakimovski D, Carl E, Zivadinov R, Ramanathan M. Complementary and Alternative Medicine Usage by Multiple Sclerosis Patients: Results from a Prospective Clinical Study. J Altern Complement Med. 2018 Jun;24(6):596-602. doi:10.1089/acm.2017.0268. Epub 2018 Mar 2.

Historic Theories of MS Alternative Treatments section

Wesselius T, Heersema DJ, Mostert JP, Heerings M, Admiraal-Behloul F, Talebian A, van Buchem MA, De Keyser J. A randomized crossover study of bee sting therapy for multiple sclerosis. Neurology. 2005 Dec 13;65(11):1764-8. Epub 2005 Oct 12.

Moreau T, Loudenot V. Dental amalgam and multiple sclerosis: what is the connection? Presse Med. 1999 Sep 4;28(25):1378-80.

Research section

Inglese M, Petracca M. MRI in multiple sclerosis: clinical and research update. Curr Opin Neurol. 2018 Jun;31(3):249-255. doi: 10.1097/WCO.0000000000000559.

Mentis AA, Dardiotis E, Grigoriadis N, Petinaki E, Hadjigeorgiou GM. Viruses and Multiple Sclerosis: From Mechanisms and Pathways to Translational Research Opportunities. Mol Neurobiol. 2017 Jul;54(5):3911-3923. doi: 10.1007/s12035-017-0530-6. Epub 2017 Apr 28.

Nasios G, Messinis L, Dardiotis E, Papathanasopoulos P. Repetitive Transcranial Magnetic Stimulation, Cognition, and Multiple Sclerosis: An Overview. Behav Neurol. 2018 Jan 18;2018:8584653. doi: 10.1155/2018/8584653. eCollection 2018.

MS Facts and Figures section

Nicholas R, Rashid W. Multiple sclerosis. Am Fam Physician. 2013 May 15;87(10):712-4.

Yeshokumar AK, Narula S, Banwell B. Pediatric multiple sclerosis. Curr Opin Neurol. 2017 Jun;30(3):216-221. doi: 10.1097/WCO.0000000000000452.