OVERVIEW

Multiple sclerosis is a chronic disease of the central nervous system. It is probably an autoimmune disease. What
does this mean?
Chronic disease: MS is not curable. However, there are treatments that are showing great promise for slowing
down the progression of the disease.
Disease of the central nervous system: The central nervous system is comprised of your brain and spinal cord.
Autoimmune disease: This means that your body’s own immune system is attacking itself- in this case,
targeting cells in your brain and spinal cord.
What are the Symptoms of MS?

There are over 50 symptoms linked with MS, all which can vary in severity, duration and associated disability. The
most common symptoms of MS are:

Fatigue
Depression
Bladder dysfunction
Numbness and/or tingling
Sexual dysfunction
Bowel dysfunction
Pain
Dizziness and vertigo
Spasticity
Vision problems
Cognitive impairment
However, all of these symptoms are also common to many other diseases and disorders.
I Think I Have MS. What Should I Do?
If you are experiencing one or more of the symptoms listed and suspect that you have MS, you should see a
neurologist. You can either find a neurologist yourself, or get a referral from your primary care physician. Although
this is a difficult and scary time, try not to panic and continue to take care of yourself, including getting adequate
sleep and rest. While some of the MS symptoms are dramatic, MS itself is not an acute disease – there is very
little that is an emergency. It is important that you see a specialist (even if it takes some time to get the
appointment) and go through the tests required in a logical manner.

How is MS Diagnosed?

MS is very difficult to diagnose on the basis of symptoms alone, because:

There is such a large number of symptoms

Symptoms may appear alone or in combination
Symptoms can vary in severity
Symptoms can disappear suddenly
Symptoms are all common to other diseases
However, there is also no blood test to diagnose MS. Instead, neurologists rely on a combination of the following:

MRI scans
Medical history
Neurologic exam
Evoked potential testing
Lumbar puncture
Blood tests (used to rule out other things)
What Types of MS Are There?

Relapsing-Remitting MS: The majority (about 85 percent) of people with MS receive an initial diagnosis of
relapsing-remitting MS. This type of MS is characterized by definite periods of relapses, then a remitting
of symptoms, where the person recovers either entirely or almost entirely.
 Secondary-Progressive MS: Within 10 years of an MS diagnosis, 50 percent of people diagnosed with
relapsing-remitting MS will develop secondary-progressive MS, where the symptoms steadily worsen.
However, this was the case before the disease-modifying therapies and we don’t yet know the impact of
these medications on progression to secondary-progressive MS, but there are indications that the percent
of people (who are taking disease-modifying therapy) who progress to this type might be much lower.
Primary-Progressive MS: 15 percent of people are initially diagnosed with primary-progressive MS, a form of
the disease in which there are no relapses or remissions, rather a steady course of progression.
Progressive-Relapsing MS: Only six to ten percent of people receive this diagnosis. As with primary-
progressive MS, the disease follows a steady course of progression, but the patient also experiences
relapses of acute symptoms.
Can MS be Treated?

MS treatment: MS cannot be cured. However, there are medications, called disease-modifying drugs, that work
to slow down the damage and symptoms caused by MS by preventing relapses.
Symptom management: There are excellent medications to address most symptoms. In addition, your doctor
may prescribe behavioral or dietary modifications, physical therapy or psychosocial therapy.
Relapse treatment: High-dose corticosteroids, usually taken intravenously, are used to reduce inflammation in
the central nervous system, which can shorten the duration and severity of relapses.
What Causes MS?

No one knows what causes multiple sclerosis (MS), only that it is probably an autoimmune disease. Four main
theories have emerged to attempt to explain MS. Each of these theories can explain a piece of the MS puzzle, but
none explain everything. It is likely that the cause of MS is a complicated interaction of these four factors: the
immune system, the environment, infectious diseases and genetics.

What is a Relapse?

A relapse is either a worsening of symptoms that you already have, or the appearance of new symptoms.
Relapses are also referred to as “exacerbations,” “flares” or “attacks.”

What is my Prognosis?

This is difficult to predict, because everyone’s disease course and symptoms are different. Also, the introduction
of the disease-modifying therapies seems to be greatly improving the statistics over time, but they are still so new
that the long-term benefits are just starting to be seen.

However, the prognosis is the best for people with the following characteristics:

Women
Diagnosed before age 35
Have long intervals between relapses and complete recovery from relapses
Have relapses with sensory symptoms (such as numbness and tingling), rather than symptoms such as tremor
or spasticity
MS usually has very little effect on life span, except in very severe cases.
Is There Anything I Should Avoid?
Infection: Infections may cause relapses. Avoid getting sick by practicing good hand-washing and get a flu
shot if your doctor recommends it.
Overheating: Heat causes symptoms to get worse temporarily, so do your best to stay cool.
Stress and Fatigue: There can be an increase in relapses during or right after periods of extreme stress.
Fatigue makes all symptoms of MS more difficult to deal with.
Stimulating Your Immune System: Several herbs have been shown to stimulate immune function, such as
echinacea, Asian ginseng and licorice. These should be avoided – look for them in teas and “natural” cold
remedies.

PATHOPHYSIOLOGY
Although much is known about how multiple sclerosis causes damage, the reasons why multiple sclerosis occurs
are not known.
Multiple sclerosis is a disease in which the myelin (a fatty substance which covers the axons of nerve cells)
degenerates. According to the view of most researchers, a special subset of lymphocytes, called T cells, plays a
key role in the development of MS.
According to a strictly immunological explanation of MS, the inflammatory process is triggered by the T cells. T
cells gain entry into the brain via the blood-brain barrier (a capillary system that should prevent entrance of T-cells
into the nervous system). The blood brain barrier is normally not permeable to these types of cells, unless
triggered by either infection or a virus, where the integrity of the tight junctions forming the blood-brain barrier is
decreased. When the blood brain barrier regains its integrity (usually after infection or virus has cleared) the T
cells are trapped inside the brain. These lymphocytes recognize myelin as foreign and attack it as if it were an
invading virus. That triggers inflammatory processes, stimulating other immune cells and soluble factors like
cytokines and antibodies. Leaks form in the blood-brain barrier. These leaks, in turn, cause a number of other
damaging effects such as swelling, activation of macrophages, and more activation of cytokines and other
destructive proteins such as matrix metalloproteinases. A deficiency of uric acid has been implicated in this
process.[11]
It is known that a repair process, called remyelination, takes place in early phases of the disease, but the
oligodendrocytes that originally formed a myelin sheath cannot completely rebuild a destroyed myelin sheath. The
newly-formed myelin sheaths are thinner and often not as effective as the original ones. Repeated attacks lead to
successively fewer effective remyelinations, until a scar-like plaque is built up around the damaged axons,
according to four different damage patterns.[12] The central nervous system should be able to recruit
oligodendrocyte stem cells capable of turning into mature myelinating oligodendrocytes, but it is suspected that
something inhibits stem cells in affected areas.
The axons themselves can also be damaged by the attacks.[13] Often, the brain is able to compensate for some
of this damage, due to an ability called neuroplasticity. MS symptoms develop as the cumulative result of multiple
lesions in the brain and spinal cord. This is why symptoms can vary greatly between different individuals,
depending on where their lesions occur.

DIAGNOSTICS
Multiple sclerosis (MS) diagnosis is extremely difficult. The reasons for this include:
More than 50 symptoms are linked to MS, and each person develops symptoms differently.
Many of the symptoms mimic problems that occur with other diseases.
There is no blood test for MS yet.
Symptoms usually come and go.
Many symptoms are vague and hard to quantify, such as fatigue, sexual dysfunction, depression and cognitive
difficulties. These often get attributed to stress by general practitioners, and patients may never be
referred to a neurologist.
In my case, the neurologist that finally diagnosed me estimated that -- based on things that he saw on my MRI -- I
had MS for at least 15 years before my diagnosis. Sure enough, I could think back that many years to a series of
tremors, sensory symptoms and cognitive clues which took me to many doctors (including some neurologists), but
never resulted in a diagnosis.
Things are improving on this front because of the increased use of MRIs, which allow neurologists and
radiologists to actually take a look at the brain and spinal cord for characteristic MS lesions. However, MS is still a
very tricky disease to definitively diagnose, and the process may require patience. It is important to find a
neurologist that you feel comfortable with and have confidence in to work on your diagnosis. After all, if you do
have MS, this person will likely be your partner in health for a long time.
Diagnostic Tests and Procedures

Magnetic Resonance Imaging (MRI) Scan MRIs use magnetic waves to produce images of the brain and spinal
cord. If MS is suspected, a special contrast material (gadolinium) injection is usually at the time of the
scan, as it reacts to areas of inflammation and will "light up" when a lesion is active. This indicates that
demyelination is occurring. The MRI does not hurt, but it can be a strange experience. It helps if you know
what to expect during this test. There are also some things you can do to make your experience better. As
mentioned, this is considered the best test for diagnosing MS, as abnormal lesions appear on MRIs in
over 95% of people with MS. However, 5% of people with MS do not have abnormalities that can be
detected on an MRI (producing a false negative), and some age-related damage looks like MS lesions
(producing a false positive).
Medical History The doctor will ask a number of questions about the symptoms that you are currently
experiencing and any that you have experienced in the past. It is a good idea to make a “symptom log”
before you see the doctor, listing any sort of symptom that you have had in the past, how long it lasted
and other information about it. List all symptoms, even if other doctors told you there was nothing wrong.
In addition, take all other medical information along, including which prescription drugs you are on, any
 medical test results you may have and other doctors’ findings. You will also be asked several questions
about medical history of relatives, drug and alcohol use, as well as other health issues that you may have
had in the past. All of this information will help a neurologist piece together a picture to help determine if
MS is a likely diagnosis.
Neurologic Exam The doctor will be testing for the following:
Functioning of the cranial nerves (these control the senses, as well as how you talk and swallow)
Coordination
Strength
Reflexes
Sensation
He will do this by having you perform tasks (like touching your nose, then his finger in succession), touching
you with various instruments (and having you report a sensation or looking for a response himself) and
doing an examination of your eyes. These tests do not hurt. The entire test will probably last about 45
minutes, but may be as long as two hours.

Evoked Potential Testing Three main types of evoked potential tests are used in the diagnosis of MS. Each of
these tests requires that electrodes are attached to your scalp and connected to an
electroencephalograph (EEG) to record brainwaves in response to different stimuli. The different tests
are:
Brainstem Auditory Evoked Potentials (BAEP): A series of clicks are played in each ear through
headphones.
Visual Evoked Potentials (VEP): A series of checkerboard patterns are displayed on a screen.
Sensory Evoked Potentials (SEP): Mild electrical shocks are administered to an arm or leg.
The doctor is looking for both the size of the response and the speed in which the brain receives the signal.
Weaker or slow signals may indicate that demyelination has occurred and that MS is a possibility. However, this
test is also not specific to MS; abnormalities could indicate another problem. A series of all three tests could take
up to two hours to complete.

Lumbar Puncture Also called a spinal tap, this test requires that a small amount of cerebrospinal fluid (CSF) be
taken from your spinal column via a needle that is inserted between your vertebrae. The doctor will send
the fluid for evaluation, looking for the presence of oligoclonal bands (an increased number of certain
antibodies) -- an indicator of increased immune activity in the spinal fluid. This test is positive in up to 90%
of people with MS, but is not specific to MS; a positive result could indicate another disease or disorder.
Depending on results from the MRI, neurologic exam and symptom history, it is possible that you may not
have to get a lumbar puncture to receive a definitive diagnosis of MS. (I didn’t.) However, lumbar puncture
results can be useful for ruling out other things if there is still a question about diagnosis. An important
note: Lumbar punctures can be done using an x-ray technique known as fluoroscopy, which helps the
doctor or technician guide the needle. Lumbar punctures done this way are usually faster and less
stressful. However, many people (such as residents, interns and less experienced doctors) are anxious to
perform lumbar punctures without fluoroscopy, so that they can get the practice. Do not hesitate to insist
on getting a fluoroscopy-guided lumbar puncture, even if you have to get referred to another facility for the
test.
Blood Tests There is currently no blood test for MS, although scientists are working on this, so there may be
one in the near future. Still, a series of tests will be run on your blood to rule out other things, such as
Lyme disease, HIV, some rare genetic disorders and a group of diseases known as collagen-vascular
diseases (these include lupus, rheumatoid arthritis, scleroderma and others).
Diagnostic Criteria

There are two basic rules for diagnosing MS:

The person must have had at least two relapses (an episode where symptoms were present). These episodes
must have been separated by at least one month.
There must be more than one lesion on the brain or spinal cord.
Multiple sclerosis means just that -- multiple (more than one), sclerosis (areas of damage; scarring or hardening).
Diagnostic Categories
Negative: Negative means negative. You don’t have MS. It is possible for the doctor to give this diagnosis only
when another definite diagnosis is made that can account for your symptoms.
Possible: This means that you may have symptoms that look like MS, but your tests are normal. No other
diagnosis which accounts for the symptoms has been confirmed.
Probable: Many people fall into this category when they are first seen by a neurologist. You may have
symptoms that look like MS and have had two separate episodes separated by at least a month, but
 normal findings on an MRI. You could also have an MRI that showed only one lesion in your brain or
spine. In this case, your doctor will probably recommend repeating the MRI after a certain period of time
(for instance, 3 months) to see if any other lesions appear. Depending on how certain your doctor is that
you really do have MS, he may recommend that you consider starting an early therapy.
Definite: Your case fits the diagnostic criteria above. You have had at least two attacks, separated in time, plus at
least two areas of demyelination. Believe it or not, many people are relieved to receive a definite diagnosis of MS.
I was. I knew what was wrong with me and I knew what I had to do next, rather than continuing to wonder what
was causing my problems and worrying that it was something that I was doing.

SIGNS AND SYMPTOMS

Multiple sclerosis symptoms are confusing and mysterious. If you are reading this, you either are having
symptoms that you suspect might be multiple sclerosis (MS), or you know that you have it and are wondering if
what you are experiencing is yet another way that your disease is surprising you.
MS is a complicated disease. Many of the symptoms, such as fatigue, dizziness, tremor, pain or cognitive
problems, are difficult to link to MS, as they are hard to quantify and common to many other diseases. I had all of
the symptoms listed above (as well as many more) and saw at least seven or eight doctors for them over a span
of 15 years before receiving my diagnosis of MS.
The list below outlines some of the major MS symptoms, but there are more than 50 symptoms that fit the bill.
Fortunately, there are medications to modify the MS disease course and management strategies for the
symptoms of MS. Remember, in many patients, the symptoms will remit (resolve or partially resolve) after some
period of time.
Vision Problems

People with MS can experience double vision, eye discomfort and uncontrollable eye movements. Generally, eye
pain is present when the eyes are moved. Inflammation of the optic nerve (optic neuritis) causes blurred vision,
color confusion and even blindness in one eye.

Fifty-five percent of MS patients will have an attack of optic neuritis. In 15% of people, optic neuritis is the
symptom that results in an MS diagnosis.

Dizziness and Vertigo

Dizziness describes the feeling of being lightheaded or feeling faint. Vertigo is the sensation that your
surroundings are spinning or the ground is rushing toward you. In some cases, this can even cause the feeling of
nausea, as if you had motion sickness.

Muscle-Related Symptoms

These include weakness, problems with coordination and loss of balance. The muscle-related symptoms most
often occur in the arms and legs. At times, these symptoms may impair walking. Spasticity, which is the
involuntary tightening of a muscle, can manifest as stiffness, pain or spasms.

Some may experience difficulty making small or complex movements and may notice that their hands shake when
trying to pick something up, write or button their shirt. This is called "intention tremor."

Pain

Some people with MS experience pain, often in the arms and legs. Another common symptom can be a tight,
painful band around the stomach or torso, which is often referred to as a “girdle sensation” or "MS hug." Facial
pain can also occur. Additionally, people with MS can experience muscle pain from trying to compensate for poor
coordination or weakness.

Fatigue

This common MS symptom may be triggered by heat (from weather or exertion) or physical activity, or it may be a
more constant lack of energy. MS-related fatigue is tiredness that often does not respond to adequate sleep and
rest and may last all day.
Sensory Symptoms

Parasthesias, or abnormal feelings, can occur in MS. These usually take the form of numbness or tingling, usually
in the arms and legs. Some people also experience a loss of sensation or an inability to feel temperature (for
example, hot things may feel cold).

Speech-Related Symptoms

Some people with MS report having difficulty speaking, often due to slurred speech. Others struggle with
understanding language. Still others “lose words” mid-sentence, or switch words or syllables when speaking.
These difficulties are probably related to the cognitive symptoms discussed below.

Cognitive Symptoms

About 50% of people with MS experience cognitive difficulties, although some estimates are closer to 80%. These
symptoms are usually seen as problems with attention, memory and concentration. Some people with MS have
difficulty making decisions, thinking abstractly and generalizing.

These cognitive problems are not usually severe and may not be directly noticed by the person with MS. Friends
and family members are sometimes better at estimating cognitive changes than the person with MS.

Mental Health Symptoms

Many MS patients (some estimate that as many as 50%) suffer from depression at some point. While this is
sometimes a reaction to the effects that MS is having on their lives, often this depression is directly caused by MS
itself.

Depression can also be a side effect of the interferon disease-modifying therapies (Avonex, Rebif and Betaseron).
Regardless of the cause, it is important to seek help for depression.

About 10% of MS patients also are affected by other mental illnesses, such as anxiety and paranoia. Five percent
may suffer from “laughing/weeping syndrome,” also called involuntary emotional expression disorder (IEED) or
pseudobulbar affect, which causes the person to experience periods of laughing or crying that are unrelated to
their mood or an event.

Bladder and Bowel Symptoms

Dysfunction in the workings of the bladder or bowels occurs in up to 80% of people with MS. These symptoms
appear as difficulty urinating (urinary hesitancy), a sudden urge to urinate (urinary urgency), or leakage of urine or
loss of control of urination (frequent urination or incontinence). Bowel symptoms usually manifest as constipation,
although diarrhea can also occur. Many of these types of symptoms can be managed with medications combined
with modifications in diet, fluid intake and habits.

Sexual Dysfunction

Sexual dysfunction is estimated to effect about 80% of people with MS at some point. This symptom ranges from
a lack of interest in sexual activity to a loss of sensation during sex. Men can experience difficulty maintaining an
erection, while women may not become lubricated or be able to achieve orgasm.

Heat Sensitivity

In most MS patients, warm temperatures or an increase in the body’s temperature from exertion can cause a
temporary worsening of MS symptoms. Things return to normal once body temperature is reduced. Cooling
products, common sense and avoiding sources of heat (like steam rooms) can prevent heat-related symptoms.