Written by Dr. Sanjana V.B Bhms,dbrm,cdn

Founder & medical director of siahmsr wellness.in

All rights reserved with siahmsr digital healthcare[siahmsr wellness]

Reviewed by SIAHMSR medical team

MULTIPLE SCLEROSIS [MS]

  Multiple sclerosis is a neurological disease affecting mostly young people between the ages of 20 to 40 years, although no age is exempt from it. This disease affects nerve sheaths of eyes, brain and spinal cord causing loss of vision, muscle weakness and paralysis & some variants of this disease may progress to death rapidly.

 It is an autoimmune condition in which the cells of the immune system of the body mistakenly attack the myelin sheath of nerves of brain, spinal cord etc. Myelin is a protective covering or sheath over the nerve fibers.

 “Multiple sclerosis” refers to the "numerous areas of scar tissue" resulting from the attack on myelin by the immune system. Inflammation of nerves is the hallmark of multiple sclerosis [MS].

What are the causes of multiple sclerosis?

Genetic

This neurological disease is linked to genes. Studies show that multiple sclerosis runs in families. Women are mostly affected with this condition.

Smoking 

Smoking can worsen the severity of disease. People who smoke tend to have more brain lesions and brain shrinkage than non-smokers.

Epstein–Barr virus 

It is linked with Epstein Barr virus infection also. Studies have provided evidence that multiple sclerosis (MS) is a rare complication of infection with the Epstein–Barr virus (EBV]. The risk of MS increases markedly after infectious mononucleosis (symptomatic primary EBV infection) and with high titres of antibodies to specific EBV antigens in people affected with the virus.

How does multiple sclerosis affect nervous system?

Neurons (nerve cells) are the fundamental units of the brain and nervous system, which receives and transmits signals throughout body and are vital for the sensory and motor functions of body.

A neuron has three main parts: dendrites, an axon, and a cell body.

In Multiple sclerosis immune cells of the body mistakenly attacks myelin covering of axons of nerve cells in the central nervous system. The myelin sheath covered nerve groups are commonly called white matter.

MS can also damage the nerve cell bodies, which are found in the brain's gray matter, as well as the axons themselves in the brain, spinal cord, and optic nerves that transmit visual information from the eye to the brain. As the disease advances the grey matter and outer cortex area of brain is also affected.

 The severity of multiple sclerosis symptoms is based on the intensity of inflammatory reaction as well as the location and extent of the plaques, which primarily occur in the brain stem, cerebellum , spinal cord, optic nerves, and the white matter around the brain ventricles.

 Multiple sclerosis impacts people differently and symptoms manifested range from mild to severe. In some people the disability caused by myelin sheath destruction of nerves worsens overtime.

 Most people with MS, will experience short periods of symptoms followed by long symptom free intervals or period of dormancy.

What are the signs & symptoms of multiple sclerosis?

Symptoms of multiple sclerosis vary from person to person depending on the area of brain affected and intensity of inflammatory response.

There are four main types of Multiple sclerosis [MS]:

· Relapsing-remitting MS

 Symptoms appear and disappear in this type of MS. In between attacks, there is remission and people return to normalcy or to their usual level of disability.

The period of intense symptoms is called an attack, a relapse, or exacerbation. The periods of disease inactivity between MS attacks are referred to as remission. The period of attack and remission always alternate with long intervals of time in between these. Most people with MS are initially diagnosed with this form of the disease.

· Secondary-progressive MS

In this type of MS, disease comes to a steady phase with history of MS attacks in the past. Now start developing gradual and steady symptoms and deterioration in their function over time.

· Primary-progressive MS

 This type of MS is not seen often. It presents with progressively worsening symptoms from the beginning itself with no relapses or exacerbations. There might be short symptom free intervals sometimes in this type of MS.

· Progressive-relapsing MS

This very uncommon type of MS has steady worsening of symptoms from the beginning with acute relapses that can occur over the course of disease.

Rare variants of Multiple sclerosis which progress rapidly are:

1 .Marburg variant MS (also known as malignant MS) is characterized by sudden and steady occurrence of symptoms with decline in functions. This variant can cause marked disability or it can cause death soon.

2. Balo's concentric sclerosis is characterized by presence of concentric rings of myelin destruction in MRI scan of brain. This variant of MS also can progress rapidly.

 Symptoms & signs of multiple sclerosis 

Early symptoms of multiple sclerosis

· Eyes are affected in this disease early. Multiple sclerosis may cause blurred vision or double vision. Inflammation of the nerves of eye [optic neuritis], causes pain with eye movement and rapid vision loss.

· Musculoskeletal system is also affected soon: Muscle weakness of hands and legs, and muscle stiffness accompanied by painful muscle spasms may occur.

    Other symptoms include:

     Tingling, numbness, or pain in the arms, legs, trunk, or face. Clumsiness, especially difficulty in maintaining balance when walking.

·       Bladder control is difficult.

·       Intermittent or constant dizziness

·       Mental or physical fatigue

·       Later symptoms of multiple sclerosis

·       depression or difficulty with emotional control

·       difficulty in concentrating, multitasking, thinking, learning

·       problems with memory or judgment

·       Muscle weakness, stiffness, and spasms causing difficulty in walking or standing.

·       Partial or complete paralysis in individuals who are untreated or have advanced disease.

·       Exacerbation of symptoms may occur following common infections.

·       Pain is a major symptom as MS affecting nerves of eyes and face [optic neuritis and trigeminal neuralgia].

·       Pain and spasms of lower limbs and sharp pain shooting down the legs or around the abdomen can happen.

·       Transverse myelitis (an inflammation of the spinal cord) may develop in those with MS.

   The symptoms include sudden onset of lower back pain, muscle weakness, abnormal sensations in the toes and feet, or difficulties with bladder control or bowel movements.

    This can rapidly progress to more severe symptoms, including arm and/or leg paralysis. In most cases, people recover at least some function within the first 12 weeks after an attack begins.

Complications of Multiple sclerosis

·       Optic neuritis or inflammation of nerves to eyes cause blurred or grayed vision, temporary blindness in one eye, loss of normal color vision, depth perception, or loss of vision in parts of the visual field.

·       Uncontrolled horizontal or vertical eye movements (nystagmus), “jumping vision" (opsoclonus), and double vision (diplopia) are common in people with MS.

·       Muscle weakness and spasticity is common in MS. Physical inactivity can worsen stiffness, weakness, pain, fatigue, and other symptoms.

·       Tremor, or uncontrollable shaking.

·       ataxia—unsteady, uncoordinated movements—due to damage to the areas of the brain that coordinate muscle balance.

·       Sexual dysfunction can result from damage to nerves running through the spinal cord. Sexual problems may also arise from MS symptoms such as fatigue, cramped or spastic muscles, and psychological factors

·       Cognitive impairment—a decline in the ability to think ,remember ,understand etc. affect around 75 percent of people with MS.

·       Depression

·       Difficulty in swallowing

·       Reduced capability to care for self

·       Urinary incontinence & infections.

·       Osteoporosis or thinning of the bones

·       Pressure sores

·       Side effects of medicines used to treat the disorder

 Diagnosis of multiple sclerosis

In addition to a complete medical history, physical examination, and a detailed neurological examination, different tests are conducted to rule out other similar neurological problems and confirm the diagnosis of MS.

The disease is confirmed when symptoms and signs develop and are related to different parts of the nervous system at more than one different interval and after other alternative diagnoses have been excluded.

Tests to diagnose MS are:

Lab investigations

Blood tests to rule out other conditions that may resemble MS.

Lumbar puncture (spinal tap) for cerebrospinal fluid (CSF) tests, including CSF oligoclonal banding may be needed.

Imaging studies:

MRI scan of the brain or the spine, or both are important to help diagnose and follow MS.

Nerve function study (evoked potential test, such as visual evoked response) is less often used.

Treatment for multiple sclerosis

There is no known permanent cure for this disease. However it is manageable with medications.

The available treatment methods aim at symptomatic management. Treatments can reduce the number and severity of relapses and delay the progression of the disease to disabilities.

Medications

· Corticosteroids- may help to suppress the immune system and reduce inflammation.

· Plasma exchange (plasmapheresis) can treat severe flare-ups in people with relapsing forms of MS who do not have a good response to methylprednisolone. However ,it is not effective in all types of MS.

· Beta interferon drugs are among the most common medications used to treat MS. Interferons are signaling molecules that regulate immune cells.

· Natalizumab, Ocrelizumab, Mitoxantrone etc. are a few drugs used for different types of MS.

·  Trigeminal neuralgia (facial pain) is treated with anticonvulsant or antispasmodic drugs, or less commonly, painkillers.

Other helpful interventions for managing multiple sclerosis

· Physical therapy, speech therapy, occupational therapy, and support groups may help the people with disabilities resulting from multiple sclerosis.

· Assistive devices, such as wheelchairs, bed lifts, shower chairs, walkers, and wall bars etc. may  help to do the life's routine activities with independence.

· Spinal devices may help to decrease the pain and spasticity in the legs

· A well-planned exercise program early in the course of the disorder is useful.

· A healthy lifestyle, with good nutrition and enough rest and relaxation

· Mind body relaxation exercises such as simple yoga poses.

· Vitamin D and other essential nutrient supplements such as vitamin B12 are good for managing MS

Complementary &alternative medicine

Acupuncture is used for some spine related problems.

Homeopathy

 According to  a research study [5]some homeopathic remedies are used frequently for managing Multiple sclerosis symptoms and these include:

Bladder symptoms and urinary retention managed with Causticum.

Bowel dysfunction, mainly constipation, may be treated by Opium, Alumina, Nux vomica, and sulphur.

Daily use of phosphorus has been reported to be helpful for optic neuritis; combination with Hypericum makes it more effective.

Gelsemium for double vision.

Cuprum metalicum, Cuprum arsenicum, Nux vomica and Ignatia for cramp and spasm.

Secale for sensory symptoms have been reported to be effective in MS patients.

Ayurveda

Some Ayurvedic medications along with lifestyle changes, diet and yoga may be helpful in managing symptoms of Multiple sclerosis.

Complementary and alternative medicines may be used as an adjuvant therapy to improve the quality of life reducing the symptoms from nerve inflammation.

How does exposure to sunlight help to prevent multiple sclerosis?

  Sun exposure may mitigate the incidence as well as severity and relapse of multiple sclerosis. The research studies points out that people who get exposed to sun every day and having higher levels of vitamin D in their blood are less likely to develop MS. Vitamin D is produced by exposure to sun from the skin cholesterol.

   In people with MS also the severity of course of disease and  relapses are considerably low if they get exposed to sun and get enough vitamin D. Moderate exposure to sunlight for 15-20 minutes a day helps human skin produce vitamin D. Studies state that vitamin D may help regulate the immune system in ways that reduce the risk of MS or autoimmunity in general.

copyright of the article - dr sanjanavb.

References
 
1.    https://www.nature.com/articles/s41582-023-00775-5#:~:text=The%20link%20between%20IM%20and,an%20elevated%20risk%20of%20MS.
2.    https://medlineplus.gov/ency/article/000737.htm
3.    https://www.ninds.nih.gov/health-information/disorders/multiple-sclerosis
4.    Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology
         https://pubmed.ncbi.nlm.nih.gov/29686116/
5.https://www.sciencedirect.com/science/article/pii/S2225411016302267