Multiple Sclerosis

September 17, 2011

Multiple sclerosis is the most common inflammatory disease of the central nervous system. The cause stems from faulty regulation of the immune system. Myelin, the insulator of nerves, is attacked by the immune system because of improper recognition. Inflammation surrounding the nerves strips the myelin from the nerve fibers and damages some of the fibers (axons) preventing the normal transmission of nerve impulses.

The prevalence of multiple sclerosis is 70/100,000 in the United States with regional variation. Young women are unfortunately disproportionately affected, outnumbering men nearly 2:1. The disease typically begins from age 20 to 50 although onset at both younger and older ages exists. Familial tendencies are apparent. The children of patients with multiple sclerosis have a sixfold greater risk of developing multiple sclerosis than those children of parents without disease. Crucial genetic markers have not yet been identified.

Various subtypes of multiple sclerosis exist. Each subtype depicts the clinical course of the illness. onset may be either relapsing-remitting (improving, then relapsing) or continuously progressive (worsens over time). The most common subtype, relapsing-remitting, begins before the progressive subtypes by nearly a decade. The peak incidence of relapsing-remitting multiple sclerosis occurs between the ages of 25 and 29, whereas progressive is most commonly diagnosed between ages 35 and 39. Distinguishing a person’s subtype is important because therapy depends upon disease classifications.

The clinical symptoms and physical findings in multiple sclerosis are varied. No region within the central nervous system is spared. Cognitive impairment (loss in memory and concentration) occurs to variable degrees in more than one half of individuals with multiple sclerosis. Cognitive speed, recent memory, attention, and abstraction are commonly impaired. Mood disorders ranging from euphoria through depression are not uncommon.

The optic nerve (primary nerve supply to the eye) is often involved. Optic nerve inflammation causes eye pain worsened with movement and visual blurring. Progression over several days with decrease in color vision is classical for the diagnosis. Central visual loss reflecting swelling within the optic nerve is frequently noted during ophthalmologic testing.

Additional cranial nerves (nerves to the head and neck) also may be involved. Eye movement difficulties caused by disturbances in brainstem pathways result in double vision or feelings of imbalance. Facial pain may occur associated with numbness and tingling. Unexplained facial pain in a young adult may be the first symptom of multiple sclerosis. Slurring of speech (dysarthria) and difficulty swallowing (dysphagia) are frequent.

Disturbances of sensation and strength often occur. Regional inflammation within the brain results in loss of sensation or strength usually on the opposite side of the body. Problems with strength or sensation occurring simultaneously on both sides of the body imply inflammation within the brainstem or spinal cord.

Coordination difficulties often are seen. Clumsiness of the body or legs frequently impairs walking. Speech may be affected resulting in an awkward speaking pattern. Poorly coordinated eye movements may cause imbalance or a sense of movement when none is apparent.

Autonomic nervous system involvement commonly causes urinary incontinence. Persons may lose the ability to inhibit their bladder from emptying when the urge arises. Less frequently, the bladder loses its tone and distends until pressure builds and leakage occurs. Problems with defecation are less common. Erectile dysfunction (difficulty having an erection) in men and absence of orgasms in both men and women are not infrequent.

External factors influence the course of multiple sclerosis. Infectious agents such as viruses and some bacteria often precede worsening of the illness. Trauma has not been shown to convincingly worsen the illness. It has been suggested that vaccination has been implicated to exacerbate disease, although most experts no longer hold this to be true, and recommend vaccination when indicated. Pregnancy seems to inhibit disease activity. However, attacks seem to increase in frequency in the first 3-6 months after delivery.

Diagnosis is based on historical information requiring multiple episodes affecting various regions of the central nervous system at different times. Laboratory tests and radiographic imaging are used for confirmation. Blood and cerebrospinal fluid samples along with magnetic resonance imaging are frequently obtained. Alternative diagnoses including infections, a variety of immune disorders, metabolic and inherited disorders should be excluded.

Pharmacologic therapy (medication management) for multiple sclerosis has evolved during the last decade. Acute treatment with intravenous or oral antiinflammatory steroids speeds functional recovery following acute worsening. Individuals who do not respond to standard treatment of a severe initial attack may benefit from plasma exchange. Subcutaneous and intramuscular medications (medications injected beneath the skin) decrease the frequency of relapses in patients with either relapsing-remitting or relapsing-progressive subtypes. Various other intravenous and oral immune system inhibitors have met with mixed success.

Scant information exists regarding the social impact of multiple sclerosis and a woman’s ability to fulfill the demands of an active lifestyle. Chronic illness often strains relationships resulting in marital or familial discord. Employment may be jeopardized from either physical or cognitive disability. Rehabilitative experts with interest in multiple sclerosis and its associated conditions may be available. Social support thankfully exists through local MS Society chapters. Counseling and pharmacologic management of depression should be sought early to prevent social isolation.

SEE ALSO: Autoimmune disorders, Pregnancy

Suggested Reading

  • Galetta, S. L., Markowitz, C., & Lee, A. G. (2002, October 28). Immunomodulatory agents for the treatment of relapsing multiple sclerosis: A systematic review. Archives of Internal Medicine,
  • 162(19), 2161-2169.
  • O’Connor, P., & Canadian Multiple Sclerosis Working Group. (2002, September 24). Key issues in the diagnosis and treatment of multiple sclerosis. Neurology, 59(6 Suppl. 3), S1-S33.
  • Stuifbergen, A. K., & Becker, H. (2001, February). Health promotion practices in women with multiple sclerosis: Increasing quality and years of healthy life. Physical Medicine and Rehabilitation Clinics of North America, 12(1), 9-22.

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