Multiple sclerosis (MS) is the most common cause of neurological disability among white populations in temperate regions.1 In Europe and North America the prevalence is one in 800 people, and the incidence two to 10 per 100,000.
It is most often diagnosed between the age of 20 and 40 years and is more likely to affect women than men. The life expectancy of people with MS is on average around 10 years less than that of the general population.2 However, it is rare for MS to be the direct cause of death.
The main symptoms of MS result from the damage in the brain and spinal cord. They include weakness, fatigue, numbness, tingling, depression, bladder, bowel and sexual dysfunction, visual problems, pain, cognitive deficits and ataxia (loss of muscle co-ordination). Other related symptoms include contractures, urinary tract infections, osteoporosis, muscle atrophy and skin breakdown.3
Problems with mobility can mean people with MS lose their jobs and suffer the consequent problems with status and their social life, and can become isolated and depressed.
The cause of MS is not known, although there is evidence it may be an autoimmune disorder triggered by environmental factors in individuals genetically predisposed to develop MS.1
There is also some debate about whether MS is a single condition or a cluster of disorders with distinct characteristics that clinicians do not yet have the tools to separate sufficiently clearly.
The three types of MS
There are three main types of MS, which are characterised by the course the condition takes, namely relapsing-remitting, primary progressive and secondary progressive:4
1. Relapsing-remitting MS The most common form of the disease, relapsing-remitting MS is characterised by attacks followed by periods of recovery and of no disease progression. These are believed to reflect a pathological process of inflammation that causes damage and then subsides, and is followed by healing that results in the formation of myelin plaques.
The lesions have been used as a surrogate marker for the disorder, but their relationship with the progression of disability associated with the disease is controversial.
The symptoms seen in MS are thought to be due to an immune response that damages the myelin sheath around the nerves; however, as well as targeting myelin (and the oligodendrocytes that make myelin), the acute inflammatory process can damage axons and their cells, the neurons. Axonal and neuronal loss can be seen on MRI as black holes, even at the earliest stages of the disease.5
Relapsing-remitting MS affects around 85 per cent of people with MS at the outset; on average, relapses varying from mild to severe last for about four to six weeks and occur slightly less than once a year.
2. Secondary progressive MS follows on from relapsing-remitting MS with gradually more or worsening symptoms. Clear evidence of sustained deterioration for at least six months that is independent of the effect of relapses confirms that the patient’s condition has evolved from relapsing-remitting to secondary progressive MS.
Typically, 65 per cent of people with relapsing-remitting MS will have developed secondary progressive MS after 15 years.3
3. Primary progressive MS exhibits a slow progression of disability from the start, with no relapses or remissions. Commonly, it is diagnosed later than relapsing-remitting MS, and affects men and women equally. Problems tend to occur in one main area and often relate to walking. This may be because the spinal cord is affected more than the brain, and so bowel, bladder and sexual function may be compromised. Primary progressive MS occurs in 10 to 15 per cent of people diagnosed with MS.
Two further classifications are benign and malignant MS:
* Benign MS is where MS symptoms do not become worse after 10 to 20 years and there is little or no disability. This is the case in around 10 to 30 per cent of people with MS. However, MS is rarely completely problem free, and a relapse can happen after years of inactive disease.
* Malignant MS is also know as Marburg’s disease or acute MS, and is a rare form that develops rapidly, leading to severe disability or death within a year.
Diagnosis
Diagnosing MS is difficult because there is no single specific diagnostic test. A thorough neurological history and examination together with MRI scan and cerebrospinal fluid testing are required, but are not enough on their own Ð a diagnosis can be made only if there is no other explanation for the patient’s symptoms.2
Nice says the diagnosis of MS should be made clinically by a specialist clinician, on the basis of evidence of CNS lesions separated in space and time, and a history and examination.4
Nonetheless, GPs should suspect MS in any young adult with symptoms including:
– double or blurred vision
– poor balance and coordination
– muscle weakness (often in legs)
– stiffness or spasticity in muscles
– altered sensation (numbness, tingling or a burning feeling)
– slurred speech
– fatigue inappropriate to activity
– bladder and bowel problems
– impotence
– forgetfulness and poor concentration.
After diagnosis, according to the Nice guidelines, an individual should be:
– offered at least one more appointment in the near future to see, wherever possible, the doctor who gave the original diagnosis
– put in touch with an MS nurse, or other professional with specialist knowledge of MS or other neurological conditions and counselling experience
– offered written information about local and national disease-specific support groups, including details of local rehabilitation services
– offered information about the disease, preferably in the form of an information pack, specific to the newly-diagnosed (the MS Society produces an information pack for recently diagnosed patients)
– offered the chance to take part in an educational programme on all aspects of MS within six months of diagnosis.
MS nurses generally provide a comprehensive service to people newly diagnosed with MS and work with the primary health care team on meeting Nice guideline requirements.
The first symptom in about 20 per cent of patients with MS is optic neuritis. Nice says “every individual presenting with an acute decline in visual acuity, with or without associated pain, should be seen by an ophthalmologist for diagnosis”.
The Nice guidelines also state that if the diagnosis of optic neuritis is confirmed and no other specific cause is identified, the ophthalmologist should discuss the potential diagnosis with the individual and refer them to a neurologist for additional assessment. The guidelines acknowledge the anxiety and potential problems with insurance that a possible diagnosis of MS might raise.4
To help patients maintain their quality of life, people with MS will need support from a multidisciplinary team of health professionals to manage a range of related symptoms including:
– fatigue
– bladder dysfunction
– bowel problems
– weakness and cardio-respiratory fitness
– spasticity and spasms
– contractures at joints
– ataxia and tremor
– visual problems
– pain
– sensory loss
– cognitive loss
– depression
– anxiety
– emotionalism
– swallowing difficulties
– speech difficulties
– sexual dysfunction
– pressure ulcers.
The MS Society guide3 emphasises that it is particularly important that primary care professionals are aware of the hidden symptoms of MS, which can include cognitive dysfunction, depression or other mood changes, sexual dysfunction, pain, fatigue, and bladder and bowel problems.
“Often, people with MS neglect to mention such symptoms, either because they are unaware of their relationship to MS or are too embarrassed to talk about them,” says the organisation.
“It is important to ask people with MS about any new or uncomfortable problems they may be experiencing at every opportunity, and to understand the complex pattern of disability that can arise from MS symptoms, and the impact of treatment. For example, anti-spasticity and antidepressant agents can exacerbate fatigue.”3
Steve Titmarsh MRPharmS is a former editor of the journal Progress in Neurology and Psychiatry
A new era in the struggle against multiple sclerosis
News that the US FDA’s peripheral and central nervous system advisors have recommended it should approve the new oral treatment for relapsing-remitting multiple sclerosis, fingolimod, must come as a real fillip to many patients with the disease.
Current disease modifying drugs for MS are administered by regular injection, but the new drug is both the first oral disease-modifying treatment for MS, and the first of a new drug class known as sphingosine-1 phosphate receptor modulators.6
In another move, the effective legalisation of components of cannabis as Sativex spray for the relief of spasticity associated with MS will come as good news to many and has long been advocated by some MS sufferers as providing effective relief from some symptoms of MS that impact significantly on quality of life.
For MS patients for whom the available drug treatments do not work or who have a form of MS for which current treatments are not licensed, these items of news may also provide hope that progress is being made in the fight against what is potentially a severely disabling condition that can even prove fatal for those with its most aggressive manifestation.
Clinically isolated syndrome
Clinically isolated syndrome (CIS) is an episode of symptoms suggestive of multiple sclerosis (MS) that results from demyelination Ð damage to the myelin sheath around the nerve cells Ð in one or more areas of the central nervous system, a hallmark of MS.
Confirmation that a person has a CIS is made by carrying out tests such as magnetic resonance imaging (MRI) and eliminating all other potential causes. Symptoms of CIS depend on where in the CNS damage occurs and can include: optic neuritis, muscle weakness, bladder and bowel problems.
More than eight out of 10 people who have clinically isolated syndrome are eventually diagnosed with MS.1
A new era in the struggle against multiple sclerosis
News that the US FDA’s peripheral and central nervous system advisors have recommended it should approve the new oral treatment for relapsing-remitting multiple sclerosis, fingolimod, must come as a real fillip to many patients with the disease.
Current disease modifying drugs for MS are administered by regular injection, but the new drug is both the first oral disease-modifying treatment for MS, and the first of a new drug class known as sphingosine-1 phosphate receptor modulators.6
In another move, the effective legalisation of components of cannabis as Sativex spray for the relief of spasticity associated with MS will come as good news to many and has long been advocated by some MS sufferers as providing effective relief from some symptoms of MS that impact significantly on quality of life.
For MS patients for whom the available drug treatments do not work or who have a form of MS for which current treatments are not licensed, these items of news may also provide hope that progress is being made in the fight against what is potentially a severely disabling condition that can even prove fatal for those with its most aggressive manifestation.
Reflect
Who is most likely to be affected by multiple sclerosis? What are the main types of MS and the differences between them? What does Nice recommend for newly diagnosed MS patients?
Plan
This article describes multiple sclerosis and includes information about its different types, symptoms and diagnosis. The Nice guidelines for newly diagnosed patients and the help health professionals can give is also discussed.
Act
Find out more about MS and how it interferes with nerve function from the Multiple Sclerosis Resource Centre (MSRC) website at http://tinyurl.com/msclerosis 1.
– Read more about the causes of MS on the MSRC website at http://tinyurl.com/msclerosis 2.
– Find out more about how MS is diagnosed from the Multiple Sclerosis International Federation website at http://tinyurl.com/msclerosis 3.
– Find out more detailed information about the symptoms of MS including optic neuritis, pain,
bladder and bowel problems, spasticity and cognitive problems from the MSRC website at http://tinyurl.com/msclerosis 5.
Evaluate
Are you confident in your knowledge of the types of multiple sclerosis, how the disease affects the nervous system and its main symptoms? Do you know how MS is diagnosed and about the help and advice health professionals can give?