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Multiple sclerosis, also

known as disseminated
sclerosis or
encephalomyelitis
disseminata is an
autoimmune condition in
which the immune
system attacks the
central nervous system,
leading to demyelination.
Multiple sclerosis is more common in
individuals of northern European
descent.

Women are more than twice as likely to


develop multiple sclerosis as men.

Multiple sclerosis usually affects people


between the ages of 20 and 50 years,
and the average age of onset is
approximately 34 years.

Myelin is made up of lipids and
proteins.

t acts as a type of insulation


around the axon of nerves.

emylenization occurs when the


myelin sheath becomes
damaged.

n MS, this is the result of an


abnormal autoimmune reaction

MYELIN
Exacerbations
= aharacterized by a sudden worsening of
symptoms.
x Lasts at least 24 hours
x Separated from last exacerbation by at least
one month
= aan last from a couple days to a few weeks.
= Followed by demyelinazation.
¦ EUDOEXACERBATION
= Symptoms are present in the same form as
regular exacerbations except:
x Something triggers the symptoms to come
out.
ΠFever, infection, hot weather, etc.
x When the trigger disappears the symptoms
disappear as well.
G  G
   


Relapsing-remitting M

Many cases initially take the form


of what is generally described as
relapsing-remitting MS. especially
in younger people. Symptoms
worsen during an µattack¶ or
µrelapse¶ or µÀare-up¶, may be at
their worst for several days or a
little longer, and then gradually
improve in the following weeks.
G  G
   

econdary ¦rogressive

Ghis describes another pattern


where symptoms gradually worsen
after the ¿rst µepisode¶ or µattack¶,
with a continuing increase in
disability; often this will involve
deterioration in bodily movement
(described as motor symptoms) of
one kind or another, or sensory
performance(especially eyesight).
G  G
   


¦rogressive Relapsing

aharacterized by relapses
followed by periods of remission,
however, during those periods of
remission there is a general
worsening of symptoms.
G  G
   


¦rimary ¦rogressive
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¦ GENES S F MULG ¦LE SaLERS S

n MS, sensitized G cells remain in the aNS and


promote infiltration of other agents that damage the
immune system. Ghe immune system attack leads to
inflammation that destroys myelin and
oligodendroglial cells that produces myelin in the
aNS.

emyleniation interrupts the flow of nerve impulses


and results in a variety of manifestation, depending
on which nerves are affected.

reas which are commonly affected: optic nerves,


cerebrum, brain stem, cerebellum, chiasm,
tracts, and the spinal cord.
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CLINICAL MANIFE TATION
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COGNITIVE ¦ROBLEM

f course people with MS, just like anyone else of a


similar age and sex, can suffer mental illness or
dementia but, clinically, people with MS do appear to
have more depression compared to other people, and
perhaps have what might be called mood swings rather
more often. More recently, studies have shown that
many people with MS have some problems with
memory and with what are called their cognitive
abilities, and these seem to be associated with the
effects of the disease. t is thought that MS could lead to
a subcortical dementia but this is not inevitable.
DE¦RE ION

Ghe incidence of depression amongst people with MS


has been a matter of controversy for many years. n the
early years of research it was thought that relatively few
people with the condition had µclinical¶ depression, but
more recent research indicates that the level of
depression is far higher than was previously thought.
Recent research suggests that up to 50% of people
with MS (compared to only 5±15% of people without)
will experience serious depression at some point in
their lives, and at any one time perhaps one in seven
may be experiencing this kind of depression.
DE¦RE ION


s far as depression is concerned, it is important that


you seek medical help partly because there are
various forms of depression that may require different
kinds of management. t is good that you have
recognized that you may need help, because much
can be done for you. nitially you may feel that seeking
such help is a µwaste of time¶, or indeed carries with it
some kind of stigma, similar to what people some-
times feel is associated with mental illness or
µweakness¶, but a sensible approach can substantially
prevent you feeling miserable and improve your
relationships.
EU¦ORIA

Ghe previous clinical concern with euphoria has led to


far less attention being paid to the much more serious
problem of depression, which we have just discussed.
t is possible that, in some people with MS, a euphoric
presentation has cloaked an underlying depression.
Euphoria is viewed as a widespread phenomenon
because of the very positive reactions ± the relief
almost ± that some people with MS feel once
diagnosed.
DY ARTRIA

When people speak it requires considerable coordination of a


large number of facial and related muscles. Your speech may
slur because the normal muscular control of voice production
has failed through weakness, or because the muscles are not
operating in the right sequence. s a result your speech may
sound slurred or be uncoordinated. Sometimes your speech
will just sound slightly slurred, but still be intelligible to others,
but with more serious problems of coordination it may be
dif¿cult for others to understand you.
DY ¦AGIA

Some people have major dif¿culty in swallowing! Ghere are a


number of different causes for this dif¿culty, depending on
exactly which muscles are affected in the journey of food and
drink from the mouth to the stomach. ¦roblems might be
linked to the chewing process, or to the muscles that push the
food or drink towards the throat, or to those muscles that
coordinate the swallowing process through the throat and
esophagus to the stomach. owever, normally, the problems
that people with MS experience are ones related to delays in
the swallowing process, and a slowing down of the passage of
food and drink through the throat area.
O¦TIC NEURITI

What is called optic neuritis is probably the most common


visual symptom of MS, perhaps appears in 50% of people with
MS, and indeed may well appear before any other symptoms
of the disease are obvious. ptic neuritis (inÀammation of the
optic nerve, which is at the back of the eye) may result in
various kinds of vision loss or dif¿culty. Ghe acute form may
result in temporary loss or disturbance of vision in one eye,
and very occasionally vision loss at the same time in both
eyes ± although one eye may follow the other in being
affected. Vision loss or disturbance may most often be in the
centre of the eye, but it may also be in peripheral vision.
O¦TIC NEURITI
((,G

Ghese visual symptoms are not, unfortunately, correctable by


glasses or contact lenses, because they are caused by nerve
damage or inÀammation. ¦robably the most sensible
approach is to wait, if you can, for the visual disturbances to
correct themselves. You may be able to deal with the double
vision temporarily by putting a patch over one eye, but this
strategy will slow the natural adaptation of the brain to double
vision. Sometimes prisms placed in glasses can help to
reduce the effects of double vision by bringing the two images
together.
O¦TIC NEURITI
((,G

igh-dose corticosteroids (such as


methylprednisolone or dexamethasone) can clear
problems earlier, but like other powerful drugs, they
can cause side effects. You will need to be aware
that visual problems can increase with fatigue,
infection, stress, etc., and so managing these issues
will help those visual problems.
DIZZINE

izziness (if due to true µvertigo¶) is when you feel that


things around you are moving, or feel that you are
moving, sometimes quite rapidly, when in reality neither is
happening. Ghis can sometimes be alarming, especially if
you feel that you are falling. Sometimes other sensations,
like feeling sick (µnausea¶), are associated with vertigo.
izziness from loss of balance is also related to damage
to the cerebellum (or brain stem), the nerve connections
to it from the middle ear, or within what is called the
µvestibular system of the inner ear¶. n almost all cases in
MS, the dizziness goes away of its own accord after a few
hours or days.
DIZZINE
((,G

izziness can be helped by some drugs:

Steroids (particularly intravenous methylprednisolone)


can help when the dizziness is both acute and
persistent.

iazepam (Valium) is given to dampen down the


reÀexes of the vestibular system.

ntihistamines can provide some help if the


symptoms of vertigo or dizziness are mild.

Stemetil (prochlorperazine) may be prescribed.


BALANCE

Socially and physically loss of balance is a dif¿cult issue


to manage. Unfortunately, there is no easy solution, as
the loss of balance is basically a problem caused by
damage to part of the brain ± the µcerebellum¶ (or its
pathways in the brain stem). ther factors can
compound the problem, such as spasticity or weakness
in the legs. fter a while you will probably adjust to
some of your problems and, although you may wish to
keep going for as long as possible, the most obvious
way of helping yourself is by using walking aids perhaps
sticks or crutches.
¦AIN

For many years MS was considered, medically, to be a


painless disease, probably because the process of
demyelination was thought in itself not to be painful.
owever, people with MS themselves have known for
many years that speci¿c symptoms could cause
considerable pain, and this is now being recognized.
¦AIN
Trigeminal neuralgias
very acute knife-like pain, usually in one cheek, and sometimes over
one eye, but it rarely affects both sides of the face. t is caused by the
lesions of MS damaging trigeminal nerve pathways. nother approach
is to try and block the inÀammation; if this is associated with a relapse,
steroid therapy is given. f there is a continual problem of trigeminal
neuralgia linked to several relapses, then a prostaglandin analogue
called misoprostal (aytotec) can bring relief. n some cases, various
surgical operations, including the µgamma knife¶, can destroy the
relevant nerve pathways. Even if the trigeminal neuralgia reappears,
as it can do, then the treatment can be started again, and it will almost
certainly reduce the pain.
¦AIN

# 1!# 

¦ain from poor posture when sitting or lying, and from


unusual walking patterns, is quite common. n most cases
the pain does not result from the neurological damage of
MS, but from its effects on movement.
¦AIN
¦A TICITY

Muscular cramps and spasms are known as µspasticity¶.


Several muscles contract simultaneously, both those
assisting movement and those normally countering it. Ghese
muscles will feel very tense and inÀexible ± this is because
what is medically called their µtone¶ increases, and movement
becomes more dif¿cult, less smooth and possibly rather
µjerky¶. Spasticity is quite a common symptom in MS and is
often very painful: it can occur in the calf, thigh or buttock
area, as well as the arms and, occasionally, the lower back.
Spasticity can lead to µcontractures¶, where the muscle
shortens, making disability worse
NUMBNE

Numbness is quite a common and upsetting symptom in


MS, although it can be only temporary if you have a relapse.
Ghere may be other strange and sometimes unpleasant
skin-based sensations. Usually the worst of these will µwear
off ¶ relatively quickly, although they may stay for days and
sometimes longer. Because sensory nerves, in various parts
of the aNS, link to all parts of your body, inÀammation or
damage to them can produce numbness almost anywhere,
but particularly in your feet, hands, limbs or face.
CON TI¦ATION

aonstipation is problematic in MS because it can make


other symptoms, such as spasticity and urinary
dif¿culties, worse as well as producing pain or discomfort.
aonstipation may result from several causes in MS:

emyelination may reduce the speed with which the


movement passes through the bowel; as moisture is
drawn from the stool continuously, the lower the speed,
the more the movement becomes dry and hard and
dif¿cult to pass.
CON TI¦ATION

You may have decreased sensation in your bowel or


rectal area thus not realizing that a bowel movement
is needed, and therefore the stool is left in your
bowel for a very long time.

You may have too low Àuid intake thus making the
stool dry and hard.

You may have weakened those muscles that push


the stool out and thus have dif¿culty in this respect.

n some cases drugs for other symptoms or for the


MS itself may affect either the dryness of the stool, or
the capacity to push it out.
CON TI¦ATION
((,G

Your diet should be high in ¿ber (e.g. bran, cereals,


fruit and vegetables), which allows stools to pass
more easily through the intestinal tract.

Fluid intake should also be increased for the same


reason.

etting as much exercise as possible can help,


although clearly this particular advice will be less
easy to follow by those who are bed- bound or using
wheelchairs. n this latter case seek advice from your
physiotherapist.

¦roprietary bulking agents (such as Fibogel,
Metamucil, Mucasil), and stool softeners, can help
produce regular motions.

You could use laxatives, suppositories or enemas


occasionally if all else fails, but be careful about using
any of these too regularly, because they can actually
increase constipation if overused, by slowing down
natural bowel function still further.
BLADDER CONTROL

f particular nerves in the spinal cord are damaged by MS, then


urinary control will be affected. Ghere are several kinds of urinary
control in people with MS that might then be affected:

Ghey may urinate involuntarily ± either just dribbling a little, or


sometimes even more (a problem of µincontinence¶).

Ghey may wish to urinate immediately (a problem of µurgency¶).

¦eople may wish to urinate more often than before (a problem


of frequency). When people have frequency at night, i.e. needing
to urinate several times during the night, it is called µnocturia¶.

Ghey may fail to empty their bladder (a problem of µvoiding¶).

Ghey may ¿nd it dif¿cult to begin to, or to continue to urinate (a


problem of µhesitancy¶)
BLADDER
((,G
CONTROL

Ghe patient is instructed to drink a measured amount of fluid


every 2hours and then attempt to void 30 minutes after drinking.

¦atient is encouraged to take prescribed medications to treat


bladder spasticity because this allows independence.

Ghe male patient may wear a condom appliance for urine


collection.

f the female patient has permanent urinary incontinence,


urinary diversions may be considered.
MANAGEMENT
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MANAGEMENT
nterferons are naturally occurring
substances in the body, produced in
response to µinvasion¶ by a foreign
substance, such as a virus. Gwo different
kinds of beta-interferons have shown a
signi¿cant effect in MS by reducing the
number and severity of its µattacks¶: beta-
interferon 1b (trade name Betaferon) and,
more recently, beta-interferon 1a (trade
names vonex and Rebif). Ghey seem to
stabilize the immune system but there is
conÀicting evidence as to whether it also
slows disease progression.
MANAGEMENT
Rehabilitation

µRehabilitation¶ is perhaps the new watchword


of longer term care in MS. Broadly it means
professional care targeted to achieve your
maximum potential. Regional Rehabilitation
Units have been created in recent years for
the support of people with many conditions,
but there are also an increasing number of
more specialist MS rehabilitation units or
programs. t present there are only a limited
number of places available on these
rehabilitation programs, and there is a
selection process involved, usually on the
basis of who might be expected medically to
get the most bene¿t.
MANAGEMENT

Ghere are many forms of massage. Some of them are very vigorous
and seek to realign any muscles of the body that the therapists believe
are out of line. Such forms of massage should be avoided by people
with MS, for many of the problems faced by people with the disease,
such as spasticity, are a result of neurological damage, and cannot
just be µreworked¶ by a very vigorous massage. Ghe more relaxing and
gentle forms of massage, on the other hand, are potentially of
considerable value, not only in relaxing muscles and reducing
spasticity, but also in promoting a general sense of wellbeing. t is very
important that you check what form of massage the therapist is
offering, and ensure that the therapist has been well trained and,
above all, knows about MS.
MANAGEMENT
Types of Exercises

For your overall ¿tness, general exercises may be recommended, not


necessarily linked to any particular movement symptom of your MS.

Exercises to improve your cardiovascular ¿tness will increase your heart rate,
and are good for your circulation.

Stretching exercises will decrease the risk of spasticity and contractures. Ghese
exercises work by stretching muscles and tendons to increase their Àexibility and
elasticity.

Resistance exercises, with the use of weights or other devices, help increase the
strength of muscles that have been weakened.

Range of motion exercises focus on improving the degree of motion of joints in


the body, and aim to overcome, as far as possible, difficulties caused by stiffness
in joints or problems in tendons and ligaments.
M N EMENG
A ealthy Diet

Very little intake of saturated fat (with very limited dairy produce, and
generally only certain speci¿c cuts of meat, liver for example);

plenty of ¿sh;

plentiful intake of vegetables and salads ± either raw or as lightly


cooked as possible;

¦ulses;

¦lenty of fresh fruit;

good intake of most nuts, seeds and seed oils (but excluding those
containing saturated oils and certain nuts containing saturated fats,
such as brazil nuts);

s little as possible re¿ned carbohydrates, sugar, processed or


packaged foods;

autting down on alcohol consumption, and

autting out smoking.


OUTLOOK

minority of people with multiple


sclerosis have a very mild form of the
disease with little or no disability. Gheir
neurologic disability may barely affect
their daily activities, and the disease
does not shorten their life span.
owever, cases of "benign" multiple
sclerosis can only be ascertained
retrospectively, after many years, and it
is therefore not advisable for multiple
sclerosis patients doing well to assume
this inactive disease state will be
permanent.
bout 65% of people with
multiple sclerosis have a
relapsing and remitting form of
the disease. Ghey have
intermittent worsening of their
neurologic symptoms that lasts
several days or weeks before
returning to their original state
of health. Some patients,
however, are left with residual
deficits (residual disability) after
some attacks.
Oral Teriflunomide or ¦lacebo Added to
Glatiramer Acetate for 6 Months in ¦atients
with Relapsing Multiple clerosis: afety
and Efficacy Results

Mount Sinai researchers took part in a ¦hase study of


teriflunomide, an investigational oral medication for
relapsing-remitting multiple sclerosis (RRMS), the most
common form of the disease. Ghe study analyzed
teriflunomide added to ongoing treatment with glatiramer
acetate, a currently prescribed medication, and determined
that teriflunomide was safe and effective as part of
combination therapy.
imple Eye Test Measures Damage
from Multiple clerosis

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Blocking Cell Movement for Cancer,
Multiple clerosis Treatment

" number of diseases like cancer and autoimmune


diseases, such as multiple sclerosis and arthritis,
involve the inappropriate migration of cells," says
¦rofessor Mcaoll.

Ghe researchers have identified a number of such


receptors in multiple sclerosis and have developed
potential therapeutic drugs that could control this
disease, and other autoimmune diseases.
Ghey are also in the process of identifying receptors
on the surface of metastatic cancer cells.