Definition

Multiple Sclerosis (MS) is one of the most commonly encountered neurological diseases, yet its cause is unknown and its course unpredictable. MS is a disorder of the brain and spinal cord which results from a scattered loss of myelin, a fatty substance that surrounds the nerve cells. Myelin is considered important for separating nerve pathways from each other, so that impulses can travel from one location in the nervous system to another. "Multiple" comes from the multiple sites where the disease is scattered in the brain and spinal cord. "Sclerosis" refers to "sclera" or scar tissue which can obstruct or distort the flow of messages between nerves and to muscles. 

Facts 

About 350,000 people nationwide have MS. MS affects people of all ages, but is most likely to begin between the ages of 20 and 40. Women are twice as likely as men to develop MS. MS differs markedly from one patient to another.  

Prognosis 

It is often very difficult to predict the course of MS. The great variability of this disorder must be considered in each individual case. Some studies have shown that the degree of disability present at five years after the onset of symptoms is a good predictor of disability at 10 or 15 years after onset, and many neurologists use this "five year" rule in predicting a person's course. Other studies suggest that sensory problems (e.g., loss of feeling on the skin's surface, "pins and needles," or increased sensitivity to pain) are associated with a good prognosis, that is, a relatively benign course. Early onset of cerebellar findings, (e.g., tremor, coordination problems and slurred speech) tend to be linked to a more progressive disease course. 

MS tends to take one of four clinical courses. Some people have the benign sensory form, where attacks are characterized by sensory symptoms and/or optic neuritis. These individuals generally do not have severe long-term disability. Many people with MS have a relapsing/remitting course characterized by periodic, unpredictable exacerbations where existing symptoms worsen or new symptoms appear. Remission from such flare-ups may be complete or partial. When remission is partial, the course may be referred to as relapsing/remitting turned progressive. Such individuals sometimes develop a progressive form. A minority of people with MS have a severe, progressive form of the disease from onset, where symptoms generally do not remit, but tend to be progressive from the onset. Research is currently going on to try and identify more precise prognostic indicators of disease activity. 

Symptoms 

The most prominent symptoms are: 

Visual Problems--Ranging from blurred vision to more serious visual impairment, often a symptom which disappears later. Blindness in MS is rare. 

Ataxia--Difficulties in controlling the strength and precision of movements, so that holding things is a problem; balance and coordination may be impaired. 

Sensory Problems--Numbness, tingling and sensitivity to heat or cold. 

Bladder--Control problems and urinary tract infections. 

Mood Swings--Ranging from depression to euphoria. 

Fatigue--Mild to severe fatigue and weakness. 

Cognitive Problems 

Most people with MS do not show any evidence of intellectual deficits. However, it is estimated that about 40 percent of people with MS have mild cognitive dysfunction and another 10 percent have moderate to severe cognitive impairment. Among those individuals affected by cognitive impairment, the most common problems include: 

• Memory recall, particularly remembering recent events. 
• Slowness in learning and processing new information. 
• Difficulty with abstract reasoning, such as analyzing a situation, planning a course of action, and following through. 
• Poor judgment. 
• Impaired verbal fluency, such as slowed speech or difficulty coming up with a word during conversation. 

Cognitive problems associated with MS are not related to a person's level of physical disability and can potentially affect people with few physical symptoms of MS. In addition, cognitive problems can develop rapidly during an exacerbation of the disease. In these cases, the cognitive deficits can improve as the person comes to a remission. It is important to stress that cognitive impairment in MS bears little resemblance to the intellectual decline in Alzheimer's disease. People with MS virtually never experience severe, progressive cognitive decline. Cognitive impairment in MS is typically mild and may stabilize at any time. 

Individuals with MS and their families should be aware of potential cognitive problems. Recognizing and learning about certain deficits can dispel misunderstandings about a person's apparent forgetfulness, carelessness, or seeming indifference. Families can be supportive and help the person compensate. Understanding deficits can alleviate fears about losing one's capacities. If cognitive impairment is suspected, this topic should be discussed with the person's doctor. In some cases, depression or medications can mimic cognitive problems. These can be treated separately. A neurologist can perform a brief evaluation to test for pronounced (severe) cognitive deficits. However, a neuropsychologist (preferably one with experience with MS) may be recommended to perform a more complete evaluation to test for subtle cognitive changes. If deficits are found, the neuropsychologist can follow up to help individuals and their families cope with cognitive problems and to work on cognitive rehabilitation. 

There are a number of compensatory strategies individuals can use to cope with mild cognitive problems. These include memory aides such as writing down all appointments, making check lists, or using memory "tricks" (e.g., visual images or rhymes) to help remember. Practicing concentration and focus when listening will also minimize distractions and help the person retain new information. 

Diagnosis 

There is no single test available to clearly identify MS, although Magnetic Resonance Imaging (MRI) is currently the most sensitive diagnostic test. The diagnostic process usually takes a period of time and is based on cumulative symptoms and tests and a good patient medical history.  

Treatment 

In May 1996, the U.S. Food and Drug Administration (FDA) approved Avonex (Interferon beta-1a) for its ability to slow progression of physical disability and reduce the number of relapses, or flare-ups, in people with relapsing forms of MS. This joined Betaseron (Interferon beta-1b), which was approved in 1993 for reducing the number and severity of relapses in people with relapsing/remitting MS. 

Other treatment is targeted to help patients function at their best level on a day-to-day basis. Some evidence indicates that steroid-type drugs such as ACTH or prednisone will reduce the severity of an attack. This varies, however, from individual to individual. Medications are available for symptomatic treatment. Muscle relaxers aid in reducing spasms. Bowel and urinary distress are treated with management programs. Some people benefit from intermittent catherization. A urologist or neurologist can help determine if this option is suitable. Rehabilitation programs are helpful in some cases to increase muscle strength or improve walking ability. 

Getting Support 

It is important for both individuals and family members to get support when dealing with MS. Support groups are often available for both individuals and family caregivers. Counseling also may be helpful for individuals or couples learning to cope with chronic illness or periodic health crises. Caregivers with constant care responsibilities should schedule some time off from caregiving. Respite care can be arranged through family members, friends, volunteer services, independent living centers, or home care agencies.