Multiple Sclerosis

Multiple sclerosis (MS) is an auto immune disease, where the immune system targets certain proteins that are present in the central nervous system (CNS), which includes your brain, spinal cord and optic nerve cells. First and foremost let’s understand what that term “auto-immune” means.

In the most basic terms, an auto-immune disease is a disease where the body’s own immune system and cells make a “mistake”. The most basic function of your immune system is to protect you from threats that come from “outside” the body (bacteria, viruses, fungi, parasites, etc). The “mistake” in an auto-immune process is that a native cell or protein in the body gets misidentified as an outside attacker. Think of it as friendly fire.

We don’t always know why the immune system makes these mistakes. The evidence so far is that there is a genetic component, but we’ve never been able to isolate a single gene or process which causes the problem in all individuals. Vitamin D is being studied in detail because there seems to be some evidence that Vitamin D deficiencies can contribute to the development of the disease. Vitamin D is known to have a supportive role in the immune system.

In MS, the friendly fire is targeted against a native protein called “myelin” that is present on all the neurons of the CNS. It’s a fatty substance which insulates one neuron from another. Think of it as acting like the insulation of an electrical wire. It helps make sure that the neuron signal ends up going in the right direction and doesn't “short circuit’ in the process.

Keep in mind that I am actually simplifying things here quite a bit, most experts don’t like calling MS an auto-immune disease anymore. They like saying that it is an “immune-mediated disease”. The reason is that, so far we haven’t been able to identify exactly which part of the myelin protein is being targeted.

Anyway, to sum up, we can say that MS involves immune attack on the myelin sheath in your CNS.  Now let’s move forward. What happens when these myelin sheaths are damaged? What kind of symptoms are seen?

Symptoms of MS 

When the myelin sheath of the nerve fiber is damaged or destroyed, nerve impulses that are traveling to and fro in the CNS tend to short circuit. This causes far and wide ranging symptoms, all due to CNS malfunction. The symptoms can include some, a few or even all of the following:

• Fatigue (in more than 2/3rd of cases)
• Numbness and tingling (on face, arms, extremities)
• Weakness of affected muscle groups
• Difficulty walking
• Stiffness of muscles
• Problems with vision (blurriness, loss of contrast. Sometimes this is the very first symptom patients notice)
• Dizziness and vertigo

In later stages of the disease, patients can suffer from:

• Bladder control problems
• Pain
• Problems making decisions, problem solving, forgetfulness (we calls these cognitive changes)
• Emotional Changes (uncontrollable laughing, anger, crying)
• Severe depression and suicidality

There are some rare symptoms that you occasionally see, like:

• Speech problems / Slurring
• Difficulty swallowing
• Tremors / seizures
• Headaches
• Hearing loss

If you look carefully at all of these symptoms, you’ll notice the common thread behind all of them is the fact that they all involve the CNS.

Types or Patterns of MS

Depending on the extent of damage and the severity of the immune problem, the symptoms typically take on 1 of 4 different patterns.

1. Relapsing and Remitting MS (RRMS)
2. Secondary Progressive MS (SPMS)
3. Primary Progressive MS (PPMS)
4. Progressive Relapsing MS (PRMS)

1. RRMS:The most common disease course (85% of patients), is characterized by clearly defined attacks of worsening neurologic function, followed by mostly complete remissions. In other words, the symptoms come and go at unpredictable times.
2. SPMS: Many patients with RRMS eventually lose the remission periods and eventually the symptoms become continuous. This is what we mean by Secondary Progressive MS
3. PPMS: Here the neurological worsening starts and progresses continuously. There are never any periods of remission
4. PRMS: This is the least common presentation. Here the disease starts with baseline neurologic problems that will occasionally ‘Flare-Up” and get even worse for a short duration. Eventually though the flare-up ends and goes back to baseline.

Diagnosis of MS

When it comes to MS, there isn’t any single test that can diagnose the problem quickly. When the symptoms appear, a neurologist has to get involved and examine the patient in detail. This detailed examination includes:

• History and physical examination
• MRI
• Spinal fluid analysis / Spinal tap
• Evoked potentials (Where they check the rate at which information travels through the patient’s nerves)

A textbook diagnosis of MS requires the following:

• Evidence of damage in at least two separate areas of the central nervous system (CNS), which includes the brain, spinal cord and optic nerves                                                                                                                                                  AND
• Evidence that the damage occurred at least one month apart

                                                 AND

• Ruling out all other possible diagnoses

This is a long process and requires multiple trips to the neurologist.

Treatment of MS

So far, MS is not a curable disease. Effective treatment regimes will help slow the disease course, treat relapses, manage symptoms, improve muscle and neurologic function, and hopefully address emotional health.

This kind of disease requires a “multi-disciplinary” approach, with physicians, psychiatrists,  therapists, pharmacologists and nurses. A neurologist usually acts as the coordinator and leader of the team.

Disease Modifying Drugs:

Drugs with names like interferon beta, glatiramer, natalizumab and many others have been developed to combat the symptoms of MS and try and prevent the immune mediated damage.

These drugs, would hopefully reduce the frequency and severity of relapses. They are meant to decrease the damage caused by the immune system on the CNS.

Treating ‘Flare-Ups’:

High Dose steroids are sometimes used during an extreme flare-up to tamp down the immune system and prevent severe damage.

Rehabilitation:

A comprehensive rehab program is a must. Rehab therapists create a series of exercises that help the patient remain mobile and capable of caring for themselves as long as possible. The rehab is just as important, if not more important, than the drugs.

Emotional support:

A good neuropsychiatrist helps the patient battle the depression and cognitive loss that is so commonly associated with the disease. Regular screenings by the psyche team can provide an early warning system to see if cognitive changes are the sign of worsening of the disease or a flare-up.