Multiple Sclerosis Q&A
1. What is multiple sclerosis?
Multiple sclerosis (MS) is a central nervous system disorder-that is, it affects the brain and spinal
cord and spares the nerves and muscles that leave the spinal cord. MS is an inflammatory
disorder in which infection-fighting white blood cells enter the nervous system and cause
injury. It is a demyelinating disorder because the myelin sheath that protects nerves is stripped
off during inflammation. When this happens, the nerves cannot conduct electricity as well as
they should, causing various symptoms. Symptoms may be the type that come and go over
time (relapsing-remitting MS) or progress over time (progressive MS). MS can happen to just
about anyone and is long-term.
2. How is MS diagnosed?
Multiple sclerosis is often difficult to diagnose because there is no single test or finding on an
exam that makes the diagnosis and because the disorder varies from person to person. In
most cases, there is a history of neurological symptoms that come and go over years. The
neurological exam may show changes that suggest problems with the spinal cord or brain. The
magnetic resonance imaging (MRI) may show areas of abnormality that suggest MS, though
the MRI in and of itself does not make the diagnosis. Spinal fluid testing may show that the
immune system is active in and around the brain and spinal cord, supporting the diagnosis.
Evoked potentials may assist in diagnosis. All of these need to be put together by the physician
to determine if MS is the actual diagnosis. Even when all the tests are done, some people
cannot be diagnosed for years after the beginning of symptoms.
3. What are some early symptoms of MS?
MS varies from person to person so there is no 'standard' set of symptoms for MS. However, we
know that common symptoms of MS include:
numbness or tingling in various parts of the body
weakness of one or more body part
visual blurring, and occasionally, double vision
Lhermitte's phenomenon, a symptom in which people feel electrical tingling or shocks
down their back, arms, or legs when they bend their neck forwards
Urinary symptoms, such as hesitancy when trying to urinate, or a feeling of urgency (when
you have to go, you have to go)
There is no way to predict which symptoms one person might develop.
4. What is demyelination? many research institutions around the
In MS, patients develop various areas in the world, and new knowledge is being added
brain and spinal cord where the myelin is constantly. For example, we now know that
stripped off of the nerves. These areas are even with early MS, the nerve fibers
called plaques or sometimes lesions. When themselves (the axons) are affected more
the myelin is off, the electrical conduction of than we knew before. We know from MRI
these nerves is altered. It is like getting a studies that new lesions (abnormal areas in
fuzzy signal on a television set. This event the brain or spinal cord) occur about 5 to10
may affect any aspect of central nervous times as often as people with MS have new
system functioning, causing symptoms. The symptoms; that is, much of the disease
symptoms may vary over time depending on occurs 'under the radar scope'. We know that
how extensive the demyelination is and on myelin repair occurs in the central nervous
factors such as fatigue and heat. system all the time. Some groups feel there
are different types of immune or
5. What do we know about multiple sclerosis? pathological processes going on that we call
There has been widespread research about MS, and perhaps MS may be many different
MS over the past 50 years. We do not know disorders that we have lumped together.
the cause of MS, but do know that it is an
inflammatory disorder of the central 8. Do any other diseases look like MS?
nervous system that occurs in people with a When neurologists evaluate MS they are also
tendency to such a problem. We know that considering other diagnoses. While MS is
about 350,000 people in the United States the most likely cause of typical white matter
have MS, about 1 in 1,000 people. We know changes and symptoms in an otherwise
that it is more common further north and healthy young person, there are some other
south of the equator, though we are still diseases that we consider and occasionally
unsure why this is. Females tend to get MS diagnose. These include a vitamin B12
about three times as often as males, a rate deficiency that can cause an MS-like illness,
similar to other immune diseases. MS is and rarely, lupus, which may have symptoms
more common in Caucasians, but can occur that suggest MS. The MRI is very useful in
in other populations. It is not contagious, ruling out many other disorders that could
nor is it infectious. be confused with MS, and the blood tests
and spinal fluid may also be helpful in
6. Did I do anything to bring on the MS or diagnosing other diseases.
make it worse?
As far as we know there are no activities that 9. What does magnetic resonance imaging
specifically cause MS or make it worse. show in MS?
People with MS may not tolerate heat as well Magnetic resonance imaging has become
as they used to and may need to avoid the single most useful test for the diagnosis
particularly hot or humid situations. There of MS; MRI is sensitive to brain changes
is evidence that having infections makes which are seen in MS. Classically, the MRI
having an exacerbation of MS more likely. shows lesions in the white matter deep in
There does not appear to be a link to trauma. the brain near the fluid spaces of the brain
However, emotional stress has been linked (the ventricles). The test may also show
to a worsening of MS symptoms. Having MS changes in the cortex or near the cortex. MRI
is not the fault of people who have it; it can can also show changes in the brainstem and
happen to anyone. in the spinal cord.
7. Is there anything new that we know about MS? There may be a loss of brain or spinal cord
Multiple sclerosis is being studied actively in volume, a change which is called atrophy.
Neurologists will occasionally use immune activity that we can use clinically. In
gadolinium, a heavy metal dye, to look at the people with MS, there may be an increase in
brain more carefully. In a lesion that is active white blood cells and antibody formation in
(a new plaque), this dye will leak out into the the spinal fluid. There may be 'oligoclonal'
brain and show abnormalities. It is not clear bands, which are a measure of immune
how useful repeated MRIs are for following activity found in MS but also in other
MS. However, many neurologists will repeat immune disorders. Spinal fluid helps to
an MRI about a year after starting treatment diagnose other diseases such as Lyme
for MS, or when there are unexplained disease and lymphomas of the nervous
changes in the patient's course that make it system. Not everyone needs a lumbar
important to take another look. In MS, the puncture, but it can be very useful.
MRI may not make the diagnosis, as
sometimes the changes are not specific for 12. Are there different types of MS?
MS. Other times the appearance may be MS varies from patient to patient so that
characteristic of MS. each individual has their own set of
symptoms, problems, and their own course.
10. What are evoked potentials, and what There are people who have MS so mildly that
are they used for? they never even know that they have it. Of
Evoked potentials are tests where different course, there are also others that have it
sets of nerves are stimulated, and the activity severely. It is really a spectrum that ranges
of the brain, spinal cord, or nerves is from mild to severe. An international panel
measured electrically. Visual evoked of experts developed a classification of MS
potentials are done by flashing a in 1999 that most neurologists use today:
checkerboard image in front of the patient
and recording the brain's response at the Relapsing-remitting: Patients have attacks
back of the head. Auditory evoked responses of symptoms/signs, with or without
are stimulated with a clicking noise in the recovery, but between attacks have no
ears, recording the brain's response. interval worsening.
Somatosensory evoked responses are
recorded after stimulation of the nerves Secondary progressive: This is often after a
usually in the arms or legs and are a few years of relapsing-remitting MS. The
measure of the nerve activity coming up the pattern changes from a relapsing
nerves and into the spinal cord. In MS, these pattern to progressive in between attacks,
tests may be normal but may show changes usually with fewer attacks.
such as slower electricity conduction along
the nerve pathways. In MS, visual evoked Primary progressive: This involves a
potentials are the most useful as they may gradual onset from the beginning and no
show evidence of injury to the optic nerve attacks.
not suspected clinically.
Progressive relapsing: This is a rare form,
11. What is the lumbar puncture (spinal and begins with a progressive course,
tap) for? while later developing attacks.
The lumbar puncture helps to show signs of Fulminant: This is a rare form, and is very
inflammation and immune system activity severe, rapidly progressive MS.
in and around the brain and spinal cord.
The test is really the only direct measure of
13. Is there such a thing as benign MS? disease and two are for people with more
The term, "benign MS," is not part of the severe MS or for those failing standard
international classification. It is used when therapy. In general, the medications do not
people have had MS for many years without 'make you feel better,' but do reduce MS
developing significant measurable activity. People treated for MS are less likely
disability. Recent studies have shown that to develop new attacks, have fewer new
it cannot be predicted early in the disease MRI changes, and tend not to progress as
and so the term can only really be used much as those on no treatment. So, while
retrospectively, after people have done very the medications may not make people feel
well with MS for many years. better in the present, they do help prevent
people from feeling worse in the future.
14. What is an attack?
An MS attack is also known as a 'relapse', 17. What is spasticity?
an 'exacerbation,' or a 'bout' of MS. All of Spasticity is an increased muscle tension
these terms mean the same thing--usually a and tightness that may interfere with
worsening of MS symptoms or new MS useful movements. It is often present when
symptoms lasting more than 48 hours and people have had MS for a few years, and
not due to infection or fever. An attack may tends to be happen more often in the legs
be mild or severe; it may or may not than in the rest of the body. Phasic spasms
correlate with MRI changes, though are rapid movements of limbs that occur
neurologists do not usually perform MRI suddenly, such as sudden flexing of a leg.
imaging as part of an attack evaluation. Tonic spasms are a tightening of limbs in
Many patients have a daily variation of their place. Spasticity may be painful and may
symptoms; this is not an attack. Similarly, interfere with walking, transferring, and
some patients may develop transient sitting; in general, this is when spasticity is
symptoms lasting only seconds such as treated. While patients with spasticity may
twitching in an arm or a leg. This is also not be weak, the two are not the same, and
an attack. Attacks are one marker of strength may be preserved in someone with
disease activity. spasticity.
15. What is the prognosis for MS? 18. Do people with MS get pain?
Most people think that MS is a rapidly In the past, physicians thought that MS did
disabling disorder. This is not true for most not cause pain. However, recent studies
people with MS. A recent study of people have shown that up to one-third of people
with MS in the Olmstead county area near with MS will have pain related to their MS
the Mayo clinic showed that most people at some time during the course of their
did well even without treatment. An older disease. This pain comes in a variety of
study showed that after 25 years without forms, including trigeminal neuralgia, a
treatment most people were still able to syndrome involving sharp, stabbing pain in
walk. However, only a small percentage of the side of the face or the jaw. It may come
people followed for years do not show some and go for days, weeks, or even longer.
measurable signs of MS on examination. Medication may help with this. Some
people develop back or neck pain, similar
16. Will the medications for MS make me to the pain that many other people get.
feel better? Some patients may get burning or tingling
There are now six FDA-approved pain in the legs, arms, or body which may
medications to control the course of MS; stay or come and go. Pain is part of MS and
four are for relapsing patients with active should be treated appropriately.