Multiple sclerosis (MS) is an unpredictable disorder. Symptoms can vary from one individual to another and from one day to the next. Common symptoms include: difficulties with vision, speech, balance, and coordination; bladder, bowel, and sexual dysfunction; cognitive changes, mood swings, pain, weakness, numbness, fatigue, and impaired mobility.
Most individuals with MS may only experience a few of these symptoms, especially at the onset, and the majority of people may go for long periods of time without symptoms. This writing addresses several of the common symptoms and lists specific medications and/or therapies used to help provide relief.
The purpose of this publication is to serve as a guide for individuals with MS, their family members, or other interested people, when they want to know more about a particular MS symptom and its treatment options. While each symptom is discussed from mild to severe, please keep in mind that often a symptom is temporary and could well be on the mild side – so one should not expect the worst.
Also, this publication must never be used in place of the advice of a medical professional. Any change in treatment must always come from the treating physician; this writing is for informational purposes only.
People with MS today have much to celebrate. In less than ten years, the number of FDA-approved, long-term treatments for MS has gone from zero to five! These include Betaseron®, Avonex®, Copaxone®, Novantrone®, and Rebif®, which have all been shown to significantly reduce disease activity. And many more studies for additional drugs and treatment therapies are underway.
Anyone diagnosed with MS who is not presently taking one of these medications should speak with their neurologist about the benefits they may derive from these new drug therapies. While they are not for everyone, the majority of individuals with MS have much to gain from the treatments available today. For more information about disease-modifying treatments and facts about MS, please refer to MSAA's publication, "Multiple Sclerosis, The Process and Medical Treatments."
Eighty percent of those diagnosed with MS start out with the relapsing-remitting form of the disease (RRMS). In this phase, individuals experience periodic flare-ups of symptoms (also referred to as exacerbations, relapses, or attacks), each followed by a complete or nearly complete recovery (remission).
The majority of individuals with RRMS will enter a second phase of RRMS, known as secondary-progressive MS (SPMS), within 25 years. This phase is reached when the person experiences a progressive worsening of symptoms. SPMS may occur with or without superimposed relapses. A small subgroup of individuals with RRMS may follow a relatively benign course, still doing well – with little or no disability – after 20 years with the disease.
While the majority of people with MS (80 percent) are diagnosed with RRMS, another 15 percent fall under the heading of primary-progressive MS (PPMS). This form of MS presents a gradual accumulation of neurologic deficits from the onset, without the presence of relapses and remissions.
The two other types of MS are: progressive-relapsing MS (PRMS), which shows a progressive course from the beginning while also having acute relapses, and malignant or fulminant MS, which describes a rapidly progressing disease course. Both types are very uncommon and rarely mentioned other than in a clinical setting.
MS is a demyelinating disease of the central nervous system (CNS), which includes the brain, brain stem, and spinal cord. With MS, the CNS experiences a loss of myelin – the protective coating or insulation found along the nerve fibers (axons). Areas of inflammation and scar tissue (known as lesions or plaques) form along the damaged areas of the nerves. Without proper insulation, nerve impulses "short circuit," and messages from the CNS are unable to reach their destinations. The location and size of these plaques determine the type and extent of symptoms experienced.
More recent studies have provided evidence that the nerves themselves are experiencing degeneration – so nearby nerve cells may also be dying. Researchers are testing agents designed to protect the nerves and form new insulating myelin.
Components of the CNS along with their functions give some insight into where symptoms originate. The cerebrum is the front, upper portion of the brain which controls thought and movement. Demyelination (loss of myelin) in this area can affect such functions as memory, motivation, insight, personality, touch, hearing, vision, and muscle tone.
The cerebellum is located behind the cerebrum and controls the coordination of movement and smooth muscle activity, including those of the legs, arms, and hands. This part of the brain also enables the body to balance while performing activities such as walking or running.
The 12 cranial nerves of the brain may also be affected, potentially causing difficulty with areas such as vision, eye movement, speech, swallowing, and hearing.
The brain stem is found at the base of the skull and is in charge of eye movement as well as autonomic (involuntary) functions. Breathing, heart rate, sweating, urination, and defecation are examples of autonomic functions. These are usually not affected by MS.
The final component is the spinal cord. Similar to a large electical wire, the spinal cord allows nerve impulses to flow freely between the brain and other parts of the body. Demyelination in this area causes a loss of communication between the brain and parts of the body, and messages may not be able to reach areas such as the legs, arms, hands, and organs.
The resultant symptoms of demyelination are quite diverse and unique to each individual. Some experience severe symptoms while others report mild ones. These may be temporary, occurring only during an exacerbation, or they may remain indefinitely.
Symptoms, their impact, and length of duration, are all unpredictable. Working with a doctor and keeping apprised of any developments, as well as using proven treatments, is the way to the successfulmanagement of MS.
Visual problems are common among those with MS and are often a first sign of the disease. Visual symptoms with MS may be caused by a condition known as optic neuritis, which occurs when inflammation and demyelination are present along the optic nerve (the nerve which connects the brain to the eye).
While a variety of visual disorders may arise from optic neuritis, these disorders are seldom permanent. In fact, some visual symptoms are quite transient, at times lasting only a few minutes or seconds.
Full loss of vision, decreased vision, or blurred vision frequently affect only one eye of a person with MS who is experiencing optic neuritis. Colors may appear washed out, and night vision may be particularly difficult. Sensitivity to contrasts in light or the presence of holes (blind spots) may also occur.
Other people with MS may experience cecocentral scotoma, a disorder that causes a blind spot to appear in the center of vision. Another disorder, homonymous hemianopsia, occurs rarely, causing vision to be lost on the right or left visual fields of both eyes. Occasionally, optic neuritis will cause pain upon movement of the affected eye.
Muscle weakness and loss of coordination can also occur around the eye. This may result in nystagmus, a condition that causes the eye to move in fast, jerky movements. With nystagmus, an object may appear to jump or move unpredictably as the two eyes no longer coordinate well with each other. This disorder is not as common as diplopia, or as it is better known, double vision.
Whenever a visual problem arises, an ophthalmologist should be consulted. At times, the doctor may decide that the best treatment is to wait for the inflammation to go down and to see if the visual symptoms disappear on their own. On other occasions, intravenous steroid treatment may be used to reduce the inflammation and accelerate the recovery process.
One type of steroid, cortisone, works well to alleviate inflammation. Unfortunately, this drug has the long-term side effect of promoting the growth of cataracts. Causing vision to become cloudy, cataracts usually require surgical removal to correct a patient's vision. Long-term use of steroids may also promote osteoporosis along with other side effects.
Although an eye patch is sometimes used to treat diplopia (double vision), the ophthalmologist may advise the patient to reserve use until absolutely necessary, such as when driving or reading. Given time, the brain will often adjust to diplopia and eventually perceive images correctly, but this does not take place as rapidly when an eye patch is being used.
An ophthalmologist may offer additional ideas or treatments for specific visual symptoms, such as the use of yellow lenses to tone down light for those experiencing a light sensitivity. In other instances, a patient may find ways to simply adjust – as by turning the head to see better with homonymous hemianopsia (lost vision on one side of both eyes).
Individuals with MS experiencing visual problems are often comforted by the fact that these symptoms are almost always temporary. As with so many MS symptoms, keep in mind that these are also worsened by stress, fatigue, infection, certain medications (such as tricyclic antidepressants), or an increase in temperature.
A very common symptom of MS is numbness, often in the limbs or across the body in a band-like fashion. Numbness is divided into four categories:
The first three types of numbness – paresthesia, dysesthesia, and hyperpathia – are all frequently seen at various times and to various degrees in people with MS. The fourth type, anesthesia, is rarely experienced by someone with MS.
Sensory symptoms tend to come and go for most people and usually carry a good prognosis for not being permanent. Often, the change in sensation occurs only along a patch of skin or in specific areas, such as one or both hands, arms, or legs.
For someone not yet diagnosed with MS, numbness is not necessarily indicative of the disease. A number of conditions can cause similar symptoms of numbness. Among others, these include diabetes, carpal tunnel syndrome, toothache, back and neck problems, vitamin deficiencies, anemia, and even tight clothing.
When caused by MS, numbness is typically harmless, often producing little or no pain. Medications are not typically prescribed for this condition, unless it becomes painful or dysesthetic (pain when skin is touched). According to individuals with MS, thinking too much about this symptom can actually increase the sensation of numbness, so most try to ignore this symptom.
Should medication be prescribed, steroids (such as cortisone) may improve the condition by reducing inflammation. This can be particularly helpful if lack of sensitivity has impaired functioning to a point where activities are affected. In general, however, steroids are best avoided whenever possible in order to reserve their use for a more serious medical need.
Niacin (one of the B complex vitamins) sometimes assists with reducing numbness. Gabapentin (Neurontin®), phenytoin (Dilantin®) and carbamazepine (Tegretol®) are each antiseizure drugs which may be prescribed for controlling painful burning or electric shock-like sensations.
Amitriptyline (Elavil®) is a tranquilizer and antidepressant that may also be effective in reducing numbness. Its list of side effects does include drowsiness, therefore, this medication should only be taken at night before going to bed. Other antidepressants, such as nortriptyline (Pamelor®) or imipramine (Tofranil®), may also be tried.
As mentioned previously, numbness in most cases is considered to be a harmless symptom of MS. Despite the drugs mentioned, medications are rarely prescribed for this condition alone, unless the sensory symptoms are painful or dysesthetic.
Numbness caused by MS may be best treated by ignoring the sensation and directing attention elsewhere. As with all MS symptoms, a doctor should be contacted about any numbness experienced to be sure the numbness is attributable to MS and to see if he or she may want to recommend further investigation or treatment.