Ask five people who have multiple sclerosis to list their top symptoms, and you are likely to get five different answers. Commonly known as MS, multiple sclerosis is a chronic disease that attacks the central nervous system, including the brain, spinal cord, and optic nerves. Because the central nervous system controls such a vast array of functions, MS symptoms can vary greatly and may include incoordination, paralysis, fatigue, cognitive and memory problems, speech disorders, vision problems, spasticity, pain, depression, bowel and bladder problems, sexual dysfunction, and many more. Moreover, symptoms can be unpredictable; they may come and go, and range in severity from one patient to the next.
What causes MS? No one knows for sure. It is believed to be an autoimmune disease, which means the body’s own defense system turns on itself. In MS, the immune system attacks the protective coverings around the nerve fibers known as myelin; often, the nerve fibers, or axons, may be harmed as well. Damage to the myelin or the axons interferes with nerve impulses traveling in the central nervous system, resulting in the symptoms.
Most patients develop MS between the ages of 20 and 40, although it has been reported in all ages from infants to the elderly. The disease affects approximately 400,000 Americans; it is most common among Caucasians of northern European ancestry, and is diagnosed more often in women than in men.
Because so many symptoms of MS can be caused by other factors – for example, numbness can be caused by a pinched nerve – it can be difficult to diagnose. Generally, it is diagnosed by a neurologist who will perform an examination and diagnostic tests, such as an MRI of the brain and possibly a spinal fluid assessment, to confirm the diagnosis.
Once MS is diagnosed, the next step is to determine what course of MS the patient will likely follow. Eighty-five percent of newly diagnosed patients have “relapsing-remitting” MS, which means they have flare-ups of symptoms followed by periods of full or partial recovery. For this type, patients are encouraged to consider first-line medications such as beta-interferon or Copaxone®. First-line medications are generally safe but may have side effects; for example, interferon can cause flu-like symptoms. In addition, because nearly all of the first-line medications are given by injection at least once a week and often more frequently, some patients may not be able or willing to take them. If the disease does not respond, more potent and possibly hazardous forms of medication may be needed.
The next step is to address the patient’s specific symptoms. Since no two patients present with the same symptoms, this is a very individualized process. Fatigue, for example, is a common complaint of MS patients. Typically, MS patients experience the most fatigue in afternoon but wake up in the morning feeling well. Patients can be shown how to organize their activities around their fatigue rather than struggle through demanding activity later in the day when fatigue is at its worst. Besides medical treatment, a simple approach is to reserve the most physically and mentally demanding tasks, such as going shopping or doing challenging analytical work, for early in the day.
It is also important to determine whether a symptom is truly a direct result of MS or is caused by something else. Fatigue can result from inadequate or poor quality of sleep for reasons unrelated to MS, such as sleep apnea. It may also be caused by other symptoms of the disease, such as bladder problems that force a patient to get up several times during the night or leg spasms that continually interrupt sleep. When these symptoms are treated, fatigue often improves as well.
In addition, some MS treatments can actually cause fatigue, so the doctor and the patient need to determine whether the benefits of the medication outweigh the side effects.
Fatigue is just one example of an MS symptom that may have a number of causes and treatments. The same individualized approach is needed with other symptoms to determine the best course of treatment to resolve complaints and restore the patient’s quality of life.
_Charles Smith, MD, is a neurologist with Scripps Health.