Multiple sclerosis

Multiple sclerosis is a chronic disease that affects the central nervous system (CNS). Your CNS consists of your brain, spinal cord, and the bundle of nerves (called the optic nerves) that transmit messages from your eyes to your brain. “Sclerosis” is a term used to describe hardening of tissue. 

In the case of MS, multiple areas of hardened or scar tissue called lesions or plaques form along the CNS because of damage and inflammation. These lesions disrupt or stop the flow of information within the brain and between the brain and other parts of the body.  

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Multiple sclerosis symptoms can vary and follow an unpredictable pattern. The symptoms you experience can differ from those experienced by others with MS and they can change over time. 

Which MS symptoms are more common? 

Common multiple sclerosis symptoms include: 

Ataxia: MS can cause impairment to muscle control and coordination in the arms and legs. This can cause you to walk with an unsteady or awkward gait or move in an uncoordinated, unwieldy, or clumsy way.  

Bladder issues: MS can cause spastic (overactive) bladder and urinary retention, a condition in which you can’t fully empty your bladder when you urinate.  

Bowel issues: This can include constipation, diarrhea, and loss of bowel control. 

Cognitive changes (sometimes called cognitive fog or “cog fog”): MS can impact one or more high-level brain functions, such as: 

• Information processing (sorting information gathered by your five senses) 
• Memory 
• Focus and concentration 
• Executive functions such as planning and prioritizing 
• Verbal fluency (the ease with which you can find the right words to express what you’re trying to say) 
• Visuospatial functions (the ability to relate visual information to the space around you) 

Depression: Rates of depression may be higher in people with MS compared to those of the general public or people with other chronic health conditions. 

Emotional changes: Anxiety, mood swings, irritability, grief, and sadness are some of the emotions that you might experience. These might be in response to the stresses of being diagnosed with and living with MS or they might be brought on by the damage to nerve fibers in the brain. 

Fatigue: You may feel constantly tired. 

MS hug (dysesthesia): This feels like your torso is being squeezed, much like a blood pressure cuff squeezing your arm when it tightens. 

Muscle weakness: This might be due to nerve damage in areas of your brain that stimulate your muscles or it may be a result of being less physically active because of symptoms such as fatigue and pain. 

Numbness and tingling: You might experience numbness or a burning or prickling sensation called paresthesia (also known as “pins and needles”) in your arms, legs, torso, or face. 

Pain and itching: You might experience acute or chronic nerve pain due to damage in your CNS or as a result of changes to your body caused by MS (such as to your manner of walking, which can cause back and hip pain). 

Sexual issues: Nerve damage caused by MS can lead to issues with sexual arousal and orgasm. These may also stem from mental and emotional issues associated with MS, such as changes to your self-esteem and mood. 

Spasticity: Sudden and sustained muscle contractions can cause muscle spasms and stiffness in your extremities, especially your legs.  

Vertigo and dizziness: You might feel lightheaded or have vertigo, which makes you feel like your surroundings are spinning. 

Vision issues: The three most common eye conditions people experience with MS include optic neuritis (swelling of the optic nerve), diplopia (double vision), and nystagmus (rapid, involuntary shaking of the eye). 

Many of these symptoms can amplify the risk of falls and lead to injuries, ranging from bruises and sprains to fractures and head trauma. According to a 2020 review of studies published in the International Journal of MS Care, 56 percent of people with MS reported falling at least once over a three-month period, with 37 percent falling more frequently.  

Which MS symptoms occur less often? 

Less common MS symptoms include: 

Breathing issues: Over time, damage to the nerves that control chest muscles can make it hard to breathe, making you feel even more fatigued and interfering with speech. 

Dysphagia: Damage to the nerves that control the muscles that help you swallow can raise your risk of aspiration pneumonia due to food and fluids getting stuck in your lungs. MS can also cause numbness in your mouth and throat, which can also affect swallowing. 

Hearing loss: Hearing loss is an uncommon symptom of MS and deafness very rarely occurs. It may be caused by damage to the nerve pathways in the brain that control hearing. 

Lhermitte's sign: Also known as Lhermitte's phenomenon or syndrome or barber chair sign, phenomenon, or syndrome, this type of nerve pain causes sudden, brief, sometimes buzzing sensations (like an electric shock) that move down your neck into your spine and sometimes radiate out into your arms, legs, fingers, and toes. Bending your head forward usually triggers this phenomenon, hence the reference to the barber chair. 

Loss of taste: Diminished taste occurs in around 25 percent of people with MS. 

Pseudobulbar affect (PBA): PBA causes sudden, frequent, uncontrollable episodes of laughing and crying, even though your feelings may not align with your outward expressions. People with amyotrophic lateral sclerosis (ALS), Alzheimer’s disease, epilepsy, Parkinson’s disease, stroke, and traumatic brain injury (TBI) may also experience PBA. 

Speech issues: These might include dysarthria (slurring), dysphonia (loss of speech), stuttering, or scanning dysarthria, in which your normal speech pattern or rhythm is disrupted with abnormally long pauses between words or syllables.  

Seizures: Though somewhat uncommon with MS, seizures can occur due to abnormal electrical discharges in areas of the brain that are scarred or injured. 

Tremors: Damage to the complex nerve pathways that control movement can cause uncontrollable shaking of your limbs, body, or head. 

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Multiple sclerosis is most often classified as an autoimmune or immune-mediated disease. Ordinarily, your immune system identifies and attacks viruses, bacteria, or other agents that may harm the body. When you have MS, your immune system mistakenly attacks, damages, or destroys cells in the CNS.  

Myelin is a fatty substance that makes up the protective layer or sheath that coats long, threadlike nerve fibers called axons. These axons allow nerve cells to send electrical and chemical messages to other nerves, as well as to glands and muscle cells throughout the body. When you have MS, your immune system attacks myelin and the cells that make myelin called oligodendrocytes. 

Demyelination is the term used to describe the resulting damage to the myelin sheath and the failure of oligodendrocytes to replace it. In the process, axons become damaged since they no longer have myelin to coat and insulate them. 

Although scientists are still trying to unravel the precise mechanism behind this damage, they believe it involves genetics, infectious disease, and environmental factors.  

How sex, age, and race affect multiple sclerosis risk 

People assigned female at birth are three times more likely to have MS than people assigned male at birth. 

Around 10 percent of the time, MS symptoms first appear before the age of 18, but most people with MS are diagnosed between the ages of 20 and 50. Members of most racial and ethnic groups get MS, but it is most common among white people of northern European descent. Recent research has suggested a higher prevalence than was previously understood among Black people.  

How genes can affect multiple sclerosis risk 

Multiple sclerosis isn’t an inherited disease, meaning your parents can’t directly pass it on to you. But you can inherit certain genes that increase your risk for the disease.  

Around 200 genes have been identified as possible contributors to MS risk. These combine with hundreds of variants in the genetic code (called gene variants) to increase the likelihood of developing the disease. Having any of these genes or gene variants doesn’t mean you’ll necessarily develop MS; it just means your risk for the disease may go up if you carry one or more of them. 

Can infectious diseases impact multiple sclerosis risk? 

One theory suggests that being infected with certain viruses can increase one’s risk of developing MS. These viruses may remain dormant in your system for many years without causing any noticeable symptoms. Some people may develop MS after being exposed to certain viruses because they are more prone to getting sick from them. Examples of viruses that have been or are being investigated for possible links to MS include: 

• Chlamydia pneumoniae  
• Epstein-Barr virus (the virus that causes mononucleosis)  
• Human herpes virus t (HHV-6) 
• Human T-lymphotropic virus (HTLV) 
• Measles 

Although viruses may play a role in its development, MS isn’t contagious and you can’t get infected with MS from another person. The viruses that may trigger MS can be contagious, however. 

Can where you live influence multiple sclerosis risk? 

MS is more prevalent among people who live farther from the equator in cooler climates, either to the north or south, compared to people who live in hotter areas close to the equator. Scientists theorize that this might have to do with lower vitamin D levels among people in cooler regions.  

People who live close to the equator are exposed to more year-round sunlight, which is a natural source of vitamin D. In contrast, people who live farther away from the equator may have lower levels of vitamin D because they get less sun exposure during the year. It’s thought that vitamin D supports immune function and offers protection against immune-mediated illnesses like MS. 

Are there other risk factors for multiple sclerosis? 

Smoking tobacco may raise the risk of developing MS. It can also lead to a more severe and rapid development of the disease. Quitting smoking may slow down disease progression. 

Obesity increases inflammation in the body, which can raise the risk of developing MS. If you already have MS, being obese can also increase MS activity. This includes experiencing more flare-ups of the disease and forming more CNS lesions. 

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Diagnosing multiple sclerosis can pose challenges. Early signs of MS may be confused with symptoms of other diseases such as myasthenia gravis (a neuromuscular disease), lupus (another autoimmune disease), Lyme disease, or stroke. 

No test by itself can confirm or rule out MS. But your healthcare provider (HCP) may recommend additional tests to help with the diagnosis after discussing your symptoms and medical history and performing a thorough physical and neurological exam. Neurological tests may include those for: 

• Balance and coordination 
• Cognition (high-level brain functions) 
• Cranial nerve functions (such as facial sensation, hearing, strength, swallowing, and vision) 
• Reflexes 
• Other physical sensations 

There are also certain criteria that your HCP can use as part of their investigation to help reach a diagnosis of MS. These include finding evidence of damage in more than two different areas of the central nervous system along with indications that this damage took place at different points in time. Your HCP will use a variety of tests to help pinpoint these clues, while working to rule out other possible diagnoses. 

Blood tests to rule out causes other than MS 

Your HCP will likely order blood tests to rule out other health conditions that might be causing your symptoms. Examples of blood tests that might be ordered include: 

• Complete blood count (CBC): A CBC measures the various components of your blood (such as red blood cells, white blood cells, and platelets). Results can help detect a range of health conditions, including infectious diseases and anemia. 
• Thyroid stimulating hormone (TSH): TSH levels that are higher or lower than typical levels may indicate a thyroid disorder, whether hyperthyroidism or hypothyroidism. 
• Vitamin B12: This test rules out vitamin B12 deficiency as the cause of your symptoms.  
• Erythrocyte sedimentation rate (ESR): ESR shows how fast your red blood cells sink. An elevated ESR indicates higher levels of inflammation in your body. 
• Rheumatoid factor (RF): Being positive for this immune system protein can point to another autoimmune disease such as rheumatoid arthritis. 
• Antinuclear antibody (ANA): A positive ANA points more toward lupus than MS. 
• Extractable nuclear antigen (ENA): This test looks for the presence of ENA autoantibodies to further distinguish between other autoimmune disorders such as Sjögren syndrome. It may be ordered if your ANA comes back positive. 

Your HCP may also order other blood tests to test for conditions such as Lyme disease, syphilis, or HIV, as needed. 

MS lesions in MRI scan 

A magnetic resonance imaging (MRI) scan may show clear evidence of lesions in the brain or spinal cord that may be due to MS. It may also show multiple areas of damage or confirm that damage occurred at different points in time. 

CNS stimulation with evoked potential (EP) tests 

EP tests measure the electrical activity in your brain and spinal cord when painless electrical pulses, images, or sounds are delivered through an electrode placed on your scalp and other places on your body. They record how quickly and accurately your CNS responds to stimulation.  

EP tests can help confirm whether MS has damaged your auditory (hearing), visual, or sensory pathways and may reveal more subtle damage than a neurological exam may be able to catch. 

Cerebrospinal fluid (CSF) analysis for MS 

Your HCP might also perform a lumbar puncture (also called a spinal tap) to obtain a small sample of your CSF for testing. Myelin damage releases proteins called oligoclonal bands into CSF. These proteins wouldn’t be present in your blood sample, but your CSF sample may show elevated levels with MS.  

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Multiple sclerosis is divided into four main types: 

• Relapsing-remitting multiple sclerosis (RRMS) 
• Secondary-progressive multiple sclerosis (SPMS) 
• Primary-progressive multiple sclerosis (PPMS) 
• Progressive-relapsing multiple sclerosis (PRMS) 

Another condition, called clinically isolated syndrome (CIS), may occur prior to being diagnosed with MS.  

There is no way to fully predict the course of MS, as the disease can progress in different ways for different people. That said, the various types and phases of MS can include the following: 

Clinically isolated syndrome (CIS)  

Prior to being diagnosed with multiple sclerosis, you may experience an initial episode of symptoms caused by inflammation and damage to myelin in the CNS. This first episode tends to last at least 24 hours.  

CIS damage seen on your MRI scan is often confined to the area of the CNS causing the symptoms, unlike a confirmed diagnosis of MS, which shows multiple lesions. CIS may be limited to this one episode. That is, MS may or may not develop after this single episode. 

Relapsing-remitting multiple sclerosis (RRMS) 

Relapsing-remitting multiple sclerosis (RRMS) describes a cycle in which you experience MS symptom flare-ups—also called relapses, attacks, or exacerbations—followed by partial or complete recovery periods called remissions. 

During a relapse, the symptoms you already have may get worse or you may experience new symptoms. These symptoms may go away while in remission or they may persist or become permanent, but the disease often doesn’t progress further during recovery periods. 

RRMS is the most common MS experience. Around 85 percent of people with the disease have this type when they’re first diagnosed. 

Secondary-progressive multiple sclerosis (SPMS) 

Secondary-progressive multiple (SPMS) tends to follow RRMS once the disease progresses. Therefore, it’s often the second phase of MS. Unlike RRMS, this MS type doesn’t usually produce dramatic symptom variations. Rather, MS symptoms progress slowly and steadily with SPMS.  

Occasional relapses may occur with SPMS followed by periods when MS symptoms stabilize. Disability tends to develop slowly over time. 

Primary-progressive multiple sclerosis (PPMS) 

Around 10 to 15 percent of people are first diagnosed with primary progressive multiple sclerosis (PPMS). With PPMS, cycles of relapse and remission don’t occur. Instead, MS symptoms and disability progressively get worse from the onset with no noticeable exacerbations.  

Progressive-relapsing multiple sclerosis (PRMS) 

Progressive-relapsing multiple sclerosis (PRMS) is the rarest type of MS. MS symptoms and disability steadily get worse from the start with PRMS. Unlike PPMS, relapses occur with PRMS, although remissions may or may not happen. 

Are there other types of multiple sclerosis? 

There are also several rare and unusual variants of MS. These include: 

• Balo’s concentric sclerosis: Also called Balo disease or concentric sclerosis, this MS variant produces round concentric lesions that resemble the rings of a bull’s-eye when seen on an MRI scan. It can quickly destroy myelin, causing symptoms such as trouble speaking, thinking, or understanding others, muscle pain, spasms, and weakness, and possibly paralysis over time. 
• Fulminant multiple sclerosis: Also called Marburg variant MS or malignant MS, this type produces severe and unrelenting symptoms and a swift decline in function. These severe relapses often occur within five years following diagnosis, with marked disability and possibly death occurring soon after the onset of the disease. 
• Benign or inactive multiple sclerosis: In this form of the disease, a patient experiences minor or no changes in symptoms and disability over a 15-year period, although the disease can still progress at any time. 
• Burned-out multiple sclerosis: Although the term is somewhat controversial, it describes the dramatic slowdown in disease progression that may occur later in life with this form of the disease. 

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There’s currently no cure for multiple sclerosis. Scientists are investigating ways to repair neurological damage and restore function lost to MS. Myelin can restore itself to some extent, but axons can’t be repaired and damage to these nerve fibers often occurs during the earliest stages of the disease.  

That’s why early diagnosis and treatment are key to managing MS symptoms and curbing the progression of the disease. If you’ve been diagnosed, your HCP will discuss multiple sclerosis treatment options with you. 

Disease-modifying treatments (DMTs) for MS 

DMTs, also called immunomodulators, affect how your immune system functions. These FDA-approved multiple sclerosis treatments can help: 

• Suppress inflammation caused by MS 
• Slow disability progression 
• Decrease the number and severity of relapses, if you have them 
• Keep new lesions from forming 

Injectable DMT options include glatiramer acetate, interferon beta-1a, interferon beta-1b, ofatumumab, and peginterferon beta-1a. Oral DMT options include cladribine, dimethyl fumarate, diroximel fumarate, fingolimod, monomethyl fumarate, ozanimod, ponesimod, siponimod, and teriflunomide. Intravenously (IV) infused DMT options include alemtuzumab, mitoxantrone, natalizumab, ocrelizumab, and ublituximab-xiiy. 

DMTs can’t treat MS symptoms, nor are they effective at shortening a relapse once it’s started, so you and your HCP will discuss a multipronged approach to treating your MS. In addition to DMTs, therapies might include: 

Treatments for MS flare-ups 

Not all MS flare-ups require treatment. Mild relapse symptoms—such as intermittent episodes of fatigue that don’t significantly impact your daily activities and mild sensory changes such as slight numbness and tingling—may get better on their own without treatment. 

But severe relapses can impact mobility and your ability to function. They can also increase your chances of falling or being injured. 

In these situations, your HCP will likely recommend a short-term course of high-dose corticosteroids (also called glucocorticoids) to ease inflammation and shorten the length of a relapse. The most common treatment regimen used is a three- to five-day course of intravenous (IV) or oral corticosteroids.  

Other treatment options for MS flare-ups include: 

• H.P. Acthar Gel: This preparation of adrenocorticotropic hormone (ACTH) may be an option if you can’t tolerate corticosteroids. ACTH stimulates the adrenal cortex glands, located on top of the kidneys, to secrete the hormones cortisol, corticosterone, and aldosterone. 
• Plasmapheresis (plasma exchange): This “blood-cleansing” procedure separates plasma (the liquid portion of blood) from red and white blood cells, after which the cells are injected back into your body along with plasma replacement fluid. It may be used for certain autoimmune diseases since it removes the circulating antibodies thought to be triggering these diseases. 

Treatments for MS symptoms 

The treatment approach used will depend on which symptoms you have and how severe they are. Examples of medicines used to treat some MS symptoms include: 

• Bladder issues: darifenacin, desmopressin, imipramine, mirabegron, onabotulinumtoxin A, oxybutynin, solifenacin succinate, tamsulosin, tolterodine 
• Bowel issues: bisacodyl, docusate, gylcerin suppository mineral oil, musilloid, magnesium hydroxide, psyllium hydrophilic sodium phosphate 
• Depression: bupropion, citalopram, duloxetine hydrochloride, fluoxetine, paroxetine, sertraline, venlafaxine 
• Dizziness and vertigo: meclizine 
• Fatigue: dextroamphetamine and amphetamine, fluoxetine, modafinil, methylphenidate 
• Infection: ciprofloxacin, levofloxacin, methenamine, nitrofurantoin, phenazopyridine, sulfamethoxazole 
• Itching: hydroxyzine 
• Pain: amitriptyline, carbamazepine, duloxetine, gabapentin, lamotrigine, nortriptyline, oxcarbazepine, pregabalin, venlafaxine 
• Pseudobulbar affect: dextromethorphan and quinidine 
• Sexual issues: alprostadil, avanafil, tadalafil, vardenafil 
• Spasticity: baclofen, clonazepam, dantrolene, diazepam, onabotulinumtoxin A, tizanidine 
• Tremors: isoniazid 
• Ataxia (walking/gait issues): dalfampridine 

Rehabilitation therapy for multiple sclerosis 

Rehabilitation therapy is part of a comprehensive multiple sclerosis treatment plan. Your rehabilitation care team can help you address a range of everyday needs including personal hygiene, driving, exercise and leisure activities, speech and swallowing issues, thinking and memory issues, and moving around safely at home, work, and in the outside world. Rehab might involve learning to use assistive devices such as walkers or canes, retraining your muscles, or practicing new habits.  

Rehabilitation therapy includes: 

Cognitive rehabilitation: A neuropsychologist, occupational therapist (OT), or speech-language pathologist (SLP) can evaluate and treat cognitive issues such as your ability to think, focus, reason, and remember things. 

Occupational therapy: OTs help support your independence, productivity, and safety as they relate to personal hygiene, leisure activities, and employment. They teach you ways to conserve your energy, how to use adaptive tools and devices to simplify daily tasks, how to modify your home and workplace to improve accessibility, and how to improve thinking and memory issues. 

Physical therapy (PT): The goal of PT is to help you move and perform physical functions safely, while preventing complications of MS such as loss of muscle conditioning, muscle weakness, and shortening of muscles and connective tissue related to spasticity. A physical therapist can also help you learn pelvic floor exercises to address bladder and urinary issues. 

Speech-language pathology, also called speech-language therapy: SLP therapists can teach you how to articulate sounds and words with greater ease and clarity. They also prescribe oral strengthening exercises and show you safe swallowing techniques. 

Vocational rehabilitation: State vocational rehabilitation programs can help you maintain your current job or a find a new one that accommodates your needs. They offer job readiness training, coaching, and placement assistance, as well as mobility training and help using assistive technology. 

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Living with multiple sclerosis can be challenging. The following strategies can help you get on the path to living well with MS. 

Follow your MS treatment plan: This can help relieve MS symptoms and keep your condition from getting worse. Talk with your HCP about modifying your treatment plan if your condition changes or your treatments are no longer working well for you. 

Divide up household tasks: Break these up into smaller chunks of time throughout your day instead of trying to do too much too fast, and don’t pressure yourself to get it all done. If possible, share these responsibilities with others in your household. 

Eat whole, nourishing foods: Although there’s no specific diet for multiple sclerosis, the National MS Society recommends preparing meals at home as much as you can, eating colorful fresh fruits and vegetables daily, choosing whole grains over refined grains, and limiting or avoiding processed foods and added sugars. 

Quit smoking tobacco and avoid alcohol: Smoking can make MS symptoms and flare-ups worse and speed up the progression of the disease. Alcohol can impair your nervous system further and may interact dangerously with MS medications you take. 

Manage stress: Find healthy ways to cope with everyday stress and the added stress of having MS. You might try techniques such as deep breathing, meditation, journaling, spending time with loved ones and friends, and engaging in meaningful hobbies. 

Practice good sleep hygiene: Sleep disturbances, such as insomnia, are common in people with MS. Aim to get restful sleep on a regular basis by practicing good sleep hygiene techniques such as going to bed and getting up around the same time each day and engaging in relaxing activities such as reading or taking warm baths that help you wind down before bedtime. 

Seek counseling: Talking with a mental health provider about your fears, concerns, and stressors can help you sort through the emotions that might arise from having MS. Joining an in-person or online support group can help you connect with others living with the complexities of the disease. 

Share your MS diagnosis: You can share your MS diagnosis, along with your thoughts and concerns, with people you know to be compassionate and supportive. Doing so can strengthen your support network, but it’s important to do this in your own time and own way. 

Stay physically active: Water workouts such as swimming can help with range of motion. Yoga, Pilates, and tai chi can improve strength, balance, flexibility, and coordination. Trying adaptive sports at your local recreational center can connect you with other people who have learned how to stay active with MS. 

Stay socially active and stimulate your mind: A variety of activities can bolster high-level brain function. Try creative writing, listening to music or playing a musical instrument, reading, doing crossword puzzles, socializing, or having stimulating conversations with loved ones, neighbors, or online friends. 

Work with your employer on accommodations: Before disclosing your diagnosis with your employer, learn about your rights under the Americans with Disabilities Act (ADA). Work with your employer to restructure your environment to physically accommodate your needs, according to the ADA. This might include telecommuting from home, working flexible or reduced hours, or installing assistive equipment such as grab bars in restrooms. 

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