Assessment of the Multiple Sclerosis Patient

 

Multiple Sclerosis (MS) is a very challenging condition to diagnose and manage. Symptoms are variable between different patients. The disease can progress at irregular paces, while relapses and remissions occur in irregular and even confusing patterns. Understanding how MS acts in this way is important for its diagnosis and treatment. The assessment of the MS patient is more than just a regular neurological assessment.

 

How is evaluation of MS performed?

 

We use specific clinical scores that are performed at the bedside. During clinical studies, two different scales are used:

  • Functional Systems Scores (FSS)

  • The Kurtzke Expanded Disability Status Scale (EDSS)

 

Both of these assessments examine eye and facial function, strength and reflexes, muscle tone, coordination, sensation, bowel and bladder function and the extent of fatigue, problems with thinking and memory and other functions.

 

How is MRI used in MS?

 

MRI is our best tool to see the impact of MS within the brain and spinal cord. It shows the lesions due to MS, but also shows the loss of brain matter (see below images). It can show where new lesions occur and also where active lesions develop.

 

MS lesions appear as white spots on different forms of MS scanning. They tend to occur in particular locations that help physicians in determining their nature.

 

Some conditions can appear as MS, but are not. Other testing may be useful to help differentiate these conditions.

What is the cause of damage in MS?

  • Multiple sclerosis was called such due to multiple areas of the nervous system being affected by scar tissue (sclerosis). These lesions, or plaques as they are called, slow or block signal transmission between areas in the brain and from the spinal cord and the brain. Signals from the brain are required to tell your muscles how to move. Also, signals from the spinal cord are received at the brain for recognizing sensations. Due to MS plaques, movement and sensation are impaired. 


We do not completely understand how MS occurs, but it is clear that an autoimmune process plays an important role. There are also genetic and environmental factors. Doctors have speculated that viral infections, vitamin D levels, and exposure to sunlight and the outdoors play roles.

There are different patterns of MS, expressed as three categories:

  • Relapsing-Remitting MS: in this case, symptoms fluctuate and come and go. There can be long periods of good health, callde remission, followed by sudden symptoms or relapses. This is the most common presentation at the start of MS.

  • Secondary Progressive MS: This can follow from Relapsing-Remitting MS. In this case, the condition is more steadily progressive with worsening symptoms and fewer remissions. About half of patients with Relapsing-Remitting MS  develop Secondary Progressive MS within the first decade after onset.

  • Primary Progressive MS: In this fortunately less common form, symptoms worsen from the beginning without remission. Symptoms gradually develop further and continue to worsen over time

 

When acute attacks occur, these are followed by remissions. During that time, myelin can repair to some extent (remyelination). However, as disease progresses or worsens, this process is less successful and less frequent.

 

What is the epidemiology of MS?

 

In general, the global distribution of MS increases as one moves away from the equator. That is, in areas further north or south of the equator, MS is more common. However, there are locations that do not follow this rule.

 

MS usually starts in early adult life, with the first episode often occurring in 20-45 year old patients. About 1 in 1,000 have MS, but this varies by location. In Canada, proportions can be higher in some locations. Females are more commonly affected than males by a ratio of 3:2. People of Caucasian descents have the highest risk for MS. 

 

Family history can be important, as 4% of people with a first-degree relative with MS will develop the condition. As many as 20% of MS patients have a relative with MS.

 

Pregnancy does not influences the overall course of MS over time. However, women with MS who become pregnant will have lower risks of relapses during their pregnancy, with this increasing for a short time postpartum.

 

How is the Diagnosis of MS made?

 

There is no single specific diagnostic test that can give the diagnosis of MS. MRI by itself cannot make the diagnosis of MS. In most cases, the diagnosis should be made clinically by a Neurologist.

 

In cases where another condition may be present, further investigations will be performed 

 

In general, Neurologists identify dissemination in space and time - this means that at least two separate lesions apparent on clinical exam and on MRI meeting specialized McDonald criteria can be used to make the official diagnosis. This objective evidence of dissemination in time and space for the MS lesions is critical.

 

In some cases, historical reports of symptoms experienced by patients may suggest prior demyelinating episodes, but this cannot be used to make the diagnosis without objective evidence.

 

In some cases, other tests such as visual evoked potentials and a lumbar puncture can be used to assist in making the diagnosis.

 

How does MS present?

 

There is a wide range of symptoms and signs possible with MS. Some doctors call MS "the great mimicker" because it can appear to be other diseases at first.

 

The most common effects of MS are upon:

 

  • Vision:

    • This is very common, and is due to demyelination of the optic nerve.

    • This can lead to blindness in some cases, or simply blurred vision in other cases.

    • Optic neuritis often is painful

    • MS can affect vision in other ways as well

 

  • Eye Movements:

    • This is also very common

    • This will often lead to double vision.

    • Shaking of the eyes, called nystagmus can often be seen and sometimes noticed.

 

  • Face weakness, numbness and pain:

    • This can be one side or both sides of the face.

    • Trigeminal neuralgia can result, giving severe facial pain.

    • Numbness over portions of the face is sometimes seen.

 

  • Hearing and Balance:

    • Deafness can sometimes occur

    • Imbalance of walking and unsteadiness are common.

    • Clumsiness in walking and using the arms and legs is common.

    • There can be vertigo, vomiting, ataxia and headache in some cases.

 

  • Cognitive symptoms:

    • Attention spans may be affected beginning in the early stages of MS

    • A decline in intelligence can occur as the disease progresses, with loss of memory and inability to form new memories most affected.

 

  • Psychological Symptoms:

    • Depression is common, and sometimes anxiety and even psychosis can occur

 

  • Unpleasant Sensations or Pain:

    • A number of abnormal sensations can occur over the torso and over the limbs. These can include burning, stabbing, shooting and pressure sensations.

    • There can be loss of thermal and pain sensation.

    • Tingling to different regions will be frequent.

    • Loss of joint position sense to the arms and legs can lead to clumsiness and inability to walk without assistance.

 

  • Autonomic system:

    • Bladder problems including incomplete or sudden emptying can be difficult to manage. There can be urgency and frequency of bladder voiding, with incontinence (leakage) occurring. In some cases, bowel incontinence can be present.

    • Sexual problems can occur in men (impotence) and women (reduced lubrication)

 

  • Spasticity

    • This can lead to muscles and limbs stuck in place

    • In some cases, this can lead to inability to perform functions, may limit walking, and lead to skin infection and breakdown

 

How can MS be managed?

 

There are many important aspects to MS management beyond just medicines. MS patients should have:

  • Good communication with doctors, nurses and other health professionals performing their care.

  • Education and information provided regarding the disease, treatments and possible forms of help and support.

  • Support with rehabilitation, employment and mobility as needed.

  • Encouragement towards self management as much as possible.

  • Family support including respite care if possible.

  • Teamwork between all health professionals involved in caring for the patient.

 

Pharmacological treatments are performed in certain circumstances, and should be discussed with your doctors. 

 

What other features of MS can be managed?

 

  • Fatigue:

    • Underlying causes, such as depression, insomnia, chronic pain and poor nutrition may be causative.

    • In some cases, medication may cause fatigue, such as with beta interferon.

    • Aerobic exercise can be helpful if possible.

    • Amantadine may be helpful in some patients.

    • Another medication called Modafinil may be helpful in some patients.

 

  • Pain:

    • This may be due to nervous system lesions (neuropathic) or may be due to musculoskeletal problems related to reduced mobility, or both.

    • Suitable medications, including some antidepressant medication such as duloxetine or amitriptyline may be helpful.

    • Also, anticonvulsants such as gabapentin or pregabalin may be helpful

    • Cognitive behavioural treatment methods may be beneficial in some patients.

 

  • Visual problems:

    • An ophthalmological opinion may be needed.

    • If nystagmus is contributing to poor vision, gabapentin can sometimes help

    • Low-vision equipment and adaptive technology may be needed in more severe cases.

 

  • Speech difficulties:

    • Slurred speech may require a speech and language therapist consultation.

    • In some cases, alternative non-verbal means of replacing speech are necessary such as speech recognition or writing devices

 

  • Weakness:

    • Exercises to maximise strength and endurance, including aerobic training, are often recommended.

    • Equipment, such as orthoses, canes, crutches, or wheel chairs/scooters may be required.

 

  • Spasticity and spasms:

    • Pain and infection can worsen spasticity and should be examined for.

    • Passive stretching to reduce spasticity and avoid contracture development is important.

    • Baclofen or gabapentin are usually tried first.

    • Tizanidine, clonazepam, or dantrolene should only be used when treatment with baclofen or gabapentin is insufficient. 

    • Severe spasticity and spasms may require Intramuscular botulinum toxin to treat localised hypertonia or spasticity 

    • If contractures develop at joints, specific treatments include prolonged stretching and use of serial plaster casts.

 

  • Pressure ulcers:

    • Many patients with MS are at high risk of developing pressure ulcers due to limited mobility, reduced sensory functioning and reduced cognitive function.

    • Most pressure ulcers can be avoided, but if present, must be treated early.

 

  • Bladder symptoms:

    • urinary tract infections can be common

    • Urgency or urge incontinence may require drains (men) or pads (women). Specialized commodes or locations are needed in some cases. Intermittent self-catheterisation may be required if a high residual volume occurs. Anticholinergics may be helpful to treat this.

    • Desmopressin may be used for nocturnal incontinence or to control urinary frequency during the day

    • Continued incontinence, despite treatment, can be treated by a course of pelvic floor exercises preceded by a course of electrical stimulation of the pelvic floor muscles.

 

  • Gastroenterology Problems:

    • Bowel urgency, abdominal pain, or incontinence may develop.

    • Fecal incontinence is possible.

    • Constipation may require use of laxatives, suppositories or enemas.

 

  • Swallowing difficulties:

    • Choking and even aspiration of food or liquid can occur, the latter of which can lead to lung infections.

    • If swallowing is problematic, a speech and language therapist should assess and provide advice

    • In some cases, short term nutritional support via nasogastric tube or even a percutaneous endoscopic gastrostomy (PEG) tube may be required.

 

  • Cognitive problems:

    • Impaired memory and thinking abilities, planning, concentrating and processing information correctly and quickly can occur.

    • Sometimes medication and depression can impair these functions.

    • Neuropsychology assessment is sometimes needed.

    • Excessive emotions, including laughing or crying without good reason can be present.

    • Depression is a common occurrence in MS. Chronic pain, disability, social isolation, and factors unrelated to MS can contribute. Interventions should be appropriate to the cause, and antidepressant medications and cognitive behavioural therapy may be helpful.

    • Anxiety can also be prevalent in a disease where it is uncertain when or if it may wornen. This may require psychology intervention or medication as with antidepressants or short term benzodiazepines.

 

  • Sexual dysfunction

    • spasms may make normal sexual behaviour difficult

    • assistance with erections or female sexual function can sometimes be helpful

 

What is the overall prognosis of MS?

 

  • This is always uncertain. Some patients may spend several years in each of phases of MS, while a few will quickly progress to greater progressive disability.

  • While approximately 25% of patients have a non-disabling form of MS, 5% have frequent relapses without recovery - this leads to rapid disability. In the worst case scenario, up to 15% of patients are severely disabled soon after diagnosis or onset.

  • In general, episodes start at approximately 1.5 episodes/year with recovery being slower than onset of symptoms. As well, recovery may be incomplete.

MS leads to loss of myelin seen as plaques in the white matter. In this sagittal brain MRI scan, they appear as white oval or streak abnormalities. In this brain, they affect the corpus callosum which bridges the two sides of the brain

In additon to the damage of myelin, seen here in the corona radiata level in an axial MRI scan of brain, MS also leads to loss of grey matter, which appears grey in this scan. 

MS affects the spinal cord as well as the brain. In this picture, three large ovoid lesions of damaged myelin are seen as in this sagittal MRI scan of the cervical spine. These can be even more disabing than the brain lesions in some cases, as these lesions can lead to weakness affecting the limbs, loss of sensation, loss of bowel and bladder control, and inability to walk. 

Burnaby Neurology

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