Multiple sclerosis (MS) is a progressive disease caused by demyelination of the white matter of the brain and spinal cord. (See Demyelination in multiple sclerosis.) In this disease, sporadic patches of demyelination throughout the central nervous system induce widely disseminated and varied neurologic dysfunction. Characterized by exacerbations and remissions, MS is a major cause of chronic disability in young adults.
The prognosis varies; MS may progress rapidly, disabling some patients by early adulthood or causing death within months of onset. However, 70% of patients lead active, productive lives with prolonged remissions.
The exact cause of MS is unknown, but current theories suggest a slow-acting or latent viral infection and an autoimmune response. Other theories suggest that environmental and genetic factors may also be linked to MS. Emotional stress, overwork, fatigue, pregnancy, and acute respiratory tract infections have been known to precede the onset of this illness.
MS usually begins between ages 20 and 40. It affects more women than men. A family history of MS and living in a geographical area with higher incidence of MS (northern Europe, northern United States, southern Australia, and New Zealand) increase the risk.
Clinical findings in MS depend on the extent and site of myelin destruction, the extent of remyelination, and the adequacy of subsequent restored synaptic transmission.
Signs and symptoms in MS may be transient, or they may last for hours or weeks. They may wax and wane with no predictable pattern, vary from day to day, and be bizarre and difficult for the patient to describe.
In most patients, visual problems and sensory impairment, such as numbness and tingling sensations (paresthesia), are the first signs that something may be wrong.
Other characteristic changes include:
❑ocular disturbances: optic neuritis, diplopia, ophthalmoplegia, blurred vision, and nystagmus
❑muscle dysfunction: weakness, paralysis ranging from monoplegia to quadriplegia, spasticity, hyperreflexia, intention tremor, and gait ataxia
❑urinary disturbances: incontinence, frequency, urgency, and frequent infections
❑emotional lability: characteristic mood swings, irritability, euphoria, and depression.
Associated signs and symptoms include poorly articulated or scanning speech and dysphagia. Clinical effects may be so mild that the patient is unaware of them or so bizarre that he appears hysterical.
A misdiagnosis of psychiatric problems is common. Because early symptoms may be mild, years may elapse between onset of the first signs and the diagnosis, which typically requires evidence of multiple neurologic attacks and characteristic remissions and exacerbations. Magnetic resonance imaging may detect MS lesions; however, diagnosis still remains difficult. Periodic testing and close observation of the patient are necessary, perhaps for years, depending on the course of the disease.
Abnormal EEG findings occur in one-third of patients. Lumbar puncture shows elevated gamma globulin fraction of immunoglobulin G but normal total cerebrospinal fluid (CSF) protein levels. Elevated CSF gamma globulin is significant only when serum gamma globulin levels are normal because it reflects hyperactivity of the immune system due to chronic demyelination. Oligoclonal bands of immunoglobulin can be detected when gamma globulin in CSF is examined by electrophoresis, and these bands are pres-ent in most patients, even when the percentage of gamma globulin in CSF is normal. In addition, the white blood cell count in CSF may rise. Differential diagnosis must rule out spinal cord compression, foramen magnum tumor (may mimic the exacerbations and remissions of MS), multiple small strokes, syphilis or other infection, and psychological disturbances.
The aim of treatment is to shorten exacerbations and relieve neurologic deficits so that the patient can resume a normal lifestyle. Those with relapsing-remitting courses are placed on immune modulating therapy, with interferon or glatiramer acetate. Steroids are used to reduce the associated edema of the myelin sheath during exacerbations.
Other drugs include baclofen, tizanidine, or diazepam to relieve spasticity, cholinergic agents to relieve urine retention and minimize frequency and urgency, amantadine to relieve fatigue, and antidepressants to help with mood or behavioral symptoms. During acute exacerbations, supportive measures include bed rest, comfort measures such as massages, prevention of fatigue, prevention of pressure ulcers, bowel and bladder training (if necessary), administration of antibiotics for bladder infections, physical therapy, and counseling. Physical therapy, speech therapy, occupational therapy, and support groups are also useful. Planned exercise programs help with maintaining muscle tone.
Management considerations focus on educating the patient and his family.
❑Assist with physical therapy. Increase patient comfort with massages and relaxing baths. Assist with active, resistive, and stretching exercises to maintain muscle tone and joint mobility, decrease spasticity, improve coordination, and boost morale.
❑Educate the patient and his family concerning the chronic course of MS. Emphasize the need to avoid temperature extremes, stress, fatigue, and infections and other illnesses, all of which can trigger an MS attack. Advise him to maintain independence by developing new ways of performing daily activities.
❑Stress the importance of eating a nutritious, well-balanced diet that contains sufficient roughage and adequate fluids to prevent constipation.
❑Evaluate the need for bowel and bladder training during hospitalization. Encourage adequate fluid intake and regular urination. Eventually, the patient may require urinary drainage by self-catheterization or, in men, condom drainage. Teach the correct use of suppositories to help establish a regular bowel schedule.
❑Promote emotional stability. Help the patient establish a daily routine to maintain optimal functioning. Activity level is regulated by tolerance level. Encourage regular rest periods to prevent fatigue and daily physical exercise.
❑Inform the patient that exacerbations are unpredictable, necessitating physical and emotional adjustments in lifestyle.
❑For more information, refer him to the National Multiple Sclerosis Society.
Review other book chapters online related to Multiple Sclerosis:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X 
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