Introduction
Multiple sclerosis (MS) is a disease affecting nerves in the brain and spinal cord, causing problems with muscle movement, balance and vision.
Each nerve fibre in the brain and spinal cord is surrounded by a layer of protein called myelin, which protects the nerve and helps electrical signals from the brain travel to the rest of the body. In MS, the myelin becomes damaged.
This disrupts the transfer of these nerve signals, causing a wide range of potential symptoms, such as:
Loss of vision – usually only in one eye
Spasticity – muscle stiffness that can lead to uncontrolled muscle movements
Ataxia – difficulties with balance and co-ordination
Fatigue – feeling very tired during the day
Types of multiple sclerosis
Around 8 out of 10 people with MS will have the relapsing remitting type of MS.
Someone with relapsing remitting MS will have periods of time where symptoms are mild or disappear altogether. This is known as remission and can last for days, weeks or sometimes months.
Remission will be followed by a sudden flare-up of symptoms, known as a relapse. Relapses can last from a few weeks to few months.
Usually after around 10 years, around half of people with relapsing remitting MS will go on to develop secondary progressive MS.
In secondary progressive MS, symptoms gradually worsen and there are fewer or no periods of remission.
The least common form of MS is primary progressive MS. In this type, symptoms gradually get worse over time and there are no periods of remission.
Treatment
There is currently no cure for MS but there are a number of treatments that can help.
Relapsing remitting MS and secondary progressive MS can be treated with disease-modifying drugs. These are designed to slow the progression of the disease and reduce the number of relapses. But they are not suitable for all people with MS.
For example at the moment, there is no treatment that can slow the progress of primary progressive MS.
There are also a wide range of treatments, including steroid injections and physiotherapy, that can help relieve symptoms and make day-to-day living easier.
Causes
MS is known as an autoimmune condition. This is where something goes wrong with the immune system (the body’s defence against infection) and it mistakenly attacks healthy body tissue – in this case, the myelin covering of nerves.
This can cause multiple sections of the brain and spinal column to become damaged and hardened (sclerosis), which can disrupt the nerve signals passing through these areas.
Exactly what causes the immune system to act in this way is unclear, but most experts think a combination of genetic and environmental factors are involved.
Who is affected
Symptoms usually first develop between the ages of 15 and 45, with the average age of diagnosis being about 30.
For reasons that are unclear, MS is twice as common in women than men, and more common in white people than black and Asian people
Outlook
MS can be a challenging and frustrating condition to live with but new treatments over the past 20 years have considerably improved the quality of life of people with the disease.
MS is not fatal, but some complications which can arise from more severe MS, such as pneumonia, can be.
As a result, the average life expectancy for people with MS is around 10 years lower than the population at large.
Symptoms of multiple sclerosis
The central nervous system (brain and spinal cord) controls all of your body's actions. When MS damages the nerve fibres that carry messages to and from your brain, symptoms can occur in any part of your body.
There are many different symptoms of MS and they affect each person differently. Some of the most common symptoms include:
Numbness and tingling
Blurring of vision
Problems with mobility and balance
Muscle weakness and tightness
Most people with MS only have a few of these symptoms and it is unlikely someone would develop all possible symptoms.
The symptoms are unpredictable. Some people's MS symptoms develop and increase steadily over time, while for others, they come and go periodically.
Periods when symptoms get worse are known as relapses. Periods when symptoms improve or disappear are known as remissions.
Visual problems
In around one in five cases of MS, the first noticeable symptom is problems with one of your eyes. You may experience:
Some loss of vision in the affected eye – this can range from mild to severe (total loss of vision occurs in 1 in 35 cases)
Colour blindness
Eye pain; usually made worse when moving the eye
Flashes of light when moving the eye
These symptoms are the result of optic neuritis, which is inflammation (swelling) of the optic nerve that transmits visual information to the brain. This normally only affects one eye.
Other visual problems that can occur in MS include:
Double vision
Eye pain in both eyes
Involuntary eye movements (usually from side to side), known as nystagmus
Abnormal sensations
Abnormal sensations can also be a common initial symptom of MS. This can take the form of numbness or tingling in different parts of your body.
Muscles in your arms and legs may also feel unusually weak.
Muscle spasms and spasticity
MS can damage nerve fibres in your brain and spinal cord, which can cause muscles to contract tightly and painfully (spasm). Your muscles may also become stiff and resistant to movement, which is known as spasticity.
Pain
Around half of people with MS experience pain, which can take two forms:
Neuropathic pain – caused by damage to the nerve fibres in the brain and spinal cord. It can be a stabbing pain, extreme skin sensitivity, or a burning sensation.
Musculoskeletal pain – this is not caused directly by MS, but can occur if there is excess pressure on muscles or joints as a result of spasms and spasticity.
Mobility problems
MS can affect balance and co-ordination. It can make walking and moving around difficult, particularly if you also have muscle weakness and spasticity. You may experience:
Ataxia – difficulty with co-ordination
Tremor – shaking of the limbs, which is rare, but can be severe
Dizziness and vertigo can happen late on and can make you feel as if your surroundings are spinning
Extreme tiredness (fatigue)
Feeling extremely tired (fatigue) is a common symptom of MS that many people describe as one of the most troublesome.
It is estimated as many as 9 out of 10 people with MS will experience episodes of fatigue.
People with MS have reported feeling an overwhelming sense of weariness where even the most simple physical or mental activity seems to be a tremendous struggle to carry out.
Fatigue may be worse in hot weather, after exercising, or during illness.
Problems with thinking, learning and planning
Around half of people with MS have problems with thinking, learning and planning (known as cognitive dysfunction) in the early stages of the disease. They may experience:
Problems understanding and using language
A shortened attention span
Problems learning and remembering new things (long-term memory is usually unaffected)
Problems understanding and processing visual information, such as reading a map
Difficulty with planning and problem solving – people often report that they know what they want to do, but can’t grasp the method of how to do it
Problems with reasoning, such as mathematical laws or solving puzzles
Mental health issues
Around half of all people with MS experience at least one episode of depression at some point in their life.
It is unclear whether the depression arises from the damage to the brain caused by MS, or due to the stress of having to live with a long-term condition, or both.
Anxiety can also be a problem for people with MS, especially during the start of a relapse, as they are naturally anxious about the return of their symptoms.
Some people with MS can sometimes experience rapid and severe mood swings, suddenly bursting into tears, laughing or shouting angrily for no apparent reason.
Sexuality
Many people with MS lose interest in sex.
Men with MS often find it hard to obtain or maintain an erection (erectile dysfunction). They may also find it takes a lot longer to ejaculate when having sex or masturbating, and may even lose the ability to ejaculate altogether.
Women may find it more difficult to achieve orgasm.
Bladder problems
Bladder problems are common in MS.
These may include:
Difficulty emptying the bladder completely
Having to urinate more frequently
Having a sudden, urgent need to urinate which can lead to unintentionally passing urine (urge incontinence)
Having to get up frequently during the night to pass urine (nocturia)
Constipation
Constipation affects around half of people with MS. They may pass stools much less frequently than normal, and find this difficult.
Severe constipation can lead to faecal impaction, where a large, solid stool becomes stuck in the back passage (rectum) and begins to stretch the muscles of the rectum, weakening them. This can cause loss of normal bowel control (bowel incontinence), where watery stools leak out.
Causes of multiple sclerosis
Multiple sclerosis (MS) occurs because of damage to the nerve fibres of the central nervous system. Your central nervous system consists of the brain and spinal cord and is responsible for controlling every action, conscious and unconscious, of your body.
Myelin
When you perform an action, your brain sends messages to the appropriate part of your body through the nerve fibres in your spinal cord. These nerve fibres are covered by a substance called myelin. Myelin insulates the nerve fibres and helps carry messages to and from your brain quickly and smoothly. In MS, the myelin around your nerve fibres becomes damaged. This disturbs the messages coming to and from your brain.
Autoimmune condition
MS is an autoimmune condition. This means your immune system mistakes the myelin for a foreign substance and attacks it. The myelin becomes inflamed in small patches (called plaques or lesions), which can be seen on an MRI scan. This process is called demyelination.
Demyelination disrupts the messages travelling along nerve fibres. It can slow them down, jumble them, accidentally send them down a different nerve fibre, or stop them from getting through completely.
When the inflammation goes away, it can leave behind scarring of the myelin sheath (known as sclerosis) and sometimes damage to the underlying nerve cell.
Why do people develop multiple sclerosis?
It is not understood what causes the immune system to attack myelin, although there are several theories. Most experts agree that MS is probably caused by a combination of genetic and environmental factors. This means it's partly due to genes you inherit from your parents and partly due to outside factors that may trigger the condition.
Genetic factors
MS is not defined as a genetic condition because there is no single gene that causes it. It's not directly inherited, although research has shown people who are related to someone with MS are more likely to develop it.
Researchers have found that if one twin develops MS then the second twin has around a one in four chance of also developing MS.
The chances of a brother, sister, or child of a person with MS also developing MS themselves is less than 1 in 30.
It's possible that different combinations of genes make developing MS more likely, and research into this is continuing. However, genetic theories cannot explain the wide variation in occurrences of MS throughout the world.
Sunlight and vitamin D
Research into MS around the world has shown that it's more likely to occur in countries far from the equator. For example, MS is relatively common in the UK, North America and Scandinavia, but rare in Malaysia or Ecuador.
It’s possible that people living further from the equator are exposed to less sunlight and, therefore, have less vitamin D in their bodies. Some studies have found a link between lower levels of vitamin D and incidence of MS.
Some researchers have suggested that vitamin D supplements may reduce the risk of MS. However, this has not been proven.
Viral infection
Another theory is that MS may be the result of viral infection of the nervous system and /or the immune system.
The idea is that the virus lies dormant for many years and then periodically ‘re-awakens’, triggering an autoimmune response against the nervous system.
This could explain the relapse-remission nature of most cases of MS.
A virus called the Epstein-Barr virus (EBV) is known to act in this way, but there is currently no firm evidence that EBV, or any other virus, is responsible for MS.
Problems with blood flow
A new and controversial theory is that some cases of MS may actually be due to problems with the flow of blood inside the body.
The idea is that some people may have narrowing of veins inside their brain and spinal cord and the blood supply from the brain and spine has trouble returning to the heart (known as cerebrospinal venous insufficiency).
This could lead to a build-up of tiny iron deposits inside nerve tissue, which may damage the nerves and /or trigger an immune response.
Some studies have found higher-than-expected levels of cerebrospinal venous insufficiency in people with MS, but others have not.
Further research is ongoing looking at larger groups of people and using more sophisticated brain imaging scanning.
Diagnosing multiple sclerosis
If you have unexplained symptoms that are similar to those of multiple sclerosis (MS), see Dr. B C Shah. If Dr. B C Shah suspects MS, they will ask you for a detailed medical history, including past signs and symptoms as well as the current state of your health.
Dr. B C Shah can refer you to a neurologist (a specialist in conditions of the central nervous system).
If Dr. B C Shah suspects MS, you should see a neurologist within six weeks.
Diagnostic tests
Diagnosing MS is complicated because no single laboratory test can positively diagnose it.
Several conditions have symptoms similar to those of MS, so your neurologist may rule them out first.
It may also not be possible to confirm a diagnosis if you have had only one ‘attack’ of MS-like symptoms. A diagnosis can usually only be made with confidence once a person has a relapse (return of symptoms).
To confirm MS, your neurologist may carry out a number of tests.
Neurological examination
Your neurologist will look for changes or weakness in your eye movements, leg or hand co-ordination, balance, speech and reflexes. This will show whether your nerve pathways are damaged.
Magnetic resonance imaging (MRI) scan
An MRI scan creates a detailed image of your brain and spinal cord.
MRI scans can show whether there is any damage or scarring of the myelin in your central nervous system. Over 9 out of 10 people with MS are diagnosed using an MRI scan.
The procedure is painless and usually takes between 10 and 30 minutes. A standard MRI scanner is like a giant tube or tunnel. You may feel claustrophobic when going into the tunnel and the machine is noisy.
Tell your neurologist if you have any concerns about this experience.
Evoked potentials test
An evoked potentials test involves placing small electrodes on your head. These monitor how your brain waves respond to what you see and hear. It is painless and can show whether it takes your brain longer than normal to receive messages.
Lumbar puncture
A lumbar puncture is also sometimes called a spinal tap. A sample of your cerebrospinal fluid (the fluid that surrounds your brain and spinal cord) is taken using a needle inserted into the area around your spinal cord.
This is done under local anaesthetic, which means that you will be awake but the area that the needle goes into will be numbed. The sample is tested for antibodies, the presence of which means that your immune system has been fighting a disease in your central nervous system.
A lumbar puncture is usually only needed if other tests for MS are inconclusive.
Blood tests
Blood tests are usually performed to rule out other causes of your symptoms, such as vitamin deficiencies. In addition, antibody tests may be required, for example to rule out a special type of MS called Devic's disease.
Diagnosing the different types of multiple sclerosis
Once a diagnosis of MS has been made, your neurologist may be able to identify which type of MS you have.
However, this often only becomes clear over time as the symptoms of MS are so varied and unpredictable.
A diagnosis of relapsing remitting multiple sclerosis (RRMS) may be made if:
You have two relapses of your symptoms more than 30 days apart
You have one relapse and an MRI scan shows new myelin damage or scarring three months later
A diagnosis of secondary progressive multiple sclerosis (SPMS) may be made if:
You have had relapses of your symptoms in the past
You have become steadily more disabled for at least six months, with or without relapses
A diagnosis of primary progressive multiple sclerosis (PPMS) may be made if you have had no previous relapses of your symptoms, and:
You have become steadily more disabled for at least one year
An MRI scan shows damage and scarring to myelin
a lumbar puncture shows antibodies in the fluid surrounding your brain and spinal cord
Treating multiple sclerosis
Multiple sclerosis (MS) is a complex disorder that can impact on many aspects of your life so you will need to receive treatments from Dr. B C Shah and his team working together.
Members of your care team may include:
A neurologist (a specialist in treating conditions that affect the nervous system)
A physiotherapist
A speech and language therapist
An occupational therapist
An incontinence adviser
A psychologist
A pharmacist
A specialist MS nurse who will often serve as a point of contact
Living with multiple sclerosis
A diagnosis of MS is life changing. You may need long-term treatment to control your symptoms and you may have to adapt your daily life.
Self-care
Self-care is an integral part of daily life. It means you take responsibility for your own health and wellbeing, with support from people involved in your care. Self-care includes the things you do each day to stay fit, maintain good physical and mental health, prevent illness or accidents, and effectively deal with minor ailments and long-term conditions. People living with long-term conditions can benefit enormously if they receive support for self-care. They can live longer, have less pain, anxiety, depression and fatigue, have a better quality of life, and be more active and independent.
Regular reviews
Because MS is a long-term condition, you'll be in regular contact with your healthcare team. A good relationship with the team means you can easily discuss your symptoms or concerns. The more the team knows, the more they can help you.
Keeping well
Everyone with a long-term condition such as MS is encouraged to get a flu jab each autumn to protect against flu (influenza). It's also recommended that they get an anti-pneumoccocal vaccination. This is a one-off injection that protects against a specific serious chest infection called pneumococcal pneumonia.
Healthy eating and exercise
Regular exercise and a healthy diet are recommended for everyone, not just people with MS. They help prevent many conditions, including heart disease and many forms of cancer. Try to eat a balanced diet, containing all the food groups, to give your body the nutrition it needs. Exercising regularly can help relieve stress and reduce fatigue.

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