Multiple sclerosis (MS): causes, symptoms, therapy, prognosis
Multiple sclerosis (MS, Encephalomyelitis disseminata) is a chronic inflammation of the nervous system. This destroys nerve structures, which results in a wide range of symptoms. There is no cure for the disease, but its progression can be alleviated with medication. Read more about the autoimmune disease multiple sclerosis, its causes, symptoms and treatment.
Multiple Sclerosis: Short overview
- Common first symptoms: Sensory disturbances in the legs, severe fatigue, problems when defecating, insecurities when walking and standing, visual disturbances in one eye, etc.
- Important research: Physical and neurological examination, evoked potentials, magnetic resonance imaging (MRT), cerebrospinal fluid diagnostics, blood and urine tests
- Treatment: medication (push therapy, basic therapy), symptomatic therapy measures and rehabilitation (physiotherapy, occupational therapy, moderate sports, psychotherapy, etc.).
- Prognosis: MS is not curable, but its course can be positively influenced by consistent treatment (fewer relapses, slower progression of the disease, improved quality of life)
What is multiple sclerosis?
Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS: spinal cord and brain, including the optic nerve). Nerve structures become inflamed, which triggers various complaints such as visual and sensory disturbances, pain or paralysis. So far, multiple sclerosis is not yet curable. However, the course of the disease can be favourably influenced by medication.
Multiple sclerosis usually begins in early adulthood between the ages of 20 and 40. Women are approximately twice as likely to develop MS as men.
Multiple Sclerosis: Symptoms
Multiple sclerosis occurs in most cases completely unexpectedly and out of complete well-being. In many cases, the first signs of MS develop relatively quickly within hours or days. Only in a few patients does the disease begin slowly, sometimes with fewer, sometimes more severe symptoms, so that those affected hardly notice that something is seriously wrong. Some patients have few MS symptoms, others have several at once.
The symptoms can therefore be very different for each person concerned. MS is therefore also called the “disease with a thousand faces”. The following table shows the type and frequency of the first multiple sclerosis symptoms (according to Krämer/Besser):
|First symptoms of multiple sclerosis||Frequency in percent|
|Sensory disturbances in the legs||30|
|Uncertainties when walking and standing||18|
|Unilateral visual impairment||16|
|Emotional disorders in the arms||10|
|Gait disorders due to spasticity (muscle cramps)||10|
|Weakness in the legs||10|
|Bladder emptying disorders||6|
|Crying in the arms||5|
|Paralysis of the face (trigeminal neuralgia)||5|
|Lhermitte’s sign (tingling in the neck when head is bent over)||3|
|Paralysis of one side of the body – arm and leg (hemiplegia)||2|
In more than one third of patients, the first symptoms of multiple sclerosis are emotional disturbances: Arms or legs feel numb, or the skin tingles. Every fifth patient feels more tired than usual and is quickly exhausted, has problems with bowel movements or feels insecure when walking or standing.
A visual impairment in one eye is the first sign of multiple sclerosis in about 16 percent of patients. Some patients suffer from weakness (mostly in the arms, less often in the legs), cannot empty their bladder properly or are in pain. Speech disorders and hemiplegia are rarely the first symptoms of MS.
Sometimes the beginning of the disease is accompanied by only one symptom. However, several symptoms may occur simultaneously.
Multiple Sclerosis: Signs in the further course
Multiple sclerosis can take a different course in each patient. Mostly it is a relapse, i.e. there is always an acute worsening of the symptoms (relapse). After a first episode, the symptoms may disappear completely or partially and reappear after a while. Sometimes other symptoms are added, which can also go back again. In some cases, the symptoms increase steadily from the beginning and relapses cannot be detected.
Type and frequency of multiple sclerosis symptoms in the course of the disease are (according to Krämer/Besser)
|Multiple sclerosis symptoms in the course||Frequency in percent|
|Gait disorders due to spasticity (muscle cramps)||90|
|Weakness in the legs||90|
|Sensory disturbances in the legs||85|
|Uncertainties when walking and standing||80|
|Bladder emptying disorders||80|
|Unilateral visual impairment||75|
|Sexual disorders (men)||75|
|Cognitive disorders (such as concentration problems)||70|
|Uncertainty in target and pointing movements||50|
|Mental disorders (especially depression)||50|
|Sexual disorders (women)||50|
|Paralysis of the face (trigeminal neuralgia)||30|
|Lhermitte’s sign (tingling in the neck when head is bent over)||30|
|Emotional disorders in the arms||30|
|Crying in the arms||22|
More than half of the patients have gait and balance disorders or spasticity (muscle cramps) during the course of their multiple sclerosis disease. They are often very tired (fatigue), have a feeling of weakness in their arms or legs or are unable to empty their bladder properly. Men can get erectile dysfunction, women lose interest in sex. Three out of four multiple sclerosis patients have impaired vision in one eye, some see everything twice.
In at least every second patient, uncertainties occur in target and pointing movements, psychological disorders (such as depression), speech disorders, cognitive disorders (such as concentration disorders) or bowel movement disorders.
Less frequent complaints are, for example, headaches, pain or paralysis in the face, pain in the body, loss of sensation or strength in the arms or a tingling in the neck when the head is bent.
Multiple Sclerosis: Causes
Most experts suspect that multiple sclerosis is based on an incorrect reaction of the body’s own immune system (autoimmune disease) – in other words, that it is an autoimmune disease:
Defense cells (immune cells) of the body, which normally render invaders such as viruses or bacteria harmless, are directed against the body’s own structures. They are therefore called autoantibodies. In MS, they cause white blood cells (leukocytes) to attack nerve tissue and cause inflammation. The sheaths of the nerve fibres (myelin sheaths) are destroyed, which is called demyelination. The nerve fibres and nerve cells themselves are also damaged.
Patients have numerous (multiple) areas in the brain and spinal cord with myelin damage and subsequent scarring (sclerotherapy). These areas are called plaques.
As a result, nerve signals can no longer be transmitted correctly – nerve failure occurs. These can manifest themselves in a variety of ways because the inflammations (centres of inflammation) can occur in all areas of the CNS. This is why multiple sclerosis is often called “Encephalomyelitis disseminata”. The word “disseminata” means “scattered”, while the term “encephalomyelitis” refers to the basic processes of the disease: “Enkephalos” stands for brain, the suffix “-itis” for “inflammation”.
But why does the immune system get so confused in MS that it attacks its own nerve tissue? The experts do not know for sure, but suspect that several factors come together in those affected, which together trigger the disease.
In multiple sclerosis, the nerve sheaths are so damaged that the nerve fibres are partially exposed. This leads to disturbed stimulus transmission.
To a certain extent, multiple sclerosis is hereditary, experts believe: Studies with twins showed that identical twins of MS patients have a 25 to 30 percent higher risk of developing multiple sclerosis than the normal population. The risk is five percent higher in fraternal twins. Parents and children of an ill person still have a two to three times higher risk of multiple sclerosis. The risk decreases the less you are related to a sick person.
It is not clear which genes are involved in the development of multiple sclerosis. For example, changes in the HLA-DRB1 antigen, the apolipoprotein E or the interferon gamma gene could play a role. However, experts believe that it is not a single gene that can cause MS, but that several genes are involved in the development of the disease.
Some experts discuss whether infections also play a role in the onset of multiple sclerosis. These include infections with the measles virus, the human herpes virus 6 (HHV-6) and especially with the Epstein-Barr virus (EBV). The latter triggers the disease Pfeiffer’s glandular fever (infectious mononucleosis). Antibodies against EBV circulate in the blood of almost all multiple sclerosis patients. In the general population, this is only the case for about 60 percent of the people.
In one study, researchers also found a possible link between MS and certain Chlamydia bacteria (Chlamydia pneumoniae). Subsequent studies could not confirm this suspicion.
Overall, researchers do not believe that a particular infectious disease can directly trigger multiple sclerosis. Rather, it is thought that, in general, the immune system’s responses to infection may trigger the development of MS in people with the disposition to do so.
Lifestyle and environment
Environmental factors or a certain lifestyle may also be involved in the development of multiple sclerosis. However, a link between lifestyle or environmental factors and MS, as demonstrated by studies, is not necessarily causal: Multiple sclerosis cannot be triggered by a “bad”, unhealthy lifestyle alone!
Smoking is considered a possible environmental triggering factor for MS. It is said to increase the risk of multiple sclerosis and accelerate the course of the disease.
Another risk factor for multiple sclerosis could be the amount of vitamin D in the body: People who were exposed to more sunlight as children and whose bodies produced more vitamin D as a result were less likely to develop multiple sclerosis than people with lower vitamin D levels. Researchers became interested in vitamin D because the incidence of multiple sclerosis seems to be related to the latitude in which one lives: the further away from the equator (north or south), the more common MS is. This suggests a connection with sun exposure. However, the Inuit in Greenland are less likely to develop MS than other peoples. The reason for this could be the Inuit’s traditional vitamin D-rich diet. However, the link needs to be explored in more detail.
Women get multiple sclerosis much more often than men. One reason for this could be that women are more likely to go to the doctor and therefore the disease is more frequently diagnosed in them. On the other hand, the gender difference could be caused by environmental factors that are as yet unknown.
There are other factors that are suspected to be involved in the development of multiple sclerosis. These include overweight and excessive consumption of salt. The intestinal flora may also play a role in the onset of autoimmune diseases such as MS.
Despite numerous scientific research projects, the real causes are still not fully understood. Research assumes a multi-causal relationship. Factors such as genetic predisposition and environmental factors are discussed.
The neurological symptoms during an episode usually occur subacutely, i.e. without prior notice. In most cases it is not possible to narrow down a specific trigger. Sometimes the symptoms are triggered by a previous infection or other stress factors.
Depending on the severity of the disease, it is advisable to take medication for prevention. As a rule, the drugs are taken on a long-term basis, i.e. over years, in order to build up an effective prophylaxis. Find a good specialist and let him or her advise and support you – this is the best way to meet your individual needs.
Living with multiple sclerosis
As a chronic and serious disease, multiple sclerosis poses many challenges for patients and their families. The disease can affect all areas of life – from partnership, sexuality and family planning to social life and hobbies, education and work.
Is it possible to have children with multiple sclerosis? Are holiday trips possible despite MS? Should the own boss be informed about the illness or better not? Which jobs are cheap, which are rather unfavorable? These and many other questions are of concern to people with MS.
You can read more about how multiple sclerosis affects the everyday life of those affected and how to deal with it in the article Living with Multiple Sclerosis.
Multiple Sclerosis: examinations and diagnosis
Because the symptoms of multiple sclerosis can be so varied, the disease is not easy to diagnose. Unlike many other diseases, there are no typical signs that are unique to MS. Most complaints can also occur with other diseases, such as circulatory disorders of the brain or herniated discs. The complex diagnosis “multiple sclerosis” is therefore made up of different examination steps:
- Collection of the medical history (anamnesis)
- Physical examination (clinical-neurological examination)
- Apparatus-based examinations (such as magnetic resonance tomography = MRT, evoked potentials)
- Laboratory tests (examination of the nervous system, blood tests)
The first contact person is the family doctor. If necessary, the latter will refer the patient to a specialist, usually a neurologist. This person can then make the final diagnosis of MS.
The first step in the diagnosis of multiple sclerosis is a detailed discussion between doctor and patient to establish the patient’s medical history. The physician will ask you to describe the symptoms exactly, ask how long they have existed and how they have developed over time. Patients should tell about any complaints they remember. Sometimes a patient is unaware that symptoms that occurred months or even years ago were the first signs of multiple sclerosis. For example, some people with MS remember having a “funny feeling” in one arm or leg for a few days or weeks (possible indication of an inflammatory focus in the spinal cord). Some patients do not attach any importance to the symptoms because they disappear slightly or quickly (for example, in the case of inflammation of the optic nerve). Others go to the doctor, but he finds nothing despite a thorough examination.
The patient’s descriptions help the doctor to narrow down the possible causes and possibly to substantiate the suspicion of multiple sclerosis. It is also important to know whether the patient or his relatives suffer from any autoimmune disease.
The collection of the medical history is followed by a thorough physical examination. A “normal” clinical and a neurological examination are carried out. During this process the doctor checks the function of the nervous system. Above all, he’s investigating:
- the function of the eyes and the cranial nerves
- the sensation of touch, pain and temperature
- the muscle strength and muscle tension
In addition to the purely neurological examination, the doctor can also carry out a neuropsychological examination if multiple sclerosis is suspected. Various mental functions such as learning ability, language processing or memory are tested. Various tests are available for this purpose.
To determine how far multiple sclerosis has spread in the patient’s body, evoked potentials are recorded. These are electrical voltages that occur in the nerve and muscle cells of the human body when an external stimulus is applied. They can be derived and recorded with electrodes after they have been electronically amplified.
For example, visually evoked potentials (VEPs) can be triggered by a checkerboard pattern whose fields appear in rapid succession with varying brightness. The patient looks at the checkerboard pattern and the potentials are derived from his head.
In addition, if multiple sclerosis is suspected, a magnetic resonance imaging (MRI) of the skull and spinal cord is performed. Centres of inflammation or plaques in the brain that are larger than two millimetres can be detected in the early stages of the disease. MRI has a great advantage over other examinations: Even if multiple sclerosis does not yet cause symptoms, MRI can already reveal disease-related changes in the CNS.
If the patient suffers from problems urinating, the doctor may recommend a micturition protocol: The patient notes how often he or she urinates. The doctor also determines the amount of urine that remains in the bladder after urination (residual urine determination). This may be followed by a urodynamic examination – a measurement procedure in which the functioning of the bladder is examined using pressure probes and electrodes.
A further important step on the way to the diagnosis of “multiple sclerosis” is the examination of the cerebrospinal fluid (liquor diagnostics). To obtain a cerebrospinal fluid sample, the doctor inserts a fine needle between the vertebrae at the level of the middle lumbar spine (cerebrospinal fluid puncture). The evaluation of the spinal fluid sample can reveal the inflammation of the brain and spinal cord: If the patient has multiple sclerosis, the number of certain defence cells (lymphocytes, plasma cells) in the nerve fluid is increased and antibodies such as immunoglobulin G (IgG) can be detected.
In addition, the doctor can use a cerebrospinal fluid puncture to determine whether the inflammation may have been caused by germs (as in Lyme disease) and not by multiple sclerosis.
Blood tests are also important. The following values are determined:
- Liver values
- Kidney values
- Thyroid levels
- Blood sugar
- Vitamin B12
- Rheumatoid factor
- Antinuclear antibodies (ANA)
- Anti-Phospholipid antibodies
- Anti-ds-DNA antibodies
- Lupus anticoagulant
- Inflammation markers (C-reactive protein = CRP)
- Angiotensin converting enzymes (ACE)
- Borrelia (trigger of Lyme disease) and Borrelia antibodies (Borrelia serology)
A urine examination is also carried out.
Most laboratory values are normal in multiple sclerosis patients. They serve less for the direct detection of multiple sclerosis than for the exclusion of other diseases that can cause similar complaints. Sometimes further laboratory tests are necessary for this purpose. For example, “extractable nuclear antigens” (for the differentiation of various autoimmune diseases, HIV antibodies, mycoplasma antibodies and antibodies for the detection of syphilis (TPHA) are determined.
Tedious diagnostic process
Detecting MS is not easy. It can sometimes take weeks, months or even years before a clear diagnosis of multiple sclerosis is made. The search for the “disease with the 1000 names” is comparable to searching for the pieces of a puzzle: The more parts that fit together, the more certain multiple sclerosis is actually present.
Multiple Sclerosis: Therapy
Multiple sclerosis therapy is based on four pillars:
- Threshold therapy: Treatment of acute attacks with cortisone or plasmapheresis (a type of blood washing).
- Progression-modifying therapy (basic therapy, long-term immunotherapy): It aims to reduce the severity and frequency of relapses and to have a positive influence on the extent of the progressive disability.
- Symptomatic therapy: Treatment of non-specific complaints such as muscle cramps, pain, depression, bladder or bowel emptying disorders.
- Rehabilitation procedures: The aim is to enable patients to return to their family, professional and social life.
In order to achieve the therapy goals, medication, physiotherapy (physiotherapy) as well as activation and occupational therapy (ergotherapy or psychotherapy) are used.
Multiple Sclerosis: Push therapy
An MS relapse should preferably be treated in a clinic within two to five days of the onset of symptoms. Inpatient treatment has the advantage that any necessary examinations such as magnetic resonance imaging (MRI) can be carried out. In addition, the physician can discuss the relapse therapy with the patient in peace and quiet and monitor any side effects better than with an outpatient multiple sclerosis treatment.
Cortisone preparations (corticosteroids, corticosteroids, glucocorticoids) are the means of choice for relapse therapy. If they are not (sufficiently) effective, a plasmapheresis (a kind of blood washing) can be performed.
Cortisone Pulse Therapy
Cortisone preparations suppress inflammation, seal the blood-brain barrier, reduce water accumulation in the brain and improve the transmission of nerve impulses. They may even promote the formation of new nerve sheaths (myelin sheaths). They are either administered via the vein (intravenously) or taken as tablets.
The cortisone most commonly used in an acute MS attack is methylprednisolone. The reason: It gets well into the cerebrospinal fluid (liquor) and thus to the site of inflammation. Studies have shown that the best way to administer the active substance is in high doses, intravenously (as a short infusion) and on three consecutive days. After the three infusions, some doctors “sneak out” this cortisone pulse therapy (cortisone shock therapy) because some patients tolerate it better. The patient takes cortisone as a tablet in decreasing doses for a maximum of two weeks.
An alternative to the infusions is a high-dose cortisone therapy in tablet form over five days. Smaller studies indicate that this is as effective as intravenous cortisone treatment.
Two weeks after the end of the cortisone pulse therapy, the patient is thoroughly examined and asked about his or her complaints. If there is no significant improvement, a second round of therapy follows. Depending on the symptoms, a higher dose may now be given than in the first shock therapy.
Possible side effects of cortisone include slight trembling (inner restlessness), facial flushing, increased appetite, headaches, dizziness, insomnia and increased blood sugar levels. Rarely do stomach or duodenal ulcers, seizures, mental disorders, blood pressure crisis, allergic reactions or water retention (edema) occur. Prolonged use may cause gastrointestinal bleeding, high blood pressure, increased intraocular pressure (glaucoma) and Cushing’s syndrome, among other things.
Another possibility of thrust therapy is plasmapheresis. This is a type of blood washing that filters immunoglobulins from the blood that are responsible for the inflammatory process during an MS attack. Plasmapheresis is usually performed four to six times. It can be carried out either after two cortisone pulse therapies or already after the first one, if the patient’s complaints have continuously worsened during the infusion therapy.
In the case of a severe relapse that progresses very quickly and hardly responds to therapy, doctors can additionally prescribe an agent that suppresses the immune system (immunosuppressant such as mitoxantrone). Such drugs are actually used in the long-term therapy of MS (basic therapy).
Multiple Sclerosis: Progression-modifying therapy
The progression-modifying therapy (basic therapy) in multiple sclerosis aims to reduce the number and severity of acute attacks and to slow down the progression of the disease. The exact duration of the medication will be decided on a case by case basis. As long as the preparations are effective, the basic therapy can be continued for months or years. During treatment, regular check-ups are advisable or even mandatory (depending on the medication).
If multiple sclerosis is stable for a longer period of time under therapy (for example, no more relapses, no progression of MS visible on MRI), the doctor and patient can decide together to interrupt MS treatment on a trial basis. Even then, the patient should have regular check-ups by his or her neurologist and look for possible signs of returning MS himself or herself.
The drugs used for the progression-modifying treatment of multiple sclerosis are immunomodulators or immunosuppressants. Immunomodulators can be used to specifically modify immune reactions. Immunosuppressants, on the other hand, suppress activities of the immune system. Often all drugs for long-term therapy are simply summarized under the term “immunomodulators” or called “immunoprophylactics”.
Which medication is given to multiple sclerosis patients in individual cases depends, among other things, on the course of the disease: Physicians differentiate between mild/moderate and (highly) active forms of MS. The doctor also takes other factors into account, such as the age of the patient, pregnancy, etc.
The most important active ingredients for long-term multiple sclerosis therapy are
|Active substance||MS progression||Application|
|Beta-Interferons||mildly moderate||Depending on the preparation, one or more injections per week into the muscle or under the skin.|
|Glatiramer acetate||mildly moderate||One injection daily under the skin.|
|Teriflunomide||mildly moderate||One tablet once a day.|
|Dimethyl fumarate (DMF)||mildly moderate||One capsule twice a day.|
|Azathioprine||mildly moderate||One tablet once a day.|
|Natalizumab||(highly) active||Infusion into a vein every four weeks.|
|Fingolimod||(highly) active||One capsule once a day.|
|Alemtuzumab||(highly) active||One infusion cycle per year and a maximum of twice in total.|
|Mitoxantrone||(highly) active||Infusion into the vein every three months.|
|Cladribine||highly active||Take as a tablet in four treatment cycles (one to two tablets daily for four to five days per cycle; between cycles, several weeks or months).|
Interferons suppress the inflammatory processes in MS: they probably prevent certain white blood cells (T lymphocytes) from entering the blood vessels. This prevents them from entering the brain and causing inflammation and destruction of the myelin sheath. Interferons also inhibit the formation of proteins that promote inflammation. Thus, the approved interferon preparations can reduce the number and severity of MS relapses and reduce disease activity.
Side effects: At the beginning of treatment, many patients suffer from flu-like symptoms with fever, chills or muscle pain. For prevention, interferon should be injected in the evening and the patient should also take paracetamol or ibuprofen as a preventive measure.
Redness, pain and hardening can occur at the injection site and skin tissue can die off (necrosis). Women occasionally report increased menstruation during therapy. Other possible interferon side effects include skin rash, blood count changes and depressive moods.
Glatiramer acetate (GLAT)
GLAT can be an effective alternative to interferons. It prolongs the time until the next relapse and reduces the severity of a relapse. The exact mechanism of action is unclear. It is possible that GLAT changes the ratio of certain white blood cells to each other – fewer “harmful” (cytotoxic) TH1 cells and more protective TH2 cells are produced.
Side effects: The most common local side effects at the injection site are redness, pain, wheals, itching and inflammation. More rarely, other side effects occur such as infections (bronchitis, otitis media, candida infection, herpes, etc.), eye dysfunction, vomiting, weight gain or tremor. In most cases the drug is generally well tolerated.
Teriflunomid is an immunomodulator with anti-inflammatory properties. Its exact mode of action is not yet known in detail; however, it reduces the rate of relapse, slows down the progression of physical disabilities and reduces the number of brain damages in MRI.
Side effects: The most common side effects are increased liver values, hair loss, infections (such as flu, gastrointestinal infections, bronchitis, urinary tract infections), nausea, pain and discomfort.
Dimethylfumarate (fumaric acid (BG-12)) is also an immunomodulator. It ensures that immune cells are reprogrammed. It also defuses cell-damaging free radicals and nitrogen oxides and activates protective metabolic pathways in the cells. In the final analysis, this reduces the annual relapse rate in multiple sclerosis patients. In addition, the progression of the degree of disability and the number of brain damages are reduced in the MRI.
Side effects: At the beginning of the intake of dimethylfumarate, gastrointestinal complaints (such as nausea, vomiting, abdominal pain, diarrhoea) as well as reddening of the skin with a feeling of heat (flush) often occur.
Alemtuzumab is a so-called monoclonal antibody and is produced by genetic engineering. It reduces the number of lymphocytes – white blood cells that are significantly involved in the destruction of the nerve sheaths (myelin sheaths).
Side effects: Administration of alemtuzumab can cause infusion reactions (such as fever, rash), reduction of white blood cells, respiratory and urinary tract infections, digestive disorders and secondary autoimmune diseases (such as thyroid and kidney).
Today, azathioprine is only used for progression-modifying MS therapy in rare exceptional cases where beta-interferons or glatiramer acetate cannot be given or are not effective enough. Its exact mechanism of action is unknown. However, the drug inhibits the production of certain defence cells (B and T lymphocytes) and interferes with the formation and function of other defence cells (monocytes). Lymphocytes and monocytes are involved in the inflammatory process in MS.
Side effects: Multiple sclerosis therapy with azathioprine can reduce the number of white blood cells to such an extent that patients become more susceptible to infections. Other possible side effects are decrease in platelets, nausea, vomiting and liver damage. In addition, women and men should ensure reliable contraception during therapy and for a few months afterwards, because malformations in the unborn child may occur.
Mitoxantron was originally developed to treat cancer. Only later was it discovered that it was also suitable for multiple sclerosis therapy. It inhibits the growth of certain defence cells (B and T lymphocytes, macrophages) and also leads to their death. In addition, the formation of various messenger substances that are involved in inflammatory processes is inhibited.
Side effects: Nausea, vomiting and short-term diarrhoea may occur. In some of the women treated, menstruation temporarily stops. There is also a potential risk of leukemia. Other possible side effects of mitoxantrone are cardiac arrhythmia, heart muscle disease, cardiac insufficiency and decrease in white blood cells. As the dose increases, mitoxantrone causes more and more side effects, which is why it can be given for a maximum of two to three years.
The antibody Natalizumab blocks special receptors on the surface of certain white blood cells (T-lymphocytes). These can then no longer migrate into the brain and cause inflammation and destruction of the myelin sheath.
Side effects: These include urinary tract infections, inflammation of the nasopharynx, allergic rash (urticaria), headaches, dizziness, nausea, vomiting, joint pain, muscle rigidity, fever and fatigue. In addition, progressive multifocal leukoencephalopathy (PML) can develop – a viral disease of the brain that is usually fatal. Therefore, natalizumab may only be used if previous therapeutic measures have failed.
Fingolimod is an immunosuppressant that reduces the number of lymphocytes in the blood. As a result, fewer such white blood cells enter the brain, where they are involved in the destruction of the nerve sheaths. In this way, the relapse rate in multiple sclerosis patients is reduced.
Side effects: Fingolimod can cause a slowing of the heart rate and irregular heartbeat, especially in the first six hours after the first intake. The intake should therefore only be done under medical supervision and six-hour supervision. In addition, fingolimod can cause, for example, respiratory and liver problems, headaches and back pain, diarrhoea, flu-like symptoms, severe infections and eye disease (macular edema).
In individual cases, multiple sclerosis patients treated with fingolimod developed a so-called haemophagocytic syndrome (HPS) and died of it. In HPS, the scavenger cells of the immune system are overly active: they begin to eat healthy blood cells and migrate to organs (such as the spleen and brain) where they cause severe inflammation. Possible warning signs of HPS are fever, weakness, enlargement of the liver and spleen, swollen lymph nodes and decrease in blood cells.
Cladribine is an immunosuppressive agent that was first developed to treat a certain form of blood cancer (hairy cell leukemia). In these patients, the active substance is administered by injection or infusion. Since 2017, cladribine has also been approved in Germany for the treatment of highly active relapsing-remitting adult MS, in tablet form. Like fingolimod, the active ingredient reduces the number of lymphocytes in the blood of patients. This is intended to reduce the frequency of disease relapses.
Side effects: The most common adverse effects of cladribine tablets are a lack of lymphocytes (very common) as well as herpes infections in the mouth, shingles, rash, hair loss and a reduction in neutrophil granulocytes (frequent). Very rarely a hidden (latent) tuberculosis infection breaks out under cladribine.
In addition, it has been observed in clinical trials and long-term follow-up of patients under cladribine therapy that they develop cancer tumors more frequently than participants in the placebo group (comparative patients who received a sham drug instead of cladribine).
Other active substances (reserve drugs)
Under certain conditions, multiple sclerosis patients are exceptionally given other drugs that are not actually approved for the treatment of this disease.
These include, for example, intravenous immunoglobulins. This is a mixture of antibodies obtained from the blood serum of thousands of healthy people. They have a modulatory effect on immune responses, although the exact mechanism of action in MS is not known. Intravenous immunoglobulins are only used in well-founded individual cases of mild/moderately progressing multiple sclerosis when other basic therapeutic agents (such as beta-interferons) are not effective or cause unacceptable side effects.
Cyclophosphamide and methotrexate are also occasionally prescribed as reserve drugs in multiple sclerosis. These are immunosuppressive drugs that are primarily used as cancer drugs. Sometimes the doctor also uses cortisone preparations in long-term therapy, which are actually only approved for relapse therapy.
Multiple Sclerosis: Symptomatic Therapy
Multiple sclerosis can cause a wide range of symptoms such as bladder dysfunction, fatigue, muscle spasms or ataxia. Targeted measures help to alleviate these complaints and thus improve the quality of life of those affected. Both medicinal and non-drug measures are used. Here are some examples:
Physiotherapy, with its wide range of techniques and methods, can benefit people with MS in many ways: Mobility is maintained for longer; general fatigue improves with targeted movement, as learned in physiotherapy; training can eliminate incorrect strain and incorrect movements caused by pain or muscle blockages and correct gait disorders.
Movement also relieves muscle cramps (spasms): these occur when the muscle tension is so high that the joint resists movement. Then the muscles should first be relaxed by passive movements. Then the patient can gradually try to loosen the muscles by careful active movement.
Physiotherapy also helps with ataxia (a movement coordination disorder): people with MS often find it difficult to maintain balance, for example when standing. Patients initially receive help from the physiotherapist or from equipment such as straps or poles to enable them to stand safely. Slowly this support is then reduced more and more until the patient is able to maintain balance in standing position on his own again at some point.
In the case of bladder dysfunction, the physiotherapist can show the patient exercises for pelvic floor training. For these and other physiotherapeutic exercises, it makes sense for patients to do them regularly at home. The therapist gives appropriate instructions for independent training.
In addition, the physiotherapist also offers advice to people with MS on how they can better manage their daily lives. Fatigue, for example, can be combated by appropriate “energy management”. A daily schedule can help to divide up the limited resources in a sensible way and avoid unnecessary journeys.
Hippotherapy is also a proven and popular addition to physiotherapy – the feeling of balance can be trained particularly well on horseback. Electrotherapy can also be helpful: In patients with severe paralysis, the muscle is stimulated with a weak current as soon as the MS patient tenses it.
Other forms of therapy that can be used in multiple sclerosis include Bobath and Vojta therapy, proprioceptive neuromuscular facilitation and other techniques.
Occupational therapy aims to enable patients with multiple sclerosis to manage their everyday life without outside help and to remain independent as long as possible. Occupational therapists also support MS patients in the choice and use of technical aids. They show relatives and friends how to best interact with people with MS.
Specifically, occupational therapists try to stop incorrect movements and strenuous postures in MS patients. You practice normal movements with the patients again, which cost less energy. If this is no longer possible, the patient learns to deal with his handicap and trains new “substitute movements”. All exercises are geared to the needs of everyday life.
For example, a gymnastics ball is used to train balance while sitting, or a high table is used to support standing upright without tipping over. The patient learns to feel his weight on bones and joints and to align his movement accordingly. Other aids and methods of occupational therapy are, for example, therapy clay, working with salt dough or games of stick. They promote fine motor skills and dexterity.
Occupational therapy usually cannot reverse the impairments of the body and brain, but it helps the patient to remain independent for as long as possible. To do this, people with MS need patience and practice – with and without therapists.
The doctor may also prescribe medication to alleviate various complaints. There are, for example, active substances against muscle cramps (antispasticity medications) such as baclofen or botulinum toxin. Antiepileptic drugs can help with seizure-like pain. For joint, muscle or spinal pain, the doctor may prescribe anti-inflammatory drugs such as Diclofenac in addition to physiotherapy. If multiple sclerosis patients suffer from severe depression, the use of antidepressants (such as fluoxetine or sertraline) may be necessary in addition to psychotherapy.
Multiple Sclerosis: Rehabilitation
Multiple sclerosis patients are treated by many different therapists and medical specialists (such as neurologists, urologists, ophthalmologists, family doctors), physiotherapists, occupational therapists, social workers and nursing staff.
The resident neurologist (neurologist) can take over the long-term care. However, if possible once a year, MS patients should undergo four to six weeks of rehabilitation. The German Multiple Sclerosis Society (DMSG) recommends this.
Such rehabilitation may be particularly appropriate if the symptoms do not recede sufficiently after an acute episode. However, it can also be helpful in the chronic course of the disease, when physical functions deteriorate despite outpatient therapies.
Each rehabilitation is individually tailored to the needs and difficulties of the patient. Common building blocks are physiotherapy, occupational therapy, training and movement therapy, speech therapy (speech, language and swallowing therapy) and neurocognitive therapy. The latter serves to treat problems in the areas of memory, concentration, attention and perception. Another frequent component of rehabilitation is psychological therapy. It helps, for example, with difficulties in the social sphere, depression and sexuality disorders.
Multiple Sclerosis: Alternative Healing Methods
“Complementary” or “alternative” therapies are meeting with great interest among people with chronic diseases such as multiple sclerosis. Homeopathy, herbal medicine, certain forms of nutrition or other alternative approaches are often used to alleviate the symptoms. Patients should discuss with their MS physician and a physician experienced in naturopathy which procedure could be helpful in addition to the conventional multiple sclerosis treatment.
The boundaries between alternative/complementary and conventional medical treatment methods are fluid. A characteristic of many – but not all – conventional medical treatment methods is that their effect has been proven in several studies. For most alternative therapy concepts, this proof is still missing.
However, alternative and conventional medical procedures have one thing in common: both can lead to side effects.
In the following table you will find a selection of different alternative/complementary healing methods and therapies used in multiple sclerosis:
|Homeopathy||According to some patients, symptoms such as dizziness, bladder and bowel problems, concentration problems, lack of resilience and general well-being improve.|
|Acupuncture||High priority in the complementary therapy of MS. Trying to use it to relieve pain or muscle cramps can be useful.|
|Acupressure||High priority in the complementary therapy of MS. Trying to use it to relieve pain or muscle cramps can be useful.|
|Craniosacral therapy||Can reduce pain and muscle spasms in many patients.|
|Relaxation techniques (autogenic training, progressive muscle relaxation etc.)||Often recommended for chronic diseases such as multiple sclerosis. Can help to alleviate some symptoms and improve the general condition and quality of life.|
|Cannabis||May be prescribed in justified individual cases of severe multiple sclerosis to positively influence the course of the disease or to alleviate symptoms.|
|Frankincense||Anti-inflammatory effect. Good results in inflammatory bowel disease and rheumatoid arthritis. There are no studies on efficacy in MS.|
|Vitamin D||Recommended for the prevention of osteoporosis especially in women with MS after menopause and with repeated cortisone treatment. It is uncertain whether vitamin D can positively influence the course of MS. Uncontrolled intake can cause damage to health.|
|Vitamin B12||Vitamin B12 intake is only necessary if a deficiency is proven. Such a deficiency is common in people with MS and can cause similar symptoms to MS itself.|
|Other vitamins||Vitamins A, C and E can be taken (subject to the maximum dose). However, there is no evidence of a positive effect on the course of MS. Pregnant women with MS should not take vitamin A because it could harm the child.|
|Unsaturated fatty acids (Omega-3 fatty acids)||Efficacy in MS has not yet been proven.|
|Specific diets/diets||To date, no diet or diet has been shown to have a positive effect on the course and symptoms of MS. Experts generally recommend a varied diet rich in vitamins and fibre.|
|Enzyme combinations||Are supposed to break down disease-causing immune complexes. However, one study found that they are ineffective in MS.|
|Oxygen overpressure therapy (hyperbaric oxygen)||Supposed to stop the progression of MS, but this has been disproved in studies.|
|Amalgam removal||Supposedly helpful because amalgam is said to cause MS and mercury leaking from fillings is said to poison the immune system. Both allegations are considered false. No association between amalgam and multiple sclerosis has been found in studies.|
In multiple sclerosis, dangerous and sometimes very expensive treatments are often offered, most of which have not been scientifically tested. The German Multiple Sclerosis Society (DMSG) therefore warns against it. These treatments include:
- Immunaugmentation (strengthening of the immune response): There is a risk of infections and allergies. Multiple sclerosis can also worsen.
- Pig brain implantation in the abdominal wall: MS may worsen. There were also severe allergies and deaths after the operation.
- Fresh cell therapy: It can trigger severe allergies and even circulatory failure. There is also a risk of infection.
- Bee venom: There is a risk of severe allergies and even circulatory failure. In addition, one study found no benefit in MS.
- Snake venom: It can cause severe allergies and even circulatory failure.
- Intrathecal stem cell therapy (injection of the patient’s stem cells into the spinal canal): It can have severe to very severe and even fatal side effects.
Multiple Sclerosis: Prognosis
The fear that many people with multiple sclerosis will inevitably end up in a wheelchair sooner or later is not true. Thanks to improved therapies, multiple sclerosis is now progressing more favorably for many patients than in earlier years: In one third of MS patients, the disease has a favourable life course. A further third suffer from disabilities but remain self-employed. “Only” one third of patients suffer from multiple sclerosis, which causes severe disabilities or in extreme cases even death.
It is not possible to predict the prognosis for multiple sclerosis in individual cases. In the meantime, however, we know of some indications that speak for a rather favorable or unfavorable course of the disease:
|rather favourable course||rather unfavourable course|
|Start with only one symptom||Start with several symptoms|
|only sensitive symptoms (like sensory disturbances)||early motor and cerebellar (affecting the cerebellum) symptoms (such as gait disorders)|
|Thrusts last only briefly||Thrusts last long|
|good regression of the drawers||poor regression of the thrusts|
|Gain the ability to walk||early numerous lesions in the MRT|
|Start of disease < 35 years of age||early pathological SEP* and MEP**|
* SEP = somatosensory evoked potentials (testing of the nerve pathways that mediate feeling, e.g. touch stimuli)
** MEP = motor/magnetic evoked potentials (testing the nerve pathways that mediate muscle movements)
One thing is certain: the course of the disease can be positively influenced if the patient receives professional and consistent treatment and support from his social environment. Just as important is the cooperation of the patient in various therapies such as physiotherapy. However, a sense of proportion is required: if multiple sclerosis patients are too ambitious and want “too much”, their limited strength wears out and their energy reserves are exhausted prematurely.
Multiple Sclerosis: Course
Physicians differentiate between different forms of multiple sclerosis. In most patients, the disease begins with a relapsing course: there are occasional attacks in which already known or new symptoms appear. Often these are completely or partially reduced afterwards. But sometimes they persist.
The relapsing-remitting MS may develop into secondary progressive MS over time: The relapses gradually stop and the symptoms now increase continuously.
In a small proportion of patients, multiple sclerosis is chronically progressive (primary progressive): the disease condition worsens slowly and continuously from the beginning.
You can read more about the various forms of MS and the respective life expectancy in the article Multiple Sclerosis – Course.