Multiple sclerosis signs and symptoms

Multiple sclerosis
Multiple sclerosis
Multiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...

can cause a variety of symptoms: changes in sensation (hypoesthesia

Hypoesthesia

Hypoesthesia refers to a reduced sense of touch or sensation, or a partial loss of sensitivity to sensory stimuli....

), muscle weakness, abnormal muscle spasms, or difficulty moving; difficulties with coordination and balance; problems in speech (dysarthria

Dysarthria

Dysarthria is a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system and is characterized by poor articulation of phonemes...

) or swallowing (dysphagia

Dysphagia

Dysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their dysphagia....

), visual problems (nystagmus, optic neuritis

Optic neuritis

Optic neuritis is the inflammation of the optic nerve that may cause a complete or partial loss of vision.-Causes:The optic nerve comprises axons that emerge from the retina of the eye and carry visual information to the primary visual nuclei, most of which is relayed to the occipital cortex of the...

, phosphene

Phosphene

A phosphene is a phenomenon characterized by the experience of seeing light without light actually entering the eye. The word phosphene comes from the Greek words phos and phainein...

s or diplopia

Diplopia

Diplopia, commonly known as double vision, is the simultaneous perception of two images of a single object that may be displaced horizontally, vertically, or diagonally in relation to each other...

), fatigue and acute or chronic pain syndromes, bladder

Urinary bladder

The urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible organ, the bladder sits on the pelvic floor...

and bowel difficulties, cognitive impairment, or emotional symptomatology (mainly major depression). The main clinical measure in progression of the disability and severity of the symptoms is the Expanded Disability Status Scale

Expanded Disability Status Scale

The Kurtzke Expanded Disability Status Scale is a method of quantifying disability in multiple sclerosis.The EDSS quantifies disability in eight Functional Systems and allows neurologists to assign a Functional System Score in each of these....

or EDSS.

The initial attacks are often transient, mild (or asymptomatic), and self-limited. They often do not prompt a health care visit and sometimes are only identified in retrospect once the diagnosis has been made after further attacks. The most common initial symptoms reported are: changes in sensation in the arms, legs or face (33%), complete or partial vision loss (optic neuritis

Optic neuritis

) (20%), weakness (13%), double vision

Diplopia

Diplopia, commonly known as double vision, is the simultaneous perception of two images of a single object that may be displaced horizontally, vertically, or diagonally in relation to each other...

(7%), unsteadiness when walking (5%), and balance problems (3%); but many rare initial symptoms have been reported such as aphasia

Aphasia

Aphasia is an impairment of language ability. This class of language disorder ranges from having difficulty remembering words to being completely unable to speak, read, or write....

or psychosis

Psychosis

Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...

. Fifteen percent of individuals have multiple symptoms when they first seek medical attention.

Bladder

Urinary bladder

The urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible organ, the bladder sits on the pelvic floor...

problems (See also urinary system

Urinary system

The urinary system is the organ system that produces, stores, and eliminates urine. In humans it includes two kidneys, two ureters, the bladder and the urethra.-Kidney:...

and urination

Urination

Urination, also known as micturition, voiding, peeing, weeing, pissing, and more rarely, emiction, is the ejection of urine from the urinary bladder through the urethra to the outside of the body. In healthy humans the process of urination is under voluntary control...

) appear in 70–80% of Multiple Sclerosis (MS) patients and they have an important effect both on hygiene

Hygiene

Hygiene refers to the set of practices perceived by a community to be associated with the preservation of health and healthy living. While in modern medical sciences there is a set of standards of hygiene recommended for different situations, what is considered hygienic or not can vary between...

habits and social activity.
Bladder problems are usually related with high levels of disability

Disability

A disability may be physical, cognitive, mental, sensory, emotional, developmental or some combination of these.Many people would rather be referred to as a person with a disability instead of handicapped...

and pyramidal signs in lower limbs.

The most common problems are an increase in frequency and urgency (incontinence

Urinary incontinence

Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...

) but difficulties to begin urination, hesitation, leaking, sensations of incomplete urination, and retention also appear. When retention occurs secondary urinary infections are common.

There are many cortical

Cerebral cortex

The cerebral cortex is a sheet of neural tissue that is outermost to the cerebrum of the mammalian brain. It plays a key role in memory, attention, perceptual awareness, thought, language, and consciousness. It is constituted of up to six horizontal layers, each of which has a different...

and subcortical structures implicated in urination and MS lesions in various central nervous system

Central nervous system

The central nervous system is the part of the nervous system that integrates the information that it receives from, and coordinates the activity of, all parts of the bodies of bilaterian animals—that is, all multicellular animals except sponges and radially symmetric animals such as jellyfish...

structures can cause these kind of symptoms.

Treatment objectives are the alleviation of symptoms of urinary dysfunction, treatment of urinary infections, reduction of complicating factors and the preservation of renal

Kidney

The kidneys, organs with several functions, serve essential regulatory roles in most animals, including vertebrates and some invertebrates. They are essential in the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid–base balance, and...

function. Treatments can be classified in two main subtypes: pharmacological and non-pharmacological.
Pharmacological treatments vary greatly depending on the origin or type of dysfunction and some examples of the medications used are:
alfuzosin

Alfuzosin

Alfuzosin is an α1 receptor antagonist used to treat benign prostatic hyperplasia . It works by relaxing the muscles in the prostate and bladder neck, making it easier to urinate....

for retention,
trospium

Trospium

Trospium chloride is a muscarinic antagonist urinary antispasmodic. It has been developed and patented by Robert Pfleger and is sold under the brand name Sanctura in the US, Tropez OD in India,Trosec in Canada, Regurin and Flotros in the United Kingdom and Spasmex in Germany, Russia, Turkey,...

and flavoxate

Flavoxate

Flavoxate is an anticholinergic with antimuscarinic effects. Its muscle relaxant properties may be due to a direct action on the smooth muscle rather than by antagonizing muscarinic receptors.- Clinical uses :...

for urgency and incontinency,
and desmopressin

Desmopressin

Desmopressin is a synthetic replacement for vasopressin, the hormone that reduces urine production. It may be taken nasally, intravenously, or as a tablet...

for nocturia

Nocturia

Nocturia , also called nycturia , is the need to get up in the night to urinate, thus interrupting sleep. Its occurrence is more frequent in pregnant women and in the elderly...

.
Non pharmacological treatments involve the use of pelvic floor

Pelvic floor

The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus, and associated connective tissue which span the area underneath the pelvis. The pelvic diaphragm is a muscular partition formed by the levatores ani and coccygei, with which may be included the...

muscle training, stimulation, biofeedback

Biofeedback

Biofeedback is the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will...

, pessaries

Pessary

A pessary is a small plastic or silicone medical device which is inserted into the vagina or rectum and held in place by the pelvic floor musculature. - Therapeutic pessaries :...

, bladder retraining, and sometimes intermittent catheterization

Urinary catheterization

In urinary catheterization , a latex, polyurethane or silicone tube known as a urinary catheter is inserted into a patient's bladder via his or her urethra. Catheterization allows the patient's urine to drain freely from the bladder for collection. It may be used to inject liquids used for...

Cognitive

Some of the most common deficits affect recent memory

Memory

In psychology, memory is an organism's ability to store, retain, and recall information and experiences. Traditional studies of memory began in the fields of philosophy, including techniques of artificially enhancing memory....

, attention

Attention

Attention is the cognitive process of paying attention to one aspect of the environment while ignoring others. Attention is one of the most intensely studied topics within psychology and cognitive neuroscience....

, processing speed, visual-spatial abilities and executive function. Symptoms related to cognition include emotional instability and fatigue

Fatigue (physical)

Fatigue is a state of awareness describing a range of afflictions, usually associated with physical and/or mental weakness, though varying from a general state of lethargy to a specific work-induced burning sensation within one's muscles...

including neurological fatigue

Neurological fatigue

Prevalent amongst sufferers of multiple sclerosis , neurological fatigue is a feeling of overwhelming lassitude or tiredness that can occur at any time of the day, for any duration and does not necessarily recur in a recognisable pattern for any given patient...

. Cognitive deficits are independent of physical disability and can occur in the absence of neurological dysfunction. Severe impairment is a major predictor of a low quality of life, unemployment, caregiver distress, and difficulty in driving; limitations in a patient's social and work activities are also correlated with the extent of impairment.

Cognitive impairments occur in about 40 to 60 percent of patients with multiple sclerosis, with the lowest percentages usually from community-based studies and the highest ones from hospital-based. Sometimes referred to as brain fog

Brain fog

Cognitive dysfunction is defined as unusually poor mental function, associated with confusion, forgetfulness and difficulty concentrating...

, impairments may present at the beginning of the disease. Probable multiple sclerosis sufferers, meaning after a first attack but before a secondary confirmatory one, have up to 50 percent of patients with impairment at onset. Dementia

Dementia

Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging...

is rare and occurs in only five percent of patients.

Measures of tissue atrophy are well correlated with, and predict, cognitive dysfunction. Neuropsychological outcomes are highly correlated with linear measures of sub-cortical atrophy. Cognitive impairment is the result of not only tissue damage, but tissue repair and adaptive functional reorganization. Neuropsychological test

Neuropsychological test

Neuropsychological tests are specifically designed tasks used to measure a psychological function known to be linked to a particular brain structure or pathway. Tests are used for research into brain function and in a clinical setting for the diagnosis of deficits. They usually involve the...

ing is important for determining the extent of cognitive deficits. Neuropsychological rehabilitation

Rehabilitation (neuropsychology)

Rehabilitation of sensory and cognitive function typically involves methods for retraining neural pathways or training new neural pathways to regain or improve neurocognitive functioning that has been diminished by disease or traumatic injury....

may help to reverse or decrease the cognitive deficits although studies on the issue have been of low quality. Acetylcholinesterase inhibitor

Acetylcholinesterase inhibitor

An acetylcholinesterase inhibitor or anti-cholinesterase is a chemical that inhibits the cholinesterase enzyme from breaking down acetylcholine, increasing both the level and duration of action of the neurotransmitter acetylcholine.- Uses :Acetylcholinesterase inhibitors:* Occur naturally as...

s are commonly used to treat Alzheimer's disease

Alzheimer's disease

Alzheimer's disease also known in medical literature as Alzheimer disease is the most common form of dementia. There is no cure for the disease, which worsens as it progresses, and eventually leads to death...

related dementia and so are thought to have potential in treating the cognitive deficits in multiple sclerosis. They have been found to be effective in preliminary clinical trials.

Emotional

Emotional symptoms are also common and are thought to be both a normal response to having a debilitating disease and the result of damage to specific areas of the central nervous system that generate and control emotions.

Clinical depression

Clinical depression

Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...

is the most common neuropsychiatric condition: lifetime depression prevalence rates of 40–50% and 12 month prevalence rates around 20% have been typically reported for samples of people with MS; these figures are considerably higher than those for the general population or for people with other chronic illnesses. Brain imaging studies have tried to relate depression to lesions in certain regions of the brain have met with variable success. On balance the evidence seems to favour an association with neuropathology in the left anterior temporal/parietal regions.

Other feelings such as anger

Anger

Anger is an automatic response to ill treatment. It is the way a person indicates he or she will not tolerate certain types of behaviour. It is a feedback mechanism in which an unpleasant stimulus is met with an unpleasant response....

, anxiety

Anxiety

Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...

, frustration

Frustration

This article concerns the field of psychology. The term frustration does, however, also concern physics. In this context, the term is treated in a different article, geometric frustration....

, and hopelessness also appear frequently and suicide

Suicide

Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...

is a very real threat since it results in 15% of deaths in MS sufferers.

Fatigue

Neurological fatigue

is very common and disabling in MS with a close relationship to depressive symptomatology. When depression is reduced fatigue also tends to reduce and it is recommended that patients should be evaluated for depression before other therapeutic approaches are used. In a similar way other factors such as disturbed sleep, chronic pain, poor nutrition, or even some medications can all contribute to fatigue and medical professionals are encouraged to identify and modify them. There are also different medications used to treat fatigue; such as amantadine

Amantadine

Amantadine is the organic compound known formally as 1-adamantylamine or 1-aminoadamantane. The molecule consists of adamantane backbone that has an amino group substituted at one of the four methyne positions. This pharmaceutical is sold under the name Symmetrel for use both as an antiviral and an...

, or pemoline

Pemoline

Pemoline was first synthesized in 1913 but it's activity was not discovered until the 1930s. Under the names it was used as a medication used to treat attention-deficit hyperactivity disorder and narcolepsy. Under the Convention on Psychotropic Substances, it is a Schedule IV drug...

; as well as psychological interventions of energy conservation; but their effects are small and for these reasons fatigue is a difficult symptom to manage. Fatigue has also been related to specific brain areas in MS using magnetic resonance imaging

Magnetic resonance imaging

Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...

Internuclear ophthalmoplegia

Internuclear ophthalmoplegia is a disorder of conjugate lateral gaze. The affected eye shows impairment of adduction

Adduction

Adduction is a movement which brings a part of the anatomy closer to the middle sagittal plane of the body. It is opposed to abduction.-Upper limb:* of arm at shoulder ** Subscapularis** Teres major** Pectoralis major** Infraspinatus...

. The partner eye diverges from the affected eye during abduction, producing diplopia

Diplopia

Diplopia, commonly known as double vision, is the simultaneous perception of two images of a single object that may be displaced horizontally, vertically, or diagonally in relation to each other...

; during extreme abduction, compensatory nystagmus can be seen in the partner eye. Diplopia means double vision while nystagmus is involuntary eye movement characterized by alternating smooth pursuit in one direction and a saccadic movement in the other direction.

Internuclear ophthalmoplegia occurs when MS affects a part of the brain stem

Brain stem

In vertebrate anatomy the brainstem is the posterior part of the brain, adjoining and structurally continuous with the spinal cord. The brain stem provides the main motor and sensory innervation to the face and neck via the cranial nerves...

called the medial longitudinal fasciculus

Medial longitudinal fasciculus

The medial longitudinal fasciculus is a pair of crossed fiber tracts , one on each side of the brainstem. These bundles of axons are situated near the midline of the brainstem and are composed of both ascending and descending fibers that arise from a number of sources and terminate in different...

, which is responsible for communication between the two eyes by connecting the abducens nucleus

Abducens nucleus

The abducens nucleus is the originating nucleus from which the abducens nerve emerges - a cranial nerve nucleus. This nucleus is located beneath the fourth ventricle in the caudal portion of the pons, medial to the sulcus limitans....

of one side to the oculomotor nucleus

Oculomotor nucleus

The fibers of the oculomotor nerve arise from a nucleus in the midbrain, which lies in the gray substance of the floor of the cerebral aqueduct and extends in front of the aqueduct for a short distance into the floor of the third ventricle...

of the opposite side. This results in the failure of the medial rectus muscle

Medial rectus muscle

The medial rectus muscle is a muscle in the orbit.As with most of the muscles of the orbit, it is innervated by the inferior division of the oculomotor nerve ....

to contract appropriately, so that the eyes do not move equally (called disconjugate gaze).

Different drugs as well as optic compensatory systems and prisms can be used to improve these symptoms.
Surgery can also be used in some cases for this problem.

Mobility restrictions

Restrictions in mobility (walking, transfers, bed mobility etc.) are common in individuals suffering from multiple sclerosis. Within 10 years after the onset of MS one-third of patients reach a score of 6 on the Expanded Disability Status Scale

Expanded Disability Status Scale

(EDSS), requiring the use of a unilateral walking aid, and by 30 years the proportion increases to 83%. Within five years of onset the EDSS is six in 50% of those with the progressive form of MS.

A wide range of impairments may exist in MS sufferers which can act either alone or in combination to impact directly on a person's balance, function and mobility. Such impairments include fatigue, weakness

Muscle weakness

Muscle weakness or myasthenia is a lack of muscle strength. The causes are many and can be divided into conditions that have true or perceived muscle weakness...

, hypertonicity, low exercise tolerance, impaired balance

Balance (ability)

In biomechanics, balance is an ability to maintain the center of gravity of a body within the base of support with minimal postural sway. When exercising the ability to balance, one is said to be balancing....

, ataxia

Ataxia

Ataxia is a neurological sign and symptom that consists of gross lack of coordination of muscle movements. Ataxia is a non-specific clinical manifestation implying dysfunction of the parts of the nervous system that coordinate movement, such as the cerebellum...

and tremor

Tremor

A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving to-and-fro movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, face, head, vocal folds, trunk, and legs. Most tremors occur in the...

.

Interventions may be aimed at the individual impairments that reduce mobility or at the level of disability. This second level intervention includes provision, education, and instruction in the use of equipment such as walking aids, wheelchairs, motorized scooter

Motorized scooter

A motorized scooter is a small scooter designed to have the rider primarily in the standing position with a small motor attached. These scooters are generally designed with a large “deck” in the center on which the operator may stand. Gas powered stand-up scooters use a small utility engine ...

s and car adaptations as well as instruction on compensatory strategies to accomplish an activity — for example undertaking safe transfers by pivoting in a flexed posture rather than standing up and stepping around.

Optic neuritis

Up to 50% of patients with MS will develop an episode of optic neuritis and 20% of the time optic neuritis is the presenting sign of MS. The presence of demyelinating white matter lesions on brain MRIs at the time of presentation for optic neuritis is the strongest predictor in developing clinical diagnosis of MS. Almost half of the patients with optic neuritis have white matter lesions consistent with multiple sclerosis.

At five year follow-ups the overall risk of developing MS is 30%, with or without MRI lesions. Patients with a normal MRI still develop MS (16%), but at a lower rate compared to those patients with three or more MRI lesions (51%). From the other perspective, however, 44% of patients with any demyelinating lesions on MRI at presentation will not have developed MS ten years later.

Individuals experience rapid onset of pain in one eye followed by blurry vision

Visual perception

Visual perception is the ability to interpret information and surroundings from the effects of visible light reaching the eye. The resulting perception is also known as eyesight, sight, or vision...

in part or all its visual field

Visual field

The term visual field is sometimes used as a synonym to field of view, though they do not designate the same thing. The visual field is the "spatial array of visual sensations available to observation in introspectionist psychological experiments", while 'field of view' "refers to the physical...

. Flashes of light (phosphene

Phosphene

A phosphene is a phenomenon characterized by the experience of seeing light without light actually entering the eye. The word phosphene comes from the Greek words phos and phainein...

s) may also be present. Inflammation

Inflammation

Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...

of the optic nerve causes loss of vision most usually by the swelling and destruction of the myelin

Myelin

Myelin is a dielectric material that forms a layer, the myelin sheath, usually around only the axon of a neuron. It is essential for the proper functioning of the nervous system. Myelin is an outgrowth of a type of glial cell. The production of the myelin sheath is called myelination...

sheath covering the optic nerve.

The blurred vision usually resolves within 10 weeks but individuals are often left with less vivid color vision

Color vision

Color vision is the capacity of an organism or machine to distinguish objects based on the wavelengths of the light they reflect, emit, or transmit...

, especially red, in the affected eye.

A systemic intravenous treatment with corticosteroid

Corticosteroid

Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex. Corticosteroids are involved in a wide range of physiologic systems such as stress response, immune response and regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte...

s may quicken the healing of the optic nerve, prevent complete loss of vision and delay the onset of other symptoms.

Pain

Pain is a common symptom in MS; appearing in 55% of patients at some point of their disease process, especially as time passes.
It is strong and debilitating and has a profound effect in the quality of life

Quality of life

The term quality of life is used to evaluate the general well-being of individuals and societies. The term is used in a wide range of contexts, including the fields of international development, healthcare, and politics. Quality of life should not be confused with the concept of standard of...

and mental health

Mental health

Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...

of the sufferer.
It usually appears after a lesion to the ascending or descending tracts that control the transmission of painful stimulus, such as the anterolateral system

Anterolateral system

In the nervous system, the anterolateral system is an ascending pathway that conveys pain, temperature , and crude touch from the periphery to the brain. It comprises three main pathways:-External links:*...

, but many other causes are also possible.
Most frequent pains reported are headache

Headache

A headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the...

s (40%), dysesthetic

Dysesthesia

Dysesthesia comes from the Greek word "dys", meaning "not-normal" and "aesthesis", which means "sensation" . It is defined as an unpleasant, abnormal sense of touch, and it may be, or not be, considered as a kind of pain...

limb pain (19%), back pain (17%), and painful spasm

Spasm

In medicine a spasm is a sudden, involuntary contraction of a muscle, a group of muscles, or a hollow organ, or a similarly sudden contraction of an orifice. It is sometimes accompanied by a sudden burst of pain, but is usually harmless and ceases after a few minutes...

s (11%).

Acute pain is mainly due to optic neuritis

Optic neuritis

, trigeminal neuralgia

Trigeminal neuralgia

Trigeminal neuralgia , tic douloureux is a neuropathic disorder characterized by episodes of intense pain in the face, originating from the trigeminal nerve. It has been described as among the most painful conditions known...

, Lhermitte's sign

Lhermitte's sign

Lhermitte's sign, sometimes called the Barber Chair phenomenon, is an electrical sensation that runs down the back and into the limbs. In many patients, it is elicited by bending the head forward...

or dysesthesias. Subacute pain is usually secondary to the disease and can be a consequence of spending too much time in the same position, urinary retention, or infected skin ulcers. Chronic pain is common and harder to treat.

Trigeminal neuralgia

(or "tic douloureux") is a disorder of the trigeminal nerve

Trigeminal nerve

The trigeminal nerve contains both sensory and motor fibres. It is responsible for sensation in the face and certain motor functions such as biting, chewing, and swallowing. Sensory information from the face and body is processed by parallel pathways in the central nervous system...

that causes episodes of intense pain in the eyes, lips, nose, scalp, forehead, and jaw, affecting 1–2% of MS patients.
The episodes of pain occur paroxysmally (suddenly) and the patients describe it as trigger area on the face, so sensitive that touching or even air currents can bring an episode of pain. Usually it is successfully treated with anticonvulsants such as
carbamazepine

Carbamazepine

Carbamazepine is an anticonvulsant and mood-stabilizing drug used primarily in the treatment of epilepsy and bipolar disorder, as well as trigeminal neuralgia...

,
or phenytoin

Phenytoin

Phenytoin sodium is a commonly used antiepileptic. Phenytoin acts to suppress the abnormal brain activity seen in seizure by reducing electrical conductance among brain cells by stabilizing the inactive state of voltage-gated sodium channels...

although others such as gabapentin

Gabapentin

Gabapentin is a pharmaceutical drug, specifically a GABA analogue. It was originally developed for the treatment of epilepsy, and currently is also used to relieve neuropathic pain...

can be used.
When drugs are not effective, surgery may be recommended. Glycerol rhizotomy (surgical injection of glycerol

Glycerol

Glycerol is a simple polyol compound. It is a colorless, odorless, viscous liquid that is widely used in pharmaceutical formulations. Glycerol has three hydroxyl groups that are responsible for its solubility in water and its hygroscopic nature. The glycerol backbone is central to all lipids...

into a nerve) has been studied
although the beneficial effects and risks in MS patients of the procedures that relieve pressure on the nerve are still under discussion.

Lhermitte's sign

Lhermitte's sign, sometimes called the Barber Chair phenomenon, is an electrical sensation that runs down the back and into the limbs. In many patients, it is elicited by bending the head forward...

is an electrical sensation that runs down the back and into the limbs and is produced by bending the neck forwards. The sign suggests a lesion of the dorsal columns of the cervical cord or of the caudal medulla

Medulla oblongata

The medulla oblongata is the lower half of the brainstem. In discussions of neurology and similar contexts where no ambiguity will result, it is often referred to as simply the medulla...

, correlating significantly with cervical MRI abnormalities.
Between 25 and 40% of MS patients report having Lhermitte's sign during the course of their illness.

Dysesthesias

Dysesthesias are disagreeable sensations produced by ordinary stimuli

Stimulus (physiology)

In physiology, a stimulus is a detectable change in the internal or external environment. The ability of an organism or organ to respond to external stimuli is called sensitivity....

. The abnormal sensations are caused by lesions of the peripheral or central sensory pathways, and are described as painful feelings such as burning, wetness, itching, electric shock or pins and needles. Both Lhermitte's sign and painful dysesthesias usually respond well to treatment with carbamazepine

Carbamazepine

Carbamazepine is an anticonvulsant and mood-stabilizing drug used primarily in the treatment of epilepsy and bipolar disorder, as well as trigeminal neuralgia...

, clonazepam

Clonazepam

Clonazepamis a benzodiazepine drug having anxiolytic, anticonvulsant, muscle relaxant, and hypnotic properties. It is marketed by Roche under the trade name Klonopin in the United States and Rivotril in Australia, Brazil, Canada and Europe...

or amitriptyline

Amitriptyline

Amitriptyline is a tricyclic antidepressant . It is the most widely used TCA and has at least equal efficacy against depression as the newer class of SSRIs...

Sexual

Sexual dysfunction

Sexual dysfunction or sexual malfunction refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, arousal or orgasm....

(SD) is one of many symptoms affecting persons with a diagnosis of MS. SD in men encompasses both erectile

Erectile dysfunction

Erectile dysfunction is sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual performance....

and ejaculatory disorder. The prevalence of SD in men with MS ranges from 75 to 91%. Erectile dysfunction appears to be the most common form of SD documented in MS. SD may be due to alteration of the ejaculatory reflex which can be affected by neurological conditions such as MS.

Spasticity

Spasticity is a feature of altered skeletal muscle performance in muscle tone involving hypertonia, which is also referred to as an unusual "tightness" of muscles...

is characterised by increased stiffness and slowness in limb movement, the development of certain postures, an association with weakness of voluntary muscle power, and with involuntary and sometimes painful spasm

Spasm

s of limbs. A physiotherapist can help to reduce spasticity and avoid the development of contracture

Contracture

A muscle contracture is a permanent shortening of a muscle or joint.. It is usually in response to prolonged hypertonic spasticity in a concentrated muscle area, such as is seen in the tightest muscles of people with conditions like spastic cerebral palsy....

s with techniques such as passive stretching

Passive stretching

Passive stretching is a form of static stretching in which an external force exerts upon the limb to move it into the new position. This is in contrast to active stretching. Passive stretching resistance is normally achieved through the force of gravity on the limb or on the body weighing down on it...

. There is evidence, albeit limited, of the clinical effectiveness of THC

Tetrahydrocannabinol

Tetrahydrocannabinol , also known as delta-9-tetrahydrocannabinol , Δ1-THC , or dronabinol, is the main chemical psychoactive substance found in the cannabis plant. It was first isolated in 1964. In pure form, it is a glassy solid when cold, and becomes viscous and sticky if warmed...

and CBD

Cannabidiol

Cannabidiol is a cannabinoid found in Cannabis. It is a major constituent of the plant, representing up to 40% in its extracts.It has displayed sedative effects in animal tests...

extracts, baclofen

Baclofen

Baclofen is a derivative of gamma-aminobutyric acid . It is primarily used to treat spasticity and is under investigation for the treatment of alcoholism....

, dantrolene

Dantrolene

Dantrolene sodium is a muscle relaxant that acts by abolishing excitation-contraction coupling in muscle cells, probably by action on the ryanodine receptor. It is the only specific and effective treatment for malignant hyperthermia, a rare, life-threatening disorder triggered by general anesthesia...

, diazepam

Diazepam

Diazepam , first marketed as Valium by Hoffmann-La Roche is a benzodiazepine drug. Diazepam is also marketed in Australia as Antenex. It is commonly used for treating anxiety, insomnia, seizures including status epilepticus, muscle spasms , restless legs syndrome, alcohol withdrawal,...

, and tizanidine

Tizanidine

Tizanidine is a drug that is used as a muscle relaxant. It is a centrally acting α2 adrenergic agonist. It is used to treat the spasms, cramping, and tightness of muscles caused by medical problems such as multiple sclerosis, spastic diplegia, back pain, or certain other injuries to the spine or...

. In the most complicated cases intrathecal

Intrathecal

Intrathecal is an adjective that refers to something introduced into or occurring in the space under the arachnoid membrane of the brain or spinal cord...

injections of baclofen can be used. There are also palliative measures like casting

Casting

In metalworking, casting involves pouring liquid metal into a mold, which contains a hollow cavity of the desired shape, and then allowing it to cool and solidify. The solidified part is also known as a casting, which is ejected or broken out of the mold to complete the process...

s, splints or customised seatings.

Transverse myelitis

Some MS patients develop rapid onset of numbness

Paresthesia

Paresthesia , spelled "paraesthesia" in British English, is a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep"...

, weakness, bowel or bladder

Urinary bladder

The urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible organ, the bladder sits on the pelvic floor...

dysfunction, and/or loss of muscle

Motor neuron

In vertebrates, the term motor neuron classically applies to neurons located in the central nervous system that project their axons outside the CNS and directly or indirectly control muscles...

function, typically in the lower half of the body. This is the result of MS attacking the spinal cord

Spinal cord

The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain . The brain and spinal cord together make up the central nervous system...

. The symptoms and signs depend upon the nerve cords involved and the extent of the involvement.

Prognosis for complete recovery is generally poor. Recovery from transverse myelitis usually begins between weeks 2 and 12 following onset and may continue for up to 2 years in some patients and as many as 80% of individuals with transverse myelitis are left with lasting disabilities.

Tremor and ataxia

Tremor

is an unintentional, somewhat rhythmic, muscle movement involving to-and-fro movements (oscillations) of one or more parts of the body. It is the most common of all involuntary movements and can affect the hands, arms, head, face, vocal cords, trunk, and legs.
Ataxia

Ataxia

is an unsteady and clumsy motion of the limbs or torso due to a failure of the gross coordination of muscle movements. People with ataxia experience a failure of muscle control in their arms and legs, resulting in a lack of balance and coordination or a disturbance of gait

Gait (human)

Human gait is the way locomotion is achieved using human limbs. Different gaits are characterized by differences in limb movement patterns, overall velocity, forces, kinetic and potential energy cycles, and changes in the contact with the surface .- Foot strike :One variable in different gaits is...

.

Tremor and ataxia are frequent in MS and present in 25 to 60% of patients. They can be very disabling and embarrassing, and are difficult to manage. The origin of tremor in MS is difficult to precise but it can be due to a mixture of different factors such as damage to the cerebellar connections, weakness, spasticity

Spasticity

Spasticity is a feature of altered skeletal muscle performance in muscle tone involving hypertonia, which is also referred to as an unusual "tightness" of muscles...

, etc.

Many medications have been proposed to treat tremor; however their efficacy is very limited. Medications that have been reported to provide some relief are isoniazid

Isoniazid

Isoniazid , also known as isonicotinylhydrazine , is an organic compound that is the first-line antituberculosis medication in prevention and treatment. It was first discovered in 1912, and later in 1951 it was found to be effective against tuberculosis by inhibiting its mycolic acid...

, carbamazepine

Carbamazepine

Carbamazepine is an anticonvulsant and mood-stabilizing drug used primarily in the treatment of epilepsy and bipolar disorder, as well as trigeminal neuralgia...

, propranolol
and gluthetimide but published evidence of effectiveness is limited. Physical therapy

Physical therapy

Physical therapy , often abbreviated PT, is a health care profession. Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, diagnosis, treatment/intervention,and rehabilitation...

is not indicated as a treatment for tremor or ataxia although the use of orthese

Orthotics

Orthotics is a specialty within the medical field concerned with the design, manufacture and application of orthoses. An orthosis is an orthopedic device that supports or corrects the function of a limb or the torso...

devices can help. An example is the use of wrist bandages with weights, which can be useful to increase the inertia

Inertia

Inertia is the resistance of any physical object to a change in its state of motion or rest, or the tendency of an object to resist any change in its motion. It is proportional to an object's mass. The principle of inertia is one of the fundamental principles of classical physics which are used to...

of movement and therefore reduce tremor. Daily use objects are also adapted so they are easier to grab and use.

If all these measures fail patients are candidates for thalamus

Thalamus

The thalamus is a midline paired symmetrical structure within the brains of vertebrates, including humans. It is situated between the cerebral cortex and midbrain, both in terms of location and neurological connections...

surgery

Surgery

Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

. This kind of surgery can be both a thalamotomy

Thalamotomy

First introduced in the 1950s, thalamotomy is an invasive procedure, primarily effective for tremors such as those associated with Parkinson's Disease , where a selected portion of the thalamus is surgically destroyed...

or the implantation of a thalamic stimulator

Thalamic stimulator

A thalamic stimulator is a relatively new medical device that can suppress tremors, such as those caused by Parkinson's Disease or essential tremor. It was approved for use by the Food and Drug Administration on August 4, 1997. Installation is invasive, so it is typically only used when the...

. Complications are frequent (30% in thalamotomy and 10% in deep brain stimulation) and include a worsening of ataxia, dysarthria

Dysarthria

Dysarthria is a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system and is characterized by poor articulation of phonemes...

and hemiparesis

Hemiparesis

Hemiparesis is weakness on one side of the body. It is less severe than hemiplegia - the total paralysis of the arm, leg, and trunk on one side of the body. Thus, the patient can move the impaired side of his body, but with reduced muscular strength....

. Thalamotomy is a more efficacious surgical treatment for intractable MS tremor though the higher incidence of persistent neurological deficits in patients receiving lesional surgery supports the use of deep brain stimulation as the preferred surgical strategy.

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