Table of Contents
Multiple sclerosis is a chronic inflammatory disorder characterised by plaques of demyelination in central nervous system that cause neurological symptoms and disability.
Types of MS
- Relapsing-remitting (85%): intermittent relapses with subsequent total or partial recovery
- Primary progressive (15%): sustained, progressive disability from the start
- Secondary progressive: 65% of people with relapsing-remitting MS will develop secondary progressive MS with sustained, progressive disability
Any part of central nervous system can be affected but common deficits include:
- Optic nerve: reduced visual acuity, central scotoma
- Medial longitudinal fasciculus: internuclear ophthalmoplegia (disorder of lateral conjugate gaze)
- Cerebellum =DANISH:
- Intention tremor
- Speech abnormality (slurring/scanning/staccato)
- Spinal cord: spastic paraparesis, lower limb sensory loss, urinary symptoms
Diagnosis requires demonstration of demyelinating lesions ‘disseminated in time and space’
- MRI brain/spinal cord: shows demyelination
- Evoked potentials: may reveal delayed visual/auditory/sensory potentials due to demyelination
- Cerebrospinal fluid analysis: oligoclonal bands
Management requires a multi-disciplinary approach (including neurologist, specialist nurse, physiotherapist, occupational therapist, GP, speech and language therapist)
- Methylprednisolone (IV or oral)
Preventing relapses (disease-modifying agents)
Suitable for some patients depending on type of MS:
- Monoclonal antibodies: alemtuzumab, natalizumab, ocrelizumab
- Oral therapies: sphingosine 1-phosphate receptor modulators (e.g. fingolimod, siponimod), teriflunomide, fumarates (e.g. diroximel fumarate, dimethyl fumarate)
- Platform injection therapies: glatiramer, β-interferon
- Neuropathic pain: tricyclic antidepressants, gabapentin, pregabalin
- Incontinence: timed voiding, intermittent self-catheterisation for overflow, anticholinergics for urge
- Spasticity: physiotherapy, baclofen, gabapentin
- Oscillopsia: gabapentin
- Fatigue: exercise, diet, amantadine, modafinil, SSRI
Reference: NICE ‘NG220 Multiple sclerosis in adults: management’ 2022
Try some questions
What is oscillopsia?
Does multiple sclerosis cause upper or lower motor neuron lesions? Why?
What is Lhermitte’s sign?
What are the clinical findings of a internuclear ophthalmoplegia due to a right medial longitudinal fasciculus lesion?