Multiple Sclerosis Etiology Multiple Sclerosis,

Multiple Sclerosis Etiology

Multiple sclerosis, some researchers argue, constitutes "a disease of unknown etiology," which reportedly implies a single causal organism triggers MS. Numerous infectious agents suspected as possible etiological agents include: "the corona, measles, Epstein-Barr, herpes simplex type 6, and canine distemper viruses, the human T-cell lymphotrophic virus (HTLV)-I, an 'MS-associated agent' and, most recently, Chlamydia." (Poser 12) No one has been able to confirm any these infectious agents, however, this contention continues even though competent investigators routinely utilize sophisticated techniques to conduct exhaustive searches. (Poser 12) Numerous steps leading to the development process of MS remain invisible and unidentified. The contemporary consensus regarding MS. Albeit, posits it likely evolves from a genetically susceptible subject, of the immune system's activation by various viral agents, consequently initiating a pathogenetic surge ultimately contributing the myelin sheath and axon being destroyed. (Poser 12) Multiple sclerosis (MS) constitutes the current, most common neurological illness in North America and Europe. MS, Doughty reports, affects approximately 2.5 million individuals worldwide. At times, the complex, daunting aspects of MS contribute to challenging individuals, with MS, mentally, physically personally, socially, and vocationally. Accompanying challenges continually confront individuals with MS with critical crossroads in life and require relevant rationale choices be made by them and/or those who work with and care for this particular population. Population and the geographic location both reportedly influence the frequency of MS. Current research reflects that white persons of northern European descent who live in temperate climates are more frequently diagnosed with MS, an observation suggesting genetic, as well as, environmental factors may influence the frequency of MS. Anderson et al., cited by Wilson and Islam, estimates approximately 250,000-350,000 cases of MS were diagnosed in 1990, the incidences of MS (noting total population of approximately 250 million) equates to a prevalence of approximately 1 case per 1000 population. This amounts to half the prevalence of MS in northern Europe, which equates to two cases per 1000 population. Wilson and Islam define MS as: "an inflammatory demyelinating condition of the central nervous system (CNS) traditionally deemed autoimmune in nature. White matter tracts are affected, including those of the cerebral hemispheres, infratentorium, and spinal cord."

The locality where MS lesions or plaques may develop in CNS white matter may vary. Clinical presentations of MS may also be dissimilar. Frequently, the ongoing lesion formation in MS fosters physical disability and, in some cases, leads to cognitive decline. MS characteristics include its unpredictable nature, the time delay between the onset of symptoms and the confirmed MS diagnosis, as well as, the physiological and psychological symptomatology (collective symptoms MS) ranges potentially present in an individual with MS. As common in a number of other autoimmune conditions, the MS patient's immune system attack its host, likely due to exposure to a molecular sequence mimicking the host tissue's molecular sequence. Wilson and Islam explain that even though the immune trigger has not yet been identified, the targets are known to be myelinated CNS tracts. In inflamed areas, the blood-brain barrier breaks down, accompanied by perivascular lymphocytic and monocytic infiltration. "Focal destruction of myelin ensues, with axonal damage, gliosis, and the formation of sclerotic plaques. Gradually, cumulative damage results in significant loss of white matter and a reduction in total brain volume." (Wilson and Islam)

MRI Images

The following figures compare MRI images of a "normal" brain with one of a person with MS.

Point-resolved spectroscopic study performed in MS patient reflects " slightly decreased N-acetylaspartate peak and a mildly elevated choline peak;... findings... compatible with demyelination with neuronal loss and increased cell membrane turnover." (Wilson and Islam)

Challenging Characteristics

MS can adversely impact a number of body functions with symptoms displayed as: pain, speech and visual impairment, loss of memory, muscle weakness, loss of coordination, depression, numbness, and bowel and bladder problems. Sexual dysfunction may also be experienced by individuals with MS.

According to National Multiple Sclerosis Society, MS affects as many as 400,000 people in the U.S. Approximately, 2.5 million individual may be affected throughout the world. Most individuals diagnosed with MS are females between 20 and 50 years old. ("RNew MRI Finding") Out of the four classifications of MS, the two most prevalent types include relapsing-remitting and secondary-progressive. Individuals with relapsing-remitting MS experience symptom flare-ups, followed with times when MS does not progress. A person with secondary- progressive MS, however, undergoes an initial period of relapsing-remitting MS, followed by MS steadily progressing. ("RNew MRI Finding")

Resources in the book review of Multiple Sclerosis: A Guide for Rehabilitation and Health Care Professionals, edited by Rumrill and Hennessey, Doughty reports that in addition to exploring the challenging characteristics of MS, this work depicts a vital virile volume of information relating to MS. Basically, in Multiple Sclerosis: A Guide for Rehabilitation and Health Care Professionals, contributing authors, including nurses, individuals with MS, and others knowledgeable about the illness offer the reader a comprehensive, interdisciplinary view of MS.

This work includes topic areas, germane to lives of individuals with MS, as at the end of each chapter, the contributing authors, with MS, wrote personal prospective relating to particular issues presented in each chapter (Doughty). Hennessey and Rumrill, cited by Doughty, orient the reader to MS, as they present credible context and prepare the foundation for information accessible in subsequent chapters. The physiological and psychological impacts on issues, including family and community concerns, employment and/or lack of career development are also related to the reader. Randall T. Schapiro enhances introductory information relating strategies on how to best manage MS, while also encouraging the reader to apply relevant knowledge to daily life challenges and issues. Lynn C. Koch and Connie J. McReynolds, cited by Doughty, examine symptom management issues, along with psychological factors for individuals with MS.

Peggy a. Crawford, cited by Doughty, discusses how MS may affect an individual's children, his/her marital relationship, as well as other family members. Koch and McReynolds, cited by Doughty, examine parenting issues. Nancy Cooper, Wendy Sullivan, and Rosemary Zuck, Doughty notes, focus on challenging contemporary, community living issues for individuals with MS, as they provide information on community-based care programs such as respite care, adult day programs, and assisted living facilities. The authors also share information regarding services the National MS Society in local area(s) offer. Other components covered in Multiple Sclerosis: A Guide for Rehabilitation and Health Care Professionals include:

Techniques aimed to foster and/or strengthen independence among individuals with MS.

Career development and employment issues for individuals with MS, including physiological and psychological factors that affect the critical rate of unemployment among individuals with MS.

Wilson and Islam note the following known characteristics about MS:

Race: MS is most prevalent in white persons of northern European descent (Hauser, 1994).

Sex: Male-to-female ratio is approximately 1:2 (Noseworthy, 2000).

Age: MS is a disease of early adulthood.

Onset has been documented in patients aged 2-74 years, although the disease usually appears between the late teenage years and the fourth decade of life, peaking at approximately age 35 years.

In men, the onset is slightly later than in women (Hauser, 1994).

Anatomy: MS is a demyelinating CNS disorder, and it may affect any central white matter. Lesions are commonly located in the optic nerves and tracts, throughout the supratentorial and infratentorial white matter, and along the myelinated tracts of the spinal cord. Locations may include the corpus callosum, cerebellar white matter, and corticospinal tracts.

Clinical Diagnosis: A diagnosis of MS is made on the basis of clinical findings by using supporting evidence from ancillary tests such as cerebrospinal fluid (CSF) examination for oligoclonal banding and MRI.

Clinical course: The clinical course of MS can follow different patterns, and this observation has led to the classification of distinct types of MS. The most common form of MS is termed relapsing-remitting MS, in which progression involves symptoms of neurologic dysfunction frequently followed by partial or complete clinical recovery. In relapsing-remitting MS, global clinical deterioration has traditionally been attributed to cumulative deficit due to incomplete recovery from repeated occurrences of individual relapses. Recently, however, this cumulative deficit has been questioned, because evidence increasingly suggests an ongoing background neurologic deterioration that is independent of the relapses.... (Wilson and Islam)

New Insight

An ASNA News Release on August 28, 2007, entitled "RNew MRI Finding Sheds Light on Multiple Sclerosis Disease Progression," purports that from the use of magnetic resonance (MR) images of the brain, researchers recently delineated a previously unrecognized abnormality related to the progression of MS, and the disability accompanying this disease.

Based on these findings, "Rohit Bakshi, M.D., associate professor of neurology and radiology at Harvard Medical School and director of clinical MS-MRI at Brigham and Women's Hospital and Partners MS Center in Boston; leader of this study contends, "physicians may be able to diagnose multiple sclerosis more accurately and identify patients at risk for developing progressive disease." ("RNew MRI Finding")

The following questions and answers to the FDA Consumer Quiz relate several prominent points about MS (Appendix contains full test text):

At what age is multiple sclerosis most frequently diagnosed?

A d.) between 20 and 50.

Studies have shown that people with multiple sclerosis who exercise:

c.) have less fatigue

How many people in the United States are diagnosed with multiple sclerosis every week?

A b.) about 200 ("Take the FDA Consumer")

Dealing with Depression

As depression is reportedly the most common psychiatric disorder in multiple sclerosis (MS) patients, those caring for MS patients who express any sort of suicidal ideation should be closely monitored and referred for a psychological evaluation. Frequently, MS patients experiencing bouts with depression or suicidal thoughts are not assessed, under assessed, and/or consequently not diagnosed. Unlike some of the other aspects accounting MS, yet similar to some MS, depression can be effectively treated. Numerous reasons contribute to MS patients experiencing depression, according to Wallin. These may include:

The psychosocial effects of MS disability.

The direct effect of lesions on brain structures that are involved in regulating and maintaining mood state

The untoward effects of interferon (IFN)- ? For treating MS, which may be associated with mood changes.

Immune dysfunction. (Wallin)

Early intervention for depression, Wallin stresses, is vital as relief from depression related to MS can prevent declines in a MS patient's quality of life. It may also prevent a person attempting or completing suicide. (Wallin)

Surgical Treatments Deep brain stimulation (DBS), a variation of a surgery from the 1960s, is sometimes still used to treat tremors in MS patients. Surgeries in the past destroyed the thalamus (thalamotomy) or another part of the brain, the globus pallidus (pallidotomy). Today, instead of these type surgeries, which carry significant risk, due to the intentional destruction of part of the brain, deep brain stimulations are performed. When treating MS with DBS, a medical specialist places an electrode with the tip of the electrode in the thalamus (for tremor and multiple sclerosis). The medical specialist leaves the electrode for deep brain stimulation in the brain, connected by a wire to a pacemaker-like device. he/she then implants the stimulating device under the skin over the chest of the MS patient.

The device delivers electrical shocks to help to relieve tremors accompanying MS. (Doctors)

Doctors)

Doctors at the Mellen Center for Multiple Sclerosis Research at the Cleveland Clinic relate the following questions/answers regarding the surgical treatment of DBS:

Can Deep Brain Stimulation Cure MS?

No. Electrical stimulation does not cure multiple sclerosis nor does it prevent the disease from getting worse; it helps to relieve the symptom of tremor related to MS.

Is Deep Brain Stimulation Considered Experimental?

Deep brain stimulation is not experimental. The FDA has approved DBS to treat Parkinson's disease, essential tremor and dystonia. Dystonia is a type of movement disorder characterized by abnormal postures and twisting motions.

The FDA has not specifically approved deep brain stimulation of the thalamus to treat multiple sclerosis. However, this does not mean that the treatment is experimental or that it would not be covered by insurance. There are many examples of treatments that are used every day and are standard and accepted but that have not been approved by the FDA.

Deep brain stimulation is a way to inactivate parts of the brain without purposefully destroying the brain. Therefore, the risks are much lower. In Who Should Consider Deep Brain Stimulation?

There are many important issues to be addressed when considering deep brain stimulation. These issues should be discussed with a movement disorders expert or a specially trained neurologist.

Before considering surgery, you should have tried medication first. Surgery should not be undertaken if medications are able to control your symptoms. However, surgery should be considered if you do not achieve satisfactory control through medications. If you are unsure if DBS is right for you, consult a movement disorders expert or a neurologist who has experience with movement disorders.

Where Should the Operation Be Performed?

The surgery should be performed in a center where there is a team of experts to care for you. This means neurologists and neurosurgeons who have experience and specialized training in doing these types of surgeries.

Another thing to consider when deciding where to go for the surgery is to find out how the target (that is the thalamus) is localized. Different centers may perform the surgeries in different ways. It is clear that the chances of benefit and the risks of complications are directly related to how close the electrode is to the correct target. (Doctors)

Treatment Options

Treatment options for MS, according to the Mayo Clinic, in addition to DPS, include may include medications, physical and occupational therapy, as well as, experimental therapies. Currently, two primary strategies are recommended for MS:

Managing the symptoms accompanying MS;

Treatment of MS prior to permanent damage contributing to onset of symptoms.

The Mayo Clinic utilizes a multidisciplinary approach and offers expertise to help best manage neurological diseases such as MS. Treatment techniques may include:

Careful Monitoring

Medications to Treat MS

Beta Interferons: Interferon beta-1b (Betaseron) and interferon beta-1a (Avonex, Rebif), genetically engineered copies of proteins naturally occurring in the body, reduce MS flare-ups of MS.

Glatiramer, an alternative to beta interferons, prescribed if a MS patient experiences relapsing-remitting, like beta interferons, effectively curbs MS attacks. Glatiramer, which blocks the immune system's attack on myelin, has to be injected, once a day, subcutaneously once daily.

Medications for Treatment of MS Symptoms

Corticosteroids reduce inflammation in nerve tissue and decrease flare-ups' length.. Prolonged use of these medications, however, may cause side effects such as osteoporosis and high blood pressure (hypertension).

Muscle Relaxants: Tizanidine (Zanaflex) and baclofen (Lioresal), oral medications treat muscle spasticity. MS patients may experience painful or uncontrollable muscle spasms and/or stiffening, especially in their legs.

Medications to Reduce Fatigue may include amantadine (Symmetrel), the antiviral drug or modafinil (Provigil), a medication for narcolepsy, both possess stimulant properties

Other Medications may be prescribed to treat accompanying pain, bladder and/or bowel control issues, or depression.

Physical and Occupational Therapy strive to help preserve a MS patient's independence by strengthening exercises, and utilizing devices to assist with daily tasks.

Counseling sessions such as individual or group therapy may help MS patients and their family members cope with MS in more positive ways, as well as, help them know how to best counter related emotional stress.

Special Therapies include:

Plasma Exchange involves "removing some blood and mechanically separating the blood cells from the fluid (plasma). Blood cells then are mixed with a replacement solution...[and] returned to the body." Plasma Exchange, however, "is only for people with sudden, severe attacks of MS-related disability who don't respond to high doses of steroid treatment." ("Multiple Sclerosis" Mayo Clinic)

Learning to "see" the best way to deal with MS and its accompanying symptoms, this researcher suggests, evolves from not only learning as much as possible about treatment options, but also follow through with day-to-day healthy counters to symptoms. Exercise and positive life-style choices this researcher contends from research, can be serve as extra effective efforts to help ensure one with MS does not experience debilitating, destructive depression. A person with MS, as well as, those who care for him/her could benefit from remembering to note a message that can be dissected from this paper's introduction: "A swollen, pale optic nerve could be a symptom of multiple sclerosis." ("The Eyes Have it;" 50) Although this particular symptom would likely be recognized by a medical specialist, noting other everyday not so subtle symptoms, however, symptoms, does not require a medical degree. As the resource for the introductory posits, this researcher suggests: "The Eyes Have it." Dealing with MS requires, this researcher purports, the ability to train the spirit's eyes to see beyond symptoms that may darken one's spirit. The eyes have it - the ability to make a point to see hope for life, despite challenges MS may present.

APPENDIX a Take the FDA Consumer Quiz

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How's your knowledge of health-related topics such as multiple sclerosis, arthritis, stroke, and skin cancer?

Find out by taking our quiz.

Hint: The answers to all these questions can be found in the March-April 2005 issue of FDA Consumers)

Take any of our past quizzes

1. At what age is multiple sclerosis most frequently diagnosed?

a. () during the teen-age years b. () between 10 and 12 c. () between 60 and 70 d. () between 20 and 50 e. () 80 and over 2. Studies have shown that people with multiple sclerosis who exercise:

a. () often have relapses triggered by exercise b. () have more fatigue c. () have less fatigue

3. How many people in the United States are diagnosed with multiple sclerosis every week?

a. () between 50 and 100 b. () about 200 c. () about 300 d. () more than 500

4. How many Americans are limited in their everyday activities because of arthritis?

a. () 80,000 b. () 8 million c. () 750,000 d. () 2.5 million

5. Traditional non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, act by blocking the production of a family of chemicals known as:

a. () estrogen b. () prostaglandins c. () testosterone

6. Approximately how many people in the United States have a stroke each year?