Ana sayfa | MS’in Derinliği  | MS Slide Resource

Multiple sclerosis (MS) produces a wide range of clinical symptoms. The pathological lesions consist of discrete areas of inflammation and demyelination in the central nervous system (CNS), called 'plaques'. Plaques can disturb nerve impulse conduction in any CNS pathway. The scattered distribution of plaques accounts for the diversity of primary neurological problems in the disease.

Some symptoms are secondary to these neurological problems. For example, limb disuse caused by weakness promotes osteoporosis, making fractures more likely. Tertiary 'symptoms' occur too. These include social, vocational, personal and marital difficulties.^1,2

The most common or troublesome symptoms are outlined below. Specialized texts provide further information on less usual symptoms.^3,4,5,6,7,8

Optic neuritis

Acute attacks of optic neuritis are a well known feature of MS. The attacks are characterized by visual disturbances (varying from dulling of colour vision to complete blindness) and pain in or around the eye.^1,9

Motor symptoms

The most common motor disturbances in MS are spasticity, weakness and cerebellar problems.¹⁰

Spasticity - This is one of the most frequent and disabling symptoms of MS. There is increased muscle tension, particularly in the legs and trunk. This gives patients a stiff-legged gait and abnormal posture, which may aggravate sciatica and low back pain. Spasticity may be accompanied by spasms (sudden muscular contractions), which can be flexor or extensor.¹¹

Weakness - Plaques that interrupt motor pathways cause weakness. Secondary symptoms can result, including osteoporosis, muscle wasting (which increases weakness further), and pressure sores.^{1,11, 12}

Rises in temperature aggravate MS symptoms, and this is particularly so with weakness. An increase of only 0.5°C causes temporary conduction block in partially demyelinated nerve fibres. Consequently, summer temperatures, a hot bath, or fever, can all make weakness worse.^9,13

Cerebellar symptoms - MS plaques frequently occur in the cerebellum, causing dysarthria, nystagmus, tremor and an unsteady ataxic gait. The tremor may be so severe that activities of daily living become impossible, making nursing-home care essential. The cerebellar gait abnormality, when combined with spasticity, can be seriously disabling.^13,14,15

Sensory symptoms

Many sensory symptoms occur in MS. They can be irritating, but unless painful, usually do not have a severe effect on quality of life. Sensory symptoms include tingling, numbness, constricting feelings (like a tight band around a toe) and loss of temperature sensation.^2,11,13

Lhermitte's sign (strictly a symptom) - This is an electric shock-like feeling that passes briefly down the back of the legs when the neck is flexed. It occurs frequently in MS.¹¹

Autonomic symptoms

The role of the autonomic nervous system (ANS) includes regulation of bladder, bowel and sexual function. Spinal cord plaques affecting the ANS can cause problems with these functions.

Bladder dysfunction - This is a major problem for many MS patients. Urgency, frequency, urinary retention and incontinence can all occur, often causing significant social embarrassment. Urinary tract infection is a common complication of bladder dysfunction, and may make other neurological symptoms appear worse (a pseudoexacerbation). Likewise, constant wetting of the perineal area can cause skin breakdown. This is a particular problem in bedridden patients if perineal care is difficult because of contractures.^2,13,14,15

Bowel dysfunction - Constipation is very common. Other symptoms are abdominal bloating, flatulence, abdominal cramping, urgency and faecal incontinence.^13,15

Sexual dysfunction - This frequently exists with bladder and bowel problems. Sensory defects, fatigue and psychological reactions may contribute to sexual dysfunction in both men and women.^2,11,13

Psychological symptoms

The psychological disorders of MS are mainly emotional and cognitive.

Emotional and mood disorders - The most frequent emotional disorder is depression, despite the widespread misconception that MS patients have an elevated mood.^11,15

Cognitive disorders - These include memory impairment and poor concentration. They can be severely handicapping, preventing patients from working or performing simple domestic tasks - even in the absence of significant physical disability.^13,15

Non-system-specific symptoms

Fatigue - MS patients often complain of fatigue, which is usually worse in the late afternoon. They describe it as an overwhelming sleepiness.^{1, 13, 16}  

Paroxysmal symptoms - Repeated attacks of a particular neurological symptom occur, each lasting seconds or minutes and taking place hundreds of times a day. These symptoms are not a form of epilepsy, but probably result from impulses crossing between adjacent demyelinated nerve pathways (ephaptic transmission).^14,17

Rare symptoms

Patients with MS can experience almost any neurological symptom. Examples of rare symptoms are weight loss secondary to plaques affecting the hypothalamic appetite centre and hypothermia.^7,10

Patient types and their management

MS patients range from those who have suffered one attack of optic neuritis that has since resolved, to those who are paralysed, demented, doubly-incontinent and bedridden. Moreover, the clinical course is unpredictable. Some people never develop significant disabilities; others are confined to bed within months. Caring for patients in such a variety of clinical stages, and with such different rates of disease progression, requires a flexible approach to management.^12,14,15

Presenting symptoms

The first symptoms of MS typically appear when patients are between 15 and 50 years old. Common forms of presentation are limb weakness, paraesthesiae, unilateral visual loss (optic neuritis), and incoordination (ataxia). The symptoms can appear within minutes or take days to develop.^12,15

Types of disease progression

Although the natural course of MS is extremely variable, it is possible to recognize broad categories of disease and to classify patients according to their disease course. A variety of terms are used to describe the different disease patterns; these do not have precise meanings unless specifically defined for research purposes. However, the following categories are widely used and recommended by an international consensus paper.¹⁸

Relapsing/remitting disease

This form of MS has clearly defined relapses characterized by neurological symptoms that slowly resolve, either completely or partially, over several weeks. Further attacks (relapses or exacerbations) occur at irregular intervals. There is no disease progression between relapses.

A relapse is the appearance of a new symptom, the reappearance of a previous symptom, or worsening of an existing symptom, at any time after the original attack. A true relapse lasts for more than 24 to 48 hours. Recovery usually occurs over a few weeks, and may be complete. If complete recovery does not occur, the patient's disability will increase over time with each relapse (but not between relapses). Some symptoms are more likely to remit than others. Those most likely to do so are optic neuritis, double vision, and some sensory disturbances.^11,12,18,19

Reported prevalence rates for this pattern of disease vary from study to study, depending upon the criteria used by the investigators. The work of Weinshenker et al. gives typical rates. They found that 66% to 85% of patients had relapsing/remitting disease (the percentage varies because different populations were studied).²⁰

Patients who have relapsing MS with increasing disability between relapses are said to have a secondary progressive form of the disease (see below).¹⁹

Primary progressive disease

In some patients, symptoms worsen steadily and slowly from the onset, and disability gradually worsens with no distinct relapses or remissions, although there may be plateaus and temporary minor improvements. This is primary progressive MS. Prevalence estimates vary from 9% to 37%, although a rate of around 10% is widely quoted.^19,21 A few patients rapidly develop severe disability - within months or a few years. This is called malignant MS.^14,18

Secondary progressive disease

Secondary progressive MS occurs when relapsing/remitting MS gives way to a gradual accumulation of irreversible disability, with or without occasional relapses, minor remissions and plateaus. The proportion of patients in whom this occurs increases with length of follow-up. Weinshenker et al. found that 41% of relapsing/remitting patients had entered the secondary progressive phase within 6 to 10 years of disease onset.^18,19

Progressive/relapsing disease

The international consensus paper¹⁸ recommends that this additional, albeit rare, clinical course deserves a separate definition. These patients show disease progression from the outset. However, unlike primary progressive patients, they show clear acute relapses, with or without full recovery. The periods between relapses are characterized by continuing progression.

Benign disease

Benign MS is either disease in which there is little disability many years after diagnosis, or disease with a very slow accumulation of disability over time. In the mildest cases, MS is discovered at post-mortem examination in extreme old age. Overall, at 10 years post-diagnosis, one-third of patients have a benign disease course; this proportion decreases to one-fifth by 20 years.^11,19 The international consensus suggests that benign disease should be defined as that which allows a patient to remain fully functional in all neurological systems 15 years after disease onset.¹⁸

Bu sayfadaki bilginin en son güncellendiği/doğrulandığı tarih:

11/09/2001

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