Multiple sclerosis

Multiple sclerosis is a chronic inflammatory disease affecting the central nervous system (CNS). The CNS includes the brain, spinal cord and optic nerves.

Typical functional limitations that occur over the course of the disease include visual impairments or impaired mobility.

In general, the symptoms are very diverse and differ from person to person. For this reason, MS is sometimes called the “disease with a thousand faces”.

Nerve structures usually suffer multiple focal areas of damage within the CNS. If they are destroyed, this leads to scarring of the nerve tissues, which is known in medical terms as “sclerosis”.

Is multiple sclerosis curable?

MS cannot be cured at present. However, very promising treatments have been developed and approved in recent years, which can help slow the progression of the disease. 

Multiple sclerosis (MS) has a very wide range of symptoms and presents very differently in different people.

In principle, any bodily function may be impaired, depending on which areas of the central nervous system are damaged.

Based on the severity of the damage, the physical limitation may be barely noticeable or may significantly impact everyday life.

Common symptoms of MS include:

• rapid and frequent exhaustion (fatigue) 
• weakness, paralysis or shaking 
• sensory impairments, such as feelings or numbness or crawling sensations on the skin 
• pain – for example, burning pain in the limbs and painful sensations of hot or cold in the feet or hands 
• visual impairments, such as tunnel vision or double vision 
• coordination difficulties, such as uncontrolled movements (ataxia) 
• impaired balance 
• impaired emptying of the bladder and bowel 

In most cases, the symptoms are relapsing, i.e., they recur time and again during acute attacks. Symptom-free periods alternate with periods in which symptoms flare up. This type of MS is known as relapsing-remitting multiple sclerosis (RRMS). 

With this type, the symptoms that occur during the initial stage of MS clear up completely once the attack has passed.

Some patients experience symptoms that are stable rather than episodic in nature. This type of MS is known as primary-progressive multiple sclerosis (PPMS). 

The exact causes of multiple sclerosis (MS) remain unclear.

Experts presume that an interaction between a person’s genetic predisposition and environmental factors triggers and autoimmune response, whereby the immune system attacks the body’s own tissues.

More specifically, immune cells travel to the nervous system, where they attack the protective sheath covering the nerve fibers – known as the myelin sheath. This causes inflammation and may lead to damage, both to the sheath around the nerve fibers and the underlying nerve fibers themselves.

This damage impacts nerve function and individual parts of the nervous system gradually lose their function.

This means that nerve signals can no longer be transmitted correctly, causing the bodily functions they control to malfunction.  

Several factors appear to increase the likelihood of developing multiple sclerosis (MS). These include:

• being female 
• living in northern regions  
• genetic predisposition  
• smoking  
• being overweight in childhood and adolescence. 
• vitamin D deficiency  
• occurrence of MS within the family 
• occurrence of autoimmune diseases within the family, e.g., type 1 diabetes  
• a prior infection with the Epstein-Barr virus (EBV), which triggers glandular fever 

Multiple sclerosis (MS) is one of the most commonly occurring neurological diseases in young adults.  

It usually occurs between the ages of 20 and 40. It is about three times more common in women than men.

Approximately 125 people in every 100,000 have multiple sclerosis in Europe. In general, MS is more common among people living in Europe and North America than in other parts of the world. 

Multiple sclerosis (MS) occurs in two phases, which may overlap.

The disease begins with an inflammatory phase, in which immune system cells are activated and travel to the central nervous system. There, they attack the protective sheath surrounding the nerve fibers (myelin sheath).

In a later, second phase, nerve structures are broken down. This phase is also known as the degenerative phase.

In addition to these two phases, which occur in every case of MS, doctors distinguish between four types of the disease, based on how it progresses.

Clinically isolated syndrome (CIS)

This is a potential precursor to multiple sclerosis. Symptoms and signs initially occur and then disappear without treatment. Around half of all people with CIS go on to develop MS.

Relapsing-remitting multiple sclerosis (RRMS)

With this type, patients experience self-contained episodes interspersed with periods during which symptoms partially or completely resolve (remittance periods). The disease begins this way for most people with multiple sclerosis.

Secondary progressive multiple sclerosis (SPMS)

Following the initial course of relapsing-remitting MS, the disease worsens slowly but progressively. People may experience individuals flare-ups or none at all. For 80 percent of people with MS, the relapsing-remitting form of the disease develops into the secondary progressive form.

Primary progressive multiple sclerosis (PPMS)

With this type, people experience a gradual, steady worsening of symptoms. There are no isolated attacks. This type occurs in around 10 to 15 percent of people with multiple sclerosis.

A person’s own medical history and that of the family, together with an in-depth neurological examination, provide initial indications of multiple sclerosis (MS).

In particular, doctors will examine: 

• eyes and vision 
• muscle tension, muscle strength and reflexes of the limbs 
• gait and coordination 
• the sensory functions of the entire body, such as the perception of touch, pain, the body’s position in space and temperature 

Other relevant tests

If these examinations indicate that the person may have MS, the next step is normally to use magnetic resonance imaging (MRI) to check the brain and spinal cord. This is considered the most reliable screening method.

It is also important to test the liquor, i.e. the cerebrospinal fluid that surrounds the brain and spinal cord. Various indications of inflammation in the central nervous system can be detected in a sample.

A liquor sample is collected by means of a lumbar puncture. This procedure involves a doctor inserting a hollow needle into the spinal canal in the lumbar region of the spine in the lower back.

Evoked potentials can be used to detect potential problems in the transmission of nerve impulses. These are electrical messages that serve to test the visual pathway, for example. The visual pathway is the neural pathway that transmits electrical signals from the retina to the visual cortex in the brain.

Blood tests may also be useful to exclude other diseases with similar symptoms, such as overactive thyroid, underactive thyroid or type 2 diabetes.  

At present, there is no cure for multiple sclerosis (MS). However, there are various treatments.

All available treatments aim to: 

• slow the progression of the disease 
• alleviate symptoms 
• delay disabilities 

The treatment options available can be divided into three categories: 

• treatment of acute attacks 
• long-term treatment to slow the progression of the disease
• symptomatic treatment to treat the symptoms

Treatment of acute attacks

To treat an acute flare-up of MS symptoms, doctors use anti-inflammatory glucocorticosteroids – usually methylprednisolone. Patients are given a high dosage of this active ingredient intravenously over several days.

If this type of high-dose cortisone therapy fails to relieve symptoms effectively, another cortisone shot may be administered. In rare cases, there is an oral “tapering off” period with a low dose of methylprednisolone administered in tablet form.

If this also fails to produce the desired effect, a blood purification technique in the form of plasma separation or immunoadsorption is possible. In this procedure, the antibodies that wrongly attack and damage the body’s tissues are removed from the blood.

Long-term treatment

A very large number of immunosuppressive drugs are now available. These are drugs that influence or suppress the immune system.

They have varying strengths and a range of different side-effects. The choice of drug therefore depends on the type and the severity of the disease.

For people with the relapsing-remitting type, medication that is injected under the skin or into the muscles (such as interferone and glatiramer acetate) have been in use for decades. Newer drugs are also available in tablet for (e.g., teriflunomide, dimethyl fumarate, cladribine, diroximel fumarate, fingolimod, ozanimod, siponimod and ponesimod). Some of these drugs are also used to treat secondary-progressive MS.

Drugs that have to be administered intravenously, such as natalizumab, ocrelizumab and alemtuzumab, may also be used.

For patients with primary-progressive MS, only one drug with ocrelizumab as the active ingredient has been approved to date. However, doctors may also use other active ingredients in exceptional cases.

Symptomatic treatment

This treatment is targeted at the individual symptoms, impairments and disabilities that MS can cause. As these vary widely from one patient to the next, symptomatic treatment is adjusted to each individual.

Frequent ailments that occur in connection with the disease include fatigue, impaired mobility, muscle stiffness (spasticity) and bladder problems.  

Fatigue – one of the most common MS symptoms – is treated with physiotherapy and moderate physical training, for example.

Physiotherapy and occupational therapy are generally important components of symptomatic treatment. They are used to treat – and often also to prevent – paralysis, coordination problems, spasticity and difficulties with walking and balance.

Medication may also help with spasticity and the associated difficulties with walking.

Speech and language therapy is required to treat speech and language disorders and swallowing disorders. 

Living with a chronic disease like multiple sclerosis (MS) isn’t easy – people have to accept that the illness is here to stay and learn how to cope with the impairments it causes.

Due to the progressive disability and ailments it may cause, MS severely impacts quality of life for many people.

For example, if a person is constantly fatigued or has limited mobility and can no longer continue to work or pursue hobbies, this is usually very distressing. 

Talking to others in the same boat

Many people with MS also draw new strength from talking with other people affected by the disease and their loved ones. Self-help groups provide an opportunity to talk about problems and challenges and to identify strategies for coping effectively with the disease.

You can find self-help groups through the database provided on the website of the National Contact and Information Point for Encouraging and Supporting Self-Help Groups (NAKOS).

Staying active and eating well

Despite all the limitations it brings, people with MS are advised to lead a life that is as active and healthy as possible. Regular physical activity and eating a balanced diet can usually help a person to feel better.

Avoiding smoking and stress

As smoking contributes to the progression of MS, it is important to quit and to follow a course of withdrawal treatment if necessary. 

Emotional stress also appears to have a negative effect on the progression of the disease and should be avoided where possible. Regular periods of rest and relaxation and being aware of your limits can help.

Attending check-ups

It’s also important to attend regular check-up appointments with family doctors and neurologists to ensure that any new accompanying conditions are identified and treated in good time.

Being overweight, high blood pressure, type 1 diabetes and high cholesterol levels appear to intensify MS symptoms. 

For more information about MS, in particular about diagnosis and treatment, see the multiple sclerosis guide for patients by the German Neurological Society (Deutsche Gesellschaft für Neurologie e.V. ), which is published by the German Brain Foundation (Deutsche Hirnstiftung e.V.). 

Answers to frequently asked questions are provided on the website of the German Multiple Sclerosis Society, National Federation (Deutsche Multiple Sklerose Gesellschaft Bundesverband e.V.).