Multiple sclerosis treatment
Multiple sclerosis is a demyelinating, autoimmune disease with a chronic course that affects the brain and spinal cord. Common symptoms are extreme fatigue, visual disturbances, altered sensation, and difficulty moving. However, advances in the treatment of MS appear every year, and progress in research to find a cure is quite encouraging.
Multiple sclerosis (MS) is a chronic autoimmune neurological disease that affects the central nervous system. It refers to demyelinating conditions that cause damage to the nerve cells, so they lose their myelin sheaths, usually rendering them unable to perform their normal function. It can affect the brain, spinal cord and optic nerves. This group includes relatively rare types of sclerosis:
- Нemorrhagic leukoencephalitis develops due to damage to small elements of the vascular system. It is often defined as a post-infectious complication with a pronounced autoimmune reaction. It is characterised by the rapid progression of the inflammatory process, brain oedema, the appearance of foci of haemorrhage, and necrosis.
- Concentric sclerosis (Balo's disease) is the appearance of a specific pathomorphological substrate of concentric foci of demyelination in the form of rings with alternating layers of remyelination and demyelination. The actual frequency of Balo's disease is unknown, but it is more common in Asian countries between the ages of 20 and 50.
- Myelinoclastic diffuse sclerosis (Schilder's disease) is a sporadic, progressive degenerative demyelinating disease of the central nervous system (CNS), which usually begins in childhood and adolescence (in most cases, boys aged 7-12 years are affected). Schilder's disease often occurs shortly after an infectious disease and may begin with a headache, general discomfort or malaise, and fever.
- Transverse myelitis is caused by bilateral inflammation of one level or segment of the spinal cord. Inflammation can damage or destroy myelin, forming "scars", which interfere with the transmission of signals between nerves in the spinal cord and other body parts. Most people with transverse myelitis have only one episode, and only a small percentage of patients experience more episodes.
There are many indications that it is an autoimmune disease. The immune system begins to produce antibodies to the cells of the nervous system and the protein - myelin, which covers nerves. Commonly, myelin can be compared to electrical tape used to wrap wires. If myelin is destroyed, demyelination ("holes") foci appear in the central nervous system. It causes problems with the nerve impulse's conduction, which leads to the appearance of a wide variety of symptoms and disorders in the nervous system.
To date, four main types of MS have been identified:
- Clinically isolated syndrome (ICS) is the first episode of neurological symptoms caused by inflammation and demyelination in the CNS. An attack, defined as lasting at least 24 hours, is clinically characteristic of MS, but people who have had an ICS may not develop MS later.
- Relapsing-remitting MS (RRMS) is the most general course of the disease (85% of cases). It manifests as well-defined episodes of the appearance of new neurological symptoms or the strengthening of existing ones.
- Primary-progressive MS (PRMS) is characterised by deterioration of neurological function ("accumulation of disability") since the onset of symptoms, without early relapses or remissions. It is diagnosed in approximately 15% of people with MS.
- Secondary-progressive MS (SPMS) follows the initial relapsing-remitting course of the disease. Most people initially diagnosed with RRMS eventually progress to an SPMS, in which there is a progressive deterioration of neurological function ("accumulating disability") over time.
Multiple sclerosis usually occurs in early adulthood, sometimes in childhood and rarely in old age. Especially in the case of non-relapsing forms of MS, the disease usually begins after the age of 40. It is noticeable that women are affected twice as often, which is why hormonal influences are suspected.
Possible causes of MS
Despite intensive clinical research, the root of MS has not yet been clearly understood. It is most apparent that it is a combination of hereditary factors and the influence of the external environment, leading to an incorrect reaction of the body's immune system. Multiple factors may need to be present simultaneously for the condition to occur. There are some points about causes and risks:
- MS is not a "classic hereditary disease" passed from parent to child. The risk for children of a parent with MS to get a disease is slightly increased compared to the general population (approximately 0.1%).
- Interest in sun exposure grew from realising that MS risk increases with higher latitudes. Regions with higher levels of solar radiation, such as Africa and much of Asia, have less disease than areas further north and south.
- Smokers are more likely (approximately 1,5 times) to develop multiple sclerosis than non-smokers. A possible connection between nutrition, intestinal flora and multiple sclerosis is increasingly becoming a focus.
A precise "MS pathogen" could not be identified so far. However, various viruses (e.g. Epstein-Barr virus, herpes viruses) are suspected of being able to activate multiple sclerosis.
Signs of multiple sclerosis
Symptoms of the disease are caused on the one hand by damage to the nerve insulation layer (demyelination) and, on the other hand, by the breakdown of nerve fibres and cells. Statistically, the most common initial symptom of multiple sclerosis is sensory disturbances in the arms or legs (30 to 50% of those affected).
Visual disturbances are the second most common symptom, particularly in young patients when the disease first presents (about 20% of those affected). A one-sided deterioration in vision over hours, plus pain with eye movements, can indicate an optic nerve inflammation.
The third most common problem is muscle dysfunction at the onset of the disease, which can manifest as weakness, paralysis or increased muscle stiffness. At the same time, coordination and balance disorders also occur.
In addition, the following symptoms may occur:
- Disorders of bladder emptying (urinary bladder, urinary retention, urinary incontinence);
- Fatigue (abnormal tiredness and exhaustion);
- Speech disorders;
- Weakness, sensory disturbances, especially in the legs, insecurity when walking and standing;
- Problems with defecation;
- Uncertainty in targeted movements;
- Mental illness.
Multiple sclerosis symptoms vary in type and severity between patients and the same patient over time. They may go away, achieve complete remission, or persist and worsen over time.
Diagnostic methods for MS
To secure the diagnosis of multiple sclerosis, the doctor must consider the symptoms, course and examination results together. Because no single laboratory test can confirm or deny a diagnosis of MS, magnetic resonance imaging (MRI) is of great help in establishing a definitive diagnosis.
MRI does not use X-rays but uses strong magnetic fields. In 85% of patients with multiple sclerosis, brain images show changes in the early stages that indicate foci of inflammation. In advanced cases, this is the point for almost all patients. The spinal cord is also examined in the case of some neurological dysfunctions.
Lumbar puncture reveals changes in the composition of the cerebrospinal fluid. The doctor inserts a thin hollow needle between the second and fifth lumbar vertebrae and takes some cerebrospinal fluid for laboratory analysis. Typically, specific proteins are found in increased numbers (cerebrospinal fluid-specific oligoclonal bands). In addition, the number of inflammatory cells is often slightly increased.
The conductivity and thus the functionality of nerve tracts can be determined using so-called evoked potentials: the doctor stimulates a sensory organ or a nerve with an external stimulus. It triggers a signal in the brain that the doctor can measure with electrodes (electrical potential). However, in about 75% of patients with MS, this stimulus is delayed, and the strength of the reaction is reduced.
Doctors use visual evoked potentials (VEP) to measure the impulse conduction via the optic nerve. Acoustically evoked potentials (AEP) indicate disorders in the auditory nerve, the cerebellum and the nerve tracts leading to the brain. The specialist also uses somatosensory evoked potentials (SEP) to determine the touch sensitivity of body parts (typically hands and feet) and their impulse conduction to the brain.
Treatment options for multiple sclerosis
There is still no cure for demyelinating diseases, but several treatment options are available. The aim is to stop the disease activity or at least slow down its progression. Specialised, experienced doctors should tailor the therapy to the patient and the course of the disease. MS therapy is based on various pillars:
In the event of an acute flare-up, the patient receives high doses of cortisone preparations (corticosteroids) as an infusion through a vein or for oral administration.
If the cortisone therapy has no effect, a so-called blood wash (plasmapheresis, alternatively immune adsorption) can be considered a further acute therapy. Blood is taken from the patient, cleaned with various components using special filters, and returned. In almost 50% of patients, the symptoms improve with this method.
There is the newest drug for treating relapses - Ponvory. The active ingredient appears to block T-cells and B-cells (two types of white blood cells involved in the immune system) inside the lymph nodes. By blocking these cells in the lymph nodes, Ponvory prevents them from travelling to the brain and spinal cord, thus stopping the damage they do to multiple sclerosis patients.
Course -modifying therapy (immunotherapy)
The aim is to positively influence the course of multiple sclerosis through the long-term use of certain drugs (interferon-beta preparations, teriflunomide, dimethyl fumarate, natalizumab, alemtuzumab).
For example, ocrelizumab (Ocrevus) is a monoclonal antibody that recognises and attaches to a target on the special white blood cells (B cells). They play an essential role in multiple sclerosis by attacking the sheaths around the brain and spinal cord nerves, causing inflammation and damage. By acting on B-cells, Ocrevus helps reduce their activity and relieve symptoms or slow disease progression. Which active ingredient is used depends on the potential benefit, the risks, the patient's age, the course of the disease and the individual tolerability to the drug.
It includes measures to alleviate various MS symptoms. For example, antispasmodic medication for painful muscle spasms. Extensively research is dedicated to exploring stem cell therapy for multiple sclerosis. For example, doctors might indicate stem cells aiming to repair damaged nerve tissues.
Physiotherapy and occupational therapy help against the tremors. Chronic pain in multiple sclerosis is usually not treated with the usual over-the-counter pain medication but with active ingredients such as amitriptyline, carbamazepine or gabapentin. Pelvic floor exercises, urine drainage via a catheter and certain medications can help with bladder dysfunction. Antidepressants and psychological support can be advised in case of depressive disorders. Rehabilitation for multiple sclerosis aims to enable those affected to return to their family, professional and social life.
Bone marrow transplantation is the most advanced method of multiple sclerosis treatment used abroad. This technique can be considered relatively new, but 60-70% have been cured of multiple sclerosis in this way and are gradually returning to everyday life.
Chances of recovery or recurrence
As a rule, about a third of MS patients live without significant disabilities throughout the disease. Another third have neurological complaints relevant to everyday activities but can often be combined with work, for example. In another third, MS leads to disabling neurological symptoms, which can go hand in hand with occupational disability and often the need for care.
However, disease development depends, among other things, on medical care, the response to the treatment, the care, the rehabilitation measures and socio-medical care.
Life expectancy with multiple sclerosis is hardly reduced these days - especially if there are no higher-grade disabilities. However, if serious complications occur, the life expectancy is statistically about six to ten years below the general life expectancy.
Who treats patients with multiple sclerosis?
Different therapists and medical specialities treat patients depending on their individual needs to achieve the therapy goals. Therefore, in addition to various doctors (such as neurologists, ophthalmologists, urologists or GPs), the MS team also includes psychologists, physiotherapists, occupational therapists, speech therapists, nursing staff and social workers.
Can you be entirely cured of multiple sclerosis?
Not yet. Currently, some drugs have demonstrated their ability to "modify" the course of MS by reducing the number of relapses and, to some extent, slowing the rate of progression of disability.
Can you live your ordinary life with MS?
In almost 25% of cases, the disease develops in a benign form. With timely, qualified treatment, people retain their ability to work for a long time and can take care of themselves. As a result, only 10% of patients five years after diagnosis become disabled. Today, specialists have developed many medications that help maintain physical and mental health. Therefore, the most favourable prognosis for multiple sclerosis is for those who seek help on time and receive quality treatment.
Does MS ever stop progressing?
The disease is amenable to treatment for a very long time, only temporarily weakening the symptoms. In the later stages, the symptoms are more pronounced and persistent, and the remission period comes less often. Life with multiple sclerosis turns into a swing from relapses to remission and vice versa. Most often, the disease gains momentum and progresses steadily, changing from a mild form to a more severe one.
What are the new treatment options for multiple sclerosis?
Since there is still no way to cure MS completely, research and the discovery of new methods are constantly ongoing. The latest drugs include Ponvory and Ocrevus (suppress cells of the immune system that attack the myelin sheath of nerves). Other methods still being researched are stem cell therapy and bone marrow transplantation. Currently, there are research data on the positive results of such approaches.
Where can I get Multiple sclerosis treatment?
What are the best clinics for Multiple sclerosis treatment?
Who are the best doctors for Multiple sclerosis?
Prof. Dr. med. Christian E. Elger from Beta Clinic Bonn
Prof. Dr. med. Bernhard Hemmer from University Hospital rechts der Isar Munich
PD. Dr. med. Florian Masuhr from Academic Hospital Bundeswehr Berlin
PD. Dr. med. Axel Lipp from Park Clinic Weissensee Berlin
Dr. med. Gerhard Siebenhuner from Centre of Advanced Medicine Frankfurt am Main