Multiple Sclerosis - Multiple sclerosis (MS) is an immune-mediated inflammatory disease that attacks myelinated axons in the central nervous

system, destroying the myelin and the axon in variable degrees and producing significant physical disability within 20-25 years in more than 30% of patients. The hallmark of MS is symptomatic episodes that occur months or years apart and affect different anatomic locations. The Four Courses of Multiple Sclerosis There are 4 courses of the disease. In each case, the MS may be mild, moderate or severe. Relapsing-Remitting MS (RRMS): Over 80% of patients start off with this type. Relapsing - there are acute and unpredictable "exacerbations" (acute attacks, also called "flareups"). During this period symptoms get worse. Remitting - and then there are periods of full or partial recovery. Sometimes there is no recovery. The attacks may evolve over days or even weeks, and recovery can take weeks, or even months. In between the attacks there is calm, and symptoms do not worsen. Primary-Progressive MS (PPMS): About 15% of patients have this type. There are no clear relapses or remissions. The progression of the disease is steady. It is the most common form of MS in those who develop the disease after 40 years of age. Secondary-Progressive MS (SPMS): Starts off as a relapsing-remitting type of MS. Relapses and partial recoveries occur. However, in between cycles the disability does not go away. Eventually it becomes a progressive disease with no cycles. The progressive stage may start very early on, years, or even decades later. Progressive-Relapsing MS (PRMS): The least common form. Symptoms worsen progressively, steadily There are acute attacks. Some recovery may follow, or may not. In the early stage, it seems the patient has primary progressive MS. Signs and symptoms Classic MS signs and symptoms are as follows: 1. Sensory loss (ie, paresthesias): Usually an early complaint 2. Spinal cord symptoms (motor): Muscle cramping secondary to spasticity 3. Spinal cord symptoms (autonomic): Bladder, bowel, and sexual dysfunction 4. Cerebellar symptoms: Charcot triad of dysarthria, ataxia, and tremor 5. Optic neuritis

6. Trigeminal neuralgia: Bilateral facial weakness or trigeminal neuralgia 7. Facial myokymia (irregular twitching of the facial muscles): May also be a presenting symptom 8. Eye symptoms: Including diplopia on lateral gaze 9. Heat intolerance 10. Constitutional symptoms: Especially fatigue and dizziness 11. Pain: Occurs in 30-50% of patients at some point in their illness 12. Subjective cognitive difficulties: With regard to attention span, concentration, memory, and judgment 13. Depression: A common symptom 14. Euphoria: Less common than depression 15. Bipolar disorder or frank dementia: May be a late finding but is sometimes found at initial diagnosis 16. Symptoms associated with partial acute transverse myelitis Laboratory and Diagnostic Tests Magnetic Resonance Imaging is important in both confirming the diagnosis of MS and understanding the dynamics of demyelinating plaques development in patients with MS. However, it is important to understand that abnormal MRI findings without clinical evidence are not sufficient to confirm a diagnosis of MS. Conversely, an absence of abnormal MRI findings in clinically definite MS does not disprove the diagnosis. 2. Blood and urine tests are nonspecific and unremarkable in patients with MS. Attempts are currently under way to develop quantitative techniques to assess Myelin breakdown products excreted in urine in MS patients. No clinical applications of this technique are available yet. 3. Cerebral spinal fluid studies can confirm demyelinating disease of the nervous system. They show an increase in immunoglobulin concentrations in more than 90% of patients with MS. Protein level can be higher if the patient is going through a marked relapse (i.e.,. severe optic neuritis).
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Management Treatment of MS has 2 aspects: immunomodulatory therapy (IMT) for the underlying immune disorder and therapies to relieve or modify symptoms. Treatment of acute relapses is as follows: - Methylprednisolone (Solu-Medrol) can hasten recovery from an acute exacerbation of MS - Plasma exchange (plasmapheresis) can be used short term for severe attacks if steroids are contraindicated or ineffective - Dexamethasone is commonly used for acute transverse myelitis and acute disseminated encephalitis The following agents are used for treatment of aggressive MS: - High-dose cyclophosphamide (Cytoxan) has been used for induction therapy - Mitoxantrone is approved for reducing neurologic disability and/or the frequency of clinical relapses in patients with SPMS, PRMS, or worsening RRMS

Treatment of the symptoms of MS involves both pharmacologic and nonpharmacologic measures. The following symptoms may be amenable to pharmacologic therapy: Fatigue: Off-label treatments include amantadine, methylphenidate, and fluoxetine Depression: Selective serotonin reuptake inhibitors are preferred Spasticity: Baclofen is effective in most cases Pain: Tricyclic antidepressants are first-line drugs for primary pain Sexual dysfunction: Oral phosphodiesterase type 5 inhibitors (eg, sildenafil, tadalafil, vardenafil) - Optic neuritis: Intravenous methylprednisolone may speed recovery Nursing Diagnosis 1. Activity Intolerance May be related to:

Motor weakness Jerky movements Muscle Spasms