An Overview of Multiple Sclerosis: Diagnosis and Management Strategies

Kathleen Costello, RN, MS, CRNP, MSCN; Colleen J. Harris, RN, MN, NP, MSCN

Topics in Advanced Practice Nursing eJournal. 2006;6(1)

Abstract and Introduction

Multiple sclerosis (MS) is a complex and unpredictable disease that affects the central nervous system. It is the most common neurologic disease of young adults, usually diagnosed between the ages of 20 and 40 years. Most individuals begin with a relapsing-remitting disease course that often evolves to a more progressive decline in function, called secondary-progressive MS. A small percentage of individuals never experience a relapse, but rather have a steady decline in functional ability and a primary-progressive course of MS. The diagnosis can be difficult as no specific diagnostic tests exist. The treatment of MS requires a multidisciplinary approach that includes relapse management, disease modification, and symptom management. On the basis of recommendations from the Consortium of MS Centers, a North American multidisciplinary group, all persons with MS should have access to care from a multidisciplinary care team that is expert in MS.

Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) that is characterized by relapses and remissions of neurologic symptoms and progression of disability over time. It is the most common neurologic disease affecting young adults, diagnosed in approximately 500,000 individuals in the United States and approximately 50,000 in Canada. Most are diagnosed between the ages of 15 and 50. Two thirds of those with MS are women. The majority are white and of northern European descent.^[1]

The etiology of MS is not known; however, it is considered by most researchers to be an immune-mediated disease. The etiology is thought to be multifactorial with some genetic predisposition, environmental exposure in childhood, and a later trigger such as infection in young adulthood.

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Cite this: An Overview of Multiple Sclerosis: Diagnosis and Management Strategies - Medscape - Mar 21, 2006.

MS Symptoms at Disease Onset
Symptoms	Percentage of Patients (N = 1721)
Sensory symptoms in arms and legs	33
Unilateral vision loss	16
Polysymptomatic onset	14
Slowly progressive motor deficit	9
Acute motor deficit	5
Diplopia	7
Other	16

Adapted with permission from Paty D. Initial symptoms. In: Burks J, Johnson K, eds. Multiple Sclerosis Diagnosis, Medical Management, and Rehabilitation. New York, NY: Demos Publishing; 2000.

The 2005 Revisions to the McDonald Diagnostic Criteria for MS
Clinical Presentation	Additional Data Needed for MS Diagnosis
≥ 2 attacks; objective clinical evidence of ≥ 2 lesions	• None
≥ 2 attacks; objective clinical evidence of 1 lesion	• Dissemination in space, demonstrated by: • MRI OR • ≥ 2 MRI-detected lesions consistent with MS plus positive CSF OR • Await further clinical attack implicating a different site
1 attack; objective clinical evidence of ≥ 2 lesions	• Dissemination in time, demonstrated by: • MRI OR • Second clinical attack
1 attack; objective clinical evidence of 1 lesion (monosymptomatic presentation; clinically isolated syndrome)	• Dissemination in space, demonstrated by: • MRI OR • ≥ 2 MRI-detected lesions consistent with MS plus positive CSF AND • Dissemination in time, demonstrated by: • MRI OR • Second clinical attack
Insidious neurologic progression suggestive of MS	• 1 year of disease progression (retrospectively or prospectively determined) AND • 2 out of 3 of the following: a. Positive brain MRI (9 T2 lesions or ≥ 4 T2 lesions with positive visual evoked potentials; b. Positive spinal cord MRI (≥ 2 focal T2 lesions); c. Positive CSF

Table used with permission: National Multiple Sclerosis Society Research Bulletins. International panel updates diagnostic criteria for MS. Available at www.nationalmssociety.org/research-2005nov10.asp.

Blood Tests for Diseases That May Mimic MS
Blood Test	Possible Diagnosis
Antinuclear antibodies	Collagen vascular disease
Antiphospholipid antibodies	Antiphospholipid syndrome
Antibodies to Borrelia burgdorferi	Lyme disease
Antibodies to Treponema pallidum	Neurosyphilis
HTLV-1	Tropical spastic paraparesis
Thyroid function	Thyroid disease
Vitamin B₁₂, folate	Vitamin deficiency
Angiotensin converting enzymeCalcium, IgG levels	Sarcoidosis
Sedimentation rate, C-reactive protein, ANCA (antineutrophil cytoplasmic antibody)	Vasculitis
Very long chain fatty acids	Adrenoleukodystrophy
Anti-acetylcholine receptor antibodies	Myasthenia gravis

Adapted with permission from Coyle P. Diagnosis and classification of inflammatory demyelinating disorders. In: Burks J, Johnson K, eds. Multiple Sclerosis Diagnosis, Medical Management, and Rehabilitation. New York, NY: Demos; 2000:85

Symptom Management
Symptom	Possible Treatment Strategies	Off-label Medications
Fatigue	• Energy conservation strategies • Cooling measures • Elimination of contributing factors, including some medications or poor dietary habits	• Amantidine, modafinil, methylphenidate
Bladder dysfunction	• Adequate and appropriate fluid intake • Avoidance of stimulant such as caffeine and aspartame • Intermittent self catheterization	• Oxybutinin, hyoscyamine, tolterodine, flavoxate, desmopressin, trospium, solifenacin
Bowel dysfunction	• Dietary and fluid modification • Exercise • Establish a bowel routine	• Psyllium hydrophilic, methylcellulose, mucilloid lactulose • Docusate, lactulose • Suppositories, stimulants, enemas
Spasticity	• Stretching and rehabilitation • Eliminating noxious stimuli • Appropriate assistive devices	• Baclofen, tizanidine, gabapentin, clonazepam, diazepam
Tremor	• Patterning, immobilization, weighting • Thalamic electrostimulation, thalamotomy	• Clonazepam, propanolol, gabapentin, isoniazid
Depression	• Regular screening • Psychosocial intervention by psychiatrist/psychologist	• Antidepressant medications such as fluoxetine, paroxetine HCL, sertraline, citalopram, venlafaxine, duloxetine, bupropion, mirtazapine
Cognitive impairment	• Neuropsychological evaluation • Memory aids and retraining	• Donepezil HCL

Adapted with permission from Halper J, ed. Symptom Management. Advanced Concepts in Multiple Sclerosis Nursing Care. New York, NY: Demos; 2001:175-265.

Resources for Patients
Online Resources	Purpose	Web Address
National MS Society	Provides assistance to those with MS and support research in MS	www.nmss.org
MS Association of America	Provides programs and services for patients and care partners	www.msaa.com
MS Foundation	Provides educational resources, support group links, and educational programs	www.msfacts.org
Montel Williams MS Foundation	Furthers the study of MS and disseminates information to survivors, their loved ones, and the public	www.montelms.org
MS Awareness Foundation	Promotes self-awareness and educates the public at large about the health and lifestyle challenges facing those affected with the disease.	www.msawareness.org
Multiple Sclerosis International Federation	Links the activities of MS Societies	www.msif.org
Myelin Project	Conducts research on myelin repair	www.myelin.org
Consortium of Multiple Sclerosis Centers	provides educational opportunities to MS healthcare professionals	www.mscare.org
International Organization of MS Nurses	Provides education, resources, and networking opportunities for nurses in MS care worldwide	www.IOMSN.org

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