Introduction
Multiple sclerosis is a chronic disease that affects the central nervous system, especially the brain, spinal cord, and optic nerves. This can lead to a wide range of symptoms throughout the body. Pain, weakness, and tingling being the common symptoms of MS, it is not possible to predict how multiple sclerosis (MS) will progress in any individual. Some people have mild symptoms, such as blurred vision and numbness and tingling in the limbs. In severe cases, a person may experience paralysis, vision loss, and mobility problems. MS is recently diagnosed in many people in the developed countries, which is believed to be due to unhealthy food habits, sedentary lifestyle and pollution. However, some doctors take genetic changes as the cause of MS. The exact cause is still unknown. Though not an immediately fatal or life threatening one, this disease is a chronic debilitating disease which makes the affected person completely bedridden or dependent by time. However, new treatments are proving effective at slowing the disease. Some scientists believe it is an autoimmune disorder that affects the central nervous system. When a person has an autoimmune disease, the immune system attacks healthy tissue, just as it might attack a virus or bacteria. In the case of MS, the immune system attacks the myelin sheath that surrounds and protects the nerve fibres, causing inflammation. Myelin also helps the nerves conduct electrical signals quickly and efficiently. When the myelin sheath disappears or sustains damage in multiple areas, it leaves a scar, or sclerosis. Doctors also call these areas plaques or lesions. Multiple sclerosis means scar tissue in multiple areas. As more lesions develop, nerve fibres can break or become damaged. As a result, the electrical impulses from the brain do not flow smoothly to the target nerve. This means that the body cannot carry out certain functions.
Signs & symptoms
Central Nervous System (CNS) controls all the actions in the body. MS affects the CNS, and thereby causing symptoms can affect any part of the body. Vision changes can be an early sign of MS.
The most common symptoms of MS are:
Muscle weakness – due to lack of use or stimulation due to nerve damage.
Numbness and tingling – A pins and needles-type sensation is one of the earliest symptoms of MS that can affect the face, body, or arms and legs.
Lhermitte’s sign – A person may experience a sensation like an electric shock when they move their neck, known as Lhermitte’s sign.
Bladder problems – A person may have difficulty emptying their bladder or need to urinate frequently or suddenly (urge incontinence). Loss of bladder control is an early sign of MS.
Bowel problems – Constipation can cause faecal impaction, which can lead to bowel incontinence.
Fatigue – This can undermine a person’s ability to function at work or at home. Fatigue is one of the most common symptoms of MS.
Dizziness and vertigo – balance and coordination issues.
Sexual dysfunction – Both males and females may lose interest in sex.
Spasticity and muscle spasms -This is an early sign of MS. Damaged nerve fibres in the spinal cord and brain can cause painful muscle spasms, particularly in the legs.
Tremor – Some people with MS may experience involuntary shaking and shivering movements.
Vision problems – Some people may experience double or blurred vision, a partial or total loss of vision, or red-green colour distortion. This usually affects one eye at a time. Eye movements can be painful.
Gait and mobility changes – MS can change the way people walk, because of muscle weakness and problems with balance, dizziness, and fatigue.
Emotional changes and depression – Demyelination and nerve-fibre damage in the brain can trigger emotional changes.
Learning and memory problems – These can make it difficult to concentrate, plan, learn, prioritize, and multitask.
Pain – Pain is a common symptom in MS. Neuropathic pain is directly due to MS. Other types of pain occur because of weakness or stiffness of muscles.
Less common symptoms include:
- headache
- hearing loss
- itching
- respiratory or breathing problems
- seizures
- speech disorders
- swallowing problems
There is also a higher risk of:
- urinary tract infections
- reduced activity and loss of mobility
These can impact a person’s work and social life.
In the later stages, people may experience changes in perception and thinking and sensitivity to heat.
MS affects individuals differently. For some, it starts with a subtle sensation, and their symptoms do not progress for months or years. Sometimes, symptoms worsen rapidly, within weeks or months.
A few people will only have mild symptoms, and others will experience significant changes that lead to disability. However, most people will experience times when symptoms worsen and then get better.
Causes
Scientists do not really know what causes MS, but risk factors include:
Age: Most people receive a diagnosis between the ages of 20 and 40 years.
Sex: Most forms of MS are twice as likely to affect women than men.
Genetic factors: MS runs in families, but scientists believe an environmental trigger is also necessary for MS to develop, even in people with specific genetic features.
Smoking: People who smoke appear to be more likely to develop MS. They tend to have more lesions and brain shrinkage than non-smokers.
Infections: Exposure to viruses, such as Epstein-Barr virus (EBV), or mononucleosis, may increase a person’s risk of developing MS, but research has not shown a definite link. Other viruses that may play a role include human herpes virus type 6 (HHV6) and mycoplasma pneumonia.
Vitamin D deficiency: Some experts think that low levels of vitamin D may affect the way the immune system works.
Vitamin B12 deficiency: The body uses vitamin B when it produces myelin. A lack of this vitamin may increase the risk of neurological diseases, such as MS.
Previous theories have included exposure to canine distemper, physical trauma, or aspartame, an artificial sweetener, but there is no evidence to support these
There is probably no single trigger for MS, but multiple factors may contribute for the development of the disease.
Pathophysiology
MS refers to the plaques that form in the CNS combined with inflammation, demyelination, axonal injury and axonal loss. These plaques are found in the brain and spinal cord, essentially in the white matter, but also found in the Gray matter. They are seen in all forms of MS, but vary over time quantitatively and qualitatively. A wide heterogeneity in the structure and immunopathological patterns of demyelination and oligodendrocyte pathology between relapsing remitting course and progressive forms of disease is observed.
During the early stages of the relapsing remitting course, the pathology is marked by demyelination and a variable degree of axonal loss and reactive gliosis. Patients in general, present with focal inflammatory plaques that contain demyelinated axons, reduced number of oligodendrocytes, astrocyte proliferation with subsequent gliosis, and perivenular as well as parenchymal infiltrates of lymphocytes and macrophages. In the progressive course, MS is dominated by diffuse Gray and White matter atrophy and characterized by low-grade inflammation and microglial activation at the plaque borders combined with diffuse injury of the normal-appearing white matter outside the plaque. Then secondary demyelination follows. In general, the patterns of tissue injured in patients presented with primary or secondary progressive course of MS are homogeneous. They show oligodendrocyte loss, preferential destruction of small-caliber axons, astrocytic gliosis, and demyelination that consists of the essential criteria. Demyelination and subsequent neurodegeneration associated with different forms of MS involved various components of adaptive and innate immunity. Myelin sheaths are particularly vulnerable to non-specific products, such as cytotoxic cytokines, excitotoxins, reactive oxygen or nitric oxide species, which are released by activated macrophages and microglia. However, the most commonly observed patterns of demyelination are antibody and complement-associated changes, as well as hypoxia-like tissue injury, in which the initiation of demyelination is attributed to the degeneration of distal oligodendrocyte processes and apoptosis of oligocytes, while the loss of polarity by astrocytes leads to the disturbance of the structural organizational of the perivascular glia limitans.
Classically, MS is regarded as a T cell-mediated autoimmune disorder with a predominance of CD8+ cells compared with other T-cell subsets, B cells or plasma cells. It is believed that this disease begins in inflammatory-induced lesions consisting mainly of CD8+ T cells, and CD4+ T cells, and activate microglia/macrophages.
Evidence of the suppression of function that restricts CD4+ T-cell responses and the tissue-damaging role of CD8+ T cells reported to co-localize with axonal pathology have been observed. Indeed, the specific interaction of CD8+ T cells with target cells requires MHC-I expression which is tightly regulated in neurons and MHC-I molecules only in response to strong danger signals such as proinflammatory cytokines IFN-γ or TNF-α.
There are four types of MS:
Clinically isolated syndrome (CIS): This is a single, first episode, with symptoms lasting at least 24 hours. If another episode occurs at a later date, it will be diagnosed as relapse-remitting MS.
Relapse-remitting MS (RRMS): This is the most common form, affecting around 85% of people with MS. RRMS involves episodes of new or increasing symptoms, followed by periods of remission, during which symptoms go away partially or totally.
Primary progressive MS (PPMS): Symptoms worsen progressively, without early relapses or remissions. Some people may experience times of stability and periods when symptoms worsen and then get better. Around 15% of people with MS have PPMS.
Secondary progressive MS (SPMS): At first, people will experience episodes of relapse and remission, but then the disease will start to progress steadily.
Genetic factors influence MS pathogenesis susceptibility. Studies of families and twin have shown a 40-fold increased susceptibility among first degree relatives of MS patients, suggesting a genetic basis.
Environmental factors, such as exposure to infectious agents as well as sunlight exposure/vitamin D are felt to account for changing risk of MS when a person migrates from one risk area to another before age 15 years old. Many recent studies suggesting an infectious aetiology have been conducted in children and adolescents with MS. Among the pathogens possibly involved are human herpes virus type 6, Epstein Barr virus, and mycoplasma pneumoniae. It is speculated that one way for pathogens to produce MS would be by molecular mimicry. The pathogens may have peptides with direct sequence homologies with myelin components. Also, it is clear that common viral infections such as upper respiratory tract infections and bacterial urinary tract infections may trigger MS relapses. The mechanism by which this happens is still unknown. Multiple studies of sunlight exposure and vitamin D levels suggest a potential protective effect of early life sun exposure or vitamin D consumption.
Detailed case history
Physical examination with nervous system examination
No single test can confirm a diagnosis, multiple measures are used for excluding other diagnoses and a confirmative diagnosis of MS
These include:
MRI scans of the brain and spinal cord, which may reveal lesions
- spinal fluid analysis, which may identify antibodies that suggest a previous infection
- an evoked potential test, which measures electrical activity in response to stimuli
Treatments
There is no cure for MS, but treatment is available that can:
- slow the progression and reduce the number and severity of relapses
- relieve symptoms
Medications to slow progression
Several disease modifying therapies (DMTs) have approval from the Food and Drug Administration (FDA) for the relapsing forms of MS. These work by changing the way the immune system functions. This can be introduced by mouth, or as injection, and some as an infusion. Dosage and frequency will depend on the drug.
The following DMTs currently have approval:
Injectable medications
- interferon beta 1-a (Avonex and Rebif)
- interferon beta-1b (Betaseron and Extavia)
- glatiramer acetate: (Copaxone and Glatopa)
- peginterferon beta-1a) (Plegridy)
Oral medications
- teriflunomide (Aubagio)
- fingolimod (Gilenya)
- dimethyl fumarate (Tecfidera)
- mavenclad (cladribine)
- mayzent (siponimod)
Infused medications
- alemtuzumab (Lemtrada)
- mitoxantrone (Novantrone)
- ocrelizumab (Ocrevus)
- natalizumab (Tysabri)
Adverse effects of immunosuppressant drugs include a higher risk of infections. Some medications may also harm the liver.
Medications for relieving symptoms during a flare up
These are the drugs to be used when one or more discomforts worsen. They will not need these drugs all the time.
Corticosteroids: These reduce inflammation and suppress the immune system. They can treat an acute flare-up of symptoms in certain types of MS. Examples include Solu-Medrol (methylprednisolone) and Deltasone (prednisone). Steroids can have adverse effects if a person uses them too often, and they are not likely to provide any long-term benefit.
Behavioural changes: If vision problems occur, a doctor may recommend resting the eyes from time to time or limiting screen time. A person with MS may need to learn to rest when fatigue sets in and to pace themselves so they can complete activities.
Problems with mobility and balance: Physical therapy and walking devices, such as a cane, may help. The drug dalfampridine (Ampyra) may also help.
Tremor: A person may use assistive devices or attach weights to the limbs to reduce shaking. Medications may also help with tremors.
Fatigue: Getting enough rest and avoiding heat can help. Physical and occupational therapy can help teach people more comfortable ways to do things. Assistive devices, such as a mobility scooter, can help conserve energy. Meditation or counselling may help boost energy by improving sleep.
Pain: A doctor may prescribe anticonvulsant or antispasmodic drugs. Pain relief medication, such as gabapentin, may help with body pain. There are also medications to relieve muscle pain and cramping in MS.
Bladder and bowel problems: Some medications and dietary changes can help resolve these.
Depression: Antidepressants like a selective serotonin reuptake inhibitor (SSRI).
Cognitive changes: Donepezil, a drug for Alzheimer’s, may help.
Medical marijuana-Some studies suggest that when medically used, cannabis may help relieve pain, muscle stiffness, and insomnia.
Rehabilitation- Rehabilitation can help improve or maintain a person’s ability to perform effectively at home and work.
Rehabilitation programs generally include:
Physical therapy: This aims to provide the skills to maintain and restore maximum movement and functional ability.
Occupational therapy: The therapeutic use of work, self-care, and play may help maintain mental and physical function.
Speech and swallowing therapy: A speech and language therapist will carry out specialized training for those who need it.
Cognitive rehabilitation: This helps people manage specific problems in thinking and perception.
Vocational rehabilitation: This helps a person whose life has changed with MS to make career plans, learn job skills, get and keep a job.
Plasma exchange
This treatment involves withdrawing blood from the individual, removing the plasma, replacing it with new plasma, and transfusing it back into the person. This process removes the antibodies in the blood that are attacking parts of the person’s body.
Stem cell therapy
Scientists are looking into the use of stem cell therapy to regenerate various body cells and restore function to those who have lost it due to a health condition. Researchers hope that one day, stem cell therapy techniques may be able to reverse the damage done by MS and restore functionality in the nervous system.
Prognosis
MS has a bad prognosis with a long-term pathology. The treatment may arrest the progress of disease and improve the patient’s quality of life.
Complications
- Stiffness of muscles or spasms.
- Paralysis, typically in the legs.
- Problems with bladder, bowel or sexual function.
- Mental changes, such as forgetfulness or mood swings.
- Depression.
- Epilepsy.
Disease & Ayurveda
As MS is a degenerative disease affecting the whole body, especially the nervous system, it can be correlated to Vaata dosha imbalance. The whole pathology of demyelination along with sensory & motor manifestations make it be called as Vaatakopa in whole body, especially asthi, and majja. Many Vaatadoshalakshanas like kshaya, kampa, saada, etc. can be seen in MS patients. As the samprapti grows, Vaata affects each and every system in the body and produce symptoms.
Nidana
Physical
Dry, cold and old food items
Excess travelling & exertion
Trauma/injury
Exposure to wind
Loss of sleep
Psychological
Mental trauma or grief
Fear
Anxiety
Purvaaroopa
Not mentioned
Samprapti
Due to either obstruction to channels, or depletion of body tissues, the movement of Vaata gets deranged. The normal functions of Vaayu when disturbed like this and gets lodged in muscles, bones, nerves and tendons mainly it produces the symptoms.
Lakshana
Soola in asthi-sandhi, pesi etc.- pain in muscles, bones and joints
Dehasadana and ruja – Weakness of body & pain
Teevrabalakshayam – Severe weakness
Sabdhata – Stiffness
Kampa – Shivering
Divisions
Not mentioned
Prognosis
Yaapya
Chikithsa
Samana
Ayurvedic treatment for MS depends upon the cause for Vaatakopa and any associated dosha present. If Vaata is vitiated due to obstruction in channels/Kapha is the associated vitiated dosha, first approach should be to remove the accumulated toxic metabolic waste (Aama) from the body. It can be done by drying up and body-lightening therapies like:
Lepanam with Rookshana dravyas
Swedanam
Mild fasting
Internal medicines with dry and tikta potency
If the Vaatakopa is due to degeneration and Vaata-Pitta doshas are aggravated, only mild Aamapaachana with some medicines or diet modifications will be enough. The treatment with snehana swedana sodhana panchakarma and then bruhana will be more suitable in this case.
Sodhana
Snehana-swedana
Virechana
Kashayavasti
Snehvaasti
Commonly used medicines
Kolakulathadi choornam
Maharasnadi kashayam
Yogarajaguggulu
Amruthaguggulu
Brands available
AVS Kottakal
AVP Coimbatore
SNA oushadhasala
Vaidyaratnam oushadhasala
Home remedies
No effective home remedies are proven to cure Multiple sclerosis. It is always appreciated to get a professional consultation.
Diet
- To be avoided
Heavy meals and difficult to digest foods – cause indigestion.
Junk foods- cause disturbance in digestion and reduces the bioavailability of the medicine
Carbonated drinks – makes the stomach more acidic and disturbed digestion
Refrigerated and frozen foods – causes weak and sluggish digestion by weakening Agni (digestive fire)
Milk and milk products – increase kapha, cause obstruction in channels and obesity
Curd – causes vidaaha and thereby many other diseases
- To be added
Light meals and easily digestible foods
Green gram, soups, fresh fruits and vegetables
Freshly cooked and warm food processed with cumin seeds, ginger, black pepper, ajwain etc
Behaviour:
Protect yourself from cold climate.
Better to avoid exposure to excessive sunlight wind rain or dust.
Maintain a regular food and sleep schedule.
Avoid holding or forcing the urges like urine, faeces, cough, sneeze etc.
Avoid sedentary lifestyle. Be active.
Avoid stress and emotional hurrycanes.
Yoga
Regular stretching and mild cardio exercises are advised upto the possible extent. Also, specific yogacharya including naadisuddhi pranayama, bhujangaasana, pavanamuktasana is recommended to control Vaatadosha in the early stages.
Regular exercise helps improve bioavailability of the medicine and food ingested and leads to positive health.
Yoga can maintain harmony within the body and with the surrounding system.
Pavanamuktasana
Nadisudhi pranayama
Bhujangasana
Simple exercises for lungs and heart health
All the exercises and physical exertions must be decided and done under the supervision of a medical expert only.
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