Symptoms of MS
The central nervous system (CNS, that is, the brain and the spinal cord) controls and coordinates all the functions of our organism. The damage to myelin and nerve fibres, which occurs with MS, disrupts the transmission of signals between the brain, the spinal cord and other parts of the body.
This interruption of signal is then responsible for development of the clinical signs (symptoms) of MS.
The nature of such symptoms largely depends on the place of the CNS, in which the inflammatory infiltrate formed. If a place where multiple important pathways are found together is affected, multiple different neurological symptoms will appear at the same time. If the area around cerebral ventricles is affected, the clinical symptoms may not manifest themselves at all or only in a highly unspecific manner.
The degree of damage is also important. If a nerve fibre is merely exposed (demyelinated) and not disrupted, it is possible to partly restore the transmission. However, the transmission then always remains slower; in clinical terms, it corresponds to partial adjustment of symptoms. After the acute stage subsides, it is perhaps even possible to partly restore myelin (remyelination).
However, the newly created myelin is always of lower quality, which, once again, means that the transmission via the nerve is never restored to the original standard. The symptoms can be largely or completely adjusted but they can recur temporarily during higher physical strain or in a hot environment, that is, under conditions which place higher demands on the nerve pathways. Permanent symptoms are caused by the loss of nerve fibres because these are the carriers of the function.
Most Frequent Clinical Symptoms of MS
The nerve pathways whose myelin has degraded are unpredictably different in individual persons. This is why there is actually no single clinical picture of MS; the symptoms can be very different among individual patients. Nevertheless, certain symptoms are quite uniform and characteristic of the disease.
1. Vision Impairment
Impairment of vision functions is frequent with MS, nevertheless, MS seldom results in complete permanent blindness. The 3 main vision disorders caused by RS are optic neuritis, nystagmus and diplopia.
Optic Neuritis
Inflammation of the optic nerve manifests itself as pain when the eye moves and as vision impairment: foggy vision; loss of field of vision (scotoma); change of colour vision (colours, particularly red, sort of turn grey). Development of the problems takes hours or days; it is not a sudden onset. Complete loss of vision seldom occurs.
Unilateral inflammation of the optic nerve is typical of a case where the optic nerve is affected due to MS; bilateral inflammation is typical of neuromyelitis optica (so called Devic's disease). In the beginnings of the disease, the condition may subside spontaneously. However, optic neuritis may leave losses of field of vision, colour sense disorders as well as a severe vision impairment.
It often occurs at the beginning of MS when the patient still has no neurological symptoms. In order not to waste time for diagnosing MS, it is necessary to send the patient to a neurologist and to carry out MRI examination of the brain and lumbar puncture.
Optic neuritis may recur several times during the course of MS.
Diplopia – Double Vision
This symptom is most often caused by a lesion in the area of brain stem, in the place where brain nerves supplying eye-moving muscles branch out; however, the causal problem may lie anywhere along the pathways controlling eye movements. Double vision is sometimes accompanied by a feeling of insecurity; particularly its sudden onset can be very unpleasant.
The same is true as for other vision impairments with MS – in these cases, too, adjustment is usually good. Sometimes double vision may temporarily reappear after a higher eye strain and during fatigue but when the patient rests, the problems usually disappear.
Nystagmus
This term is used to describe involuntary, conjugate, more or less rhythmically repeated eye movements from side to side, from up to down or rotating movements. The patient perceives it as unpleasant image flicker. Sometimes, the affected person may not be aware of these movements but the people around him or her usually notice their presence.
Nystagmus may be present in one eye or both eyes; in the latter case, it can be present simultaneously or independently. Horizontal nystagmus is usually caused by a lesion in the area of the vestibular system. In this case, it is often accompanied with vertigo and loss of balance. However, the lesion may also be situated in other anatomic structure and the corresponding area usually cannot be identified according to the given type nystagmus.
2. Sensory Disorders
Sensations of decreased, increased or different sensitivity on various parts of the body are very frequent, even at the beginning of the disease. Tingling sensation, a change in perception of heat but also unpleasant sensations such as a burning sensation or a stinging sensation. If these sensations are not associated with compression of a peripheral nerve (a clear vertebrogenic syndrome, or a limb falling asleep, etc.), they should be suspected of MS. Regrettably, they are often disregarded and neglected and do not lead to diagnosing the disease.
3. Motor Disorders
Development of motor symptoms is, in terms of prognosis, always a worse sign than occurrence of sensory disorders. Most often, the main motor pathway – the pyramidal pathway – is affected, which is manifested by development of central spastic paresis (paralysis in which the muscles of the affected limb are tense to an increased degree) and heightened tendon reflexes, increased muscle tone and pyramidal irritation phenomena (Babinski). Even after the acute condition subsides, increased tiredness of the limb and heightened muscle tone, which may then be associated with pain, spasms or clonic and pseudoclonic convulsions in response to various stimuli, may persist.
The most frequent manifestation in the later stage of MS is the spastic paresis of lower limbs, manifesting itself as a walking impairment limiting the patient in the distance they can walk and the certainty of walking, inability to run a short distance, to hop on one leg or both legs. These phenomena are well describable and measurable, and therefore they are described in a routine neurological examination.
Motor impairment of upper limbs may first manifest itself as clumsiness, slower movement but it can also be a case of development of unilateral hemiparesis (impairment of upper and lower limbs on one side) with a finding similar to that which we can see with a cerebrovascular accident. A demyelination focus may also form in a place where we typically see the focus of a vascular accident.
Complete loss of mobility (paraplegia) is frequent in the terminal stages of MS and is usually accompanied by a relatively severe sensitivity disorder, which, along with immobilisation of the patient, results in development of bed sores and muscle contractures, which both place high demands on the nursing care. The condition is usually worsened by impairment of the adductor thigh muscles, which prevents normal hygiene routines.
4. Cerebellar Disorders – Balance Disorders, Tremor
Affliction of the cerebellum is another very unpleasant prognostic factor; if it appears at the beginning of the disease, it leads to faster and more severe disability of the patient. The cerebellum controls the fine movements of limbs as well as balance. Lack of coordination of movements will manifest itself as ataxia (inability to hit target) and cerebellar tremor, which is not present at rest and the amplitude of which increases as the limb is nearing its target. It limits not only work performance but also ordinary self-sufficiency (the ability to dress oneself, eat, drink, brush one’s teeth, etc.). Therefore, it is very disabling.
Coordination of movements is also necessary for such motor activities such as speech and swallowing. Cerebellar dysarthria with a typically saccadic speech, in which syllables are sort of chopped, is also frequent when cerebellum is affected. Inability to keep one’s torso upright while walking and inability to make movements, which require the coordination of axis muscles, prevents a person from working normally, walking, sitting in a quality manner and leads to frequent falls. The cerebellar system is connected to the pathways of another system, which is responsible for balance, and this is the system of vestibular nuclei. As a result, the patient has a feeling of uncertainty in 3D (mostly a condition referred to as “false vertigo”) and tendency to suffer falls.
The cerebellum is also connected to cognitive functions. If it is affected to a greater extent or if it is atrophied, it contributes to cognitive disorders with MS, too.
5. Fatigue
Approximately 85 % of patients complain about distinct fatigue, which is not related with physical strain. Fatigue significantly affects the quality of life and it can have a number of causes. The basic causes are the pro-inflammation condition of the central nervous system, damage to myelin and loss of nerve fibres. Of course, it is always necessary to rule out other concurrent diseases (comorbidities) such as anaemia, chronic inflammation (most often urinary tract infection), thyroid gland disorder and the like.
Just like in healthy population, fatigue with MS increases with excessive strain (both physical one and mental one), during long-term inactivity, during the day and in a state of low mood. It can be decreased with rest, sleep and sex. It varies in frequency, severity, chronic duration, ease of occurrence, the degree to which it can be influenced by external circumstances (particularly increased temperature), and its impact on performance of mental and physical activities.
Patients with MS consider fatigue as one of the three most significant symptoms; in 75 % of the patients, it significantly limits performance of activities both at home and work. Fatigue with MS is of chronic nature. 66 % of the patients suffer from fatigue for longer than 2 months; 39 – 69 % suffer from fatigue on a daily basis. Men are more affected by long-term fatigue during the day. Fatigue increases during the day. Patients with a lower degree of disability (according to KEDSS) consider fatigue to be one of the most significant symptoms. Fatigue increases over time but the patients no longer consider it as one of the most significant symptoms. With chronic diseases, fatigue increases with age but in patients with RS, correlation to age has not been proved. Nevertheless, it occurs with the patients with relapsing-remitting form of MS, mostly with the progressive forms. It is increased by spasticity, pain, depression and balance disorders.
In patients with RS, we can encounter normal fatigue (it occurs as a reaction to overcoming), neuromuscular fatigue (caused by nerve impulse transmission impairment; it responds to rest very well), fatigue accompanying depression and overall tiredness manifesting itself with torpidity and sleepiness (probably caused by a biochemical imbalance in the brain). Each type of fatigue occurs on the basis of specific pathophysiological mechanisms and requires a suitable therapeutic approach.
6. Pain
Pain can be understood as nociceptive afferent stimulus, which penetrated into consciousness and became a source of unpleasantly perceived sensation. Pain works as a triggering reflex mechanism and evokes a conscious tonic response, which has the nature of a defensive spasm. This can be accompanied with reflex antagonist inhibition or conscious modification of the motor system (for example, the analgesic position). Nociception, which did not penetrate to consciousness and is not interpreted as pain, subconsciously influences motor behaviour. According to Melzak and Wall, the perception of pain is influenced by gates in the spinal cord, which are opened by thin nerve fibres transmitting the nociceptive signal and which are closed by an afferent stimulus from thick fibres and the interpretation centre in the subcortex of the brain, which determines whether the nociceptive signals will be brought to consciousness and interpreted as pain.
Pain is describe in 55 % of patients with MS, among whom 9 % suffer from acute pain syndrome (neuralgia of trigeminal nerve, attacks of pain in limbs), 46 % suffer from chronic pain syndrome. The pain increases with age and duration of the disease. According to some authors, its incidence is higher in women. In people with lower degrees of disability (3.3 KEDSS), dysesthesia predominates; in people with higher degrees of disability, back ache (5.3 KEDSS) and painful spasms of limbs (6 KEDSS) predominate. Patients with MS very often suffer from dysesthesia (29 %), migraines (27 %), back aches (14 %), painful spasms of limbs (13 %). 20 % of patients with MS (more often men) suffer from headaches after waking up.
7. Sphincter Disorders
Sphincters are muscles – constrictors, which control the emptying of urine and stool. The nerve control of the functions of these organs is very complex. The pathways controlling urination, sphincters and sexual functions are very long, and therefore the probability of the possibility that there are demyelination inflammatory focuses of MS somewhere along these long pathways is very high. Most often, the extent of sphincter disorders correlates to the extent of mobility disorder of lower limbs. Rarely, sphincters can be affected even at the beginning of the disease.
Problems mostly start as what is referred to as urinary urgency (the feeling that the patient must urgently urinate or they will wet themselves – this feeling does not depend on the extent to which the urinary bladder is filled). A feeling of incomplete urination (retention) may occur. The remaining content of the urinary bladder in fact reduces its holding capacity and leads to a more frequent need to urinate. The urine, which was not passed is an ideal breeding ground for a bacterial infection. Since the sensitivity of the mucous membrane or the urinary tract is often reduced, the patient does not perceive dysuria, which commonly accompany an infection, and the infection consequently easily becomes a chronic one, which ultimately endangers the patient with an ascending infection of upper urinary tract (pyelonephritis), which may lead as far as to sepsis or renal failure.
Patients often contribute to this situation by addressing their sphincter problems by reducing their fluid intake. This is why it is necessary to pay attention to sphincter problems and take care of them actively (hydration, search for infection even in the absence of active complaints). The later stages of the disease are often accompanied by urinary incontinence.
As concerns the function of intestines, the most frequent complaint from patients with MS is about constipation. However, stool incontinence, which is very inconvenient and socially troubling, may also occur.
Up to 70 % of patients with MS suffer from erectile dysfunction already in the first years of the disease. Ejaculation disorders or other sexual disorders are less frequent. Due to the fact that these disorders may be caused by some of the medicines, which are commonly prescribed for MS (medicines reducing spasticity and depression), it is always necessary to search for other possible causes when trying to modify the patient’s condition. In women, the problems have been mapped to a far lesser extent; insufficient sensitivity of mucous membrane, spasticity of lower limbs and lubrication disorders are frequent.
The patient often does not confide their sexual problems to the physician, which is a big mistake because at present, these problems (which are usually a source of frustration and discord between partners, especially if they are not understood as a part of the disease) can often be resolved in cooperation with an experienced urologist or sexologist.
8. Stem Syndromes
In the brain stem, pathways for mobility, sensitivity, coordination of movements and nuclei of brain nerves are present in a small space. This is why more extensive symptoms of the disease may occur if the brain stem is affected. Once again, brain syndromes are an unfavourable prognostic sign for the development of the disease. In addition to that, vital centres can be fatally affected (mostly in the later stages of the disease). Besides paresis, sensitivity disorders, damage to cerebellar and vestibular pathways, some nuclei of brain nerves may also be affected. Most often, the symptoms are eye movement disorders, manifesting themselves with double vision and nystagmus (involuntary eye movements in various directions, most often in the horizontal direction). A symptom typical of MS is what is referred to as internuclear ophthalmoplegia, which means that the patient has strong nystagmus on the abducting eye (when viewed from the outside), while the presence of double vision is rare.
Another disorder is facial nerve paralysis (mostly peripheral one, which means that both upper and lower branches are affected) and neuralgia of the trigeminal nerve. This occurs 300 times more often with MS than in the general population. Its new occurrence needs to be regarded as an acute attack of MS and needs to be treated with corticosteroids. In later stages of the disease, we can also see swallowing disorders and a more severe dysarthria (speech disorder). Swallowing disorders may lead to aspiration and subsequently even to fatal bronchopneumonia. The glossopharyngeal nerve, the ninth cranial nerve belonging among the nerves of the lateral mixed system, may also be affected by unpleasant neuralgia.
In later stages of MS, n. vagus, the wandering nerve, may also be damaged and disorders of the autonomous nervous system, including heart rhythm disorders, may occur.
If the corticobulbar pathways leading from the cortex to the nuclei of nerves of the lateral mixed system are affected bilaterally, this leads to what is referred to as the pseudobulbar syndrome. Besides swallowing and speech disorders (dysphagia and dysarthria), its manifestations also include what is referred to as emotional incontinence (spastic weeping and laughter) where the patient reacts with weeping or laughter to inadequate stimuli and is unable to control this reaction with their will. With this syndrome, the white matter of both frontal lobes is usually extensively affected.
9. Mental Problems and Cognition
Some patients complain about concentration disorders, particularly during longer-lasting intellectual performances, after several years of the disease. Sometimes moodiness, tendency to weep or even actual depression appears, which usually stems from the feeling of helplessness and uncertain future, which is the case with all chronic and not completely curable diseases.
Depression affects up to a half of patients with MS. It is frequent already in the first year of the disease. It significantly reduces the quality of life and worsens the patient’s capability of performing activities. Depression causes deterioration of cooperation with the attending staff and reduces the will to work on one’s mental and physical condition. Depression needs to be detected and treated in time because the suicide rate in patients with RS is higher by up to 7 times. 25 % of patients consider suicide at one point during the disease. If they commit it, it is most often a balance type of suicide.
Anxiety, the neglected sister of depression, which occurs in approximately 36 % of patients is an accompanying symptom.
Besides the awareness of a chronic disease, pro-inflammatory agents created by immune cells contribute to depression just as they contribute to fatigue. This is why it is important to influence the inflammatory activity of the disease but it is also important to use medicines mitigating depression in cases where it is necessary, besides providing psychotherapy and positive guidance for the patient. The advantage of these medicines is that they most often also have an effect on the immune system and this effect is in accordance with the anti-inflammation treatment.
Depression represents suffering for a patient, which is often far greater than the physical problems, which any disease brings, and this is why it is necessary to speak about the symptoms of depression and address them with a physician. Depression may not depend on the physical condition of a patient at all and yet it may be significantly damaging the patient’s quality of life. This is why it should never be underestimated and neglected.
Cognition disorders are very frequent but they are not usually conspicuous in the beginning and this is why they were escaping attention for years. They cannot be examined using the scales applied to detect Alzheimer’s disease (MMSE, Mini Mental State Examination). At the beginning of the disease, these disorders are present in 30 – 50 % of patients and are not observable without specific tests. They correlate to the duration of the disease. Significant correlation to loss of the capacity to work was also revealed. The affected domains are particularly the speed of information processing, long-term episodic memory, ability to focus and executive functions. Examination requires an experienced neuropsychologist. This is necessary, for example, for the purpose of issuing an expert opinion if the patient is really losing their ability to work in their profession.
An entire range of psychopathological manifestations can be associated with MS, which can be pre-morbid ones or which can be directly related to MS. Incidence of other mental illnesses is not dramatically increased; they may occur 2-3 times more often than in the general population.
10. Rare Symptoms
An inflammatory focus may rarely form in the cortical areas responsible for clearly defined brain functions. A cortical speech disorder (aphasia) may occur in the sense of idea-related speech formation or understanding. Epileptic seizures, isolated ones or recurring ones, may also occur. Other paroxysmal symptoms may be some motor manifestations (paroxysmal ataxia, dystonia and the like).
