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Multiple Sclerosis (MS)

Brief Overview: Multiple sclerosis (MS) is a chronic immune-mediated disease of the central nervous system where inflammation leads to demyelination and neurodegeneration in the brain, spinal cord, and optic nerves. Symptoms can come and go (relapses) or gradually worsen over time (progressive disease). Care goals include reducing relapses and new MRI activity, slowing disability progression with disease-modifying therapy (DMT), managing symptoms (fatigue, spasticity, bladder issues), and supporting function/quality of life.

Prevalence: According to UpToDate, “In the United States, the estimated prevalence is 100 to 150 per 100,000, for a total of 300,000 to 400,000 persons with MS.”

Etiology: According to UpToDate, “MS is a heterogeneous disorder with variable clinical and pathologic features reflecting different pathways to tissue injury [1]. Inflammation, demyelination, and axonal degeneration are the major pathologic mechanisms that cause the clinical manifestations. However, the cause of MS remains unknown. The most widely accepted theory is that MS begins as an inflammatory immune-mediated disorder characterized by autoreactive lymphocytes. Later, the disease is dominated by microglial activation and chronic neurodegeneration.”

Risk Factors:

  • Smoking
  • Exposure to toxins
  • Low vitamin D levels
  • Virus exposure (Epstein-Barr virus (EBV), mononucleosis)
  • Childhood obesity
  • Genetics, family history
  • Female

Commonly Associated Conditions:

  • Depression/anxiety; adjustment difficulties
  • Fatigue and sleep disorders
  • Spasticity, neuropathic pain, gait imbalance/falls
  • Bladder dysfunction (urgency, frequency, retention) and constipation
  • Sexual dysfunction
  • Cognitive changes (“brain fog”), slowed processing
  • Osteopenia/osteoporosis risk (reduced mobility, steroid exposure)

Common Medications:

Common Labs, Imaging, and Tests:

  • MRI brain and spinal cord with and without contrast
  • Optic nerve MRI may be indicated for certain patients
  • Lumbar puncture for CSF analysis
  • Optical coherence tomography
  • Autoantibody testing
  • Visual evoked potentials – seldom used now
  • Additional baseline labs, screening, and tests likely indicated prior to treatment initiation

Common Symptoms:

  • Fatigue
  • Spasticity
  • Weakness
  • Incoordination, tremor, ataxia
  • Bladder/bowel/sexual dysfunction
  • Cognitive impairment
  • Depression
  • Vision, eye movement abnormalities
  • Heat sensitivity
  • Sensory symptoms, pain
  • Dysphagia, dysarthria, respiratory dysfunction
  • Vertigo
  • Insomnia

Common Treatments:

  • Medications (see above)
  • Rehabilitation therapies: PT/OT for gait, strength, balance, energy conservation; speech therapy for swallowing/communication when needed
  • Lifestyle + risk modification: smoking cessation, activity/exercise within tolerance, vitamin D optimization per clinician, sleep optimization
  • Vaccination planning and infection-risk counseling around immunomodulating therapies (patient should discussed with healthcare provider)
  • Multidisciplinary care: neurology, rehab, behavioral health, urology, ophthalmology as needed

Physical Findings: According to UpToDate, “No clinical findings are unique to MS, but some are highly characteristic of the disease. Common manifestations include sensory loss in limbs or one side of the face, optic neuritis (unilateral visual loss, typically with loss of color vision and pain with eye movements), acute or subacute motor weakness, binocular diplopia often with an internuclear ophthalmoplegia, gait disturbance and balance problems, Lhermitte sign (electric shock-like sensations that run down the back and/or limbs upon flexion of the neck), vertigo, bladder problems, limb ataxia, acute partial transverse myelitis, and pain. Presenting symptoms and signs may be either monofocal (consistent with a single lesion) or polyfocal (consistent with more than one lesion).”

Potential Complications and Contraindications:

  • Potential complications, including, but not limited to:
    • Accumulating disability, mobility impairment, falls
    • Bladder dysfunction → UTIs, retention
    • Depression/anxiety; cognitive impairment
    • Medication-related infection risk (varies by DMT)
  • Contraindications/cautions (some examples)
    • Immunosuppressive DMTs: infection risk; vaccination timing considerations
    • Anti-CD20 therapies (e.g., ocrelizumab): HBV screening required prior to initiation; contraindicated with active HBV
    • Steroids: caution in uncontrolled diabetes, severe infection; GI protection considerations as ordered

General Health and Lifestyle Guidance:

  • Encourage medication adherence and on-time infusion/injection schedules; plan refills and appointments early.
  • Track symptoms and triggers; new or worsening neurologic symptoms lasting >24 hours (without fever/infection) may represent relapse—contact neurology.
  • Heat management: cooling strategies, hydration, pacing.
  • Energy conservation: prioritize tasks, planned rest breaks.
  • Fall prevention/home safety: footwear, lighting, assistive devices, PT balance plan.
  • Encourage patient to work with their healthcare provider to manage comorbidities: depression/anxiety screening, sleep quality, bowel regimen, bladder plan.
  • Encourage a regular movement plan (tailored exercise improves function and fatigue for many patients) as approved/recommended by healthcare provider.

Suggested Questions to Ask Patients:

  • Any new neurologic symptoms (vision change, new weakness, new numbness, imbalance) lasting >24 hours?
  • Any recent infection, fever, or UTI symptoms (can mimic/worsen MS symptoms)?
  • Current DMT: name, schedule, missed doses/infusions? Any side effects?
  • Any issues with mobility/falls, walking distance, stairs, transfers?
  • Bladder/bowel: urgency, incontinence, retention, constipation?
  • Fatigue: sleep quality, possible sleep apnea, activity tolerance?
  • Mood/cognition: depression/anxiety symptoms, memory/attention changes?
  • Safety check: severe headache, sudden one-sided weakness, chest pain/SOB (consider non-MS emergencies too).

Suggested Talking Points:

  • MS symptoms can fluctuate. Your healthcare provider will watch for true relapses—new or clearly worse neurologic symptoms lasting >24 hours, not explained by infection or fever.
  • Disease-modifying therapy is used to reduce relapses and new MRI lesions—it’s important to stay consistent with your treatment plan, even when you feel well.”
  • If you think you have a UTI or fever, treating that first can often improve MS symptoms.
  • PT/OT and a tailored exercise plan are part of treatment—not just add-ons.
  • Call right away for sudden severe neurologic changes, chest pain, severe shortness of breath, or signs of stroke. Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.