Multiple sclerosis (MS) is an inflammatory disease of the central nervous system. For as yet unknown reasons, misprogrammed parts of the immune system attack nerve cells. There is a loss of the protective myelin layer that surrounds our nerve fibers. As a result, signals between nerve cells can no longer be transmitted correctly. Developmental biologist Nora Schultz provides an overview of symptoms, disease progression and treatment options .*
Over 200.000 people in Germany live with the nerve disease multiple sclerosis. (In Austria, according to the Austrian Multiple Sclerosis Society – oSMSG – there are about 12,500 MS patients; note. Red.) Misdirected cells of the immune system attack the central nervous system, triggering inflammation in the brain and spinal cord, which can lead to a variety of symptoms and very different courses of disease. Figure 1.This is why multiple sclerosis is also called the "disease of 1000 faces".
Figure 1. Multiple sclerosis – a demyelinating disease. Cells of the immune system attack the myelin sheaths, which – formed by oligodendrocytes – surround the axons of the nerve cells as an insulating layer.(Image from Red. inserted; adapted from the video: osmosis.org 2017; CC-BY-SA 4.0; in Wikipedia)
"The typical initial symptoms are sensations of discomfort, tingling and numbness, but also exhaustion that sometimes precedes the disease for a long time, which those affected cannot explain in any other way," says Judith Haas, chairwoman of the German Multiple Sclerosis Society (DMSG). Visual disturbances occur early in 20 to 30 percent of cases. Other more serious symptoms that can occur in connection with multiple sclerosis include coordination problems and paralysis. Bladder, potency and concentration disorders can also occur. Figure 2.
Figure 2. Main symptoms of multiple sclerosis, the – " disease of 1000 faces ". (Public domain image from Wikipedia, by Red. inserted)
The symptoms have a common cause. Inflammation in the central nervous system damages nerve cells. The protective myelin layer surrounding them . It is formed by the projections of other cells, the oligodendrocytes, and ensures that electrical signals are transmitted efficiently. The greater the damage, the more the transmission of signals along nerve fibers is impaired.
Which disorders occur depends on the location of the inflammatory foci in the nervous system
Not all patients experience all the symptoms during the course of the disease. Moreover, many symptoms occur only temporarily or under physical stress, especially at first, and often for the first time between the ages of 20 and 40, when most patients are otherwise still physically fit. It currently takes an average of three years until a diagnosis is made, because doctors and patients often do not think of multiple sclerosis, especially when the early symptoms are not very clear.
If the suspicion is confirmed, a combination of examination procedures together with detailed recording of the previous medical history can quickly provide clarity. In addition to neurological tests of the eyes, reflexes and coordination, as well as an electrophysiological examination of the conductivity of nerve fibers, this includes magnetic resonance imaging (MRI) of the brain and spinal cord, as well as the collection of cerebrospinal fluid (lumbar puncture). The MRI makes visible the inflammatory foci and scarred tie areas typical of multiple sclerosis. Certain inflammatory markers are found in the cerebrospinal fluid (CSF) collected during lumbar puncture in almost all affected patients.
Three years until certainty is clearly too long. Many patients become suspicious themselves after researching the Internet and urge early diagnosis: "It is very important to start therapy immediately after the first episode. All studies show that a missed early start to therapy cannot be recovered later on."Multiple sclerosis is not yet curable, but with the right combination of therapies, the course of the disease and quality of life can be decisively influenced.
encompasses three pillars:
– mitigation of acute inflammatory episodes (relapse therapy), – interventions in the immune system to prevent new episodes (progression-modifying therapy) – and direct treatment of the respective symptoms (symptomatic therapy).
In the first few years in particular, the disease progresses in relapses in most patients, before later changing to a steadily progressive form. In some cases (10 to 15 percent), the disease progresses chronically without relapses. Figure 3.
Figure 3. Different courses of multiple sclerosis (Public domain image from Wikipedia, by Red. inserted. In an episode, symptoms occur over a few days or weeks. Then partially or completely regresses again for a longer period of time. In such an acute phase, anti-inflammatory drugs such as corticoids or, in severe cases, plasmapheresis, a type of "blood washing", can slow down the attack of the patient's own immune cells on the nervous system.
Long-term treatment with progression-modifying agents, on the other hand, aims to reduce the frequency and severity of future relapses or, in the case of the steadily progressive form of the disease, to slow down its worsening. For this purpose, the immune response of the patient, which has become unbalanced, is. Drug either reprogrammed (immunomodulation) or suppressed (immunosuppression).
Influence of lifestyle
Lifestyle can probably also influence the course of the disease – and possibly also whether the disease breaks out at all.
Smoking, alcohol consumption, high levels of salt in the diet, excessive sterility in childhood and vitamin D deficiency, for example, increase the risk of disease, according to some studies. The latter could also explain why multiple sclerosis occurs less frequently near the equator . Figure 4.
Figure 4. Does vitamin D deficiency increase the risk of MS in more northern latitudes?? (Image from Wikipedia,cc-by-sa; by Red. inserted)
There, the body's own vitamin D production is increased thanks to abundant sunshine . "Since the risk of developing the disease is also genetically influenced, we strongly recommend that the children of multiple sclerosis patients supplement their diet with vitamin D," says Haas. Those who are already ill can at least alleviate certain symptoms and improve their quality of life with a healthy diet, suitable sports and rehabilitation measures, and relaxation techniques.
Hormones also play an important role. Female sex hormones, especially estrogen, strengthen the immune system and thus increase the risk of developing an autoimmune disease in the first place. On the other hand, they also ensure better repair processes in the body. On the one hand, this explains why about twice as many women as men develop multiple sclerosis, on the other hand, it also explains why they usually recover better from relapses. This is true at least until menopause, when hormone production declines. At this stage of life, therefore, the disease also often progresses into a steadily progressive form.
Haas recommends that young patients take the pill, as this ensures stable estrogen levels – or fulfill any desire to have children: "Pregnancy is one of the best therapies against multiple sclerosis. Especially in the last trimester of pregnancy, relapses usually do not occur at all.", she says. However, a significant increase in the rate of relapses must be expected in the first three months after birth.
The influence of hormones on the development and course of multiple sclerosis is also a current focus of research, with the aim of developing accompanying hormone therapies. Other questions that scientists are currently addressing revolve around a better understanding of immune mechanisms and inflammatory processes. For example, the role of the intestinal flora and how aggressive immune cells can "hide" in the central nervous system are being investigated. In the long term, scientists also hope for further progress from stem cell therapy approaches – all the way to a possible cure.
Despite all the hope for future breakthroughs, the first thing to do is to make better use of the current therapeutic arsenal, says Haas. "In Germany, we have the problem that highly effective therapies are not used to the extent that we know from other countries." She hopes for improvements from the recent amendment to paragraph 116b of the Social Security Code . This would allow the highly specialized care available in hospitals , to be delivered to patients outside hospitals as well.
With access to a range of different therapeutic approaches, patients now have numerous options for dealing with the many faces of their disease and living a full life despite limitations. Many are hardly restricted in their freedom, the disease activity often not measurable. This was also emphasized by Minister President Malu Dreyer in a recent interview with the Rhein-Zeitung: "I thought that the life I had led until then was coming to an end.