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Neurology online by Dr. Strizhak

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Multiple Sclerosis Symptoms

Typical Symptoms of Multiple Sclerosis – Sensory Symptoms – Visual Symptoms – Fatigue – Coordination and Gait – Vertigo – Seizures – Tonic Spasms – Uhthoff Phenomenon

MS Relapse Symptoms Evolution

Multiple sclerosis may present with a wide variety of symptoms. Some are more common than others. The crucial point is the dynamics of the symptoms.
Depending on the type of MS, the symptoms may be either transient, with partial or complete recovery, or gradually progressive. MS symptoms never develop on an instant. Progression of symptoms to the peak takes from hours to days

Loss of any function, whether it is vision, balance or muscle power does not develop abruptly. This type of symptom onset is more typical for strokes or other conditions.

Once the symptom develops is stays for some time – days, weeks or months. In relapsing remitting form of MS there is a full or partial recovery of the neurological symptoms within weeks or months.
Having numbness for an hour with rapid resolution or the numbness that is coming and going is not consistent with multiple sclerosis.

There are multiple short lasting phenomena in MS. Those phenomena alone are not the indicators of this disease. They are all described in different sections with appropriate comments. Here I will mention only one of them because it is universal for multiple sclerosis irrelevantly of the type of the symptom.

Uhthoff Phenomenon is a transient worsening of a preexisting neurological problem caused by MS. Any MS related neurological symptom (vision, sensation, weakness, balance, speech) temporarily gets worse in response to some triggers. The most common trigger is an elevated body temperature irrelevantly of the cause – fever due to infection, hot weather, exercise. Other triggers are emotions, menstruation, smoking, large meals, fluorescent light.
The precise mechanism of this phenomenon is not clear, but it is believed to be due to the adverse effect of these factors on the nerve fiber conduction speed.
Uhthoff phenomenon is not a sign of relapse! It does not trigger relapses either.

Sensory Symptoms in MS

Sensory symptoms are most common in multiple sclerosis. Majority of patients experience some form of sensory symptoms over the course of the disease. They are reported in about 40% of MS patients at the time of presentation. The abnormal sensation in MS is persistent. It doesn’t come and go.

Sensation of numbness, tingling, coldness, tightness may involve one limb, two limbs on one side, legs, trunk or combination of those. Considering frequent spinal cord involvement in MS, numbness and loss of sensation may involve the whole body below certain level of the spinal cord.
Persistent unilateral itchy sensation especially in the upper body or shooting/burning sensation in the chest and abdomen are suspicious for MS.
Numbness, tingling, loss of sensation, spasms or pain in the face on one side or both are relatively common in MS. Trigeminal neuralgia in young people and/or on both sides are possible MS red flags.

Neurological examination may or may not confirm objectively the abnormal sensation. Sensory examination may reveal loss of specific sensory modality: positions sense, touch, vibration, or pain/temperature. Loss of sensation may involve large parts of the body or it may be limited to patchy areas of the limbs or the trunk. Sensory examination is often inconclusive. It is hard to make judgment when sensation loss lacks any specific physiological pattern.

Lhermite Sign

Lhermite sign is typical for a variety of cervical spinal cord lesions (especially at C4 level). It is not limited to multiple sclerosis, but about 30% to 40% of MS patients report this sensation; especially early in the course of the disease.

Lhermite sign is a brief electrical sensation going down the spine, which can reach buttocks or even the hands and the feet. This electrical sensation is usually provoked by neck flexion or, less commonly, by neck extension, coughing or limb movements.

In MS Lhermit sign is a reflection of an inflammation in the spinal cord.

Brief Sensory Symptoms in MS

MS does cause brief sensation abnormalities. They can be judged as MS related only with established diagnosis. MS cannot be diagnosed based on them alone.

Transient sensation of burning, tingling, itching or numbing pain may involve any part of the body. These symptoms may last from minutes to hours.

They are not indicators of MS relapse.

Loss of Vision in Multiple Sclerosis

Loss of vision is the second most common presenting symptom in multiple sclerosis (around 15%). The most common cause of vision loss in MS is optic neuritis, which is an autoimmune attack on the optic nerve.

Loss of vision may involve one or both eyes. Vision deteriorates over hours to days. Sudden loss of vision is not a sign of MS.

Loss of contrast sensitivity and color saturation perception are common. Severity of vision loss is ranging from blurred vision to loss of light perception.

Loss of vision is usually not permanent. Most patients have at least some degree of vision recovery. More than half have a sense of full recovery after weeks to months.

Restoration of normal vision does not mean that the optic nerves recovered completely anatomically. We need only half of the optic nerve fibers for normal vision.

Optic neuritis is not necessarily a sign of multiple sclerosis. As any other symptoms in MS, optic neuritis may be recurrent. Please see Optic Neuritis Page for more details.

Double vision

Involvement of the brain stem often produces double vision. There are a few types of eye movement abnormalities, which are common in MS – pendular nystagmus and internuclear ophthalmoplegia.

Even though these abnormalities are not unique for MS, their presence is suggestive for this diagnosis.

MS is unlikely to present with these symptoms. They rather develop later in the course of the disease.

Occasionally MS patients experience a sudden brief double vision.

Pufrich Phenomenon

This phenomenon may represent a diagnostic challenge for an unprepared doctor. Patients with optic neuritis or a history or optic neuritis may experience difficulty playing ball sports, driving, pouring water, or crossing roads.

They perceive that a linearly moving object is moving along an elliptical orbit. A car is felt swerving while driving.

Unilateral optic neuritis leads to decreased light intensity perception in the sick eye, even after recovery. The difference between perceptions of illumination levels from different eyes confuses the brain and leads to the illusion of nonlinear movement.

Pufrich phenomenon is not unique for MS or optic neuritis. It can be present in other eye disorders associated with decreased retina illumination in one eye.

Motor Symptoms in MS

Motor symptoms are not very typical as an initial presentation in MS (just a few percent). Majority of patients will develop them later on.

Muscle weakness and spasticity gradually develop over hours to days. Weakness may develop relatively rapidly but it is far from sudden, not like in stroke.

In multiple sclerosis it is common to have weakness in both legs because of the frequent spinal cord involvement. In cervical transverse myelitis all 4 limbs may get weak, but the extent of the involvement is usually not symmetrical. Weakness in one side of the body is more likely due to demyelinating plaques in the brain.

These statements are not the rules. Weakness in just one leg due to spinal cord lesion or involvement of all four extremities due to extensive brain lesions is possible.

Muscle tone in the weak muscles is increased. Tendon reflexes are exaggerated.

Motor Symptoms in the Face
Muscle spasms in the half of the face (hemifacial spasm) and worm-like, rippling muscle contractions (myokymia) have multiple causes. Multiple sclerosis is one of them.
Tonic Spasms

Tonic Spasms are frequent, brief (less than 90 seconds) painful, muscle contractions involving half of the body. They may be associated with tingling, burning or itching. These spasms may be triggered by movements, sensations, or hyperventilation. Tonic spasms spontaneously remit after a few weeks.

Tonic spasms are caused by demyelinating plaques somewhere along the way of the motor fibers within brain tissue (internal capsule, cerebral peduncle), or the spinal cord.

Tonic spasms may sometimes involve both legs. Sudden loss of ability to move the legs is another transient phenomenon in MS.

Gait disorders in MS

Gait problem is common in multiple sclerosis. In fact, it is the main cause of major physical disability in MS. About 40% will experience difficulty walking and 70% will perceive it as a major challenging aspect of MS.

Ambulation is a very complex task. Walking requires adequate muscle strength, speed of movement, multiple back feed loops about real time body parts position.

MS gradually destroys this complex infrastructure. How badly the ability to walk is affected depends on the extent and the location of the disease process.

Major factors involved in the gait disorder in MS are leg weakness and spasticity (muscle stiffness),  sensation of limb position, balance and fine tuning of movements, vision, double vision, abnormal eye movements, fatigue, pain, medication, motivation (depression).

Level of disability depends on the degree of the contribution from all of these factors.

Lack of Coordination in MS

Coordination is a very complex function. It depends on normal function of many brain and spinal cord structures and their interactions.

There is a great variety of coordination issues in MS.

Lack of proper coordination may involve eyes, limbs, trunk, and gait.

Vertigo in Multiple Sclerosis

Vertigo is a rear presenting symptom of this disease.

Later on, almost half of the patients report sensation of spinning. Vertigo is caused by brain stem lesions. Considering location, vertigo is often associated with some form of hearing abnormalities, numbness in the face, and double vision.

MS attack may sometimes present as brief stereotypical episodes of vertigo or difficulty speaking. They last from seconds to minutes and repeat multiple times for at least 24 hours.

Bowel, Bladder, and Sexual Function in MS

Loss of control over bladder and bowel correlates with the level of legs involvement. Urinary urgency is the most common first symptom. Disease progression may cause a complete loss of urination and bowel movements control.

Sexual dysfunction affects 70% of MS patients with 50% becoming sexually inactive. MS per se is not always a direct cause of sexual dysfunction. Loss of libido due to depression, loss of self-esteem, and fear of rejection are common psychological factors.

Loss of erection in males correlates with severity of incontinence and legs involvement. Women may preserve the ability to experience orgasm even with complete loss of urination and bowel control.

Hypothermia in Multiple Sclerosis

There are multiple reported cases of low body temperature in late MS. There is no specific pattern. Duration is variable. Body temperature rarely goes below 31℃ (87.8℉).

Hypothermia may be a part of the MS relapse or represent a relapse (some cases respond to IV steroids).

Seizures in MS

Seizures are not very common in MS (2 % to 3%), but they are more frequent than in general population.

Seizures often precipitated by medications or Baclofen withdrawal (especially with Baclofen pumps).

MS does not have tendency to produce severe epilepsy. Seizures usually respond well to medications, when the treatment is felt necessary.

Multiple Sclerosis Associated Symptoms

Fatigue in Multiple Sclerosis

Fatigue is very common in MS. It affects almost 80% of patients. Fatigue is expressed as sense of exhaustion and getting tired while walking. The cause of fatigue is not very clear because there is no association with disease severity or specific symptoms. Presence of sleep disturbance or depression is in part responsible for this phenomenon. Fatigue is worse towards the end of the day and it is commonly exacerbated by heat. Fatigue sometimes precedes MS relapse.

Cognitive Dysfunction in MS

Cognitive problems correlate with the extent of brain involvement in the disease process and the severity of depression. Based on neuropsychological testing, the most common are slowing of the processing speed, poor attention, and suboptimal short term memory. Progressive type of MS produces more significant cognitive decline.
Severe cognitive decline, or dementia, affects only 5% of MS patients. It is associated with severe brain tissue destruction due to disease process.

Sleep Disorders in MS

The most common sleep disorder in MS is insomnia (40%), which is difficulty falling and staying asleep. Multiple factors contribute to disrupted sleep.
They are muscle spasms and pain, periodic limb movements and restless legs disorders, frequent urination at night (up to 80%), stimulants used during the day, and depression.
Sleep disturbance is an inevitable symptom of depression and depression is common in MS.
It appears that restless legs syndrome is 2 times more common in MS. There is an association between fatigue severity during the day and insomnia.
Association of MS with other types of sleep disorders is rather anecdotal.

Depression in Multiple Sclerosis

Lifetime prevalence of depression in multiple sclerosis is 50%. This is 3 times of general population. The exact cause of depression is not clear. There is no hard proof that MS treatment is responsible. Depression rate in MS is higher than in other chronic medical conditions. Suicide as a cause of death among patients attending MS clinics might be as high as 15% according to some data. Socially isolated males are at highest risk. Life expectancy in MS is reduced 5% to 10% that of general population. Suicide does not appear the major driver of the shortened life expectancy.
Depression is the major reason for cognitive problems in MS. Anxiety disorder affects 36%. Advanced MS may produce elated mood (euphoria). Occasionally, bipolar-like mood disorder or rapid mood swings (dysphoria) may be present.

Any comments about this page will be greatly appreciated at doctorstrizhak@gmail.com Content copyright 2017. DOCTORSTRIZHAK.COM. All rights reserved.
Disclosure: This Web Site is intended for education purpose only. The information provided on this site must not be perceived as a guide for self-diagnosis or self-treatment. Every effort is made to keep the information current, but there are absolutely no guarantees of timely updates. By Andre Strizhak