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Multiple Sclerosis: New Diagnostic Criteria

When is MS usually diagnosed?

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system.

In people with MS, the immune system mistakenly attacks myelin, a substance that covers and protects nerve fibers.

Damaged myelin forms scar tissue (lesions). That results in a communication gap between your brain and the rest of your body. The nerves themselves can also become damaged, sometimes permanently.

It is estimated that 2.3 million people worldwide have been diagnosed with MS. That includes an estimated 400,000 people in the United States.

You can develop MS at any age. MS is more common in women than men. It is also more common in white people compared with Hispanic or black people, and is rare in Asian people and other ethnic groups. First symptoms tend to appear between the ages of 20 and 40. For young adults, MS is the most common disabling neurological disease.

Early symptoms of MS

Warning

Lesions can form anywhere in the central nervous system, which includes the brain and spinal cord. Symptoms depend on which nerve fibers are affected. Early symptoms are more likely to be mild and fleeting.

These may include:

  • double or blurry vision
  • numbness, tingling, or burning sensations in limbs, trunk, or face
  • muscle weakness, stiffness, or spasms
  • dizziness or vertigo
  • clumsiness
  • urinary urgency

These symptoms could be due to any number of conditions, so your doctor may request an MRI before making a diagnosis. Even early on, this test may reveal active inflammation or lesions.

Common symptoms of MS

Symptoms

It’s important to remember that MS symptoms are often unpredictable. No two people will experience MS symptoms in the same way.

As time goes on, you may experience one or more of the following symptoms:

  • vision loss, eye pain
  • balance and coordination issues, difficulty walking
  • loss of sensation, partial paralysis
  • loss of bladder control
  • constipation
  • fatigue
  • mood changes
  • depression
  • sexual dysfunction
  • general pain
  • Lhermitte’s sign, which occurs when you move your neck and it feels like an electrical shock running down the spine
  • cognitive dysfunction, including memory and concentration problems, or trouble finding the right words to say

How is MS diagnosed?

Diagnosis

There’s no single test that can diagnose MS. First, other conditions must be eliminated.

Other things that can affect myelin include:

  • viral infections
  • exposure to toxic materials
  • severe vitamin B-12 deficiency
  • collagen vascular diseases
  • rare heredity disorders
  • Guillain-Barré syndrome

Blood tests can’t confirm MS, but they can rule out some other conditions.

Diagnostic criteria and related tests

For diagnosis, evidence of MS must be found in at least two separate areas of the central nervous system. That damage must have occurred at separate points in time.

Under guidelines updated in 2010, MS can be diagnosed based on these findings:

  • two attacks or symptom flare-ups (lasting at least 24 hours with 30 days between attacks), plus two lesions
  • two attacks, one lesion, and evidence of dissemination in space, or the location of the lesion
  • one attack, two lesions, and evidence of dissemination in time, or finding a new lesion since the previous scan
  • one attack, one lesion, and evidence of dissemination in space and time
  • worsening of symptoms or lesions and dissemination in space found in two of the following: MRI of the brain, MRI of the spine, and spinal fluid

MRIs will be performed with and without contrast dye to locate lesions and highlight active inflammation.

Spinal fluid is examined for proteins and inflammatory cells associated with, but not always found in, people who have MS. It can also help rule out other illnesses and infections.

Your doctor might also order evoked potentials. Sensory evoked potentials and brainstem auditory evoked potentials were used in the past. Current diagnostic criteria include only visual evoked potentials. In this test, the doctor analyzes how your eyes react to an alternating checkerboard pattern.

Learn more: Tests for multiple sclerosis »

What are the different types of MS?

Identification

Although you can never have more than one type of MS at a time, it’s possible for your diagnosis to change over time. These are the four main types of MS:

Clinically isolated syndrome (CIS)

CIS is a single instance of inflammation and demyelination in the central nervous system. It must have lasted 24 hours or more.

Some people who have CIS eventually develop other types of MS, but many do not. The chances are higher if MRI shows a lesion on your brain.

Relapsing-remitting multiple sclerosis (RRMS)

About 85 percent of people with MS are initially diagnosed with RRMS. It involves clearly defined relapses, during which there’s a worsening of neurologic symptoms. Relapses last from a few days to several months.

Relapses are followed by partial or complete remission in which symptoms are milder or absent. There is no disease progression during remissions.

RRMS is considered active when you have a new relapse or evidence of disease activity on MRI. Otherwise, it’s inactive. It’s called worsening if you have increasing disability following a relapse. Otherwise, it’s stable.

Primary-progressive multiple sclerosis (PPMS)

In PPMS, there’s a worsening of neurologic function from onset. There are no clear relapses or remissions. About 15 percent of people with MS have this type at diagnosis.

There can also be periods of increased or decreased disease activity, during which symptoms worsen or improve. This used to be called progressive-relapsing multiple sclerosis (PRMS). Under updated guidelines, this is now considered PPMS.

PPMS is considered active when there’s evidence of new disease activity. PPMS with progression means there’s evidence of worsening disease over time. Otherwise, it’s PPMS without progression.

Secondary-progressive multiple sclerosis (SPMS)

When RRMS transitions to progressive MS, it’s called SPMS. During this course the disease steadily becomes more progressive, with or without relapses. This course may be active, with new disease activity, or inactive, not showing disease activity.

Check out: My multiple sclerosis diagnosis story »

What happens after diagnosis?

Treatment

Just as the disease itself is different for each person, so are the treatments. People with MS typically work with a neurologist. Others on your healthcare team may include your general physician, physical therapist, or nurses who specialize in MS.

Treatment can be divided into three main categories:

Disease-modifying drugs

These drugs are designed to reduce the frequency and severity of relapses and slow progression of relapsing MS:

Injectables:

  • beta interferons (Avonex): Liver damage is a possible side effect, so you will need regular blood tests to monitor your liver enzymes. Other side effects may include injection-site reactions and flu-like symptoms.
  • glatiramer acetate (Copaxone): Side effects include injection-site reactions. More serious reactions include chest pain, fast heartbeat, breathing and skin reactions.
  • daclizumab (Zinbryta): This is reserved for people who haven’t responded to other treatments. Side effects include severe liver injury, immune conditions, and life-threatening events.

Oral medications:

  • dimetyl fumarate (Tecfidera): Possible side effects include flushing, nausea, diarrhea, and lowered white blood cell count.
  • fingolimod (Gilenya): It can cause a slowed heartbeat, so your heart rate must be carefully monitored after the first dose. It can also cause high blood pressure, headache, and blurry vision.
  • teriflunomide (Aubagio): Potential side effects include hair loss and liver damage. Common side effects include headache, diarrhea, and a prickling feeling on your skin. It may also harm a developing fetus.

Infusions:

  • alemtuzumab (Lemtrada): This medication can increase risk of infections and autoimmune disorders. It’s usually used only when there’s no response to other medications.
  • natalizumab (Tysabri): This medication increases risk of progressive multifocal leukoencephalopathy (PML), a viral brain infection.
  • mitoxantrone (Novantrone): This medication is used for very advanced MS, this drug can harm the heart and is associated with blood cancers.

No disease-modifying medications have been shown to be effective in progressive MS.

Treating flare-ups

Flare-ups can be treated with oral or intravenous corticosteroids such as prednisone and methylprednisolone. These drugs help reduce inflammation. Side effects can include increased blood pressure, fluid retention, and mood swings.

If your symptoms are severe and don’t respond to steroids, plasma exchange (plasmapheresis) is an option. In this procedure, the liquid part of your blood is separated from blood cells. It is then mixed with a protein solution (albumin) and returned to your body.

Treating symptoms

A variety of medications can be used to treat individual symptoms, including:

  • bladder or bowel dysfunction
  • fatigue
  • muscle stiffness and spasms
  • pain
  • sexual dysfunction

Physical therapy and exercise can improve strength, flexibility, and gait problems. Complementary therapies may include massage, meditation, and yoga.

Outlook

Outlook

There’s no cure for MS, nor is there a reliable way to gauge its progression in an individual.

Some people will experience a few mild symptoms that don’t result in disability. Others may experience more progression and increasing disability. Some people with MS eventually become severely disabled. But most people do not.

Life expectancy is near normal, and MS is rarely fatal.

Keep reading: MS treatments for newly diagnosed patients »

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