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Definition
Multiple sclerosis is an autoimmune disease of the central nervous system. It is progressive and incurable, with significant variation in terms of presentation and severity among individuals.
There are over 131 000 people with multiple sclerosis living in the UK, and it is the leading cause of neurological disability in young adults in the country (Public Health England, 2020).
There are three main types of multiple sclerosis: relapsing remitting, secondary progressive or primary progressive (Multiple Sclerosis Trust, 2020).
Around 85% of people with multiple sclerosis have the relapsing form at diagnosis, which is characterised by periods of relapse and remission. Relapses are episodes of new or worsening symptoms which may last at least 24 hours, but often from a few days to several weeks (Multiple Sclerosis Trust, 2020). Symptoms experienced during a relapse may partially or completely disappear during periods of remission.
Over time, as more of the central nervous
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Symptoms
The symptoms of multiple sclerosis are varied and fluctuate in severity across individuals and over time.
Symptoms experienced by an individual with multiple sclerosis depend to some extent on the position of the lesions or scarring ('sclerosis') within the central nervous system. Presenting symptoms can typically include:
- double vision
- optic neuritis
- dysaesthesia
- neuropathic pain
- limb weakness
- fatigue
Over time, many people with multiple sclerosis will develop new symptoms, which can include:
- bladder and bowel dysfunction
- fatigue
- cognitive problems
- depression
- sexual dysfunction
- reduced mobility
- spasms and spasticity
- swallowing problems
- difficulty communicating
- reduced coordination and ataxia
- optic neuritis, nystagmus
- neuropathic pain
- limb weakness
- tremor and poor coordination
Although many complications of multiple sclerosis are largely avoidable with the delivery of specialist, proactive care (Leary et al, 2015), some of these may include:
- sepsis resulting from pressure ulcers or urinary tract infections
- aspiration pneumonia as a result of poor respiration
- fractures
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Aetiology
The exact cause of multiple sclerosis is not known. Individuals have a genetic susceptibility to developing multiple sclerosis, although many different genes are implicated in conferring susceptibility (O’Gorman et al, 2013). This means that multiple sclerosis can appear hereditary or can be equally likely to present in an individual with no family history of the disease.
Different external factors may interact in an individual with genetic susceptibility to trigger the onset of multiple sclerosis. External factors which have been implicated include:
- exposure to sunlight (vitamin D)
- exposure to different viruses (eg Epstein–Barr virus)
- smoking
- obesity (Multiple Sclerosis Trust, 2022a)
The symptoms of multiple sclerosis result from autoimmune driven inflammation within the central nervous system (Multiple Sclerosis Trust, 2022a). Myelin surrounds central nervous system neurones and facilitates rapid and effective transmission of messages to and from the central nervous system. The oligodendrocytes which make up the myelin are the target of
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Diagnosis
The diagnosis of multiple sclerosis is undertaken by a neurologist, ideally one with a specialty in the condition. People present in many different ways and initially symptoms are often vague and transitory, which can make challenging to deliver a prompt diagnosis.
Diagnosis is usually based on eliciting a thorough medical history, neurological examination and a magnetic resonance imaging scan. Demonstration of two or more lesions within the central nervous system, is sufficient to make a diagnosis of multiple sclerosis (Thomson et al, 2018).
An individual’s medical history may provide a suggestion of previous episodes of demyelination (eg an episode of visual disturbance 2 years previously which lasted a couple of weeks and resolved spontaneously). A neurological examination can provide evidence of neurological impairment that is separated in time and space as defined by the McDonald diagnostic criteria (such as patches of numbness, reduced power in one or more limbs, impaired
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Management
There are several key components to the management of multiple sclerosis:
Relapse management
The nature of a relapse is that the individual will make a full or partial recovery over time without any intervention. However, treatment with high dose methyl prednisolone (usually oral) can help to ease symptoms and speed recovery, although this will make no long-term difference to outcomes.
Not every relapse needs to be treated with steroids and some people prefer not to take steroids at all as they can cause significant, unpleasant side effects for some. Taking a few days off work and reducing activities can also be helpful (Multiple Sclerosis Trust, 2016).
Depending on the symptoms experienced during the relapse and the speed of recovery, symptomatic treatments and/or physiotherapy may be beneficial (Craig et al, 2003).
Disease–modifying treatments
Disease–modifying treatments are the only treatments which affect the course of the disease. Medication
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 1: Procedures for assessing people’s needs for person-centred care
1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages
Part 2: Procedures for the planning, provision and management of person-centred nursing care
3. Use evidence-based, best practice approaches for meeting needs for care and support with rest, sleep, comfort and the maintenance of dignity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions
11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation
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Resources
Craig J, Young CA, Ennis M et al. A randomised controlled trial comparing rehabilitation against standard therapy in MS patients receiving intravenous steroid treatment. J Neurol Neurosurg Psychiatry. 2003;74(9): 1225-30. https://doi.org/10.1136/jnnp.74.9.1225
Goldenberg M. Multiple sclerosis review. PT. 2012;37(3):175-184
Harding K, Williams O, Willis M et al. Clinical outcomes of escalation vs early intensive disease-modifying therapy in patients with multiple sclerosis. JAMA Neurol. 2019;76(5): 536-541. https://doi.org/10.1001/jamaneurol.2018.4905
Leary A, Quinn D, Bowen A. Impact of proactive case management by MS Specialist nurses on use of unscheduled care and emergency presentation in MS: A case study. Int J MS Care. 2015;17(4):159-163. https://doi.org/10.7224/1537-2073.2014-011
Link H, Huang YM. Oligoclonal bands in MS cerebrospinal fluid: an update on methodology and clinical usefulness. J Neuroimmunol. 2006;180 (1-2): 17-28. https://doi.org/10.1016/j.jneuroim.2006.07.006
Lublin FD, Reingold SC, Cohen JA et al. Defining the clinical course of MS: the 2013 revisions. Neurology. 2014;83(3):276-86. https://doi.org/10.1212/WNL.0000000000000560
National Institute for Health and Care Excellence (NICE). Depression in adults with a chronic physical health problem: recognition and management. 2009.
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