Diagnosing and managing multiple sclerosis

The most common form of MS is relapsing remitting MS (RRMS). This is now a treatable condition and early diagnosis is becoming increasingly important in order to guide management decisions. After several years, RRMS may evolve into a slowly progressive deterioration in neurological function, known as secondary progressive MS. In 10-15% of people with MS, the condition follows this pattern of slow deterioration from onset, without relapses or remissions. This is primary progressive MS. It is difficult to predict prognosis in an individual patient. Factors associated with a favourable prognosis include female sex, onset with optic neuritis or sensory symptoms (rather than weakness or ataxia) and a long interval between initial relapses. RRMS is most commonly diagnosed in white women in their 20s. The first attack is known as a 'clinically isolated syndrome' reflecting inflammation in a single location. Common sites and symptoms are: optic nerve; spinal cord; sensory symptoms; Lhermitte's symptom and brainstem. The time course of symptoms is often helpful, as it is characteristic of inflammation. Patients tend to deteriorate over days, remain at a nadir for a week or two, and then recover over weeks. Recovery may be incomplete. Question patients directly to find out if there is a past history of any of the other common symptoms and perform a full neurological examination. Primary progressive MS should be suspected in patients presenting with a progressive spastic paraparesis or cerebellar syndrome. The diagnosis of MS should be made by a specialist and patients with a syndrome suggestive of MS should be referred to a neurologist. The mainstays of pharmacological treatment in RRMS are still the beta interferons and glatiramer acetate. These drugs reduce the rate of relapse by about a third and are therefore indicated for mobile patients with at least two relapses in the past two years.