How MS presents itself ?

For doctors, MS present itself in two forms which are very good tools for making a diagnosis or at least for starting to think about its possibility.

The first tool is called symptoms, which in other terms means, how patients tell doctors about their own worries (symptoms).

MS can present itself in a variety of symptoms, perhaps the most frequent of them is the sensory symptoms in the form of tingling, burning, numbness, sharp pain, band like tightness (MS hug) and the commonest locations for these MS hugs are arm, chest, thigh, or rarer tummy.

Fatigue is the commonest symptom of MS, which is experienced by more than 95% of all MS sufferers at one stage of their illness. MS fatigue is not as the usual fatigue all of us experience on occasions. More about MS fatigue will come under “complications” of MS.

Physical problems in MS are common presenting features as well, but not as common as the sensory symptoms. Among the physical symptoms comes muscle stiffness with muscle cramps and leg jerkiness in many occasions. An other form of spasm, called intermittent (phasic) spasm does happen frequently in MS, and it has its own features and must be identified by doctors managing MS. More details about phasic spasm will follow in the management of complications of MS.

Eye problems in MS are common as wee, including blurred or double vision fr reasons will be mentioned later under complications and management. Changes in visual acuity (sight) which may involve seeing colours especially red, green, and blue including obviously traffic lights !.

Bladder problems are very frequent in MS, and some times are accompanied by bowel and sexual problems. More will be mentioned under complications and management.

Balance problems of any sort from vertigo to dizziness to hand clumsiness, and to walking balance problems and falls. Speech slurring can be part of this sort of involvement.

Other symptoms seem to be vague, but can be disabling such as headache, depression, mood swings, lack of motivation,  lack of interest, memory problems, and sleep disturbances.

Doctors as well need to be aware and alert for not to miss thinking about the possibility of MS when they hear a story from a nervous young girl in particular and not to jump into considering her symptoms as “all in her mind”. In my experience dealing with MS for nearly 15 years, every young girl with any sensory symptoms I consider MS in my thinking and dealing with.

The clinical features of MS for doctors should be a common knowledge for every qualified doctor.

There are cor signs and additional (complementary) signs which help doctors to make the diagnosis at least on clinical grounds.

Features of brain stem involvement, what we doctors know as upper motor neuron features in the form of plasticity, brisk reflexes, ex tensor plantars (positive Babinski sign), and pyramidal weakness. Pyramidal weakness for me is very important to look at because it can help to distinguish between relevant and not really relevant features of MS as a diagnosis on the first presentation, and as a relapse when following up any patient with MS. I is also good to help to know whether the sign is MS related or not as once any patient was diagnosed with MS, we tend to blame MS for every thing else !.

Pyramidal weakness is not a feature of MS, but it is a feature of brain stem involvement by any other disease. MS is a very good example. Abduction in upper limbs is weaker than adduction, and extensors are weaker than flexors. In the lower limbs, flexors are weaker (some times clearly weaker) in lower limbs than extensors.

Sensory changes in MS are not dermatomal, and not regional such as glove and stockings. Sensory features in MS are mostly “patchy”, and posterior column functions including Romberg’s sign are very rare.

The accessory signs are widespread, and can be sometimes difficult to account for. I will probably start at the top of the body then down through to the gait.

I will consider memory as the highest top, and memory in MS secondary but not primary memory deficits.

Memory production is a gray matter function, and MS is a white matter disease. We are dealing in MS with “transmission” but not with production of memory. Memory in MS is very much characterised with “slowness  in every thing.

Memory and every other physical activity in MS is affected significantly with heat and humidity. This condition is called Uthoff’s phenomenon. Features of Uthoff’s phenomenon include: slow thinkg, sluggish memory, increased fatigue, blurred or double vision, and balance preoblems.

Next is cranial nerves, and the commonest affected if the optic nerve. Optic nerve functions are for: visual acuity, colour vision, visual fields, and pupillary reaction. We need to check for Marcus-Gunn phenomenon or other wise partial afferent visual defect. Best be elicited by performing a torch swinging test, which will produce a paradoxical reaction to light on the affected eye.

Other commonly affected cranial nerves include in order of frequency: trigeminal nerve (neuralgia), cochleo-vestibular nerve (vertigo & dizziness), and facial nerve palsy (bilateral Bell’s palsy). Other cranial nerves can be affected, but very rare.

Around the eyes, we need to look at: visual pursuit & saccades, internuclear ophthalmoplegia (INO) with its nice triad of: failure of the affected eye to adduct, and the other eye will show the examiners double vision and nystagmus. One important feature here worth mentioning: INO results from a problem with conjugate gaze due to a defect in the medial longitudinal smooth muscles around the rain stem. If the non affected eye is closed, INO disappears . This obviously help the doctor to distinguish between nerve or muscle palsy and the conjugate gaze paralysis.

We need to remember to check for the L’Hermitte’s sign, which is sign of cervical myelopathy. The patient is asked to flex his or her neck fully, and the doctor has to watch for the result of that. Doctors know what to look for !.

Going through upper and lower limbs, we would need to look for the cardinal features of upper motor euro disorder as mentioned above.

We need to remember that MS affects the cerebellum as well, but in every patient. Less than 30% of patients who present on the first time might have cerebellar involvement. We doctors need to assess for cerebellar abnormal features which could be in the form of limb ataxia, trunkal ataxia, slurred speech, and nystagmus.

I hope that, both doctors and patients find this part of MS information helpful and easy to digest !. Any more details can be provided on demand.

We end up with the MS gait !. Simply in the shortest description, I would describe MS gait as spastic, paraparetic with or without ataxia.