Multiple Sclerosis: Symptoms, Diagnosis, Therapy

Brief overview

• Symptoms: E.g., visual disturbances, sensory disturbances (such as tingling), painful paralysis, gait disturbances, persistent fatigue and rapid exhaustibility, disturbances of bladder emptying and sexual functions, concentration problems.
• Diagnosis: Medical history, physical and neurological examination, magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) diagnostics, blood and urine tests, evoked potentials if necessary.
• Treatment: Medications (for relapse therapy and progression therapy), symptomatic therapy measures and rehabilitation (physiotherapy, occupational therapy, psychotherapy, etc.).
• Course and prognosis: Not curable, but its course can be positively influenced by correct and consistent treatment (fewer relapses, slower progression of the disease, improved quality of life).

What is multiple sclerosis?

Various complaints are the result, for example visual and sensory disturbances, pain or paralysis. So far, multiple sclerosis cannot be cured. However, the course of the disease can be favorably influenced with medication.

Multiple sclerosis – courses

There are three MS courses:

• Relapsing-remitting MS (RRMS): This is the most common form of MS. The MS symptoms occur in relapses; between the relapses they completely or partially regress.
• Primary progressive MS (PPMS): From the beginning, the disease progresses steadily – the symptoms increase continuously. However, isolated relapses also occur.

You can read more about this in the article Multiple Sclerosis – Course.

Clinically isolated syndrome (CIS)

Clinically isolated syndrome (CIS) is the term used by physicians to describe the presumed first clinical manifestation of multiple sclerosis – that is, a first episode of neurological dysfunction consistent with MS. However, because not all diagnostic criteria are met, multiple sclerosis cannot (yet) be diagnosed.

Frequency

More than two million people worldwide suffer from multiple sclerosis. The distribution of the disease varies greatly from region to region. MS occurs most frequently in Europe and North America.

What are the symptoms of multiple sclerosis?

Multiple sclerosis is also called the “disease with 1,000 faces” because the symptoms vary from person to person, depending on which nerve structures are affected by the damage.

Sometimes, however, the disease appears for the first time with additional or different symptoms. These first signs of multiple sclerosis often persist in the further course. In addition, there are often other symptoms.

Overview of the most important MS symptoms

• Visual disturbances such as blurred vision, loss of vision, pain during eye movements due to optic nerve inflammation (optic neuritis), double vision due to disturbed coordination of the eye muscles.
• Cramp-like, painful paralysis (spasticity), especially in the legs
• Disturbance in the coordination of movements (ataxias), unsteadiness when walking or reaching
• Fatigue (significant persistent weakness and rapid exhaustion)
• Disorders of bladder and/or bowel emptying (e.g. urinary incontinence, urinary retention, constipation)
• Speech disorders, “slurred” speech
• Swallowing disorders
• Involuntary, rhythmic eye tremor (nystagmus)
• Cognitive disorders such as decreased attention, concentration problems, impaired short-term memory
• Sexual dysfunctions such as ejaculation problems and impotence in men, orgasm problems in women, decreasing sexual desire (loss of libido) in all sexes
• Pain, e.g. headaches, nerve pain (e.g. in the form of trigeminal neuralgia), back pain
• Dizziness

In many cases, intense heat (for example, very hot weather, fever, or a hot bath) temporarily worsens MS symptoms. Doctors call this the Uhthoff phenomenon.

How do you recognize an MS flare-up?

• They last for at least 24 hours.
• They occurred at least 30 days after the onset of the last episode.
• The symptoms were not caused by a change in body temperature (Uhthoff phenomenon), infection, or other physical or organic causes.

How is multiple sclerosis diagnosed?

Therefore, MS is a diagnosis of exclusion: The physician may only make the diagnosis “multiple sclerosis” if no better explanation can be found for the occurring symptoms as well as for clinical examination findings.

To clarify this, different examination steps are necessary:

• Taking the medical history
• Neurological examination
• Magnetic resonance imaging (MRI)
• Examination of the cerebrospinal fluid (CSF diagnostics)
• Blood and urine tests

In addition to the medical history, magnetic resonance imaging and cerebrospinal fluid (CSF) diagnostics are particularly important for the clarification of possible multiple sclerosis. Their results allow a diagnosis of MS based on the so-called McDonald criteria. These have been revised several times since their introduction and concern, among other things, the number of relapses (in the case of relapsing disease) and the inflammatory foci in the CNS.

The first point of contact when multiple sclerosis is suspected is the family doctor. He will refer the affected person to a specialist, usually a neurologist, if necessary.

Medical history

The first step towards a diagnosis of multiple sclerosis is a detailed discussion between the physician and the affected person in order to obtain a medical history. The physician asks, for example

• what exactly the symptoms are,
• when the individual symptoms were first noticed.
• whether the affected person or close relatives suffer from an autoimmune disease or
• whether there are cases of multiple sclerosis in the family.

It is important that patients tell the doctor about any symptoms they remember, even if they think they are harmless or if a symptom has long since disappeared. Sometimes symptoms that occurred months or even years ago can be identified in retrospect as the first signs of multiple sclerosis.

If necessary, do not hesitate to tell about sexual dysfunctions or problems with bladder or bowel emptying. This information is important for the doctor! The more complete and precise your descriptions are, the faster he can assess whether multiple sclerosis is actually the cause of your symptoms.

Neurological examination

• Function of eyes and cranial nerves
• Sensation of touch, pain and temperature
• Muscle strength and muscle tension
• Coordination and movement
• Interaction of nerve conduction for urinary bladder, rectum and sexual organs
• Reflexes (for example, lack of abdominal skin reflexes is a common sign of MS)

Another system for assessing neurological deficits in multiple sclerosis is the Multiple Sclerosis Functional Composite Scale (MSFC). Here, for example, physicians test arm function using a pegboard test for time (“Nine-Hole Peg Test”) and the ability to walk a short distance for time (“Timed 25-Foot Walk”).

Magnetic resonance imaging (MRI)

The diagnostic criteria for relapsing-remitting MS require that these inflammatory foci occur spatially and temporally dispersed (disseminated). This means that there must be foci of inflammation in the CNS at more than one location and that new such foci must develop in the course of the disease.

CSF diagnostics

Another important step on the way to the diagnosis of multiple sclerosis is the examination of the cerebrospinal fluid (CSF). To do this, the doctor carefully pricks the spinal cord canal with a fine hollow needle under local anesthesia (lumbar puncture) to take a small sample of the nerve fluid. It is analyzed in more detail in the laboratory (CSF diagnostics).

CSF diagnostics can also be used to clarify whether the inflammation in the nervous system is possibly caused by germs (such as the pathogens of Lyme disease) and not by multiple sclerosis.

Neurophysiological examination

To do this, doctors measure electrical voltage differences that occur when specific nerve pathways are stimulated. The recording is done by means of electrodes, mostly by EEG (electroencephalography). In the context of MS diagnostics, the following evoked potentials are helpful.

Somato-sensory evoked potentials (SSEP): In this procedure, the physician stimulates sensitive nerves in the skin with the help of electric current, for example nerves for tactile sensation.

Acoustic Evoked Potentials (AEP): AEP involves playing sounds to the affected person through headphones. Doctors then use electrodes to measure how quickly these acoustic stimuli are transmitted to the brain.

Blood and urine tests

Parameters of interest in blood analysis include:

• CBC
• Electrolytes such as potassium and sodium
• Inflammation marker C-reactive protein (CRP)
• Blood sugar
• Liver values, kidney values, thyroid values
• Auto-antibodies: antibodies directed against the body’s own tissues, such as rheumatoid factor, antinuclear antibodies (ANA), anti-phospholipid antibodies or lupus anticoagulants

Sometimes it takes weeks, months or even years until the diagnosis of multiple sclerosis is clearly established. The search for the “disease with 1,000 names” resembles a puzzle: The more pieces (findings) fit together, the more certain it really is MS.

What causes multiple sclerosis?

In the case of MS, the attack is directed against the central nervous system. Defense cells – especially T lymphocytes, but also B lymphocytes – cause inflammation in the area of the nerve cells there. The inflammatory damage mainly affects the white matter, which contains the nerve fibers. However, the gray matter is also damaged, especially as the disease progresses. This is where the bodies of the nerve cells are located.

Experts assume that in MS, among other things, certain proteins on the surface of the myelin sheath are attacked by the autoantibodies. The inflammatory processes triggered in this way gradually destroy the myelin sheath, which physicians refer to as demyelination. The nerve extension itself (axon) is also damaged, sometimes directly while the myelin sheath is still intact.

What triggers the autoimmune reaction in MS?

But why does the immune system get so confused in MS that it attacks its own nerve tissue? The experts do not know exactly. Presumably, several factors come together in those affected, which together trigger the disease (multifactorial disease development).

Genetic factors

Several observations point to a genetic component in the development of multiple sclerosis.

On the one hand, multiple sclerosis occurs in clusters in some families: First-degree relatives of MS sufferers have an increased risk of also developing the chronic nerve disease.

To a certain extent, multiple sclerosis is therefore hereditary – although it is not the disease itself that is inherited, but the tendency to develop MS. Only in combination with other factors (especially environmental factors such as infections) does the disease break out in some people, experts suspect.

Infections

Exactly how infection with EBV (or other pathogens) contributes to the development of MS is not yet known. It is possible that, in general, the immune system’s response to infection may trigger the development of MS in people who are predisposed to it.

Lifestyle and environment

Environmental and lifestyle factors may also play a role in the development of multiple sclerosis. However, an unhealthy lifestyle alone is not sufficient to trigger multiple sclerosis.

Other factors

Gender also plays a role in the development of MS. Women get multiple sclerosis more often than men. Experts do not yet know why this is so.

According to studies, a high-fat “Western” diet and the associated obesity increase the risk of MS. Scientists also discuss an increased intake of table salt and the intestinal flora as other possible factors influencing the development of MS.

Living with multiple sclerosis

As a chronic and severe disease, multiple sclerosis presents many challenges to those affected and their families. The disease affects all areas of life – from partnership, sexuality and family planning, to social life and hobbies, to education and career.

Read more about how multiple sclerosis affects the everyday life of those affected and how to cope with it in the article Living with multiple sclerosis.

Multiple sclerosis: Therapy

Multiple sclerosis therapy is based on several pillars:

• Relapse therapy: This is the acute treatment of MS relapses, preferably with glucocorticoids (“cortisone”). Alternatively, a type of blood washing called plasmapheresis or immune adsorption is sometimes helpful.
• Symptomatic therapy: This includes measures to alleviate various MS symptoms, for example physiotherapy or antispasmodic medication for painful muscle spasms.
• Rehabilitation: The aim of rehabilitation for multiple sclerosis is to enable those affected to return to their family, professional and social lives.

Relapse therapy

It is advisable to treat an MS relapse as soon as possible after the onset of symptoms. The therapy of choice is the administration of “cortisone” (glucocorticoid, corticosteroid). Alternatively, plasmapheresis is performed in certain cases.

Cortisone therapy

Preferably, the cortisone should be given in a dose in the morning because it causes sleep disturbances in some people. If intravenous cortisone administration is not possible for an affected person, the doctor may switch to cortisone tablets.

Side effects:

Possible side effects of cortisone shock therapy for multiple sclerosis include mild mood changes, stomach upset, facial flushing, and weight gain, in addition to the sleep disturbances mentioned above.

Plasmapheresis or Immune Adsorption

A so-called plasmapheresis (PE) or immune adsorption (IA) is considered if:

• after completion of cortisone shock therapy, disabling neurological dysfunctions persist or

Plasmapheresis or IA is a type of blood washing. Using a special device, blood is drained from the body through a catheter, filtered, and then returned to the body. The purpose of filtration is to remove immunoglobulins from the blood that are responsible for the inflammatory process during an MS flare.

It is unclear whether one of the procedures is superior to the other or whether both are equally effective in multiple sclerosis.

Plasmapheresis or immune adsorption is usually performed as an inpatient procedure in specialized MS centers, ideally in the first six to eight weeks after the onset of an MS relapse. Under certain circumstances, PE/IA may also be useful at an earlier stage, for example if ultra-high-dose cortisone infusions are not possible for an affected person.

• Blood pressure regulation disorders
• Kidney damage
• Tetany symptoms (disturbances in motor function and sensitivity caused by overexcitable muscles, for example in the form of muscle cramps, tingling and other mis-sensations), caused by a disturbed balance of blood salts (electrolytes) [in PE].
• Coagulation disorders [especially in PE].
• Side effects and complications of any necessary medication to thin the blood (anticoagulation), such as an increased tendency to bleed.
• Mechanical irritation or complications such as bleeding or clot formation due to the use of large catheters
• Infections in the area of catheter access (up to and including blood poisoning)
• Very rare: Pulmonary edema/transfusion-related active lung failure [with PE].

Course modifying therapy

Although immunotherapy is not able to cure multiple sclerosis, it can have a favorable influence on its course. The greatest effect is seen in relapsing MS, i.e. relapsing-remitting MS and active secondary progressive MS.

In non-active SPMS as well as in primary progressive MS, the efficacy of immunotherapy is lower. However, the use of certain immunotherapeutics is sometimes still helpful.

Types of immunotherapeutics

Currently, the following immunotherapeutics are available for the treatment of multiple sclerosis:

• Beta-interferons (including PEG-interferon)
• Glatiramer acetate
• Dimethyl fumarate
• Teriflunomide
• S1P receptor modulators: Fingolimod, siponimod, ozanimod, ponesimod
• Cladribine
• Natalizumab
• Ocrelizumab
• Rituximab (not approved for multiple sclerosis)
• Alemtuzumab
• Other immunotherapeutics

Beta-interferons

Beta-interferons (also interferon-beta) belong to the group of cytokines. These are naturally occurring signal proteins in the body that modulate immune reactions, among other things. Exactly how beta interferons administered as a drug work in multiple sclerosis has not yet been clarified.

Side effects: The most common are flu-like symptoms, especially at the beginning of therapy (such as headache, muscle aches, chills, fever). Creeping the therapy (increasing the dose slowly) or administering the injection in the evening partly helps to prevent these complaints. In addition, taking anti-inflammatory paracetamol or ibuprofen half an hour before the injection counteracts flu-like symptoms.

In people with pre-existing depression, treatment with beta-interferons may exacerbate the depression.

Often, people on interferon therapy develop a deficiency of neutrophil granulocytes and platelets, as well as elevated blood levels of transaminases.

In addition, neutralizing antibodies sometimes develop against the drug during beta interferon treatment, causing it to lose effectiveness.

Glatiramer acetate

GLAT is injected under the skin once daily or three times weekly, depending on the dosage.

Side effects: Very often, GLAT injections cause local reactions at the injection site (redness, pain, wheal formation, itching). Often there is a cosmetically disturbing local lipo-atrophy, i.e. the loss of subcutaneous fatty tissue. The skin becomes depressed in the affected areas.

Teriflunomide

Teriflunomide has an immunosuppressive effect. It inhibits the formation of an enzyme that is important for the rapid growth of cells (cell proliferation), particularly in lymphocytes. These white blood cells are involved in the pathological immune responses in multiple sclerosis.

People with MS take teriflunomide once a day as a tablet.

Typical effects of teriflunomide therapy are a decrease in white blood cells and platelets. In addition, other blood count changes occur as frequent side effects (lack of neutrophils, anemia). Infections, such as of the upper respiratory tract, or cold sores are also common.

Occasionally, peripheral nerve disorders (peripheral neuropathies), such as carpal tunnel syndrome, develop with teriflunomide.

Dimethyl fumarate

The active ingredient is taken twice daily as a capsule.

Side effects: Most commonly, DMF ingestion causes itching, a feeling of heat or “flush” (seizure-like redness of the skin with a feeling of heat), gastrointestinal symptoms (such as diarrhea, nausea, pain in the abdomen), and a lack of lymphocytes (lymphopenia). The reduction in these important immune cells makes sufferers more susceptible to infections.

Taking dimethyl fumarate also increases the incidence of shingles. In addition, there is an increased risk of protein uria – an increased excretion of protein in the urine.

Fingolimod

The active ingredient is taken once daily as a capsule.

Side effects: Due to the described mechanism of action, a deficiency of lymphocytes (lymphopenia) is a typical therapy effect.

Very often flu and sinusitis occur under Fingolimod, bronchitis, Kleienpilzflechte (form of skin fungus) and herpes infections often develop. Sometimes cryptococcosis (a fungal infection) is also observed, such as cryptococcal meningitis.

A serious, but only occasionally occurring side effect of fingolimod is macular edema. This eye disease may lead to blindness if left untreated.

Another undesirable effect of fingolimod therapy is the increased risk of certain types of cancer: for example, basal cell cancer, a form of white skin cancer, and occasionally black skin cancer (malignant melanoma) frequently develop under fingolimod.

In addition, there were individual cases of a neurological clinical picture with brain swelling (posterior reversible encephalopathy syndrome), a clinical picture with uncontrolled excessive immune reaction (hemophagocytic syndrome), and atypical multiple sclerosis courses under fingolimod.

Siponimod

Siponimod is taken daily in tablet form.

Before starting therapy, a genetic examination of the affected person is necessary. This involves analyzing genetic factors that influence the metabolism of the active substance in the body. Based on the results, the doctor decides how siponimod should be dosed and whether the patient should receive it at all.

Ozanimod

Ozanimod is another S1P receptor modulator used for MS therapy. It is taken once daily as a capsule.

Ponesimod

In the EU, a fourth S1P receptor modulator was approved for relapsing-remitting multiple sclerosis therapy in May 2021: Ponesimod. Like the other representatives of this class of agents, it is taken once daily.

Side effects: The most common side effects include upper respiratory tract infections, elevated liver enzymes, and hypertension. Other adverse effects include urinary tract infections and shortness of breath (dyspnea).

Cladribine

Cladribine therapy for multiple sclerosis consists of two therapy cycles that extend over two years. Two short-term dosing phases are scheduled per year: In two consecutive months, the patient takes one to two cladribine tablets on each of four to five days.

Serious infections also occurred more often in studies of cladribine-treated MS patients than in participants who received a placebo instead. In individual cases, such infections led to death.

In addition, cancer has been found to develop more frequently in clinical trials and long-term follow-up of people on cladribine therapy.

Natalizumab

Typically, natalizumab is administered as an infusion every four weeks.

Side effects: Very common side effects are urinary tract infections, nasopharyngitis, headache, dizziness, nausea, fatigue (excessive fatigue), and joint pain called. Hives (urticaria), vomiting, and fever often develop. Occasionally, severe allergic reactions to the drug occur.

Another rare infectious complication with natalizumab therapy is herpes virus-associated infections.

Ocrelizumab

Ocrelizumab is also a genetically engineered antibody. It belongs to the so-called anti-CD20 antibodies, as it binds to a specific surface protein (CD20) of B lymphocytes, which leads to their dissolution. The B lymphocytes are involved in the damage to the nerve sheaths (myelin sheaths) and nerve cell processes in multiple sclerosis.

Side effects: The most common side effect is infusion reactions (for example, itching, rash, nausea, vomiting, headache, fever, chills, mild increase or decrease in blood pressure). They are usually mild.

A few cases of Progressive Multifocal Leukoencephalopathy (PML) have been observed in MS patients who were recently switched to ocrelizumab. Most of these were previously treated with natalizumab (see above).

Ofatumumab

Ofatumumab is another anti-CD20 antibody. People with multiple sclerosis inject the active substance themselves under the skin using a ready-to-use pen. The therapy is initiated with three injections at intervals of seven days. After a one-week break, the next injection follows, and then another every four weeks.

As with all anti-CD20 antibodies, there is a general risk that opportunistic infections will occur or that a hepatitis B infection that has healed will flare up.

Rituximab

Rituximab is also an anti-CD20 antibody and is sometimes used in the treatment of multiple sclerosis. However, it is not officially approved for this indication (neither in the EU nor in Switzerland).

You can read more about the use, side effects and interactions of rituximab here.

Alemtuzumab

The active substance is administered as an infusion – on five consecutive days in the first year and on three consecutive days one year later. If necessary, it is also possible to administer alemtuzumab a third and fourth time on three consecutive days, in each case at a minimum interval of 12 months from the previous administration. In total, a maximum of four therapy cycles are therefore possible.

After new side effects, some of them severe, became known, the use of alemtuzumab was restricted and linked to certain precautionary measures. These side effects include new immune-mediated diseases (such as autoimmune hepatitis, hemophilia A) and acute cardiovascular side effects (such as myocardial infarction, stroke, pulmonary hemorrhage), which have so far occurred primarily one to three days after an alemtuzumab infusion.

Other immunotherapeutics

Mitoxantrone: This immunosuppressive drug is approved in the EU and Switzerland for the treatment of multiple sclerosis. However, due to the poor study situation and its high toxicity, it is only used as a reserve drug in exceptional cases. Its most serious side effects include heart damage and an increased risk of blood cancer (leukemia).

Cyclophosphamide: This immunosuppressive agent is also given in rare cases in multiple sclerosis, although it has no approval for this purpose and its efficacy in this disease has not been sufficiently proven. Therefore, the same applies here as for methotrexate: cyclophosphamide should only be administered to patients who have a secondary disease in addition to MS that requires treatment with this agent. You can learn more about cyclophosphamide here.

To date, only one drug has been approved for the treatment of primary progressive multiple sclerosis – ocrelizumab. According to the current guideline, physicians should also use rituximab if appropriate, even if it does not have approval for multiple sclerosis (off-label use, i.e. outside its approval).

In individual cases, however, appropriate immunotherapy is also justifiable in this age group (limited to two years) if the degree of disability is rapidly increasing in an affected person and the loss of independence is imminent.

Immunotherapy in secondary progressive MS (SPMS)

Only in exceptional cases should the physician prescribe mitoxantrone for active SPMS, because this agent sometimes causes considerable side effects (see above).

Immunotherapy in Clinically Isolated Syndrome (CIS).

People who experience a relapse with symptoms of multiple sclerosis for the first time without meeting all diagnostic criteria for MS should receive immunotherapy. However, only some beta interferons and glatiramer acetate have been approved for the treatment of such clinically isolated syndrome (CIS).

Duration of immunotherapy

Therefore, after a certain period of time, the physician and the affected person themselves should decide together whether they would like to interrupt the immunotherapy on a trial basis.

There is an a priori limited therapy duration for alemtuzumab (maximum four therapy cycles) and cladribine (maximum two therapy cycles). If patients do not show any disease activity after the end of such treatment, the physician should initially not prescribe other immunotherapeutics. However, regular check-ups are recommended.

Other therapies

Blood stem cells are obtained from the body of the affected person – i.e. stem cells that give rise to the various blood cells. The immune system is then destroyed with drugs, such as those used in cancer chemotherapy. The affected person then receives the stem cells that were previously removed back via an infusion. These then build up a new hematopoietic system – and thus also a new cellular immune system.

In Germany, Austria and some other EU countries, aHSCT is currently not approved for the treatment of MS, but it is in some other countries (for example, Sweden). In Switzerland, aHSCT received approval for MS therapy in 2018, subject to certain conditions.

If there is a proven vitamin D deficiency, it makes sense to compensate for it, for example with a vitamin D preparation. Taking such a preparation can also be considered if there is no vitamin D deficiency. However, it should be clear to those affected that vitamin D intake has not yet been shown to have a positive influence on the course of multiple sclerosis.

Symptomatic therapy

Multiple sclerosis causes a wide variety of symptoms. Targeted measures help to alleviate these symptoms and thus improve the quality of life of those affected. Symptomatic therapy is therefore an indispensable part of multiple sclerosis therapy. In addition to medication, it also includes non-drug measures such as physiotherapy, occupational therapy, speech therapy and psychotherapy.

Physio therapy

Spasticity – pathologically tense, stiff, cramped muscles that often also hurt – is a common symptom of multiple sclerosis. Regular physical therapy can relieve spasticity and its effects.

People who suffer from impaired coordination of their movements (ataxias) due to MS also benefit from regular physio therapy. The goal here is to promote coordination.

It is often useful for people with MS to regularly perform at home the various exercises they practice with their physical therapist (for example, pelvic floor training or exercises for muscle spasms). The therapist provides appropriate instructions for independent training.

Ergo therapy

For example, occupational therapy is recommended for impaired coordination of movement (ataxia) and involuntary, rhythmic tremors. With the help of the therapist, affected persons practice normal, energy-saving movements, among other things, and train targeted grasping for objects. In the case of an existing handicap, they also learn how to deal with it and switch to “substitute movements.

Ergo therapy usually does not reverse the impairments of the body and brain. But it does help those affected to remain independent for as long as possible. To do this, people with MS need patience and must practice – with and without therapists.

Medication for symptoms

If necessary, doctors also use medications to relieve various MS symptoms – usually accompanying non-drug measures. Some examples:

• Anti-spasticity medications (such as baclofen, tizanidine) for spasticity.
• Anti-cholinergics (e.g. trospium chloride, tolterodine, oxybutynin) for overactive bladder
• Desmopressin for nighttime urination (nocturia) or frequent urination with usually only small amounts of urine (pollakiuria)
• Painkillers, for example for headaches and nerve pain
• PDE-5 inhibitors (such as sildenafil) for erectile dysfunction
• Antidepressants (especially selective serotonin reuptake inhibitors, SSRIs) for depressive moods

Rehabilitation

To this end, doctors and therapists try, for example, to eliminate or at least improve existing impairments in everyday activities (for example, walking, dressing or personal hygiene).

Accordingly, physicians should offer rehabilitation to people with MS in the following situations:

• In case of persistent, functionally significant impairment after an MS relapse.
• When there is a threat of loss of important functions and/or independence and/or a significant increase in physical or psychosomatically related dysfunction during the course of the disease
• When there is a threat of loss of social and/or occupational integration
• For severely disabled people with MS with clearly defined treatment goals and the need for interdisciplinary care

Multi-week and multimodal

To achieve these goals, a multi-week and multimodal rehabilitation is needed. “Multimodal” means that the rehab program is composed of different building blocks – individually adapted to each person affected. Common building blocks of MS rehabilitation include:

• Physio-therapy
• Ergo therapy
• Speech therapy
• Disease management techniques
• Activating therapeutic care to promote daily living skills
• Training and information on the disease, therapy and other aspects

Outpatient or inpatient

In principle, MS rehabilitation is possible on an outpatient or inpatient basis in appropriate rehabilitation facilities. Decisive in the individual case are the extent of existing impairments and the individual rehabilitation goals.

Sometimes a treatment in a specialized clinic for multiple sclerosis is useful, where an additional intensive multimodal therapy is possible (MS complex treatment). This is the case with complex symptoms or concomitant diseases, which must be medically clarified promptly or require further medical treatment measures.

Complementary and alternative healing methods

Complementary and alternative healing methods often arouse particular interest among people with chronic diseases such as multiple sclerosis. Homeopathy, herbal medicine (phytotherapy), acupuncture – many people place great hope in these and other methods.

The effectiveness of complementary and alternative healing methods (in general or for multiple sclerosis) is usually not scientifically proven. There may also be risks associated with some methods.

The following table lists a selection of alternative/complementary procedures used in multiple sclerosis:

Method	Assessment
Acupuncture	Very often used as a supplement (complementary) to MS therapy. Trying to relieve pain with it, for example, can be useful.
Acupressure	The same applies here as for acupuncture.
Amalgam removal
Certain diets	No diet has been shown to have a positive effect on the course and symptoms of MS. Experts generally recommend a varied, balanced diet with plenty of fresh vegetables, fruits, fish and unsaturated fats, but little meat and fat.
Bee venom therapy (Api therapy)
Enzyme combinations / enzyme therapy Enzyme therapy	Supposed to break down disease-causing immune complexes Immune complexes. However, a large-scale study failed to demonstrate efficacy in MS.
Fresh cell therapy	Risk of severe allergies (up to circulatory failure) and risk of infection. Therefore considered dangerous and not advisable!
Homeopathy
Immunaugmentation (enhancement of the immune response)	Carries a risk of infection and allergy and a risk of worsening MS. Is therefore dangerous and not advisable!
Intrathecal stem cell therapy	Injection of the body’s own stem cells into the spinal canal. Carries the risk of severe to fatal side effects. Is therefore dangerous and not advisable!
Snake venom	Carries the risk of severe allergies. Therefore considered dangerous and not advisable!
Pig brain implantation into the abdominal wall
Tai Chi	The exercises, performed slowly and deliberately, can have a positive effect on some MS symptoms, such as impaired movement coordination Movement coordination (ataxia).
Qigong	Part of Traditional Chinese Medicine (TCM). The exercises have a stress-relieving and relaxing effect, which can support MS therapy.
Hyperbaric oxygen therapy (hyperbaric oxygen)	Supposed to stop progression of MS, but this has not been proven in studies.
Frankincense
Incense	Anti-inflammatory action. Good results in inflammatory bowel disease and rheumatoid arthritis. There are no studies on efficacy in MS.
Yoga	The various exercises (such as for movement, coordination, relaxation) can have a positive effect on symptoms such as spasticity and fatigue.

Course of the disease and prognosis

However, it is not possible to predict what the prognosis for multiple sclerosis will be in individual cases. However, there are some indications. For example, the following factors speak for a rather unfavorable course of the disease:

• Male gender
• Later onset of disease
• Onset of disease with multiple symptoms
• Early motor symptoms, cerebellar symptoms such as intention tremor, or sphincter symptoms such as urinary incontinence.
• High thrust frequency

One thing is certain: the course of the disease can be positively influenced if the person affected receives professional and consistent treatment as well as support from his or her social environment. Equally important is the cooperation of the patient in the various therapy measures. However, a sense of proportion is required: if patients are too ambitious and want “too much,” their limited strength wears out and their energy reserves are exhausted prematurely.