Headache, joint pain in (MS) is a common symptom of the disease caused by damage to the nervous tissue, damage to the myelin sheath of the nerves that carry out sensitive innervation of various parts of the body. As a result of this, scarred areas are formed on the impulse-conducting fibers, which interfere with their normal functioning. There are paralysis, goosebumps, discomfort, excessive sweating, pallor of the skin.

Pain syndrome in multiple sclerosis

Headaches (cephalgia) are a consequence of damage to the occipital, trigeminal, facial nerves by an inflammatory process and the formation of scar tissue. This results in muscle tension as well as neuropathic pain.

Doctors have figured out why multiple sclerosis causes sore legs. The reason is, i.e. damage to sensory nerve fibers. As a result, the lower extremities may swell.

Another reason for sore legs is the accumulation of lactic acid due to fatigue, since the motor nerves do not transmit impulses to the muscle fibers well. Therefore, not all muscles are included in the work, and the load is distributed unevenly. Pain is accompanied by convulsions and prolonged spasms.

Pain in the legs with multiple sclerosis is relieved by analgesics, non-steroidal anti-inflammatory drugs. However, the course of the underlying disease affects the intensity of this manifestation.

Joint pain in multiple sclerosis is also a consequence of polyneuropathy. When treated with immunosuppressants and glucocorticoids, they weaken. There may also be associated ailments, such as arthrosis or arthritis.

Back pain from multiple sclerosis can occur due to osteochondrosis caused by constant overexertion of the muscles surrounding the spine. The fatigue and exhaustion that are characteristic of this degenerative disease also play a role.

Diagnostics

People suffering from sclerotic nerve damage undergo an annual examination to confirm the disability and determine its degree. If the diagnosis has not yet been established, for pain in the head, back, legs, joints, an MRI is prescribed, which can indicate pathological foci.

It is also necessary to be tested for the presence of neuroinfections (herpes viruses of various types), as they can provoke inflammation of the nerves and pain.

If the patient has a headache, leg, back, joints with multiple sclerosis, complex therapy is required, prescribed by the attending physician.

Since the disease is of an autoimmune origin, glucocorticoids (), immunosuppressants (Azathioprine, Cyclosporine, Methotrexate) are prescribed. These medicinal substances suppress inflammation, preventing the progression of the clinical manifestations of the disease.

Donor immunoglobulins, administered intravenously or intramuscularly, reduce the production of their own autoantibodies, which helps to stop the damage to nerve fibers.

To relieve headaches, joint pains, as prescribed by a doctor, analgesics are used: Tempalgin, Pentalgin. Non-steroidal anti-inflammatory drugs help reduce inflammation, reduce the sensitivity of nerve endings.

With pain in the back, joints, massage of the whole body, physiotherapy, balneotherapy (therapeutic baths) are indicated. Acupuncture can help relieve muscle spasms caused by multiple sclerosis and relax the muscles in your back, legs, and arms.

To alleviate the convulsive syndrome of the lower extremities, anticonvulsants are used (Phenobarbital, Sodium Valproate, Lamotrigine). Apply muscle relaxants that relax the muscles of the body: Sirdalud, Mydocalm.

For pain throughout the body, tricyclic antidepressants (Amitriptyline) are used to relieve muscle tension. Selective serotonin reuptake inhibitors (Cymbalta) are effective. For neuropathies, your doctor may prescribe Lyrica (Pregabalin).

On a note: as it manifests itself in pregnant women.

It is useful to know what is : the use and interpretation of values.

For what purposes is prescribed: indications, contraindications, effect of the drug.

Oxybutynin is used for increased visceral sensitivity and intestinal pain caused by neuropathy. With dystrophic nerve damage, stomach problems may be the result of side effects of taking glucocorticoid hormones. To eliminate them, inhibitors of hydrochloric acid secretion and gastroprotectors are used: Omeprazole, Cimetidine, Nolpaza, Venter, De-Nol.

Treatment with glucocorticoid hormones can cause edema, potassium excretion, and hypertension. Therefore, you should reduce the content of table salt in the diet, increase the consumption of foods rich in potassium. After all, its deficiency can provoke increased tension in the back muscles and convulsive syndrome of the lower extremities.

For spastic paralysis and persistent tonic convulsions, injections of botulinum toxin are given. It causes suppression of the release of acetylcholine, which is responsible for the painful contraction of the muscles of the lower extremities.

Conclusion

Multiple sclerosis may manifest itself in a variety of ways. In case of pain in the head, joints and legs, it is necessary to consult a doctor for the appointment of analgesic medications. Should also be taken into account side effects from drugs that caused cephalgia, arthralgia, myalgia and concomitant diseases.

Multiple sclerosis (multiple sclerosis) is a neurological autoimmune disease that has a chronic progressive course, characterized by damage to the white matter of the brain, spinal cord, myelin sheath of nerve fibers, the appearance of foci of demyelination and the addition of other symptoms. The disease is characterized by variability of signs at different stages of development.

Multiple sclerosis is one of the most common causes of disability in people of working age.

Who is committed to the disease?

The disease appears mainly at a young age (16-40 years). Cases of multiple sclerosis have been recorded in children under 1 year of age, as well as in the elderly (70 years and older). Among women, the disease occurs 2 times more often. General incidence statistics: about 50 people per 100 thousand population.

Pathogenesis: what happens in the body in multiple sclerosis?

Presumably, after viruses enter the body or their long-term persistence in the tissue of nerve fibers in individuals with a genetic predisposition, disorders in protein metabolism, blood clotting, the mechanism of the development of the disease is “launched”. The immune system plays a direct role in this process: T-lymphocytes with viral nucleotides form specific antibody autocomplexes that are aggressively directed against their own myelin cells.

There is another theory for the development of sclerosis: inflammatory diseases that cause destruction of the myelin structure (for example, encephalitis) lead to a state of sensitization of the cells of the immune system with the formation of antigens, further damaging the nerve fibers and leading to the "switching on" of pathological phenomena. Thus, multiple sclerosis is a primary or secondary autoimmune disease that begins with an unfavorable combination of many circumstances.

How does multiple sclerosis progress?

The main pathomorphological changes are observed in the nerve fibers of the brain and spinal cord. They come down to the breakdown of the myelin sheaths of young nerve structures in one or another department, most often in the lateral or posterior column of the spinal cord, in the cerebellum, and in the optic nerves.

The processes are accompanied by swelling of nerve fibers, impaired conduction of impulses, and later - the formation of multiple sclerotic scars, plaques, consisting of connective tissue. The self-healing of the myelin sheath sections leads to a temporary remission in the human condition.

Causes of the disease

According to studies, the disease is multifactorial. However, the causes of multiple sclerosis are hypothetical.

Basic theory- the onset of the disease due to a viral lesion after suffering rubella, measles, herpes, mumps, particles of which can exist for a long time in the nerve trunks.

The disease is not inherited, but a person's relatives have a higher risk of developing multiple sclerosis. In many patients, the presence of a specific antigen was revealed, which confirms the theory of defects in the genotype and susceptibility to the appearance of multiple sclerosis.

With a combination of the above conditions, the development of the disease requires a determining factor - a failure in the immune system, causing an inadequate response of one's own immune cells that damage the myelin sheath.

The following conditions contribute to the occurrence of sclerosis:

• Living in cold latitudes (lack of vitamin D).
• Hormonal disruptions, other autoimmune diseases.
• Exposure to radiation.
• Irrational nutrition.
• Stress.
• Vaccination against hepatitis B.
• Decrease in the level of urates in the body below normal.

Species classification

There are several forms of multiple sclerosis, depending on the area of ​​predominance of lesions of nerve cells:

• Spino-cerebellar.
• Stem.
• Cerebrospinal (most common).
• Optical, or Devic's disease (damage to the optic nerve and spinal cord).

According to the type of course, 4 types of the disease are distinguished:

• Remitting-relapsing (exacerbation of sclerosis is replaced by partial remission, no progression is observed between episodes).
• Primary progressive (the patient's condition gradually but steadily worsens).
• Secondary progressive (after a long remitting course, the disease progresses).

Symptoms and signs

The clinical picture of the disease in patients can vary greatly, due to the zone of localization of foci of demyelination.

At the initial stage, in the presence of a small amount of sclerotic scars, the disease can go unnoticed for a long time.

The most common symptoms of multiple sclerosis are:

• weakness of the lower extremities, partial paralysis;
• paresis of the arm and leg on the right or left side of the body;
• increased tendon, decreased plantar, abdominal reflexes;
• gait disturbances (swaying, unsteadiness, shuffling of the feet);
• decrease in pain sensitivity;
• heaviness in the legs, fatigue;
• hand trembling;
• burning in the fingers of the limbs;
• inability to hold the head straight, neck tremor;
• muscle atrophy, pain in the joints;
• lack of coordination;
• headache, discomfort in the spine, in the region of the ribs;
• subfebrile body temperature.

With damage to the optic nerve, complete or partial loss of vision, pain and clouding in the eyes, doubling of objects, nystagmus (the impossibility of full movement of the eyeball) can develop.

Cerebellar sclerosis leads to difficulty breathing, speech disorders (choppiness of words), urinary retention, fecal incontinence, impotence, lack of sexual desire.

Plaques localized on the intracranial nerves cause edema and atrophy, neuritis of the optic and facial nerves, changes in the visual field, numbness of the face, pain in the forehead, cheekbones, dizziness, darkening in the eyes. The defeat of the peripheral spinal nerves is characterized by a decrease in intelligence and memory, self-criticism, concentration of attention, the development of mental disorders (depression, euphoria, apathy, anger, hysteria, and sometimes phobias, manic seizures), convulsions.

Symptoms of the disease can be aggravated after visiting a bath, a hot bath, in hot weather, with infections accompanied by fever.

The consequences of the disease for humans

The disease is characterized by a long course with a temporary reversibility of the symptom complex. In advanced cases, remissions are observed less and less, signs of the disease are persistent and pronounced. Most often, multiple sclerosis progresses steadily, often flowing from a milder form to a severe one. Relapses tend to be more difficult, leading to new symptoms.

Late stages of sclerosis, in the absence of therapy, cause serious violations of body movements, sometimes - the inability to perform the simplest of them.

Such patients are completely dependent on others. Disability can occur 2-30 years after the onset of the first symptoms. The cause of death is more often complications and concomitant diseases caused by inadequate functioning of certain organs: uro-sepsis, pneumonia, renal failure, pyelonephritis. A great danger is the formation of sclerotic plaques on the vagus nerve and its branches, as well as severe damage to the spinal nerves with an acute progressive course of sclerosis, which can cause the death of the patient.

How long do people live with multiple sclerosis?

Survival prognosis: about a quarter of patients die within 25 years from the onset of the disease. Up to 50% of people retain their ability to work for a long time, up to 70% - the ability to move without assistance. During remissions, patients lead a normal life.

Multiple sclerosis and pregnancy

The unpredictability of the course of the disease can complicate the period of gestation. However, multiple sclerosis is not a contraindication to pregnancy.

It is proved that the disease weakens its severity during gestation, its progression slows down. On the contrary, the first 3 months after childbirth is the time of greatest risk of exacerbation, therefore future mom even before conception, she should evaluate the possibility of assistance from relatives in caring for the child, as well as find out methods for preventing relapse during pregnancy, the effect of drugs for sclerosis on the fetus. Most often, drug therapy for the disease is canceled 6 months before conception.

Diagnostics

Examination and diagnosis is carried out by a neurologist.

From laboratory methods research apply:

• puncture of cerebrospinal fluid;
• blood test for the content of total immunoglobulin.

Instrumental diagnosis of multiple sclerosis includes:

• measurement of visual and auditory potentials;
• CT or MRI of the brain.

Differentiate the disease with brain tumors, infectious lesions nervous system, Behcet's disease, adrenoleukodystrophy, systemic lupus erythematosus, vasculitis, vitamin B12 deficiency, sarcoidosis, cerebral infarction.

With exacerbations, the patient is placed in a hospital. The rest of the time, the person is treated on an outpatient basis.

Specific therapy for multiple sclerosis is not used in all medical institutions and does not affect the primary progressive course of the disease. There are drugs that can slow down the dysfunction of nerve fibers: beta-interferons (avonex, betaferon), amino acid polymers (copaxone), monoclonal antibodies (tysabri), cytostatics (mitoxantrone). All drugs have many side effects and are expensive, so they are not widely used in the treatment of sclerosis. Interferons can be prescribed in prophylactic dosages.

Symptomatic therapy is selected individually, aimed at reducing the severity of the clinical picture, as well as treating complications, and includes:

• Suppression of the mechanisms of autoallergy during an exacerbation: immunosuppressants - corticosteroid drugs (prednisolone, dexamethasone), cytostatics (cyclophosphamide, azathioprine, methotrexate). In severe cases - pulse therapy with methylprednisolone.
• Antihistamines (tavegil, suprastin, pipolfen, diphenhydramine).
• Metabolism activation drugs and neuroprotectors (cerebrolysin, actovegin, pyriditol, B vitamins, glycine, nicotinic acid, methionine, linetol, levocarnitine).
• Means for improving the condition of blood vessels (pentoxifylline, cinnarizine, rutin, vitamin C, calcium chloride).
• With severe mental disorders - psychotropic drugs, tranquilizers, antidepressants.
• To relieve spasm and increased muscle tone - muscle relaxants (baclofen, listenone, akatinol, midokalm, sirdalud).
• In order to reduce pain - NSAIDs (ketorolac, ibuprofen, diclofenac, imipramine).
• In case of urination disorders - catheterization, drugs - propaneline, oxybutynin, adrenoblockers.
• With severe fatigue - neuromidin, amantadine.
• During remission - immunomodulators (amiksin, cycloferon).
• Of the physiotherapeutic measures, ozokerite applications, inductothermy, electrosleep, muscle myostimulation, and massage are used.
• Procedures for blood transfusion, plasmapheresis, the introduction of autovaccines and autosera have proven themselves positively.
• With the ineffectiveness of drug treatment and the development of paralysis of both limbs, surgical intervention is used - rhizotomy (transection of the anterior nerve roots). Partial paralysis may persist, but the function of the pelvic organs and muscles improves.

Experimental approaches to the treatment of multiple sclerosis are aimed at the use of high doses of immunosuppressive agents followed by stem cell transplantation.

Among young patients, this method can significantly slow down the course of the disease, and in some cases completely prevent relapses.

All patients with multiple sclerosis should undergo medical examination, including MRI of the head and spinal cord, immunogram, electromyography, once a year, and examination by an ophthalmologist and urologist - 2-3 times a year.

As a rehabilitation measure, it is necessary to carry out physical exercise with a light load, massage of the muscles of the back, limbs, regularly undergo reflexology courses, general strengthening spa treatment, eat rationally with the consumption of a large amount of vitamin food.

Relatives of the patient should provide him with emotional support, help with social adaptation. Proper care of bedridden patients can significantly prolong their lives.

Treatment with folk remedies

Folk recipes will help improve memory, increase motor activity, reduce pain:

• Fill a jar (1 l.) with red clover inflorescences. Pour a bottle of vodka, leave for 2 weeks. Drink at bedtime 1 spoonful, course - 3 months.
• Take propolis tincture in this way: 30 min. before meals, 20 drops. Every day you need to drink the remedy 3 times, the course of therapy is up to 4 months.
• In the same mode as in the previous recipe, consume a mixture of 10 drops of royal jelly with 1 tsp. honey. After 10 days, a break is made (for 2 weeks), then the course is repeated.
• It will be useful to drink an infusion of ginkgo biloba leaves (1 liter per glass of water) for a month.
• To restore muscles, baths are taken with an infusion of spruce, larch, and cedar needles.

Prevention

Specific preventive measures have not been developed. People with a predisposition to allergies, weak immunity are recommended:

1. Avoid stress, overwork (mental, physical).
2. Prevent infectious diseases.
3. Do not overheat or overcool.
4. Lead a healthy, active lifestyle.
5. Rule out head and back injuries.
6. Eat right, boost your immune system.

Sclerosis of the vessels of the lower extremities is one of the most dangerous pathologies of the arteries of the legs. This disease is characterized by clogging of blood vessels with plaques or blood clots, which leads to a serious violation of blood flow.

Risk factors

All risk factors for the development of pathology can be divided into two broad categories - non-modifiable and modifiable.

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The first group includes causes that are not amenable to human influence:

There are also modifiable factors, the exclusion of which is effective way prevention of this pathology:

• high cholesterol in the blood;
• the presence of diabetes;
• problems with blood clotting;
• arterial hypertension;
• insufficient physical activity;
• being overweight.

Causes

The main reason for the development of atherosclerosis of the legs is smoking. The fact is that nicotine provokes spasms of the arteries, which prevents the flow of blood through the vessels. As a result, the risk of blood clots increases.

Also, the reasons for the development of sclerosis of the vessels of the legs include the following:

• frequent consumption of foods containing animal fats;
• increased blood pressure;
• obesity;
• hypodynamia;
• excessive alcohol consumption;
• frequent stressful situations.

Symptoms

The main symptom of this disease is pain that occurs in the lower extremities. In most cases, discomfort appears in the thigh and calf muscles during movement. The fact is that when walking, the need for blood supply increases.

During physical exertion, narrowed arteries cannot provide enough blood, which leads to oxygen starvation.

It is precisely because of this that severe pain. At an early stage in the development of the disease, discomfort disappears rather quickly, but subsequently reappears after exertion.

In addition to muscle pain, there are such symptoms of sclerosis of the vessels of the lower extremities:

1. Numbness and feeling of chilliness in the feet. These symptoms may be exacerbated by walking and other physical activities.
2. Darkening of the skin on the fingers and soles of the feet.
3. Pain in the legs due to lack of exercise.
4. Different limb temperatures. A leg affected by atherosclerosis, as a rule, is slightly cooler than a healthy one.
5. The appearance of non-healing sores and wounds in the area of ​​​​the foot and lower leg.
6. Absence of pulse on the arteries of the legs - on the thigh, in the popliteal fossa, behind the inner ankle.

If multiple sclerosis of the leg develops, weakness occurs in the muscle tissue of the lower limb. There may also be problems with coordination of movements, unsteadiness of gait, impaired skin sensitivity.

Diagnostics

If symptoms of sclerosis of the vessels of the legs appear, you need to undergo a complete examination of the body - this will allow the specialist to make an accurate diagnosis. This disease is diagnosed during a detailed examination by a surgeon.

To confirm the pathology, it can be prescribed ultrasound procedure and radiography.

the most reliable diagnostic method is considered to be angiography, which is performed using a computer.

Also, to detect sclerosis of the vessels of the legs, such studies are used:

1. blood test for cholesterol;
2. blood sugar test;
3. study of blood clotting;
4. Analysis of urine.

The main indicator that is taken into account when making a diagnosis is the content of lipids in the blood.

stages

All symptoms of this disease can be divided into several stages:

Treatment of sclerosis of vessels of the lower extremities

The treatment regimen should be chosen by the doctor, taking into account the characteristics of the patient's body. The tactics of therapy depend on the stage of sclerosis, its duration and the level of vascular damage. It is also necessary to take into account concomitant human diseases.

If sclerosis was detected at an early stage, it is enough to eliminate risk factors and normalize lifestyle.

In this case, you need:

• give up smoking and other bad habits;
• adhere to a diet with a minimum content of animal fats;
• in the presence of excess weight, it is necessary to take measures to correct it;
• maintain normal blood pressure;
• exercise regularly - walking, swimming, exercising on an exercise bike are perfect;
• in the presence of diabetes, control blood sugar levels.

If sclerosis of the vessels of the legs was detected at other stages, the doctor may choose conservative, surgical or endovascular treatment.

conservative	This method of therapy can be used in the early stages of the disease. It is also prescribed in cases where a person's condition does not allow the use of other methods. Conservative treatment consists of the use of drugs and physiotherapy. It also includes physiotherapy exercises and pneumopressotherapy. Currently, there are no medications that can completely restore blood circulation in a clogged artery and completely get rid of atherosclerosis. Conservative treatment can only affect small vessels. Thanks to the use of drugs, it is possible to compensate for the lack of blood supply. To eliminate spasm of small vessels, provide blood thinning and protect the walls of the arteries from subsequent damage, you can use special medications. Some of them must be taken in courses, while others must be drunk constantly. In addition, the doctor may prescribe pneumopressotherapy, which consists in tissue massage with special devices. Due to the alternation of low and high pressure it is possible to expand the peripheral arteries, ensure blood flow to the muscles and skin, and stimulate the work of blood vessels.
Endovascular	Most often, endovascular methods are used to treat this disease. These include: angioplasty; balloon dilatation; arterial stenting. With the help of such methods, it is possible to restore normal blood circulation without resorting to surgical intervention. Such procedures are carried out with the help of special devices. After that, a pressure bandage is applied to the lower limb. For 12-18 hours, the patient must adhere to bed rest.
Surgical	If the areas of clogged arteries are long and endovascular methods cannot be applied, then normal blood circulation can be restored only with the help of surgery: Prosthetics - carried out using an artificial vessel. Thrombendarterectomy - is to remove the plaque from the broken vessel. Bypass - involves the redirection of blood through an artificial vessel. The role of the shunt can be performed by a section of the human saphenous vein. The operation often has to be supplemented with other procedures. If the intervention is performed at the fourth stage of the pathology, and there are serious consequences of sclerosis of the veins of the lower extremities, it is necessary to remove dead areas and close trophic ulcers patches of skin. With the development of gangrene, the leg is amputated. In some cases, this measure is the only way to save a person's life.
Folk remedies	A good method of preventing the development of sclerosis and cleansing blood vessels is the use of folk remedies. These include the following: Add 200 ml of vodka to 50 g of minced garlic and leave to infuse for a week in a dark place. Periodically, the composition must be shaken. The resulting product should be taken 10 drops 3 times a day, dissolving it in a teaspoon of water. After two months, the treatment must be repeated. In equal parts, mix chestnut and lemon balm flowers, adonis and trefoil grass, fennel fruits. Take a tablespoon of the resulting composition, pour 200 ml of boiling water and leave to infuse for three hours in a thermos. Take a third of a glass thirty minutes after eating for a month, then take a break for a week and repeat the course again. In equal proportions, mix raspberry leaves, strawberries and hawthorn fruits. Pour a couple of tablespoons of the mixture with 0.5 liters of water and put in a water bath for half an hour. Take half a glass of the resulting broth 3-4 times a day thirty minutes before meals; course of treatment - three months.

As an auxiliary method of treatment, hirudotherapy can be used. The use of leeches thins the blood, eliminates pain and has an anti-inflammatory effect.

In addition, due to the decrease in the amount of circulating blood in the body, hirudotherapy can lower blood pressure.

Prevention

To prevent the development of the disease, only three preventive measures are enough.

They include:

1. to give up smoking;
2. physical exercise;
3. proper nutrition with a decrease in the amount of animal fats in the diet.

At the same time, it is not at all necessary to exhaust yourself with serious physical exertion - it is quite enough to walk every day and do exercises for the legs.

In addition, to prevent sclerosis of the vessels of the extremities, you can do acupressure and use traditional medicine.

Nutrition

Successful treatment of the disease is impossible without proper nutrition. With atherosclerosis of the vessels of the legs, it is very important to exclude or limit the consumption of foods high in animal fats as much as possible. These include butter, cheese, sour cream, eggs.

At the same time, it is worth consuming a lot of vegetables and fruits, which contribute to the removal of cholesterol from the body. If a person has excess weight, you need to follow a sub-calorie diet and limit the amount of salt, sugar and animal fats.

With the development of sclerosis of the vessels of the lower extremities, it is worth eating at least 100 g of fresh or sauerkraut. You can add berries to it - blueberries, sea buckthorn, chokeberry. It is also very useful to use onion and garlic.

Sclerosis of the vessels of the legs is considered a very dangerous disease, which is accompanied by extremely unpleasant symptoms and can lead to serious health consequences. To prevent this from happening, it is very important to consult a doctor in a timely manner, who will select an effective treatment.

Clinical picture(signs and symptoms). Multiple sclerosis usually begins at the age of 18-35, but sometimes before 18 (12-16) and after 40 years. In a significant proportion of cases, the disease begins with movement disorders: when walking, patients stumble, cling toes, fall; these phenomena can occur during long walking, during pregnancy, after childbirth or any infectious diseases. Weakness in the hands is observed less frequently, mainly in the later periods of the disease. Often the first symptoms are paresthesias in the limbs and trunk in the form of a feeling of numbness, crawling; the legs become like “wooden”, like “prostheses”, there is a feeling of coldness in the fingers and toes, sometimes a feeling of a kind of electric current (A. V. Triumfov) in the hands and feet. Possible headache, pain in the arms and legs, tightness in the torso; often these initial phenomena are misdiagnosed as sciatica, rheumatism, etc. Sometimes multiple sclerosis begins with unsteady gait, quite often with damage to the cranial nerves, especially the second pair suffers [transient blindness, decreased vision, scotomas (retrobulbar neuritis)], often VI, less often III pair (diplopia suddenly appears). The disease can begin with vestibular phenomena (dizziness, nystagmus, vomiting), which is usually regarded as labyrinthitis or Meniere's symptom complex. Sometimes the disease begins with peripheral paralysis of the VII pair. The bulbar nerves are rarely affected. Sometimes the initial symptoms are pelvic disorders (urinary and fecal incontinence). Initial symptoms are unstable, may disappear quickly, sometimes intensify or occur with a new outbreak.

In the future, the clinical picture most often consists of symptoms that characterize the defeat of mainly pyramidal, cerebellar, less often sensitive pathways, individual cranial nerves and sphincter disorders. Paresis of the extremities gradually increases and passes in the final stages of the process into para- and tetraplegia with pronounced spastic hypertension. All types of sensitivity are affected, more often by the radiculoneuritic type (A. B. Rogover), less often by conduction, especially rarely by Brownsekar and segmental. Vibration sensitivity and deep muscle feeling are often disturbed (more often on the legs than on the hands); often patients complain of headache, pain in the spine, joints. If the onset of the disease is characterized by damage to the II pair of cranial nerves in the form of retrobulbar neuritis, there are still no changes at the bottom of the eye and restoration of vision is possible, then in the further course, in some cases, there is a decrease in vision, narrowing of the visual fields to red and green color, sometimes scotomas, complete or partial atrophy of the temporal halves of the optic discs. Paleness of the temporal halves of the optic discs can not always be considered pathognomonic for multiple sclerosis, since it also occurs with optochiasmal arachnoiditis and other forms, and sometimes is physiological.

The defeat of the vestibular nerve in multiple sclerosis is expressed in dizziness, unsteadiness, a feeling of failure, nystagmus. Less often than the vestibular nerve, the cochlear nerve suffers; at the same time transient deafness is observed.

Tendon reflexes in most cases are increased both on the lower and upper extremities.

Depending on the predominance of cerebellar phenomena, as well as the addition of radicular disorders, both hypotension and a decrease in tendon reflexes are possible, and in rare cases their absence (lumbosacral and pseudotabetic forms).

One of the most common symptoms in multiple sclerosis is the absence or decrease in abdominal reflexes, sometimes observed in the very early stages of the process, when there is still no pronounced picture of multiple sclerosis. Decrease and loss of a cremaster reflex are less often noted. Of the pathological reflexes, the reflexes of Babinsky and Rossolimo are most often observed. For long-term cases with deep spastic paresis, all extensor and flexor pathological reflexes are characteristic. From coordinating disorders to the most common symptoms of multiple sclerosis. Charcot attributed nystagmus, intentional trembling, and scrambled speech (Charcot's triad). However, the whole triad is not always present in the picture of multiple sclerosis. Especially often observed nystagmus (horizontal, vertical or rotatory), it can occur both in the earliest period of the disease, and during it, sometimes disappear, and then reappear.

Intentional trembling is often noted, in advanced cases, along with it, ataxia in the arms and legs, adiadochokinesis, and handwriting disorder are observed. Trembling is more often expressed in the arms and legs, less often in the trunk and head.

Often there is atactic gait, less often a symptom of Romberg. Speech is slow, abrupt, with the disintegration of words into compound syllables; scanned speech is less common. Rare in the clinical picture of hyperkinesis, although the pathological anatomical examination finds a lesion of the striopallidar system. Sometimes with multiple sclerosis, violent laughter and crying are noted. In 70-80% of cases, there is a disorder of the sphincters (incontinence or difficulty urinating, imperative urge, constipation). In long-term cases, sexual weakness, menstrual disorders are noted. Trophic disorders in the form of mild, sometimes diffuse atrophy of the muscles of the extremities, trunk with a small quantitative decrease in electrical excitability are rare. More severe atrophies are observed in the final stages.

Mental disorders are characterized by euphoria, varying degrees decrease in intelligence (decrease in criticism, memory, initiative), changes in the emotional sphere.

Changes in the cerebrospinal fluid in multiple sclerosis are observed in 25-60% of cases: a slight increase in pressure, an increase in the amount of protein (0.4-0.6%, rarely more), positive globulin reactions, slight lymphocytosis (15-20 cells per 1 mm 3 , rarely more), in a significant percentage of cases, a positive colloid reaction (like the reaction in progressive paralysis, syphilis of the brain). A number of authors point to an increase in the globulin fraction of the protein in the cerebrospinal fluid, obtained by electrophoresis on paper.

With multiple sclerosis, the temperature may rise to subfebrile, and leukocytosis is sometimes observed. There are data indicating a violation of the antitoxic function of the liver, a change in the content of albumins and globulins in the blood serum and the albumin-globulin coefficient, a shift in the Veltman coagulation tape (see Veltman coagulation tape), fluctuations in the content of cholesterol, inorganic phosphorus, copper, etc. According to M. M. Korina, the lability of these changes allows us to consider them as secondary, due to violations of the correlative activity of the nervous system.

The following forms of multiple sclerosis are distinguished: cerebral (spinal phenomena are not very pronounced), spinal and cerebrospinal. In cerebral forms, hemiparesis, vestibular phenomena, symptoms of damage to the pons (paresis of the VI, VII pairs of cranial nerves), stem-cerebellar disorders (less often purely cerebellar) are observed. Spinal forms occur with paraparesis, paraplegia, sensitivity disorder and sphincter function.

Some authors deny purely spinal forms of multiple sclerosis and indicate that with a carefully collected anamnesis, it is possible to establish attacks of dizziness, diplopia and other cerebral phenomena in the past. In the final stages, the disease in most cases proceeds according to the cerebrospinal type, and the pathoanatomical picture also corresponds to this (many plaques in the brain and spinal cord).

The course of multiple sclerosis is chronic, progressive, with exacerbations and remissions. Acute, subacute and chronic course and stationary forms are described, which refers to cases with long-term remissions. New outbreaks occur after any infection, trauma, during pregnancy, after childbirth and other debilitating moments.

The absence of remissions is observed in 10-40% of cases (Ferraro); according to Putnam, remissions occur in 44% of fresh cases. Remissions can last from several months to several years (2-4 years). The first remission is always longer than subsequent ones; the longer the course of the disease, the rarer and shorter the remission.

The duration of the course of multiple sclerosis varies, according to different authors, from 2 to 35 years. Death occurs (with the exception of acute cases occurring with bulbar phenomena) from joining intercurrent diseases (pneumonia, typhoid, etc.), urosepsis and sepsis caused by extensive bedsores.

Symptoms of multiple sclerosis. Typical and atypical symptoms of multiple sclerosis. forms of multiple sclerosis. Variants of the course of multiple sclerosis. Stages of multiple sclerosis. Prognosis for multiple sclerosis.

Retrobulbar neuritis in multiple sclerosis

A wide range of visual disorders in multiple sclerosis is due to possible damage to the visual analyzer at different levels.

most common cause visual impairment in multiple sclerosis is retrobulbar neuritis, which accompanies the onset of multiple sclerosis in 30% of cases, in 17% is the only manifest sign of multiple sclerosis, and throughout the course of the disease at different periods is observed in 75% of patients with multiple sclerosis. Back in 1890, the German ophthalmologist V. Uhthoff noted the frequent involvement of the optic nerve in the pathological process in multiple sclerosis, which manifests itself in visual impairment when taking a hot bath, eating hot food, with fatigue, and emotional stress.

The involvement of this particular nerve in the pathological process in multiple sclerosis is explained by the fact that it is, as it were, a “process” of the brain. The source of myelin in the axons of retinal ganglion cells is oligodendrocytes, not Schwann cells (unlike the myelin sheaths of other cranial and peripheral nerves). Therefore, the myelin sheath of the optic nerve is identical to the myelin of the CNS. In the foci located in the optic nerve and chiasm, one can see the same changes as in the foci located in the brain and spinal cord.

The commonality of retrobulbar neuritis and multiple sclerosis is also indicated by data indicating characteristic for multiple sclerosis violation of the synthesis of myelin phospholipids in oligodendrocytes of the optic nerve, noted in all cases of retrobulbar neuritis.

The processes of demyelination in retrobulbar neuritis, as well as in multiple sclerosis, are accompanied by changes in the axon cytoskeleton.

Typically, retrobulbar neuritis in multiple sclerosis begins with a violation of the central visual field, progressing from slight to severe visual impairment or, rarely, to complete blindness.

At the first appearance of optic neuritis, brain stem symptoms, or acute myelitis, MPT data are of prognostic value. If multiple lesions are detected on T2-weighted brain images, the probability of developing multiple sclerosis within 5 years is 50-65%; otherwise, the likelihood of developing multiple sclerosis is reduced to 5%.

In mild cases, a patient with multiple sclerosis complains that the affected eye sees the surroundings less brightly. Visual impairment in multiple sclerosis is usually unilateral, but the optic nerve can be affected on both sides.

Often with multiple sclerosis, there is pain in the orbit or above it, aggravated by eye movements. Such pain may precede visual impairment.

Routine examination may reveal decreased visual acuity and scotoma.

After the acuity of the process in the optic nerve subsides - a few weeks after the onset of the disease - the restoration of vision usually begins, and in 77% of cases of the first attack of retrobulbar neuritis in multiple sclerosis after 3-6 months. vision is fully restored.

Paleness of the optic disc is often detected after an exacerbation of multiple sclerosis. (sign of optic nerve atrophy).

Most often, after several attacks of retrobulbar neuritis due to multiple sclerosis, vision is reduced to varying degrees, but blindness rarely develops.

It is also impossible to predict with certainty whether other manifestations of multiple sclerosis will develop after the first attack of retrobulbar neuritis.

The probability of developing a typical picture of multiple sclerosis after the first transferred retrobulbar neuritis varies, according to different authors, from 13 to 85%. Most often, after retrobulbar neuritis, multiple sclerosis develops in the first 3-5 years, but there are cases of its development after 35-40 years.

Many authors believe that all patients with isolated retrobulbar neuritis of unclear etiology can be considered as patients with multiple sclerosis, and with a careful examination of the anamnesis, many of them can find signs of transient symptoms of damage to the central nervous system.

Subclinical damage to the optic nerve occurs quite often in multiple sclerosis - in 45-65% of cases. Even in the absence of acute retrobulbar neuritis, many patients with multiple sclerosis can detect impaired visual acuity, visual contrast sensitivity, subclinical visual field defects, impaired color vision or pupillary reflexes, and changes in visual evoked potentials.

Visual impairment in multiple sclerosis can be caused not only by optic neuritis, but also by diplopia. Diplopia in multiple sclerosis is usually due to internuclear ophthalmoplegia or damage to the abducens nerve, less often the oculomotor or trochlear nerves suffer.

Oculomotor and pupillary disorders in multiple sclerosis

The classic oculomotor disorders in multiple sclerosis are nystagmus and internuclear ophthalmoplegia.

Monocular nystagmus is an almost pathognomonic sign of multiple sclerosis. Eye movement disorders, leading to double vision, occur in every 10th patient at the onset of multiple sclerosis, and every 3rd in the further course of multiple sclerosis.

Internuclear ophthalmoplegia in multiple sclerosis, it occurs when the fibers of the medial longitudinal bundle are damaged, connecting the nuclei of the abducens nerve and the opposite nuclei of the oculomotor nerve. When you try to look sideways on the side of the lesion, adduction of the eye is disturbed or absent, and nystagmus occurs on the opposite side. Convergence, in contrast to paralysis of the medial rectus muscle, is preserved. With bilateral internuclear ophthalmoplegia in a patient without impaired consciousness, it is necessary to suspect, first of all, multiple sclerosis.

Often, oculomotor disorders in multiple sclerosis are represented by a violation of saccadic (rapid) eye movements (gaze dysmetria, a delay in the onset and a decrease in the speed of movements), a violation of tracking eye movements in the form of advancing or lagging behind a moving object, a violation of gaze fixation (the appearance of involuntary excessive eye movements during fixation on a stationary object).

binocular nystagmus observed in 40 - 60% of patients with multiple sclerosis.

Horizontal, "cerebellar" nystagmus - most characteristic of multiple sclerosis. This type of nystagmus occurs with active eye movements.

Positional nystagmus "central type" - can also be early symptom multiple sclerosis and is associated with the development of lesions in the brain stem or cerebellum. Central positional nystagmus in multiple sclerosis, which also occurs when the position of the head changes, can be both horizontal and vertical, and rotatory.

Converging nystagmus - occurs in multiple sclerosis in case of damage to the midbrain. It is usually combined with paresis of the upward gaze - Parino's syndrome.

The most common pupillary disorder in multiple sclerosis is the presence of an afferent pupil - the pupil of Marcus Gunn.

The difference in the size of the pupils in multiple sclerosis is rare. It is known that approximately 30% of healthy people have essential (physiological) anisocoria. It is she who in most cases is the cause of the difference in the size of the pupils in multiple sclerosis, and such efferent pupillary disorders as Horner's and Argyle Robertson's syndromes are extremely rare. The rarity of efferent pupillary disorders in multiple sclerosis is probably due to the preservation of autonomic fibers in the CNS, since they are poorly myelinated or not myelinated at all.

Movement disorders in multiple sclerosis

The most common movement disorders in multiple sclerosis are:

• spasticity,
• muscle weakness,
• cerebellar and sensitive ataxia.

Spasticity in multiple sclerosis

An increase in spastic muscle tone is the most common and most disabling symptom of multiple sclerosis, which is observed in 90% of patients. Spasticity in multiple sclerosis is a consequence of demyelination of the descending corticospinal, vestibulospinal, and reticulospinal tracts.

Clinically, spasticity in multiple sclerosis is manifested by a violation of active movements and uncontrolled painful flexor spasms (usually in advanced stages of multiple sclerosis). Rarely seen in multiple sclerosis extensor spasms, which, unlike flexor, can also occur at an early stage of multiple sclerosis. And although they are painless, they often occur at night, disturbing the sleep of patients and increasing general maladjustment.

Spasticity in multiple sclerosis often more difficult to move than actually muscle weakness.

But often with significant paresis - an increase in tone in the extensors of the legs compensates for weakness in them and retains the ability to move. In multiple sclerosis, muscle tone is more elevated in the legs than in the arms.

Muscle tone is further enhanced by cooling and a full bladder. Such dynamism of muscle tone in multiple sclerosis, the connection of its fluctuations with afferent influences are due to the involvement in the pathological process of descending cerebrospinal tracts that regulate the activity of peripheral α- and γ-motor neurons. Over time increased tone in the flexor muscle groups can lead to the formation of contractures.

Muscle weakness in multiple sclerosis

The most characteristic type of movement disorders in multiple sclerosis is lower spastic paraparesis. Less often, weakness develops in one leg or in the leg and arm on the same side. The defeat of only one hand in multiple sclerosis is extremely rare.

Movement disorders increase gradually, the rapid development of motor dysfunction is not typical for the onset of multiple sclerosis. As a rule, patients with multiple sclerosis initially feel only increased fatigue, which over time transforms into permanent muscle weakness. The sudden development of paresis forces differential diagnosis with vascular disorders.

An increase in temperature, which exacerbates all manifestations of multiple sclerosis, especially significantly affects the degree of paresis. An increase in body temperature even by 0.5°C causes a temporary conduction block in partially demyelinated CNS conductors. As a result, summer heat, a hot bath, even hot food, hyperthermia accompanying any disease, and intense physical exercise in multiple sclerosis lead to a significant increase in muscle weakness. The increase in muscle weakness, as well as the possible aggravation of other symptoms of multiple sclerosis (ataxia, visual impairment, etc.) against the background of an increase in body temperature is so characteristic that the “hot bath symptom” serves as an important diagnostic criterion for this disease.

Cerebellar injury in multiple sclerosis

With damage to the cerebellum develop:

• abasia (loss of ability to walk)
• ataxia (disorder of coordination of voluntary movements)
• dysarthria (scanded speech) - develops in severe cases of multiple sclerosis

Often, the severity of cerebellar disorders against the background of sensory and motor disorders is difficult to assess.

Cerebellar ataxia in multiple sclerosis

cerebellar ataxia, which most often develops in combination with spasticity, further aggravates the disability of a patient with multiple sclerosis. Isolated cerebellar syndrome is rare in multiple sclerosis, and in the debut of multiple sclerosis is observed only in isolated cases (and in such cases, usually a poor prognostic factor). However, the symptoms of cerebellar damage in the structure of multifocal damage to the nervous system are quite frequent, they are known to be included in the well-known Charcot triad (intentional tremor, nystagmus, scanned speech) and Marburg's pentad (blanching of the temporal halves of the optic discs, prolapse of abdominal reflexes, intentional tremor, nystagmus, slurred speech).

Cerebellar ataxia with multiple sclerosis, it manifests itself:

• gait disorder,
• dysmetria (impaired coordination of movements due to loss of a sense of distance, proportionality and accuracy of motor acts),
• dyssynergy (impaired friendly movements) and
• dysdiadochokinesis (awkward execution of fast alternating movements),
• intentional and postural tremor of the extremities,
• as well as titubation - postural tremor in the vertical position of the head and trunk.

A characteristic feature of multiple sclerosis is action - postural and intentional - tremor. In 24% of patients with multiple sclerosis, trembling is the main disabling factor. Resting tremor is very rare and occurs in less than 1% of cases.

Intention tremor often has a synonym - cerebellar. However, in multiple sclerosis, its presence and severity often correlate with the degree of focal changes in the contralateral parts of the pons. Like ataxia, tremor can also significantly limit the motor activity of a patient with multiple sclerosis, sometimes up to the loss of the ability to self-care.

Trembling in multiple sclerosis can involve the head, neck, vocal cords, trunk, and extremities. Tremor of the tongue and lower jaw does not occur. Intentional tremor in multiple sclerosis has a frequency of 5-7 Hz and occurs in a plane perpendicular to the direction of movement. The pathophysiology of tremor in multiple sclerosis has not been fully elucidated. Its occurrence is associated with damage to the efferent hemispheric-cerebellar and cerebellar-spinal tracts. A certain role in the genesis of tremor in multiple sclerosis is also played by the ventral intermedial nucleus of the optic tubercle, stereotaxic destruction of which leads to a decrease in jitter.

cerebellar dysarthria, which is a manifestation of intentional trembling of the vocal and speech muscles, can reach such a degree of severity in multiple sclerosis that it makes the patient's speech absolutely incomprehensible. Another characteristic variant of dysarthria is "scanned" speech, which, in fact, is a manifestation of dyssynergy.

In multiple sclerosis, it also occurs intentional myoclonus, in which any movement and attempt to make it causes uncontrolled rapid myoclonic movements in all limbs and trunk. The occurrence of intentional myoclonus is associated with a violation of the connections between the dentate nucleus of the cerebellum, the red nuclei and the inferior olive (Mollare's triangle).

Often seen in multiple sclerosis blepharoclonus - constant, short, low-amplitude, rhythmic contraction of the circular muscle of the eye. Usually it is observed with a slight covering of the eyes and is suppressed by closing the eyes. In addition to multiple sclerosis, blepharoclonus can also be observed in severe traumatic brain injury, stenosis of the Sylvian aqueduct, Arnold-Chiari malformation.

Discoordination when walking in most cases, with multiple sclerosis, it is combined with an increase in muscle tone (due to simultaneous damage to the pyramidal tract), and the spastic-atactic gait is the most characteristic of these patients.

In many patients with multiple sclerosis, ataxia is mixed - cerebellar-sensitive, since Gaulle's bundles in the posterior cords of the spinal cord often undergo demyelination, and therefore walking at night and when closing the eyes is especially difficult.

In the advanced stage of multiple sclerosis, large numbers cases are observed coordination disorders and in the hands. In the onset of multiple sclerosis, cerebellar ataxia in the hands alone is rare, and patients' frequent complaints of clumsy hands are usually due to deep sensory impairment rather than cerebellar pathology.

Multiple sclerosis may develop pseudobulbar syndrome: dysarthria, dysphonia, dysphagia, accompanied by a revival of the mandibular and pharyngeal reflexes and pathological laughter and / or crying.

pseudobulbar syndrome, as a rule, it develops at a late stage of multiple sclerosis, with a fairly high prevalence of focal brain damage with bilateral involvement of the corticobulbar tracts.

Swallowing disorders

Dysphagia in multiple sclerosis is rarely an isolated and pronounced symptom, but mild swallowing disorders in multiple sclerosis are quite common - 30-40% of patients with multiple sclerosis have dysphagia of varying severity, while half of the patients do not complain of swallowing disorders.

Sensory disturbances and pain syndromes in multiple sclerosis

The most common symptom at the onset of multiple sclerosis and throughout the course of the disease are - sensitivity disorders, which occurs in 80 - 90% of all patients with multiple sclerosis.

In the early stages of multiple sclerosis, sensory disturbances are short-lived, lasting from a few hours to several days. As a rule, they are manifested by transient paresthesias in various parts of the body. Especially often in patients with multiple sclerosis, paresthesias occur in the fingertips, then spreading proximally. Sensory disturbances in multiple sclerosis can also be conductive in nature, however, a clear boundary of sensory disturbances and a complete loss of sensitivity are rare. Most often in multiple sclerosis, deep sensitivity suffers - at different stages of multiple sclerosis, the posterior cords of the spinal cord are affected in 85–95% of cases.

Quite rare, but very specific for multiple sclerosis afferent paresis of the hand- “useless hand syndrome”, “Oppenheim hand deafferentation syndrome”, which occurs when deep sensitivity is lost. It is the result of a lesion in multiple sclerosis of the lemniscal system or the posterior columns of the spinal cord at the upper cervical level.

"Useless Hand Syndrome" usually unilateral, but may involve both hands. Muscle strength remains normal. Permanent or long-term sensory disturbances are often described by patients with multiple sclerosis as "contraction", "cramps" of the muscles, a feeling that "the skin seems to have become small" or "a tight belt or corset is put on." If sensory disturbances are the only symptom of an exacerbation of multiple sclerosis, they usually go away on their own after 1–2 months.

Symptom of Lhermitte - the sensation of an electric current passing through the spine with irradiation to the legs or arms when the head is tilted - so characteristic of multiple sclerosis that it was previously considered pathognomonic for it. The symptom was first described in 1891 by J. Babinski and R. Dubois in a patient with a traumatic injury to the cervical spinal cord. F. Lhermitte in 1924 noted that it is much more common in patients with multiple sclerosis. Similar sensations in multiple sclerosis can also occur when coughing or laughing, tilting the head to the side, flexing the spine in the thoracic region, and even just walking on uneven surfaces. Usually this symptom disappears on its own after a few months, is not accompanied by pain and does not require treatment. The occurrence of Lermitte's symptom in multiple sclerosis is associated with demyelination of conductors of deep sensitivity in the posterior funiculi of the spinal cord.

Pain syndrome in multiple sclerosis

It was previously thought that pain was not a symptom characteristic of multiple sclerosis. However, more than half of patients with multiple sclerosis at a certain stage of the development of the disease experience pain, different in nature and intensity, and in 11% they are the first symptom of the disease. Pain is more common with the onset of multiple sclerosis in the elderly, in women and in chronic progressive course of multiple sclerosis. Often, pain occurs during an exacerbation of multiple sclerosis and can last for several months, leading to the development of depression and anxiety, which further exacerbates it. Similar chronic pain syndrome, according to different authors, occurs in 50-85% of cases of multiple sclerosis.

Based on the pathophysiological mechanisms of pain, pain syndromes in multiple sclerosis can be divided into neuropathic, somatogenic, viscerogenic and psychogenic.

neuropathic pain - make up the largest group in multiple sclerosis. Their development is due to foci of demyelination in the nervous system, which leads to changes in the functioning of ion channels in damaged axons, to the formation of ectopic foci of generation of nerve impulses. Neuropathic pain in multiple sclerosis may present with burning, dysesthesia, tingling, or pain in response to a non-painful stimulus (allodynia or hyperalgesia). Dysesthesias are the most common in multiple sclerosis.

Quite common in multiple sclerosis occurs - trigeminal neuralgia. 1-3% of patients with multiple sclerosis suffer from paroxysmal facial pain (about 2% of all patients with trigeminal neuralgia are patients with multiple sclerosis). This type of pain syndrome is 300 times more common in multiple sclerosis than in the general population. Unlike idiopathic trigeminal neuralgia, it can be bilateral and be accompanied by a decrease in sensitivity in the zone of nerve innervation (trigeminal neuropathy).

Somatogenic (nociceptive, visceral) pain in multiple sclerosis, they are caused by stimuli emanating from bones, muscles, connective tissue; they tend to be well localized. Similar pain in multiple sclerosis is usually described as sharp, throbbing, or aching. Their cause is damage that occurs, in particular, against the background of severe motor lesions, leading to hypomobility and deformity of the joints of the extremities and spine.

Viscerogenic pain in multiple sclerosis triggered by receptor activation Bladder and intestines in the development of pelvic disorders. As with other somatogenic pains, a neuropathic component may also be involved in their genesis. Among the viscerogenic pains, the most common are painful bladder spasms, which are manifested by intermittent pain in the pelvic region and may be accompanied by loss of urine.

Psychogenic pain in multiple sclerosis. Syndromic diagnosis psychogenic pain in multiple sclerosis, it is possible in the absence of their organic cause or when the behavioral response to pain is inadequate to the existing cause. In these cases, when examining a patient with multiple sclerosis, other mental disorders can often be found - depression, conversion symptoms, or sleep disturbances. In multiple sclerosis, the pathophysiological assessment of pain as psychogenic requires great care.

In a special subgroup allocate headaches in multiple sclerosis. They are very common, although their cause remains unclear. In multiple sclerosis, headaches are 3 times more common than in other neurological diseases. Occasionally, a headache can even be the first sign of developing multiple sclerosis or a harbinger of an exacerbation. Usually such pains have the character of tension headaches, and their intensity is not related to the activity of the disease. Possible reasons headaches in multiple sclerosis can be depressive and musculoskeletal disorders.

Patients with multiple sclerosis in the presence of chronic pain are more disabled and socially maladjusted than patients with a similar neurological defect, but without pain.

Dizziness in multiple sclerosis

In multiple sclerosis, dizziness with unsteadiness when walking and nausea, resembling acute labyrinthitis, can suddenly appear. These disorders in multiple sclerosis are the result of the occurrence of foci of inflammation and demyelination in the brain stem, and not in the vestibular apparatus.

Isolated systemic dizziness (without stem symptoms) as the first manifestation of multiple sclerosis is rare, and it is mistaken for a banal vestibulopathy. Meanwhile, an indication of the presence of an episode of systemic dizziness in history can help in establishing the diagnosis of multiple sclerosis and determining the time of onset of the disease.

The onset of the disease with dizziness is a relative sign of a rather favorable course of multiple sclerosis in the future. It should be noted that dizziness in idiopathic vestibulopathy is usually much more pronounced than in cases where it is a manifestation of multiple sclerosis. In the advanced stage of multiple sclerosis, dizziness is a fairly common symptom. It can be systemic and non-systemic, it can be paroxysmal positional in nature.

Pelvic Disorders in Multiple Sclerosis

Dysfunctions of the lower urinary tract in multiple sclerosis are observed, according to various authors, in 60-96% of patients.

The nature of urinary tract dysfunctions that occur in multiple sclerosis depends on the level of disorders. There are the following levels of violations:

• cerebral
• supracacral
• sacral

The cerebral level of disorders - damage to the center of urination - is characterized by a decrease or loss of control over urination, frequent urination, imperative urges, incontinence and urinary incontinence.

When the level of the lesion is localized in the cervical and thoracic spine, patients experience frequent difficult urination with a sluggish intermittent stream, a feeling of incomplete emptying of the bladder - detrusor-sphincter dyssynergia. This type of disorder occurs most frequently in patients with multiple sclerosis.

At the sacral level of the lesion, there is a lack of urge to urinate, difficult urination with a thin stream, a feeling of incomplete emptying of the bladder, chronic urinary retention, hyporeflexia and detrusor areflexia.

Table 2 shows the frequency of certain pelvic disorders in patients with multiple sclerosis.

table 2. The frequency of various pelvic disorders in patients with multiple sclerosis

Pelvic disorders for 50% of patients are a constant problem from the onset of multiple sclerosis, and in 10-14% of cases - the only manifestation of multiple sclerosis in its early stages. In addition, in half of the patients with multiple sclerosis who do not complain about urination disorders, cystometry reveals incomplete emptying of the bladder. With a disease duration of more than 10 years, urination disorders are present in almost all patients, correlating with the degree of disability and the severity of lower paraparesis.

Pelvic disorders, of course, often cause negative emotional reactions, significantly reducing the quality of life of patients with multiple sclerosis and leading to social exclusion. Since among all the causes of urination disorders the most common is urinary tract infection, in all cases it is necessary to do a urine test to exclude the infectious genesis of these disorders.

When evaluating urinary disorders, it should be remembered that in patients with multiple sclerosis, especially in middle and old age, their cause may be prostatic hyperplasia in men, stress and menopausal urinary incontinence in women, etc.

Many patients with urge to urinate restrict fluid intake, which leads to an increase in urine concentration and can cause symptoms of urinary tract irritation. Possible iatrogenic causes should also be excluded - in particular, the influence of drugs that have an anticholinergic effect and, therefore, can cause urinary retention.

When presenting patients with complaints of impaired urination, an ultrasound examination of the bladder and catheterization after urination are necessary to determine the amount of residual urine. If it exceeds 100 ml, the risk of infectious complications is very high.

In the later stages of multiple sclerosis, defecation disorders often occur. These disorders are observed in 40 - 65% of patients with multiple sclerosis. More often they are expressed in constipation, which occurs in 33 - 55% of patients, but in 5% of cases there are imperative urges to empty the intestines and fecal incontinence.

Sexual dysfunction in multiple sclerosis

Multiple sclerosis is a disease that mainly affects young people, and it is clear that sexual dysfunction significantly reduces their quality of life. Typically, such disorders occur after urination disorders and occur in 90% of men and 70% of women.

Sexual dysfunction in patients with multiple sclerosis:

• may be the result of damage to certain parts of the central nervous system
• may occur due to other manifestations of multiple sclerosis (fatigue, paresis, pelvic disorders, muscle spasms)
• may have a psychological basis

It is important to remember the great importance of psychological factors, especially at an early stage of the disease, in the development of sexual dysfunction: at first, patients are under the "yoke" of the diagnosis, then they fear that sexual relations may lead to a deterioration in their condition. Sexual relationships are also affected by increasing disability and lack of understanding on the part of the partner.

Sexual disorders in men are manifested by a decrease in libido, erectile dysfunction and ejaculation. Erectile dysfunction develops on average 4 to 9 years after the onset of multiple sclerosis, but 75% of men with this disorder continue to experience sexual desires. It should be noted that almost half of the patients with impotence retain night and morning erections, which indicates its psychogenic nature.

Sexual disorders in multiple sclerosis in women are less studied, but more than 50% of patients experience some kind of problem. Most often they manifest themselves in the inability to achieve orgasm, lack of lubrication (which may be the result of the use of anticholinergics) and, less often, painful intercourse. Sexual disorders in women can also be associated with a violation of sensitivity in the genital area, as well as with a high tone in the adductor muscles of the thighs.

Neuropsychiatric disorders

At the end of the last century, J.–M. Charcot noted that with multiple sclerosis, memory impairment is often noted, affective disorders and a decrease in intelligence may develop. Although there are no neuropsychiatric disorders specific to multiple sclerosis, many of them are quite common, if not always.

The origin of neuropsychiatric disorders in multiple sclerosis may be due to:

• medicines

Cognitive impairment

• deterioration in memory and attention

• organic brain damage
• psychological reaction of patients to the disease and its individual manifestations
• disability and poor quality of life
• medicines
• effect of therapy and a complex of these factors

Violation of higher nervous activity in multiple sclerosis

Cognitive impairment often occur in the late stages of multiple sclerosis, but can also develop at an early stage or even from the very beginning of the disease.

Multiple sclerosis is characterized by:

• deterioration in memory and attention
• violation of logical thinking
• delayed assimilation of information
• Difficulty switching from one task to another

Patients become uncritical, prone to ridiculous jokes, emotional lability is characteristic.

With pseudobulbar syndrome, violent crying and laughter, reflexes of oral automatism, spastic dysarthria and dysphagia are observed.

IN last years The neuropsychological aspects of multiple sclerosis began to be actively studied, and it turned out that cognitive impairment in multiple sclerosis is very frequent (occurs in 54–65% of cases) and diverse.

Approximately half of the patients already at the stage of a clinically isolated syndrome and at the beginning of a significant multiple sclerosis with neuropsychological testing can detect cognitive disorders.

Conducting neuropsychological testing even before establishing a diagnosis of definite multiple sclerosis shows that:

• only 6% of the examined patients complete the tasks
• 54% do poorly on 1 or 2 tests
• 40% do poorly on 3 or more tests

Moreover, the patients themselves do not show any complaints or note only increased “mental fatigue”.

But already after 3 years from the onset of multiple sclerosis, 20% of patients have significant impairments in the cognitive sphere, noticeable to themselves.

The opposite situation is also possible, when subjective complaints about such cognitive impairments as memory and attention are not confirmed by an objective neuropsychological examination. In such cases, the violations presented by patients are the result of existing depression or fatigue.

It is currently not possible to predict on the basis of clinical data whether and at what stage of multiple sclerosis a particular patient will develop cognitive impairment. However, it cannot be ruled out that the predictors of their occurrence are a large total area of ​​foci on MPT (with a total area of ​​foci exceeding 30 cm2, the likelihood of developing cognitive impairment is very high), a decrease in the size of the corpus callosum, and an increase in the ventricles.

Sometimes cognitive disorders in multiple sclerosis reach the degree of dementia, similar in nature to the fronto-subcortical. Dementia in multiple sclerosis usually does not reach the degree of severity as in other diseases, such as Huntington's chorea or Alzheimer's disease. Severe dementia in patients with multiple sclerosis usually develops only with a long-term severe course of the disease. Thus, with the development of dementia or clinically significant mild cognitive impairment at a young age, it is necessary to remember multiple sclerosis as one of their possible causes.

Memory impairment in multiple sclerosis

memory impairment - are one of the most common cognitive defects in multiple sclerosis. One study shows that:

• 30% of patients have gross memory disorders
• 30% have moderate
• in 40% of patients, memory impairment is mild or absent

Typical for patients with multiple sclerosis cognitive disorders are also a violation:

• attention
• concept formation
• abstract thinking, planning
• speed of information processing, which is associated with severe dysfunction of the cortex of the frontal lobes and fronto-subcortical disorders

Cognitive impairment in multiple sclerosis can be caused not only by morphological (inflammatory and degenerative) changes in the brain that are present in this disease. Fatigue, depression, anxiety, which are very often symptoms of multiple sclerosis, can also lead to cognitive impairment. In addition, the appearance of cognitive impairment may be due to the side effects of certain drugs used to treat multiple sclerosis, such as corticosteroids.

Emotional-affective disorders

The association between multiple sclerosis and mood disorders is multifactorial and complex. To what extent they are a direct consequence of the disease, and to what extent they are a psychological reaction to it, remains unclear. Disturbances such as euphoria, violent laughter and crying, manifestations of frontal dysfunction, of course, are a consequence of multiple sclerosis, are very characteristic of the disease and, to a certain extent, are amenable to specific therapy for multiple sclerosis.

If the patient has emotional disturbances, it is necessary to clarify their duration, the degree of influence on everyday life, and to exclude causes other than multiple sclerosis.

depression in multiple sclerosis

Depression in multiple sclerosis is the most common affective syndrome. According to various authors, it occurs in 25 - 55% of patients with multiple sclerosis, approximately 25% of them need to be monitored by a psychiatrist. Causes of depression can be a reaction to the disease, the disease itself, and side effects of ongoing therapy.

Confirmation that depression can be an independent symptom of multiple sclerosis is its significantly higher frequency in multiple sclerosis than in the population and in other severe neurological diseases. For example, in amyotrophic lateral sclerosis, depression is noted in 3, and in myodystrophy - 4 times less than in multiple sclerosis.

In connection with the high frequency of depression in multiple sclerosis, there have been suggestions about a genetic predisposition to it in this disease. However, among relatives of patients with multiple sclerosis, depression is no more common than in the general population. The manifestations of depression in multiple sclerosis are predominantly irritability and frustration, in contrast to the guilt and hopelessness characteristic of depression in non-MS patients.

In patients with multiple sclerosis, the frequency of attempts and implementation suicides higher than in patients with other diseases of the nervous system, and 7.5 times higher than in the general population. Suicides are especially frequent in the first 5 years after diagnosis (in men - with the onset of the disease before the age of 30, and in women - with the onset of it after 30 years). 15% of patients with multiple sclerosis with depression die due to suicide.

Suicide risk scale - SADPERSONS ("sad people"): S (Sex) - male sex, A (Above age 40 - age over 40 years), D (Depression) - presence of depression, P (Previous attempt - suicide attempt in the past) ), E (Ethanol / drug abbuse - alcoholism or drug addiction), R (Rational thinking loss - lack of rational thinking), S (lack of Social Support - lack of social support), O (Organized suicide plan - the presence of suicidal thoughts), N ( No spouse or significant other - loneliness), S (Sickness - helplessness).

If the patient has 1 - 2 of the listed signs, he can be at home.

In the case of the presence of 3 - 4 signs - requires special attention of others.

With 5-6 signs, the patient is shown hospitalization.

If 7–10 signs are detected, urgent hospitalization is required with individual monitoring of the patient.

It is possible that the relationship between depression and suicide can be explained by low nocturnal secretion of melatonin in patients with multiple sclerosis. The precursor of melatonin is serotonin, and a decrease in serotonergic activity is the most important factor in the development of depression.

Anxiety disorders in multiple sclerosis

Anxiety disorders - occur in almost 25% of patients with multiple sclerosis, significantly predominating in women, especially in the initial stages of multiple sclerosis. The combination of anxiety disorders with depression, to a greater extent than isolated depression or anxiety disorders, is accompanied by suicidal thoughts, major somatic complications and social maladaptation.

It is anxiety disorders, and not depression, that are a significant predictor of the development of alcoholism in patients with multiple sclerosis. They appear to be strongly associated with disease activity, i.e. with the frequency of exacerbations, and less with its duration and severity.

For a long time, euphoria was considered a pathognomonic symptom of multiple sclerosis. Subsequent research has shown that many patients, while appearing euphoric, actually have underlying depression. Currently, it is believed that euphoria in multiple sclerosis occurs only in 13% of cases, taking only 6th place among affective disorders:

• depression - 79%
• agitation - 40%
• anxiety - 37%
• irritability - 35%
• apathy - 20%

The term "euphoria" often refers to a wide variety of emotional and behavioral disorders. Euphoria can be described as a feeling of lightness, happiness, an optimistic view of the future, despite the rather severe manifestations of the disease. Euphoria, in contrast to depression, is noted with a long course of multiple sclerosis and a significant neurological deficit and is accompanied by cognitive impairment.

alexithymia

This term refers to the difficulty in perception and verbal description by a patient with multiple sclerosis of their own emotions and feelings (“there are no words to describe the mood”). Patients describe physical symptoms and sensations instead of feelings. Another manifestation of alexithymia is the disappearance of emotionally positive reflections and a sense of loss of life prospects. Patients with alexithymia are more focused on external events than on internal experiences.

Acute psychotic disorders in multiple sclerosis

Acute psychotic disorders in multiple sclerosis develop - rarely. However, in 5–7% of cases, the onset or exacerbation of multiple sclerosis may manifest as psychosis. They can range from brief episodes to long-term disturbances with productive symptoms, which in some cases necessitate a differential diagnosis with schizophrenia. Multiple sclerosis has some characteristics similar to schizophrenia:

• start at a young age
• relapsing course
• immunological disorders

There are theories about the general nature of these diseases. However, psychotic disorders in multiple sclerosis, unlike schizophrenia, occur much less frequently, resolve faster, and their prognosis in multiple sclerosis is more favorable. MS patients with acute psychotic disorders tend to have a large area of ​​lesions on MRI, especially around the temporal horn of the lateral ventricles. There was also a connection between acute psychoses and the formation of massive foci of demyelination in the parietal and temporal regions or in the hippocampus.

Damage to the frontal parts of the brain in multiple sclerosis, in addition to euphoria, can also lead to behavioral disorders, such as abulia, apathy, and disinhibition.

Fatigue

Fatigue is one of the main manifestations of multiple sclerosis, occurring in 75 - 92% of cases, and 55 - 75% of patients with multiple sclerosis consider it one of the main symptoms of the disease. Fatigue in multiple sclerosis is different from normal fatigue in healthy people - it is inadequate to physical activity, disrupts normal daily activities and is a disabling factor even in the absence of severe focal symptoms. Patients describe fatigue as a feeling of fatigue, loss of energy, a feeling of exhaustion, compare these sensations with a flu-like condition.

The current definition of fatigue in multiple sclerosis is as follows: a subjective feeling of lack/lack of physical and/or mental energy which, in the opinion of the patient or caregivers, interferes with the performance of normal or desired activities.

Fatigue may fluctuate depending on the physical activity performed, the presence of an infectious process, temperature environment and bodies.

Fatigue in multiple sclerosis can manifest itself in individual muscle groups, recovering from rest (which resembles myasthenia gravis), and also be general. Characteristic of fatigue in multiple sclerosis is that it decreases to a greater extent after resting while awake than after sleep. Fatigue has no absolute relationship with muscle weakness, and they are based on different pathophysiological mechanisms.

Fatigue in multiple sclerosis is not related to age. It can be aggravated in the presence of other symptoms of multiple sclerosis - pain, sleep disturbances. There was a significant correlation between fatigue and depression. An increase in fatigue often occurs in parallel with an increase in the severity of depression, which suggests similar pathogenetic mechanisms in the development of both syndromes. But still, fatigue is an independent symptom. Nearly all people with multiple sclerosis with fatigue report significant aggravation in the heat and after taking a hot bath or shower, while the cold brings relief. Some authors believe that even the cognitive impairments that occur in patients with multiple sclerosis are symptoms of "mental fatigue".

The genesis of the development of fatigue in multiple sclerosis remains not fully understood. There are 3 main hypotheses that suggest the mechanisms of development of this syndrome in multiple sclerosis:

1. immune, suggesting that fatigue is based on immunological changes
2. neurofunctional, linking fatigue with impaired functional activity in various parts of the central nervous system as a result of demyelination and axonal damage
3. neuroendocrine, considering this symptom as a consequence of dysfunction of the hypothalamic-pituitary-adrenal system

Autonomic disorders in multiple sclerosis

In a targeted study, autonomic disorders are detected in approximately 80% of patients with multiple sclerosis. More often, vegetative disorders are observed in the primary progressive course of multiple sclerosis and are more correlated with the severity of spinal cord atrophy caused by neurodegenerative processes in it than with the presence of foci of demyelination.

Vegetative disorders in multiple sclerosis arise due to the involvement of the central autonomic pathways in the pathological process. Presumably, multiple sclerosis plaques may disrupt connections between the insula, anterior cingular and ventromedial prefrontal cortex, amygdala central nucleus, hypothalamic paraventricular nuclei, medulla oblongata, or damage descending autonomic pathways in the brainstem or spinal cord.

Often in patients with multiple sclerosis in the presence of lesions in the brain stem, there is constant moderate hypothermia, while even during infectious diseases, the body temperature does not rise above 37 0 C

Approximately 50% of patients with multiple sclerosis have orthostatic dizziness and orthostatic arterial hypotension due to impaired sympathetic vasoconstriction.

Almost 40% of patients with multiple sclerosis have sweating disorders. Demyelination of the central thermoregulatory pathways emanating from the hypothalamus can lead to regional or global anhidrosis, especially with a large area of ​​demyelination foci in the brainstem. The severity of sweating disorders in the legs correlates with weakness in them, impaired sensitivity and urination. This suggests an association of autonomic disorders with a significant degree of spinal cord injury.

During exacerbations of multiple sclerosis, with the localization of foci in the brain stem, cardiac arrhythmias may develop. Subclinical manifestations of cardiovascular dysfunction (for example, a change in the R–R interval on the ECG) are described quite often (10–50%).

Osteoporosis often develops in multiple sclerosis, which is associated with reduced motor activity. The predominance of women among patients, who are more susceptible to the development of osteoporosis than men, is also important. In addition, osteoporosis can develop as a result of treatment with corticosteroids.

Sleep disturbances, level of consciousness and wakefulness in multiple sclerosis

Sleep disturbances occur in 40% of patients with multiple sclerosis. Some of them have difficulty falling asleep due to painful tonic spasms or restless legs syndrome. Restless legs syndrome is manifested by a feeling of "crawling", tingling, burning, "moving under the skin", etc. It occurs in the thighs, legs and feet and makes it necessary to move the legs.

Sleep disorders can also be caused by depression or drug therapy (corticosteroids, amantadine). In addition, patients with multiple sclerosis may be disturbed by frequent awakenings due to nocturia. Insomnia, in turn, can exacerbate depression and fatigue. In general, sleep disorders in multiple sclerosis lead to a decrease in the quality of life and should be corrected.

Violation of wakefulness and the level of consciousness, more often in the form of somnolence or stunning, is rare in multiple sclerosis - in acute exacerbation of the disease that occurs with damage to the brain stem or with acute massive cerebral demyelination, accompanied by significant perifocal edema. Disturbance of consciousness in multiple sclerosis is always accompanied by a gross focal neurological defect.

Additional symptoms in multiple sclerosis - paroxysmal disorders

Paroxysmal disorders in multiple sclerosis, they occur in about 20% of patients. These disorders in multiple sclerosis can be sensory, motor, and combined. Most often, paroxysmal disorders appear in the advanced stage of the disease, but sometimes there may be early signs. They are characterized by a short duration (usually no more than 2 minutes) and a high frequency of occurrence (up to several hundred times a day), often provoked by various "trigger" factors - movement, stress, sensory stimuli, hyperventilation, etc.

One of the most common sensory paroxysmal symptoms in multiple sclerosis is Lhermitte's symptom.

Symptom of Lhermitte - This is a sudden sensation of electric shock, extending from top to bottom along the spine and into both legs. It occurs when you tilt your head, move your neck, or cough. Possible variants of Lhermitte's symptom are tingling or pain during neck movements, the spread of unpleasant sensations in both hands and the occurrence of these sensations during movements in the lumbar spine. Lermitte's symptom often develops with multiple sclerosis, but it is also possible with other lesions of the cervical spinal cord.

facial myokymia - almost constant involuntary small contractions of facial muscles - a symptom that is almost pathognomonic for multiple sclerosis. At the same time, patients often complain of a feeling of tension in half of the face; on examination, ptosis and smoothness of the nasolabial fold can sometimes be detected. In addition to multiple sclerosis, facial myokymia can be a symptom of brainstem glial tumors.

Short-term paroxysmal neurological disorders in multiple sclerosis

Epileptic seizures (4–10%) and non-epileptic tonic spasms (2–5%) are also relatively common.

Epileptic seizures among patients with multiple sclerosis are much more common than in the population, where their frequency is 0.4-2%. In addition, if in a population the peak incidence of epilepsy occurs in childhood, adolescence, and then elderly age, then in patients with multiple sclerosis, seizures develop more often at the age of about 30 years.

The occurrence of epileptic seizures in multiple sclerosis, as a rule, is due to the localization of plaques near the cerebral cortex. If epileptic seizures are a manifestation of an exacerbation of the disease, they disappear after the relief of exacerbation by conventional methods, without the use of anticonvulsants. In half the cases, however, epileptic seizures in multiple sclerosis are a manifestation of epilepsy as a separate concomitant disease.

At an early stage, including at the very beginning of the disease, so-called paroxysmal conditions often appear - short, stereotyped, recurrent attacks of dysarthria, ataxia, diplopia, transient hemiparesis, paresthesia, pain or tonic convulsions of the muscles of the limbs, face and trunk, accompanied by unpleasant sensations. , such as tingling. Such seizures may look like a single spasm, "lumbago", and may last 30 seconds or more. They usually occur in series several times a day. Often, patients can name provoking factors - hyperventilation, special movements, etc.

Other sensory paroxysmal phenomena in multiple sclerosis may include itching, pain, and paresthesias.

Forms of multiple sclerosis

According to the predominant localization of the existing lesions, the following forms of multiple sclerosis are distinguished:

1. Cerebral form of multiple sclerosis

It is characterized by symptoms of damage to the pyramidal system.

2. Cerebellar form of multiple sclerosis

It is characterized by cerebellar syndrome; its combination with the stem form is more often observed.

3. Stem form of multiple sclerosis

With this form of multiple sclerosis, stem symptoms are leading. Can be traced - bulbar syndrome, autonomic lability. Often stem manifestations are combined with cerebellar disorders (stem-cerebellar form). Rare, but also the most unfavorable option. The course is rapidly progressing, the patient becomes severely disabled for a short time, characterized by euphoria, uncritical to his condition.

4. Optical form of multiple sclerosis

The leading clinical symptom is a decrease in visual acuity (retrobulbar neuritis).

5. Spinal form of multiple sclerosis

It is characterized by symptoms of damage to the spinal cord at different levels:

• spastic lower paraparesis
• pelvic disorders
• sensory disturbances

6. Cerebrospinal form of multiple sclerosis

The most common form of multiple sclerosis. This form, already in the initial stage of the disease, is characterized by a multifocal lesion of the nervous system with symptoms of damage to the cerebellar, pyramidal formations in the brain and spinal cord, visual, oculomotor, vestibular and other systems. Often - this form of multiple sclerosis begins with retrobulbar neuritis.

The relapsing course of multiple sclerosis is characterized by sudden, unpredictable exacerbations. These exacerbations develop over several days or weeks, and then a remission occurs, during which the neurological disorders that have arisen can either persist or partially or completely disappear. The reverse development of disorders usually takes several weeks or months, but occasionally it can even last 2 years or more. Between exacerbations of multiple sclerosis, neurological disorders do not increase. With this form of the course of multiple sclerosis, the disease begins in 85% of patients.

In 25–40% of patients, a second exacerbation begins within the first year of the disease and in 60% within 3 years.

At secondary progressive multiple sclerosis the relapsing course becomes progressive soon or after several years or even decades from the onset of the disease. In contrast to the relapsing-remitting course of multiple sclerosis, there is a gradual increase in neurological disorders between exacerbations. About 40% of all exacerbations of multiple sclerosis are associated with colds, viral and bacterial diseases. In 37.5% of patients after acute respiratory infections, according to studies, there is an increase in the demyelinating process.

For primary progressive course of multiple sclerosis characterized by a steady increase in neurological symptoms from the very beginning of the disease. In some patients, periods of stabilization are observed, but obvious exacerbations do not occur. This form develops in 10 - 15% of cases, but is the most common course in the late onset of multiple sclerosis (after 40 years).

In rare cases, there is progressive relapsing-remitting multiple sclerosis, when, against the background of a primary progressive course, exacerbations occur.

Marburg type of multiple sclerosis- severe acute type of multiple sclerosis, occurring with a rapidly progressive process of demyelination and loss of axons, is often accompanied by extensive neurological deficit. It can lead to the death of the patient within one year.

relapsing course

minimal neurological impairment 5 years after disease onset

The prognosis is worse with:

1. static ataxia
2. severe postural tremor
3. primary progressive course of multiple sclerosis

In the relapsing course of multiple sclerosis, in about half of the patients, disability is associated with incomplete recovery of functions after an exacerbation, in the second half - with the transition to a secondary progressive form of the course of multiple sclerosis.

In the progressive course of multiple sclerosis, disability is due to spasticity, weakness of the muscles of the limbs, dysfunction of the pelvic organs, deterioration of vision or cognitive functions.

In general, the longer the course of multiple sclerosis, the fewer patients with a mild form remain.

15 years after diagnosis of multiple sclerosis:

• 20% of patients fully retain their ability to work
• 75% do not work
• 70% cannot serve themselves or do it with difficulty

Table 3 presents the frequency of occurrence of symptoms in the advanced stage of multiple sclerosis.

Table 3. Symptoms of the advanced stage of multiple sclerosis

by J.F. Kurtzke">Kurtzke's disability rate score (EDSS score).

Symptoms	Frequency, (%)
pyramidal insufficiency	99
visual and oculomotor disorders	85
sensory disorders	83
urination disorders	82
imbalance	80
stem and cerebellar symptoms	75