Multiple Sclerosis (MS)

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Multiple sclerosis (MS) is an autoimmune, inflammatory, demyelinating and sometimes neurodegenerative disease of the central nervous system that cause physical disability (Peterson & Fujinami, 2007). Prevalence rates vary significantly across the world, affecting from 2 individuals per 100,000 population in regions of sub-Saharan Africa and Eastern Asia, to 100 individuals per 100,000 population in regions of North America and Europe (Leray, Moreau, Fromont , & Edan, 2016). Also, studies report more than three to six fold increase of prevalence rates with increased latitude, suggesting a strong influence of environment and possible differences in climate, diet, and infectious agents (Van Der May, Ponsonby, Blizzard, & Dwyer, 2001). Females are more frequently affected than male, at a rate approximately of 2:1, and in the relapsing-remitting form of the disease at a rate of 3:1 in 2000’s from 2:1 in 1950’s and 1960’s (Leray,et al., 2016).

MS is a devastating disease with a wide range of symptoms that cause disability, including fatigue, meaning that patients find themselves struggling to carry out the simplest activities, dizziness, spasms, muscle stiffness, tremor, imbalance, temporary loss of vision, colour blindness, incontinence, constipation, numbness in different parts of the body and feelings of burning or needles, musculoskeletal pain, speech difficulty, swallowing difficulty and cognitive dysfunction.

Approximately 10% of patients suffer from a continuous deterioration of symptoms, with no remission periods; a form of the disease that is called primary progressive MS. Gradual worsening of symptoms along with periods marked by sudden deterioration appears in 5% of patients (Progressive-relapsing MS). The majority of patients, approximately 85%, experience periods of exacerbation of symptoms, followed by periods of symptoms improvement or disappearance (relapsing-remitting MS). At some point in time, about 5% of these patients may experience a progressive deterioration of symptoms, followed by periods of remission or with absence of remission (secondary progressive MS) beyond that point (Goldenberg, 2012).

The unpredictability and change of symptoms put patients at risk of anxiety and depression, denial and hopelessness. Nurses, neurologists, psychologists, physiatrists, nutritionists, physical therapists, urologists and speech therapists are needed to work closely together and react fast to changing symptoms, in order to provide co-ordinated information, medical, technical, and psychological support and facilitate easy access to available resources, primary health care, inpatient rehabilitation and community MS groups (Gibson, 2002). Other patients with different forms of the disease or at different phases may offer important support. Also, psychologists need to work closely with social workers and ensure psychosocial support and vocational rehabilitation in collaboration with employers in order to protect patients jobs and employability (Gibson, 2002; Khan, & Turner-Stokes, 2009).

The need of assessment and treatment for depression and anxiety (early as well as regular screening) is crucial for the course of MS and patients well-being. Symptoms unpredictability triggers anxiety and depressive symptomatology and often elicit chronic sorrow and grief. Up to 50% of patients with MS are affected by depression and anxiety (Landro, Celius, & Sletvoid, 2004), whereas lifetime prevalence is estimated to be approximately 24% and 21.9% (Marrie et al., 2015), accordingly. Unfortunately, it is estimated that depression is under-diagnosed in around 23%-30% of patients (Horwitz, Cutter, Tyry, Campagnolo, & Vollmer, 2009; McGuigan & Hutchinson, 2006). Also, studies report varying rates of untreated depression ranging from 20% to as high as approximately 66% of the patients as for example a study that included 260 patients with MS, which found that only 3.1% of those with depression received sufficient treatment for depression (Mohr, Hart, Fonareva, & Tasch, 2006).

Moreover, depression and fatigue, which affects up to 90% of patients with MS, directly influences patients’ cognitive function, including attention and working memory, processing speed, ability to memorize and learn new information, abstract reasoning and executive function (Chiaravalloti, & DeLuca, 2008). Fatigue and fatigue-associated difficulties in cognitive function produce additional anxiety to the individual and further compounds cognitive dysfunction and depression.  In turn, depression and anxiety reduces patients adherence to medication (DiMatteo, Lepper, & Croghan, 2000), adherence to vital exercise for MS and deteriorate rehabilitation (Gibson & Frank, 2002) and quality of life (QOL) of patients (Janssens, vanDoorn, deBoer, Kalkers, vanderMeche, & Passchier, 2003).

Adherence to exercise is important in MS. Limited physical activity and lack of exercise due to MS symptoms such as spasticity, muscle stiffness and fatigue as well as overprotection (avoiding exercise), which is exacerbated by anxiety and depression, deteriorates rehabilitation, can lead to muscular weakness, cardiovascular dysfunction and disease (Gibson & Frank, 2002). Exercise contributes significantly to muscle strength and walking speed, fatigue, cognitive function and overall QOL, whereas there is also some evidence coming from research in humans and animal models that exercise has neuroprotective effects, however more control trials are needed (Giesser, 2015; Heine, van de Port, Rietberg, van Wegen, Kwakkel, 2015).  In addition, a healthy diet, rich in low fat protein, in unsaturated fat and fibre is always beneficial and offers protection from cardiovascular and neurodegenerative diseases (Paoli, Bianco, Damiani, & Bosco; Stafstrom & Rho, 2012). In MS, more research is needed; however, the results of few studies suggest that diet, especially rich in polyunsaturated fat and vitamins, may have a positive impact on MS outcome (Farinotti, Vacchi, Simi, Di Pietrantonj, Brait, & Filippini, 2017).



Chiaravalloti, N. D., & DeLuca, J. (2008). Cognitive impairment in multiple sclerosis. The Lancet Neurology, 7, 1139–51. doi: 10.1016/S1474-4422(08)70259-X

DiMatteo, M. R., Lepper, H. S., & Croghan, T. W. (2000). Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine Journal, 160(14), 2101-2107.  doi: 10.1001/archinte.160.14.2101

Farinotti, M., Vacchi, L., Simi, S., Di Pietrantonj, C., Brait, L., & Filippini, G. (2012). Dietary interventions for multiple sclerosis. Cochrane Database of Systematic Reviews, 12. doi: 10.1002/14651858.CD004192.pub3.

Gibson, J. (2002). Supporting individuals with disabling multiple sclerosis. Journal of the Royal Society of Medicine, 95, 580-586. doi: 10.1258/jrsm.95.12.580

Giesser, B. S. (2015). Exercise in the management of persons with multiple sclerosis. Therapeutic Advances in Neurological Disorders, 8(3), 123-130. doi: 10.1177/1756285615576663

Goldenberg, M. M. (2012). Multiple sclerosis review. Pharmacy and Therapeutics, 37(3), 175-184. PMC3351877

Heine, M., van de Port, I., Rietberg, M. B., van Wegen, E. E. H., Kwakkel, G. (2015). Exercise therapy for fatigue in multiple sclerosis. Cochrane Database of Systematic Reviews, 9. doi: 10.1002/14651858.CD009956.pub2

Janssens, A. C., van Doorn, P. A., de Boer, J. B., Kalkers, N. F., van der Meche, F. G., Passchier, J., & Hintzen, R. Q. (2003). Anxiety and depression influence the relation between disability status and quality of life in multiple sclerosis. Multiple Sclerosis, 9(4), 397-403. doi: 10.1191/1352458503ms930oa

Khan,  F, Ng, L., & Turner-Stokes, L. (2009). Effectiveness of vocational rehabilitation intervention on the return to work and employment of persons with multiple sclerosis. Cochrane Database of Systematic Review, 1, doi: 10.1002/14651858.CD007256.pub2.

Landro, N. I., Celius, E. G., & Sletvoid, H. (2004). Depressive symptoms account for deficient information processing speed but not for impaired working memory in early phase multiple sclerosis. Journal of Neurological Sciences, 217, 211–216. doi: 10.1016/j.jns.2003.10.012

Leray, E., Moreau, T., Fromont, A., & Edan, G. (2016). Epidemiology of multiple sclerosis.  Revue Neurologique, 172(1), 3-13. doi: 10.1016/j.neurol.2015.10.006.

Marrie, R. A., Horwitz, R., Cutter, G., Tyry, T., Campagnolo, D., & Vollmer, T. (2009). The burden of mental comorbidity in multiple sclerosis: frequent, underdiagnosed, and undertreated. Multiple Sclerosis, 15(3), 385-392. doi: 10.1177/1352458508099477

Marrie, R. A., Reingold, S., Cohen, J., Stuve, O.,Trojano, M., Sorensen, P. S., & Reider, N., (2015). The incidence and prevalence of psychiatric disorders in multiple sclerosis: a systematic review. Multiple Sclerosis 21(3), 305-317. doi: 10.1177/ 1352458514564487

McGuigan, C. & Hutchinson, M. (2006). Unrecognised symptoms of depression in a community-based population with multiple sclerosis. Journal of Neurology, 253(2), 219-223. doi: 10.1007/s00415-005-0963-0

Mohr, D. C., Hart, S. L., Fonareva, I., & Tasch, E. S. (2006). Treatment of depression for patients with multiple sclerosis in neurology clinics. Multiple Sclerosis, 12(2), 204-208.  doi: 10.1191/135248506ms1265oa

Paoli, A., Bianco, A., Damiani, E., & Bosco, G. (2014). Ketogenic diet in neuromuscular and neurodegenerative diseases. BioMed Research International, 474296, doi: 10.1155/2014/474296

Peterson, l. K. & Fujinami, R. S. (2007). Inflammation, demyelination, neurodegeneration and neuroprotection in the pathogenesis of multiple sclerosis. Journal of Neuroimmunology, 184(1-2), 37-44. 10.1016/j.jneuroim.2006.11.015

Stafstrom, C. & Rho, J. M. (2012). The ketogenic diet as a treatment paradigm for diverse neurological disorders. Frontiers in Pharmacology, 3(59). doi: 10.3389/fphar.2012.00059

Van Der May, I., Ponsonby, A. L., Blizzard, L., & Dwyer, T. (2001). Regional variation in multiple sclerosis prevalence in Australia and its associations with ambient ultraviolent radiation. Neuroepidemology, 20, 168-174. doi: 10.1159/000054783



Symptoms unpredictability triggers anxiety and depressive symptomatology and often elicit chronic sorrow and grief. Up to 50% of patients with MS are affected by depression and anxiety (Landro, Celius, & Sletvoid, 2004), whereas lifetime prevalence is estimated to be approximately 24% and 21.9% (Marrie et al., 2015), accordingly.

Unfortunately, it is estimated that depression is under-diagnosed in around 23%-30% of patients (Horwitz, Cutter, Tyry, Campagnolo, & Vollmer, 2009; McGuigan & Hutchinson, 2006).