Multiple Sclerosis

Multiple Sclerosis: T1-weighted MRI (post-contrast) of same brain slice at monthly intervals. Bright spots within the brain tissue indicate active lesions. Source: U.S. Brookhaven National Laboratory, Wikimedia Commons.

Multiple sclerosis (MS) is a chronic, often disabling disease that attacks the central nervous system (CNS), which is made up of the brain, spinal cord, and optic nerves. Symptoms may be mild, such as numbness in the limbs, or severe, such as paralysis or loss of vision. The progress, severity, and specific symptoms of MS are unpredictable and vary from one person to another. Most people experience their first symptoms of MS between the ages of 20 and 40.

Other Names

• MS

Types

People with MS can typically experience one of four disease courses, each of which might be mild, moderate, or severe.

Relapsing-remitting

People with this type of MS experience clearly defined attacks of worsening neurologic function. These attacks—which are called relapses, flare-ups, or exacerbations —are followed by partial or complete recovery periods (remissions), during which no disease progression occurs. Approximately 85% of people are initially diagnosed with relapsing-remitting MS.

Primary-progressive

This disease course is characterized by slowly worsening neurologic function from the beginning—with no distinct relapses or remissions. The rate of progression may vary over time, with occasional plateaus and temporary minor improvements. Approximately 10% of people are diagnosed with primary-progressive MS.

Secondary-progressive

Following an initial period of relapsing-remitting MS, many people develop a secondary-progressive disease course in which the disease worsens more steadily, with or without occasional flare-ups, minor recoveries (remissions), or plateaus. Before the disease-modifying medications became available, approximately 50% of people with relapsing-remitting MS developed this form of the disease within 10 years. Long-term data are not yet available to determine if treatment significantly delays this transition.

Progressive-relapsing

In this relatively rare course of MS (5%), people experience steadily worsening disease from the beginning, but with clear attacks of worsening neurologic function along the way. They may or may not experience some recovery following these relapses, but the disease continues to progress without remissions. Since no two people have exactly the same experience of MS, the disease course may look very different from one person to another. And, it may not always be clear to the physician—at least right away—which course a person is experiencing.

Causes

In patients with MS, immune cells from the body’s own defense system (specifically "auto-reactive" T-cells) attack myelin, the fatty substance that surrounds and protects the nerve fibers in the central nervous system. The nerve fibers themselves can also be damaged. The damaged myelin forms scar tissue, called sclerosis, which gives the disease its name. When any part of the myelin sheath or nerve fiber is damaged or destroyed, nerve impulses traveling to and from the brain and spinal cord are distorted or interrupted, producing the variety of symptoms that can occur. Most people with MS learn to cope with the disease and continue to lead satisfying, productive lives.

Normal CNS, Source: CellSketch

Demyelination, Source: CellSketch

While the cause of MS is still not known, scientists believe that a combination of several factors may be involved. The major scientific theories about the causes of MS include the following:

Immunologic factors

It is now generally accepted that MS involves an autoimmune process—an abnormal response of the body’s immune system that is directed against the myelin (the fatty sheath that surrounds and insulates the nerve fibers) in the central nervous system (CNS—the brain, spinal cord and optic nerves). The exact antigen, or target that the immune cells are sensitized to attack, remains unknown. In recent years, however, researchers have been able to identify which immune cells are mounting the attack, some of the factors that cause them to attack, and some of the sites, or receptors, on the attacking cells that appear to be attracted to the myelin to begin the destructive process.

Environmental factors

MS is known to occur more frequently in areas that are farther from the equator. Epidemiologists—scientists who study disease patterns—are looking at many factors, including variations in geography, demographics (age, gender, and ethnic background), genetics, infectious causes, and migration patterns, in an effort to understand why. Studies of migration patterns have shown that people born in an area of the world with a high risk of MS who then move to an area with a lower risk before the age of 15, acquire the risk of their new area. Such data suggest that exposure to some environmental agent that occurs before puberty may predispose a person to develop MS later on.

Some scientists think the reason may have something to do with vitamin D, which the human body produces naturally when the skin is exposed to sunlight. People who live closer to the equator are exposed to greater amounts of sunlight year-round. As a result, they tend to have higher levels of naturally-produced vitamin D, which is thought to have a beneficial impact on immune function and may help protect against autoimmune diseases like MS.

Infection

Since initial exposure to numerous viruses, bacteria and other microbes occurs during childhood, and since viruses are well recognized as causes of demyelination and inflammation, it is possible that a virus or other infectious agent is the triggering factor in MS. More than a dozen viruses and bacteria, including measles, canine distemper, human herpes virus-6, Epstein-Barr, and Chlamydia pneumonia have been or are being investigated to determine if they are involved in the development of MS, but none have been definitively proven to trigger MS.

Genetic factors

While MS is not hereditary in a strict sense, having a first-degree relative such as a parent or sibling with MS increases an individual's risk of developing the disease several-fold above the risk for the general population. Studies have shown that there is a higher prevalence of certain genes in populations with higher rates of MS. Common genetic factors have also been found in some families where there is more than one person with MS. Some researchers theorize that MS develops because a person is born with a genetic predisposition to react to some environmental agent that, upon exposure, triggers an autoimmune response.

Symptoms

In patients with multiple sclerosis, damage to the myelin in the central nervous system, and to the nerve fibers themselves, interferes with the transmission of nerve signals between the brain and spinal cord and other parts of the body. This disruption of nerve signals produces the primary symptoms of MS, which vary depending on where the damage has occurred. Over the course of the disease, some symptoms will come and go, while others may be more lasting.

The more common symptoms of MS include:

• Fatigue: Fatigue can significantly interfere with a person's ability to function at home and at work, and may be the most prominent symptom in a person who otherwise has minimal activity limitations.
• Numbness: Numbness of the face, body, or extremities (arms and legs) is often the first symptom experienced by those eventually diagnosed as having MS.
• Walking (gait), balance, & coordination problems: Problems with gait (difficulty in walking) are among the most common mobility limitations in MS. Gait problems are related to several factors.
• Bladder dysfunction (usually can be managed quite successfully).
• Bowel dysfunction: Constipation is a particular concern among people living with MS, as is loss of control of the bowels. Diarrhea and other problems of the stomach and bowels also can occur.
• Vision problems: Vision problems are the first symptom of MS for many people. The sudden onset of double vision, poor contrast, eye pain, or heavy blurring can be frightening, and the knowledge that vision may be compromised can make people with MS anxious about the future.
• Dizziness and vertigo: Dizziness is a common symptom of MS. People with MS may feel off balance or lightheaded. Much less often, they have the sensation that they or their surroundings are spinning, a condition known as vertigo.
• Sexual dysfunction: Sexual problems are often experienced by people with MS, but they are very common in the general population as well. Sexual arousal begins in the central nervous system, as the brain sends messages to the sexual organs along nerves running through the spinal cord. If MS damages these nerve pathways, sexual response—including arousal and orgasm—can be directly affected. Sexual problems also stem from MS symptoms such as fatigue or spasticity, as well as from psychological factors relating to self-esteem and mood changes.
• Pain: Pain syndromes are common in MS. In one study, 55% of people with MS had "clinically significant pain" at some time. Almost half were troubled by chronic pain.
• Cognitive function: Cognition refers to a range of high-level brain functions, including the ability to learn and remember information: organize, plan, and problem-solve; focus, maintain, and shift attention as necessary; understand and use language; accurately perceive the environment, and perform calculations. Cognitive changes are common in people with MS—approximately 50% of people with MS will develop problems with cognition.
• Emotional changes are very common in MS—as a reaction to the stresses of living with a chronic, unpredictable illness and because of neurologic and immune changes caused by the disease. Bouts of severe depression (which is different from the healthy grieving that needs to occur in the face of losses and changes caused by MS), mood swings, irritability, and episodes of uncontrollable laughing and crying (called pseudobulbar affect) pose significant challenges for people with MS and their family members.
• Depression is common during the course of multiple sclerosis. In fact, studies have suggested that clinical depression, the severest form of depression, is more frequent among people with MS than it is in the general population or in persons with other chronic, disabling conditions.
• Spasticity: Spasticity refers to feelings of stiffness and a wide range of involuntary muscle spasms, typically in the legs. Spasticity may be as mild as the feeling of tightness of muscles or may be so severe as to produce painful, uncontrollable spasms of extremities. Spasticity may also produce feelings of pain or tightness in and around joints, and can cause low back pain.

These symptoms also occur in MS, but much less frequently.

• Speech and voice problems occur in approximately 25-40 percent of people with MS, particularly during relapses or periods of extreme fatigue. The problems are of two types—dysarthria refers to changes in the production of speech, including slurring, unclear articulation of words, and difficulty controlling loudness; dysphonia is the term used for changes in voice quality, including hoarseness, breathiness, nasality, poor control of pitch.
• Swallowing problems—referred to as dysphagia—result from damage to the nerves controlling the many small muscles in the mouth and throat. When dysphagia occurs, food and liquids can pass into the airway and lungs, causing the person to cough and choke. Because particles that remain in the lungs can cause aspiration pneumonia—a serious complication of MS—prompt evaluation and treatment by a speech/language pathologist are essential.
• Headache: Although headache is not a common symptom of MS, some reports suggest that people with MS have an increased incidence of certain types of headache.
• Hearing loss is an uncommon symptom of MS. About 6% of people who have MS complain of impaired hearing. In very rare cases, hearing loss has been reported as the first symptom of the disease. Deafness due to MS is exceedingly rare, and most acute episodes of hearing deficit caused by MS tend to improve.
• Seizures, which are the result of abnormal electrical discharges in an injured or scarred area of the brain, are fairly uncommon among people with MS. Their incidence has been estimated at 2% to 5%, compared to the estimated 3% incidence of seizures in the general population.
• Tremor: Many people with MS experience some degree of tremor, or uncontrollable shaking. It can occur in various parts of the body.
• Respiratory problems occur in people whose chest muscles have been severely weakened by damage to the nerves that control those muscles. Aspiration pneumonia (resulting from the food particles and/or liquids passing into the lungs) can also make breathing more difficult. Breathing problems can contribute to MS-related fatigue and interfere with speech and voice production.
• Pruritis (itching) may occur as a symptom of MS. It is one of the family of abnormal sensations—such as "pins and needles" and burning, stabbing, or tearing pains—which may be experienced by people with MS. These sensations are known as dysesthesias, and they are neurologic in origin.

Diagnosis of Multiple Sclerosis

At this time, there are no symptoms, physical findings, or laboratory tests that can, by themselves, determine if a person has MS. In order to make a diagnosis of MS, the physician must find evidence of damage in at least two separate areas of the central nervous system and find evidence that the damage occurred at different points in time — at least one month apart. In addition, the physician must rule out all other possible diagnoses.

Exams and Tests

• Medical history and neurologic examination: The physician takes a careful history to identify any past or present symptoms that might be caused by MS and to gather information about birthplace, family history, and places traveled that might provide further clues. The physician also performs a variety of tests to evaluate mental, emotional, and language functions, movement and coordination, vision, balance, and the functions of the five senses. In many instances, the person’s medical history and neurologic exam provide enough evidence to meet the diagnostic criteria. Other tests are used to confirm the diagnosis or provide additional evidence if it’s necessary.
• MRI: MRI is the best imaging technology for detecting the presence of MS plaques or scarring (also called lesions) in different parts of the CNS. It can also differentiate old lesions (T1-hypointense lesions) from those that are new or active (T2-hyperintense and gadolinium-enhanced T1 lesions). Although MRI is a very useful diagnostic tool, a normal MRI of the brain does not rule out the possibility of MS. About 5% of people who are confirmed to have MS do not initially have brain lesions on MRI. However, the longer a person goes without brain or spinal cord lesions on MRI, the more important it becomes to look for other possible diagnoses.
• Visual evoked potential (VEP): Evoked potential (EP) tests are recordings of the nervous system's electrical response to the stimulation of specific sensory pathways (e.g., visual, auditory, general sensory). Because damage to myelin (demyelination) results in a slowing of response time, EPs can sometimes provide evidence of scarring along nerve pathways that does not show up during the neurologic exam. Visual evoked potentials are considered the most useful for confirming the MS diagnosis.
• Cerebrospinal fluid analysis: Analysis of the cerebrospinal fluid, which is sampled by a spinal tap, detects the levels of certain immune system proteins and the presence of oligoclonal bands. These bands, which indicate an immune response within the CNS, are found in the spinal fluid of about 90-95% of people with MS. But because they are present in other diseases as well, oligoclonal bands cannot be relied on as positive proof of MS.
• Blood tests: While there is no definitive blood test for MS, blood tests can rule out other conditions—including Lyme disease, a group of diseases known as collagen-vascular diseases, certain rare hereditary disorders, and AIDS—that cause symptoms similar to those of MS.

Other conditions that cause demyelination (damage to myelin)

• Demyelination in the central nervous system: Although MS is the most common, other conditions can damage myelin in the CNS, including viral infections, side effects from high exposure to certain toxic materials, severe vitamin B12 deficiency, autoimmune conditions that lead to inflammation of blood vessels (the "collagen-vascular diseases"), and some rare hereditary disorders.

• Demyelination in the peripheral nervous system: Demyelination of the peripheral nervous system (the nerves outside the brain and spinal cord.) occurs in Guillain-Barré Syndrome. After some injuries, the myelin sheath in the peripheral nervous system regenerates, bringing recovery of function.

Some demyelinating conditions are self-limiting, while others may be progressive. Careful (and sometimes repetitive) examinations may be needed to establish an exact diagnosis among the possible causes of neurologic symptoms.

Treatment

Although there is still no cure for MS, effective strategies are available to modify the disease course, treat exacerbations (also called attacks, relapses, or flare-ups), manage symptoms, improve function and safety, and provide emotional support. In combination, these treatments enhance the quality of life for people living with MS. If attacks are mild or infrequent, the doctor may advise a wait-and-see approach, with counseling and observation.

Medications

For a relapsing form of the disease, the doctor may recommend treatment with disease-modifying medications early in the course of disease. Women who are pregnant or may become pregnant cannot take these medications. These medications for multiple sclerosis treatment include:

• Interferon beta-1b (Betaseron) and interferon beta-1a (Avonex, Rebif) are genetically engineered copies of proteins that occur naturally in the body. They help fight viral infection and regulate the immune system. The FDA has approved beta interferons only for people with relapsing forms of MS who can still walk. Beta interferons don't reverse damage and haven't been proved to significantly alter long-term development of permanent disability. Some people develop antibodies to beta interferons, which may make them less effective. Other people can't tolerate the side effects, which may include symptoms similar to those of the flu (influenza).
• Glatiramer (Copaxone) is an alternative to beta interferons for relapsing remitting MS. Doctors believe that glatiramer works by blocking the immune system's attack on myelin. Glatiramer is injected subcutaneously once daily. Side effects may include flushing and shortness of breath after injection.
• Natalizumab (Tysabri) is administered intravenously once a month. It works by blocking the attachment of immune cells to brain blood vessels — a necessary step for immune cells to cross into the brain — thus reducing the immune cells' inflammatory action on brain nerve cells. Use of this drug is associated with the possibility of significant liver injury as early as six days after the first dose, and have also been reported after multiple doses.
• Mitoxantrone (Novantrone) is a chemotherapy drug used for many cancers. This drug is also FDA-approved for treatment of aggressive forms of relapsing remitting MS, as well as certain forms of progressive MS. It's given intravenously, typically every three months. Mitoxantrone may cause serious side effects, such as heart damage, after long-term use, so it's typically not used for longer than two to three years. And it's typically reserved for people with severe attacks or rapidly advancing disease who don't respond to other treatments. Close monitoring is critical for anyone on this medication.
• Cyclophosphamide (Cytoxan): Some doctors are also prescribing other chemotherapy drugs, such as Cytoxan, for people with severe, rapidly progressing MS. However, these medications aren't FDA-approved for treatment of MS.

The journal, Nature Medicine, reported in August, 2009, on an experimental treatment that induces remission in mice of a disease model of multiple sclerosis.^{[1] [2]} The procedure converts harvested naive B-cells ex vivo into immune-suppressive cells evidenced by in vivo reversal of the disease after re-injection into the affected mice.

Some medications may relieve symptoms of progressive MS. They include:

• Corticosteroids: Doctors most often prescribe short courses of oral or intravenous corticosteroids to reduce inflammation in nerve tissue and to shorten the duration of flare-ups. Prolonged use of these medications, however, may cause side effects, such as osteoporosis and high blood pressure (hypertension), and the benefit of long-term therapy in multiple sclerosis isn't established.
• Muscle relaxants: Baclofen (Lioresal) and tizanidine (Zanaflex) are oral treatments for muscle spasticity. People with multiple sclerosis may experience muscle stiffening or spasms, particularly in the legs, which can be painful and uncontrollable. This typically occurs in people with persisting or progressive weakness of their legs. Baclofen may temporarily increase weakness in the legs. Tizanidine controls muscle spasms without causing the legs to feel weak, but can be associated with drowsiness or a dry mouth.

To help combat fatigue, the doctor may prescribe an antidepressant medication, the antiviral drug amantadine (Symmetrel) or a medication for narcolepsy called modafinil (Provigil). All drugs prescribed for this purpose appear to work because of their stimulant properties. One study has showed that aspirin treatment may be effective in controlling MS-related fatigue; further research is planned to address the benefits of aspirin on fatigue.

Other medications

Many medications are used for the muscle stiffness, depression, pain and bladder control problems associated with multiple sclerosis. Drugs for arthritis and medications that suppress the immune system may slow MS in some cases.

Therapies

In addition to medications, these treatments also may be helpful:

Plasma exchange may help restore neurological function in people with sudden severe attacks of MS-related disability who don't respond to high doses of steroid treatment. This procedure involves removing some of the person's blood and mechanically separating the blood cells from the fluid (plasma). The blood cells then are mixed with a replacement solution, typically albumin, or a synthetic fluid with properties like plasma. The solution with the blood is then returned to the patient's body.

Replacing a person's plasma may dilute the activity of the destructive factors in the immune system, including antibodies that attack myelin, and help the person to recover. Plasma exchange has no proven benefit beyond 3 months from the onset of the neurological symptoms.

Rehabilitation programs focus on improving or maintaining the ability to perform effectively and safely at home and at work. Rehabilitation professionals focus on overall fitness and energy management, while addressing problems with accessibility and mobility, speech and swallowing, and memory and other cognitive functions. Rehabilitation programs include:

• Physical therapy
• Occupational therapy
• Therapy for speech and swallowing problems
• Cognitive rehabilitation
• Vocational rehabilitation

Holistic and alternative treatments

Integrative medicine includes everything from exercise and diet to food supplements, stress management strategies, and lifestyle changes. These therapies come from various disciplines and traditions—yoga, hypnosis, relaxation techniques, traditional herbal healing, Chinese medicine, macrobiotics, naturopathy, and many others. They are referred to as complementary when they are used in conjunction with conventional medical treatments and alternative when they are used instead of conventional treatments.

Research

Recent discoveries

• Smoking worsens the prognosis in MS. ^[3]
• A study showed that the incidence of sleep problems was higher in patients with MS than in the general population. MS patients should be screened for sleep disturbances. ^[4]
• The use of complementary and alternative medicine was evaluated in the treatment of MS. ^[5]
• A study was done to determine whether or not inhaled cannabis improves symptoms in patients with multiple sclerosis. ^[6]
• Constraint-Induced (CI) Movement Therapy was evaluated as a treatment for MS. ^[7]
• The use of Omega-3 in the treatment of MS. ^[8]
• Using testosterone to treat MS. ^[9]

Future research

• An ongoing study is looking at whether immediate initiation of therapy with Interferon Beta-1a (AVONEX) after a first attack of multiple sclerosis continues to delay the development of further attacks and the development of neurological disability over a 10 year period of observation. ^[10]
• Another study is evaluating the safety and tolerability of a combination of interferon beta 1-b (Betaseron®) and tacrolimus (Prograf®) in patients suffering from multiple sclerosis (MS) who have failed treatment with currently approved drugs for MS. Prograf is an immunosuppressant that weakens the immune reactions responsible to protect the organism against infections. ^[11]
• A Phase II, randomized, open-label, three-arm study is comparing low-and high-dose alemtuzumab (CAMPATH) and high-dose interferon beta 1-a in patients with early, active relapsing-remitting Multiple Sclerosis (MS) who have not been previously treated with immunotherapies other than steroids. ^[12]
• The use of glatiramer acetate (Copaxone) with or without albuterol to treat MS. ^[13]

Chances of Developing Multiple Sclerosis

According to the National Multiple Sclerosis Society, there are approximately 400,000 people with multiple sclerosis in the U.S., with 200 more people diagnosed every week.^[14] Worldwide, MS is thought to affect more than 2.5 million people. While the disease is not contagious or directly inherited, epidemiologists have identified factors in the distribution of MS around the world that may eventually help determine what causes the disease. These factors include gender, genetics, age, geography, and ethnic background.

Risk factors

• Gender: As in other autoimmune diseases, MS is significantly more common (at least 2-3 times) in women than men. This gender difference has stimulated important research initiatives looking at the role of hormones in MS.
• Genetics: MS is not directly inherited, but genetics play an important role in who gets the disease. While the risk of developing MS in the general population is 1/750, the risk rises to 1/40 in anyone who has a close relative (parent, sibling, child) with the disease. Even though identical twins share the same genetic makeup, the risk for an identical twin is only 1/25—which means that some factor(s) other than genetics are involved.
• Age: While most people are diagnosed between the ages of 20 and 50, MS can appear in young children and teens as well as much older adults. Studying the disease in different age groups may help scientists determine the cause of MS and explain why the disease course differs from one person to another. Important questions include why the disease appears so early in some children and why people who are diagnosed after age 50 tend to have a more steadily progressive course that primarily affects their ability to walk.
• Geography: In all parts of the world, MS is more common in areas that are farther from the equator and less common in areas closer to the equator. Researchers are now investigating whether increased exposure to sunlight and the vitamin D it provides may have a protective effect on those living nearer the equator.
• Ethnicity: MS occurs most commonly in Caucasians of northern European ancestry, but other ethnic groups—including Africans, Asians, and Hispanics—also develop MS. And some ethnic groups (regardless of where they live in relation to the equator), such as the Inuit, Aborigines, Maoris, and others, do not develop MS. These variations that occur even within geographic areas with the same climate suggest that geography, ethnicity, and other factors interact in some complex way.

Clinical Trials

Over a dozen clinical trials testing potential therapies are underway, and additional new treatments are being devised and tested in animal models. A list of clinical trials is available here

Expected Outcome

A physician may diagnose MS in some patients soon after the onset of the illness. In others, however, doctors may not be able to readily identify the cause of the symptoms, leading to years of uncertainty and multiple diagnoses punctuated by baffling symptoms that mysteriously wax and wane. The vast majority of patients are mildly affected, but in the worst cases, MS can render a person unable to write, speak, or walk. MS is a disease with a natural tendency to remit spontaneously, for which there is no universally effective treatment.

References

1. ↑ Rafei M, Hsieh J, Zehntner S, Forner K, Birman E, Boivin M-N, Young YK, Perreault C, Galipeau J. (2009) A granulocyte-macrophage colony-stimulating factor and interleukin-15 fusokine induces a regulatory B cell population with immune suppressive properties. Nat Med advance online publication: 9 August 2009.
2. ↑ Multiple sclerosis successfully reversed in animals. PhysOrg.com August 11, 2009.
3. ↑ Sundström P, Nyström L. Smoking worsens the prognosis in multiple sclerosis. Mult Scler. 2008 Jul 16. (Epub ahead of print) Abstract
4. ↑ Bamer AM, Johnson KL, Amtmann D, Kraft GH. Prevalence of sleep problems in individuals with multiple sclerosis. Mult Scler. 2008 Jul 16. (Epub ahead of print) Abstract
5. ↑ Schwarz S, Knorr C, Geiger H, Flachenecker P. Complementary and alternative medicine for multiple sclerosis. Mult Scler. 2008 Jul 16. (Epub ahead of print)
6. ↑ Ghaffar O, Feinstein A. Multiple sclerosis and cannabis: a cognitive and psychiatric study. Neurology. 2008 Jul 15;71(3):164-9. Epub 2008 Feb 13. Abstract
7. ↑ Mark VW, Taub E, Bashir K, et al. Constraint-Induced Movement therapy can improve hemiparetic progressive multiple sclerosis. Preliminary findings. Mult Scler. 2008 Jun 23. (Epub ahead of print) Abstract
8. ↑ ClinicalTrials.gov. Omega-3 Fatty Acid Treatment in Multiple Sclerosis
9. ↑ Sicotte NL, Giesser BS, Tandon V, et al. Testosterone treatment in multiple sclerosis: a pilot study. Arch Neurol. 2007 May;64(5):683-8. Abstract | Full Text
10. ↑ ClinicalTrials.gov. Long Term Study of Avonex Therapy Following a First Attack of Multiple Sclerosis
11. ↑ ClinicalTrials.gov. Combination Therapy of Betaseron-Prograf in Multiple Sclerosis
12. ↑ ClinicalTrials.gov. A Phase II Study Comparing Low- and High-Dose CAMPATH and High-Dose Rebif in Patients With Early, Active Relapsing-Remitting Multiple Sclerosis
13. ↑ ClinicalTrials.gov. Treatment of Multiple Sclerosis With Copaxone and Albuterol
14. ↑ National Multiple Sclerosis Society. Who gets MS?

External Links

• Accelerated Cure Project for MS: www.acceleratedcure.org
• Multiple Sclerosis Association of America: www.msassociation.org
• Multiple Sclerosis Foundation: www.msfocus.org
• Multiple Sclerosis Research Center of New York: www.msrcny.org
• Myelin Repair Foundation: www.myelinrepair.org
• National Multiple Sclerosis Society - National Multiple Sclerosis Society of the United States: www.nationalmssociety.org
• Nancy Davis Foundation for Multiple Sclerosis:www.erasems.org
• MS Views and News: www.msviewsandnews.org