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MS and autonomic dysfunction
How often does autonomic dysfunction occur in MS and can it improve after the relapse that set it off?
Hey Ren,
I questioned this too, even though I still haven't gotten my MS dx. I struggle with high bp now and heart rhythm problems. Everything I've read mentions these problems as related to MS, but there haven't been any in depth studies.
They do say that spinal cord lesions are the culprit and we both have those!!
I hope you are doing okay, I miss talking to you.
L, H & P
doni
I questioned this too, even though I still haven't gotten my MS dx. I struggle with high bp now and heart rhythm problems. Everything I've read mentions these problems as related to MS, but there haven't been any in depth studies.
They do say that spinal cord lesions are the culprit and we both have those!!
I hope you are doing okay, I miss talking to you.
L, H & P
doni
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I have the problem with being too cold all the time. I am always the one with a heavy coat or sweater. I know people with MS aren't supposed to do this, but I'm always turning up the heat in the shower. I didn't use to be this way. Plus the cold hands and feet, which may be a failure of the ANS to regulate the dilation of the blood vessels in the extremities.
I got a book called "Multiple Sclerosis: Diagnosis, Medical Management, and Rehabilitation" from the library. It has a chapter on autonomic disorders by Benjamin H. Eidelman. Eidelman argues that ANS problems in MS are underappreciated because they are often "insidious and subtle in nature" compared to the more blatant symptoms like motor or balance problems. They aren't really looked for in the typical neuro exam. All the time gets used up on more in your-face-problems.
He discusses the following areas:
BLOOD PRESSURE CONTROL
"An important feature of autonomic failure is orthostatic hypotension [or postural hypotension, where your blood pressure drops abruptly when you stand up or change posture], which results in wide-ranging symptoms. Patients may describe dizziness, lightheadedness, or syncope [fainting] when adopting a sitting or standing position."
CUTANEOUS VASOMOTOR FUNCTION
This seems to mean impaired control of the blood vessels serving the skin and can lead to altered skin appearance, such as changes in color or temperature changes where the skin feels hot or cold. He says the neuro should also ask about "changes in skin texture, development of indolent ulcers, and disturbances of hair and nail growth."
SUDOMOTOR FUNCTION
ANS dysfunction can lead to little or no sweating.
TEMPERATURE REGULATION
The hypothalamus, centers in the brainstem, and descending pathways in the spinal cord are important for maintaining normal body temperature.
" Thermoregulation is a finely controlled function, which in essence requires a balance between heat production and heat loss. Temperature regulation essentially is controlled by the hypothalamus and other components of the ANS, but metabolic and endocrine responses also play a role in thermoregulation. Temperature homeostasis thus relies on a central control mechanism affected by the hypothalamus and the AND and a peripheral system where heat is generated or lost. Skeletal-muscle activity is a major source of heat production. Heat is dissipated to the environment by cutaneous vasodilation, and this can be increased by sweating, which promotes heat loss by evaporation. In MS, both the central control mechanism, namely, the hypothalamus and its autonomic components, and the peripheral components may be defective. Multiple sclerosis patients are thus at risk for the development of both hypothermia and hyperthermia."
BLADDER FUNCTION
"Disturbances may include detrusor instability, resulting in marked frequency and urgency of micturition, as well as detrusor-external sphincter dyssynergia, which may affect the ability to adequately void. Sphincter control may be impaired, resulting in incontinence."
SEXUAL FUNCTION
"Erectile function is under control of the ANS and thus may be a symptom of disturbed ANS function."
BOWEL FUNCTION
"The gastrointestinal tract is innervated by autonomic nerves, and the ANS plays an important role in maintaining normal gastrointestinal function." MS can mess up your bowel function. It usually leads to severe constipation, but can also cause diarrhea. "The upper portion of the gastrointestinal tract may be involved and gastroparesis may occur, presenting as anorexia, bloating, nausea, and vomiting. Loss of secretomotor function may result in decreased saliva production presenting as dryness of the mouth."
OCULAR FUNCTION
Dysfunction of the ANS can cause problems with the lacrimal glands that keep the eyes moist, thus leading to dry eyes. There can be other eye problems. For example, "pupil reactions may be disturbed, giving rise to photophobia, glare intolerance, and impairment of focusing."
He discusses things that neuros should look for on the exam and things they should ask patients about. He also talks about lab testing for ANS problems.
Not sure how helpful this is, but I thought the point that neuros aren't usually actively looking for autonomic problems might help explain the perception that autonomic problems are so uncommon. Plus neuros and other outsiders can't see ANS problems.. You should be able to see some of this chapter on google books at http://books.google.com/books?id=iUt_BdDDBHoC.
Some other info that may be of use if you haven't seen it:
"The hypothalamus controls autonomic functions, temperature, sleep, and sexual activity. Cortical, brainstem, and spinal cord plaques often interrupt the sympathetic nervous system. This causes slow colonic transit, bladder hyperreflexia, and sexual dysfunction. Less-recognized phenomena from sympathetic nervous system disruption are vasomotor dysregulation (cold, purple feet), cardiovascular changes (orthostatic changes in blood pressure, blood pressure response to straining, and poor variation of the EKG R-R interval on Valsalva maneuver, possibly increasing risk of surgery), poor pilocarpine-induced sweating, poor sympathetic skin responses—especially in progressive multiple sclerosis (Karaszewski et al 1990; Acevedo et al 2000), pupillary abnormalities, and possibly fatigue. Rarely, plaques in brainstem autonomic pathways cause atrial fibrillation or neurogenic pulmonary edema, sometimes preceded by multiple sclerosis lesion-induced cardiomyopathy. Cold hands and feet often precede the diagnosis of multiple sclerosis, raising the possibility that undetected spinal cord lesions have already affected the autonomic nervous system.
"Sixty percent of patients have pupillary reactions that are abnormal in rate and degree of constriction (de Seze et al 2001). Pupillary defects do not correlate with visual-evoked potentials or history of optic neuritis.
"Autonomic dysfunction does correlate with axonal loss and spinal cord atrophy, yet not with cord MRI lesions. It is possible that plaques in the insular cortex, hypothalamus, and cord all disrupt sympathetic pathways. Parasympathetic and sympathetic dysfunction correlates with duration of multiple sclerosis, but not with disability (Gunal et al 2002). Parasympathetic dysfunction (eg, heart rate variation with respiration, abnormal pupillary reactions) is most pronounced in primary progressive disease. Sympathetic dysfunction can worsen during exacerbations. It is tied to dysregulated immunity (Flachenecker et al 2001); worse autoimmune disease in animal models and worse multiple sclerosis (Karaszewski et al 1991); less response to the beta-adrenergic agonist, isoproterenol (Giorelli et al 2004); and conversion to progressive multiple sclerosis…"
http://www.medmerits.com/index.php/article/multiple_sclerosis/P2
sho