Multiple sclerosis is a slowly progressive central nervous system (CNS) condition involving demyelination of a nerve or nerves occurring in patches throughout the white matter of the brain and spinal cord.

The cause of the condition is unknown; however, an immunologic abnormality is suspected.

The onset of the condition is usually gradual. Excessive heat such as warm weather, a hot bath, or a fever, may aggravate signs and symptoms. The common initial signs and symptoms may include: weakness; numbness; tingling or unsteadiness in a limb; spastic paraparesis; neuritis behind the eyeball; double vision; disequilibrium; and urinary urgency or hesitancy. Symptoms may disappear after a few days or weeks, while examination may reveal a residual deficit. Signs and symptoms may occur months or years before the disease is recognized. Manifestations related to central nervous system involvement may include: tingling in one or more extremities, the trunk, or one side of the face; and weakness or clumsiness of a foot or hand. There may be a visual disturbance including partial blindness, pain in one eye, dimness of vision, or scotomas. The condition is also characterized by ocular palsy resulting in diplopia; transient weakness in one or more extremities; slight stiffness or unusual fatigability of a limb; minor walking disturbance; difficulty in bladder control; vertigo; and mild emotional disturbance. Mental signs and symptoms may include: apathy; lack of judgement or inattention; emotional instability; mild elation or a reactive depression; or sudden weeping or forced laughter. Occurrences late in the condition may include: dementia; and a slow enunciation with hesitancy at the beginning of a word or syllable. Signs and symptoms of cranial nerve involvement may include: inflammation of the optic nerve; partial optic nerve deterioration; changes in the visual field; double vision; nystagmus; and dizziness. Signs and symptoms of motor involvement may include increased reflexes, and intention tremor. The motion demonstrated is ataxic, shaky, tremulous, and ineffective. Babinski's sign and muscle spasms may be present. There may be muscular weakness and spasticity, causing a stiff, imbalanced gait. In addition, there may also be stumbling, weaving, and hemiplegia, which may be the presenting symptoms. Signs and symptoms of spinal cord involvement may include: urinary urgency, or hesitancy; partial retention of urine; uncontrollable urination; constipation; and erectile dysfunction.

Diagnosis of multiple sclerosis is based on clinical and laboratory tests. A firm diagnosis is difficult to make after the first attack; however, it can be suspected. Tests may include computed tomography (CT) scan, magnetic resonance imaging (MRI), and cerebrospinal fluid (CSF) examination. Early in the disease, electrical responses to stimulation of a sensory system may be abnormal.

Although there is no specific treatment, the following measures are currently being used: corticosteroid administration is the main form of treatment which may hasten recovery in acute attacks and minimize or prevent permanent neurologic deficits. Immunomodulatory therapy may be used to reduce the frequency of relapses and may help delay eventual disability. Intravenous (IV) gamma globulins may be given monthly to help control relapses. Muscle relaxants may be used to reduce spasticity. Other forms of treatment may include: medication for painful sensory symptoms; massage to make the patient more comfortable; physical therapy for gait training; range of motion training for weak, spastic limbs; and counseling and antidepressant medication for clinical depression.

Any of the signs and symptoms may continue to progress in severity. It is essential that the patient attempt to maintain as normal and active life as possible, but to avoid overwork and fatigue. Drugs used to reduce spasticity may enhance weakness and lead to further incapacitation of the patient. The condition is usually characterized by periods of remissions and exacerbation. The person may become totally incapacitated.

• In those cases where there is severe neurologic deficit, consider entitlement under 38 CFR 3.350 [Special monthly compensation ratings]; competency under 38 CFR 3.353 [Determinations of incompetency and competency]; and ancillary benefits under 38 CFR 3.807, 38 CFR 3.808 [Automobiles or other conveyances; certification], 38 CFR 3.809 [Specially adapted housing], and 38 CFR 3.809a [Special home adaptation grants].

• Multiple sclerosis is an unusual disease process in that it is not only difficult to diagnosis, but the symptoms of the disease can "wax and wane" for extended periods of time before manifesting themselves as ascertainable residuals. For example, slurred speech, visual disturbances, and unsteadiness of gait may be present one day and completely resolved in a very short period of time. It is important to recognize this characteristic when assigning an evaluation for multiple sclerosis. The importance of a complete record of chronological events is extremely helpful in this regard as are complete medical records spanning an extended period of time rather than relying on one, or even two, examinations.

• Because multiple sclerosis is difficult to diagnosis, it is not unusual to encounter a diagnosis of "demyelinating disease." If service connectable, rate demyelinating disease in analogy to multiple sclerosis; however, a definitive diagnosis of multiple sclerosis is required to meet the requirements of the presumptive provisions of 38 CFR 3.309 [Disease subject to presumptive service connection]. For additional guidance refer to 38 CFR 3.307(c) [Prohibition of certain presumptions]. In an unusual case, an Advisory Opinion may be solicited from VA Central Office.

• Multiple sclerosis has a 7 year presumptive period. This disease shall be granted service connection although not otherwise established as incurred in or aggravated by service if manifested to a compensable degree within the applicable time limits under §3.307 following service in a period of war or following peacetime service on or after January 1, 1947, provided the rebuttable presumption provisions of 38 CFR 3.307 are also satisfied [38 CFR 3.309 [Disease subject to presumptive service connection], 38 CFR 3.309(a) [chronic disease].

Notes

• It is required for the minimum ratings for residuals under diagnostic codes 8000-8025, that there be ascertainable residuals. Determinations as to the presence of residuals not capable of objective verification, i.e., headaches, dizziness, fatigability, must be approached on the basis of the diagnosis recorded; subjective residuals will be accepted when consistent with the disease and not more likely attributable to other disease or no disease. It is of exceptional importance that when ratings in excess of the prescribed minimum ratings are assigned, the diagnostic codes utilized as bases of evaluation be cited, in addition to the codes identifying the diagnoses.

• Disability in this field is ordinarily to be rated in proportion to the impairment of motor, sensory or mental function. Consider especially psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, injury to the skull, etc. In rating disability from the conditions in the preceding sentence refer to the appropriate schedule. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances.  38 CFR 4.120

• With the exceptions noted, disability from the following diseases and their residuals may be rated from 10 percent to 100 percent in proportion to the impairment of motor, sensory, or mental function. Consider especially psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, etc., referring to the appropriate bodily system of the schedule. With partial loss of use of one or more extremities from neurological lesions, rate by comparison with the mild, moderate, severe, or complete paralysis of peripheral nerves” 38 CFR 4.124a