Current Approaches for the Management of Multiple Sclerosis – A Review

Multiple sclerosis (MS) is an autoimmune, neuroinflammatory disease which interfere with the central nervous system and damage the myelin sheath and axons. It is mediated by auto-reactive lymphocytes that cross the blood brain barrier cause inflammation, demyelination and axonal loss disturb the communications between the neurons. The exact cause of the MS is not known but it is reported that it may be due to the genetic, environmental factors, viral infections (Epstein Barr virus). There are various approaches for the management of Multiple sclerosis like disease modifying agents are mainly used. Some of the monoclonal antibodies (Ocrelizumab) are approved recently for the management of MS. Due to various unwanted side effects with conventional medicines people are eager to use cost effective medicines with no or less side effects; therefore herbal medicines are best choice for them, they works by different pharmacological actions like reduce oxidative stress, anti-inflammatory, antioxidant effects and others. Mainly used herbal plants like Ginkgobiloba, Salvia officinalis, Nigella sativa.


INTRODUCTION
Multiple sclerosis is a chronic and progressive autoimmune, inflammatory, neurologicaldisease of the CNS. It destroysthe myelin sheath and axons to the varying degrees [1]. It is characterized by inflammation, selective demyelination and gliosis.It targets the Central nervous system and it is mediated by autoreactive lymphocytes that cross the blood-brain barrier. These lymphocytes enter the CNS and cause local inflammation resulting in demyelination and axonal loss; by damaging the protective covering of the nerve axons (myelin sheath)cause communication problem between your brain and rest of your body [2]. According to World Health Organization Multiple Sclerosis affects approximately 2.8 million people worldwide, and multiple sclerosis affects the people age between 20-50 years old and it is investigated that females are more prone to the multiple sclerosis than males [3]. The multiple sclerosis characteristic features are common vision loss, pain, fatigue, and impaired coordination, low personal activity-related selfeffectiveness, limitation of self-regulatory concepts, socio-demographic factors restrictions, decline employment state, and decrease educational level [4]. People with multiple sclerosis may also develop; muscle stiffness or spasm, paralysis typically in the legs, problems with bladder, bowel, sexual functions, mental changes depression epilepsy. The cause is unknown, but it appears to involve a combination of genetic factors and non-genetic factors such as environmental factors, virus, Metabolism that together result in a self-sustaining autoimmune disorder that leads to recurrent immune system attacks on the central nervous system [5]. All the Multiple Sclerosis treatments try to attempt to improve the neuronal function following Multiple Sclerosis occurs and stop any progression of the disease. The use of Multiple Sclerosis treatments in the early stage of Multiple Sclerosis can induce adverse side effects and can be ineffective at all. The treatments with good results are observed in teenager women where Multiple Sclerosis appears early with relapsing type with few neurons damaged. Multiple Sclerosis decreases life with an average 5-10 years than other healthy ones. There are many treatments and diagnostic procedures of Multiple Sclerosis are in the process of development [3].
Neurologists agree that patients may be grouped into four major categories based on the course of disease.

CAUSES
The exact cause of the multiple sclerosis is unknown but some of the investigations shows that it may be due to the genetic and environmental factors some other cause are such as viral infections. Most of the studies suggest that multiple sclerosis is immune-genetic viral disease with Epstein Barr Virus [7].
Risk factors are age (most of the time between 20-50 years old), sex (females are more prone to multiple sclerosis than males), family history (genetic susceptibility), certain viral infections like EBV, vitamin D deficiency [8].
Some other risk factors like climate (more in cold areas), autoimmune diseases (higher risks with thyroid diseases, type 1 DM, and IBS), smoking, stress, fatigue, physical injury.

PATHOPHYSIOLOGY
Due to etiological factors activated T cells (recognise self-antigen) gain entry into the brain via disruption in the blood brain barrier and macrophages (B cells) enters into the brain from peripheral circulation, production of inflammatory cytokines and free radical species than activated B cells and T cells causes demyelination and destruction of oligodendrocytes and damage the immune system; oligodendrocytes are the cells which are responsible for myelination of axonal nerves now without oligodendrocytes there's no more myelination to the axon. Formation of plaque cause scarring and destruction of sheath it further interrupt the transmission of impulses. Demyelinated axons scattered irregularly throughout the CNS. The most frequently affected areas are the optic nerves, cerebrum, brain stem, cerebellum, and spinal cord. On early stages oligodendrocytes can heal and remyelination of the axons occurs but over time remyelination will stop and damage will become permanent or irreversible with loss of axons [9,10,11].

CURRENT TREATMENT
There is currently no cure for Multiple Sclerosis. The objective of the drugs are to suppress the immune response slow disease progression, limit relapses, decrease long-term neurologic impairment, and manage symptoms while limiting adverse reactions. Disease modifying therapies discussed below are approved for RRMS. Other types of MS are typically treated with the same

Symptomatic Treatment [18,19]
Dalfampridine is a FDA approved drug which used to improve walking in people who have multiple sclerosis, it works by blocking the potassium channels on the surface of nerve fibres.

HERBAL APPROACHES FOR THE MANAGEMENT OF MULTIPLE SCLEROSIS
Nowadays peoples are eager to use treatment which must be cost effective and with lesser adverse effects. Herbal medicines have lesser side effects or no side effects as compared to conventional drug therapies. Upon several investigations it is reported that There are so many medicinal plants which contain different active constituents like flavonoids, alkaloids, saponins, essential oils, tannins etc; belongs to specific families like araliaceae, zingiberaceae, umbelliferae; have the potential to treat or

CONCLUSION
Multiple sclerosis (MS) is an autoimmune disease that affects the central nervous system in various ways. It damages the protecting myelin coating and axons, affecting neuron connection. Females are more prone to MS than males. The exact cause of MS is unknown, but according to several reports it may be due to the genetic, environmental factors, viral infections; Epstein-Barr virus. Till now there is no cure for MS and there are various synthetic FDA drugs, monoclonal antibodies which may used for the management of Multiple sclerosis. But due to the undesirable side effects of the synthetic medicines peoples are eager to use cost effective medicines with no or less side effects therefore herbal medicines are best choice for them because herbal medicines have no adverse effects or less side effects as compared to that of conventional medicines. They works by different pharmacological actions like anti-inflammatory, antioxidant, reduce oxidative stress and others.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.