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Open research questions in Multiple Sclerosis Research Studies

99 unresolved questions extracted from the limitations and future-work sections of 886 Multiple Sclerosis Research Studies papers in our library. Each links back to the study that raised it.

What the literature leaves open

  • While the present study focused on global brain volumetry and white matter lesion burden, future studies could investigate whether specific lesion locations, regional patterns of brain atrophy measures, or longitudinal changes in MRI better explain the differences observed between cognitive phenotypes. Although validated tools with proven performance were used for brain structure and MS lesion segmentation, the absence of manual refinement represents a limitation of this study, as residual segmentation errors could have influenced individual measurements. This observation may reflect the influence of cognitive reserve and other factors that modify the clinical manifestations of multiple sclerosis and warrants further investigation.

    Machine learning methods evaluation for identification of cognitive phenotypes in multiple sclerosis and their MRI correlates · 2026 · DOI
  • Introduction Cognitive reserve (CR) is associated with better cognitive outcomes in people with multiple sclerosis (PwMS), yet the neurophysiological factors mediating this relationship remain poorly understood.

    Preserved α2 oscillations underpin reserve-related resilience of semantic verbal fluency in multiple sclerosis · 2026 · DOI
  • However, clinical trials have yielded inconsistent results, and prior meta-analyses were limited by mixed MS subtypes and non-randomized studies, leaving uncertainty about MSC’s clinical utility in PMS.

    Efficacy and safety of mesenchymal stem cell transplantation for progressive multiple sclerosis: a systematic review and meta-analysis of randomized controlled trials with clinical implications for patient stratification and treatment optimization · 2026 · DOI
  • Comprehensive biomarkers of multiple sclerosis (MS) capable of simultaneously diagnosing the condition, capturing symptom severity and predicting treatment efficacy remain elusive.

    Brain Network Excitability Predicts Clinical Severity in Multiple Sclerosis · 2026 · DOI
  • Introduction- Choroid plexus (CP) enlargement on brain MRI has been identified as an emerging neuroinflammatory biomarker in multiple sclerosis (MS), yet its relationship to downstream parenchymal neurochemical abnormalities remains unknown.

    Choroid Plexus Enlargement is Associated with Disease Severity and Elevated White Matter Myo-inositol in Progressive Multiple Sclerosis · 2026 · DOI
  • Abstract Purpose Pilates-based exercise has gained attention as a non-pharmacological rehabilitation strategy for people with multiple sclerosis (MS), yet the comparative effectiveness of different Pilates modalities remains uncertain.

    Comparative effects of pilates-based interventions on functional mobility, balance, fatigue, and quality of life in people with multiple sclerosis: a systematic review and network meta-analysis · 2026 · DOI
  • Several limitations warrant consideration. First, SWI phase imaging was only available for a limited period, and consequently the sample size was small. Second, the majority of patients had low EDSS scores and short disease duration, which was an obstacle to evaluating long-term progression. Third, age and REFERENcEs 1. Buzzard K, Chan WH, Kilpatrick T, Murray S. Multiple Sclerosis: Basic and Clinical. Adv Neurobiol. 2017;15:211-252. doi: 10.1007/978-3-319-57193- 5_8. PMID: 28674983. 2. Sarbu N, Shih RY, Jones RV, Horkayne-Szakaly I, Oleaga L, Smirniotopoulos JG. White Matter Diseases with Radiologic-Pathologic Correlation. Radiographics. 2016 Sep-Oct;36(5):1426-47. doi: 10.1148/rg.20161600 31. Update in: Radiographics. 2020 May-Jun;40(3):E4-E7. doi: 10.1148/ rg.2020190204. PMID: 27618323. 3. Kornienko VN, Pronin IN. Diagnostic neuroradiology. 1st ed. Berlin: Springer; 2009. p. 1–1288. 4. Alroughani R, Boyko A. Pediatric multiple sclerosis: a review. BMC Neurol. 2018 Mar 9;18(1):27. doi: 10.1186/s12883-018-1026-3. 5. Krieger SC, Cook K, De Nino S, Fletcher M. The topographical model of multiple sclerosis: A dynamic visualization of disease course. Neurol Neuroimmunol Neuroinflamm. 2016 Sep 7;3(5):e279. doi: 10.1212/NXI. 0000000000000279. PMID: 27648465; PMCID: PMC5015541. 6. Samuels MA, Ropper AH, Klein J. Adams and Victor’s principles of neurology. 10th ed. New York: McGraw-Hill; 2014. 7. van Munster CE, Uitdehaag BM. Outcome Measures in Clinical Trials for Multiple Sclerosis. CNS Drugs. 2017 Mar;31(3):217-236. doi: 10.1007/ s40263-017-0412-5. baseline EDSS were not well balanced between the IRL-positive and IRL-negative groups, resulting in a possibility of confounding. Fourth, information on treatment regimens, duration of DMTs, and recent relapses was not uniformly available and therefore could not be studied, although these factors may have affected disability status. Inter- and intra-ob- server reproducibility were not evaluated because of limited resources, which is recognized as a limita- tion. Finally, as this report is an exploratory study with a small sample size, the statistical results are also vulnerable to overfitting; uncorrected p-values were presented, and secondary findings without ad- justment for multiple comparisons should be inter- preted cautiously. cONcLUsION Iron rim lesions on SWI phase imaging were as- sociated with higher disability scores and lesion vol- ume in patients with relapsing–remitting multiple sclerosis. The data suggest that IRLs may correspond to long-lasting active inflammatory pathology in the context of more severe disease; however, causal or predictive statements cannot be drawn due to the cross-sectional nature of the study and the small sample size. The findings should be considered hy- pothesis-generating and need to be confirmed in larger, treatment-stratified prospective studies. Fur- ther studies are needed before IRLs detected on SWI phase imaging can be recommended for routine clinical management in MS. Conflict of interest: The authors declare no conflict of interest. Financial support: none declare 8. Csépány T. Diagnosis of multiple sclerosis: A review of the 2017 revisions of the McDonald criteria [A sclerosis multiplex diagnosztikája: Összefoglaló a McDonald-kritériumok 2017-es felülvizsgálatáról]. Ideggyogy Sz. 2018 Sep 30;71(9-10):321-329. Hungarian. doi: 10.18071/isz.71.0321. PMID: 30335264. 9. European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS). ECTRIMS Congress 2024. Copenhagen; 18–20 September 2024. Available from: https://www.ectrims.eu. 10. Multiple sclerosis. Radiopaedia.org [Internet]. Radiopaedia; 2025 [cited 2026 Feb 2]. Available from: https://radiopaedia.org/articles/multiple- sclerosis. 11. Filippi M, Preziosa P, Arnold DL, Barkhof F, Harrison DM, Maggi P, et al. Present and future of the diagnostic work-up of multiple sclerosis: the imaging perspective. J Neurol. 2023 Mar;270(3):1286-1299. doi: 10.1007/ s00415-022-11488-y. Epub 2022 Nov 24. PMID: 36427168; PMCID: PMC9971159. 12. Kim S, Lee EK, Song CJ, Sohn E. Iron Rim Lesions as a Specific and Prognostic Biomarker of Multiple Sclerosis: 3T-Based Susceptibility-Weighted Imaging.

    Paramagnetic iron rim lesion in multiple sclerosis: a potential imaging biomarker · 2026 · DOI
  • 4 4.2 (1.6) 5 4.9 (1.0) − 1.467.143 Evaluation of the intervention (6-point Likert scale: 1 = very good; 6 = insufficient) Grade (i.e., school grade) 3 3.1 (1.4) 2 2.4 (0.9) − 0.975.330 Table 5. Comfort ratings for the dim red and blue light glasses. DRL, dim red light; BL, blue-enriched light; Mdn, median; M, mean; SD, standard deviation. Inferential statistics were calculated using the Wilcoxon signed-rank test comparing ratings for the DRL (dim red light) and BL (blue light) intervention interventions on VAS_F-measured fatigue levels immediately after exposure and hours later (at 13:00), with significantly higher effects with BL than with DRL. The feasibility of our light treatment was high, and both light interventions were well tolerated. Patients reported a higher severity of side effects regarding overexertion (on two days), stinging eyes (on one day), and glare (on four days) using BL, with significantly better ratings for these glasses than for DRL regarding items such as increasing fitness and well-being, positively influencing the morning, and, importantly, reducing fatigue. Subjectively assessed sleep parameters revealed no negative effects of the light interventions on sleep, but patients reported taking significantly more naps during the day when using the BL than with the DRL glasses. A strength of the present study is the temporal resolution at which fatigue was assessed using the VAS_F. This allowed explorations of the effects of both interventions on the temporal dynamics of MS-related fatigue immediately after light treatment and hours later. Thus, this study provides first evidence for the slight superiority of BL, compared to DRL, in reducing fatigue levels immediately after light exposure as well as for a prolonged duration after light exposure. Considering the small sample size included in the present study, these findings should be interpreted with caution and need to be validated using bigger sample sizes. Comparing baseline with follow-up values, our results add to the findings of past research42,43 by demonstrating a reduction of MS-related fatigue levels in both interventions after only 1 week of usage. Further, we also found clinically significant changes in FSS scores, but only with BL. In contrast to past research, we further analysed each participants’ individual changes in FSS scores throughout the intervention weeks and found variations between patients. Some patients responded only to BL, some responded only to DRL, some responded to both interventions, and some did not respond at all. This highlights stark inter-individual variability of the effects of light therapy and poses the question of whether there are responders and non-responders to light therapy among patients MS and fatigue, as observed in studies evaluating light therapy for SAD60.

    Exploratory crossover field study indicates efficacy and feasibility of light therapy glasses to mitigate fatigue in multiple sclerosis · 2026 · DOI
  • The wider use of ultra-high-field (7T) MRI will further refine the detection of cortical lesions, PRL and microvascular pathology, improving the spatial resolution of compartmentalized inflammation and chronic active lesion dynamics advanced functional and metabolic techniques will be essential to capture network-level and cellular dysfunction. Functional MRI and connectomics may provide sensitive markers of large-scale network disruption, hub vulnerability, and exhaustion of compensatory plasticity, offering clinically meaningful correlates that are only partially explained by focal  Journals (/journals). Beyond structural imaging,   [22,39 ▪ ] lesion burden  hypoconnectivity may better characterize disease-related network collapse and progressive. Integrating structural disconnection with functional hyper- or   Books (/booksbrowse) [44,45] ® [46 ▪▪,47 ▪▪ ].

    MRI in multiple sclerosis: progress in in-vivo pathobiology · 2026 · DOI
  • BackgroundBrain age gap (BAG) is increased in multiple sclerosis (MS), but whether it reflects microstructural pathology beyond conventional atrophy remains unclear.

    Brain age gap correlates with DTI-derived microstructural abnormalities in multiple sclerosis. · 2026 · DOI
  • Introduction Maintenance immunotherapy is effective in AQP4-IgG-positive neuromyelitis optica spectrum disorder (NMOSD), but how mechanistically distinct maintenance therapies organize the remission immune landscape and its relationship to neurological disability remains poorly defined.

    Distinct remission immune architectures under rituximab and azathioprine in AQP4-IgG-positive neuromyelitis optica spectrum disorder · 2026 · DOI
  • Future studies are required to provide clearer insight into the role of environmental contaminants —such as pesticide residues, heterocyclic amines, polycyclic aromatic hydrocarbons, and water pollution—in the etiology of MS.

    Knowledge Levels of Multiple Sclerosis Patients in Hygiene and Food Preparation: A Case-Control Study · 2026 · DOI
  • This study has several limitations. It is a small, singlecentre retrospective analysis and therefore relies on information available in hospital records rather than prospectively collected data. Some potentially relevant variables were not captured. Quality-of-life outcomes and medical comorbidities, which may influence survival, were not routinely recorded and could not be evaluated. We have no data on patients who were offered SPC but declined, or on those managed with IC or indwelling urethral catheterization during the same period. This selection bias means the cohort may not be representative of the broader MS population requiring urinary bladder management. Therefore, conclusions regarding the relative benefits of SPC over alternative urinary bladder management strategies cannot be drawn. Some 145 non-MS patients underwent radiologically guided SPC insertion at our centre during the same period; future studies could use this group as a comparator to better contextualize these findings. Additionally, as data were derived solely from hospital records at a single tertiary centre, complications managed in primary care or by community nursing teams may not have been fully captured, potentially leading to under-reporting of events such as catheter-associated urinary tract infections or catheter expulsions. Urodynamic data were not available for all patients; 1 patient with overactive urinary bladder symptoms could not have NDO formally confirmed. It was also not possible to confirm from available records whether patients received instructions regarding urinary bladder irrigation as part of their catheter care. Our centre has a dedicated neuro-urology service delivered by a urology consultant and MS nurse specialists for people with MS. This specialized service may have facilitated better patient selection and closer monitoring, potentially leading to lower complication rates and improved outcomes. Consequently, these results may not be generalizable to centres without similar multidisciplinary expertise. Retrospective ascertainment of cause of death is subject to inaccuracy. Death certificates were used as the primary source; however, the cause of death could not be ascertained in 4 of 15 patients (27%), which limits the completeness of mortality data. The small sample size and limited number of deaths restricted the complexity of survival modelling. Regression analyses were therefore deliberately limited to parsimonious models to minimize the risk of overfitting.

    Suprapubic catheter insertion in people with multiple sclerosis: long-term complications and survival in a retrospective cohort study · 2026 · DOI
  • However, longitudinal pharmacy dispensing data from Germany indicate stable DMT prescription volumes between 2019 and 2021, with stockpiling limited to the initial pandemic phase and not observed during the present observation period (Orschiedt et al.

    Clinical, demographic, and pharmacological predictors of medication adherence to disease-modifying therapies in multiple sclerosis: a multidimensional analysis of merged survey and claims data · 2026 · DOI
  • The cross-sectional design does not permit causal inference. Although permutation-based multivariable analyses are well suited to non-normally distributed outcomes, they do not provide effect estimates on an additive scale. Claims data capture dispensing rather than ingestion and cannot account for dose adjustments or distinguish intentional from unintentional non-adherence (Hempenius et al. 2021). They also lack clinical detail, including MRI activity, which may influence adherence but was unavailable. Coding misclassification is possible, although unlikely to be systematically related to adherence. The observation period overlapped with the first year of the SARS-CoV-2 pandemic in Germany, during which healthcare delivery and treatment selection were systematically modified (Platen et al. 2022; Reitzle et al. 2021; Portaccio et al. 2022). German pharmacy data nevertheless indicate that overall DMT dispensing remained stable across 2019–2021, with no systematic disruption observed during the present observation window (Orschiedt et al. 2023). Voluntary survey participation Naunyn-Schmiedeberg's Archives of Pharmacology introduces selection bias, and subjective measures remain vulnerable to recall and social desirability effects. Missing survey data were imputed using validated non-parametric procedures; while imputation introduces uncertainty, sensitivity analyses yielded consistent findings. The adherence metric limits generalisability. MPR is derived from dispensing records and depends on patient- initiated refills, rendering intravenous therapies non- evaluable and limiting the analysis to self-administered DMTs. The intramuscular group was small (n = 54; 6.8%), and although the oral–intramuscular difference was not statistically significant, this comparison was estimated less precisely than those involving larger groups. Route and active substance are structurally aligned across available DMTs: the intramuscular group comprises a single once- weekly formulation, whereas the subcutaneous group includes multiple agents with differing schedules and tolerability profiles. Cross-route comparisons therefore reflect combined regimen characteristics rather than isolated route effects, although the within-interferon comparison indicates that route remains relevant when active substance is held constant. MPR quantifies dispensing relative to a label-based reference and is therefore sensitive to differences in prescribed regimens, but it does not identify which regimen-specific features account for the observed effects.

    Clinical, demographic, and pharmacological predictors of medication adherence to disease-modifying therapies in multiple sclerosis: a multidimensional analysis of merged survey and claims data · 2026 · DOI
  • Major strengths of this study include the comprehensive evaluation of reliability, validity, and discriminative perfor- mance, the use of multiple advanced statistical approaches (ICC, SEM, MDC, Bland–Altman, and ROC analysis), and stratification of participants according to EDSS scores, which allowed for a nuanced understanding of functional mobility across the MS spectrum. Limitations include the relatively small and homogeneous sample, the restricted EDSS range (≤ 3.5), cross-sectional sin- gle-center design, and potential confounding factors such as comorbidities and fatigue. These limitations may affect gener- alizability and causal interpretation. Future longitudinal stud- ies with larger and more diverse samples are recommended to confirm these findings and examine the sensitivity of the L Test to disease progression and rehabilitation outcomes.

    Psychometric evaluation of the L Test for functional mobility across EDSS-based severity levels in multiple sclerosis · 2026 · DOI
  • This review adopts a narrative rather than systematic meth- odology. While it provides a broad overview of emerging trends, it does not include a formal risk-of-bias assessment or meta-analysis. The selection of studies was purposive to illustrate key concepts, which may introduce selection bias. However, to mitigate selection bias, studies were selected to reflect a balance of positive, neutral, and critical find- ings, including reports highlighting technical limitations of SyMRI (e.g., synthetic FLAIR artifacts, indirect myelin estimation) and challenges in radiomics reproducibility. Additionally, we did not identify any large-scale studies that conclusively refuted the utility of SyMRI or radiomics in MS; however, several papers highlighted technical and validation challenges. These limitations are inherent to nar- rative reviews and should be considered when interpreting the conclusions.

    Synthetic MRI and radiomics in multiple sclerosis: improving precision in diagnosis and prognosis · 2026 · DOI
  • The provision and reimbursement of physiotherapy and occupational therapy in PwMS varies largely between countries (20, 25, 26, 61). In the Netherlands, a maximum of 10 h of occupational therapy are reimbursed annually and physiotherapy is generally not covered by the basic health insurance, unless part of multidisciplinary rehabilitation. For some chronic conditions, such as MS, only the first 20 physiotherapy sessions are not covered, but subsequent sessions are reimbursed if medically indicated. Citizens can purchase additional health insurance or pay for these therapies themselves. Some study participants reported financial barriers to join therapy. Denmark provides free of charge physiotherapy.

    Importance of physiotherapy and occupational therapy according to people with multiple sclerosis—results from an online survey · 2026 · DOI
  • Ongoing research is focused on refining disease mechanisms, identifying novel therapeutic targets, and integrating advanced technologies to improve diagnosis and treatment outcomes in NMOSD. 9.1 Novel Therapeutic Targets Future therapies aim to go beyond immune suppression and focus on astrocyte protection and complement modulation. Strategies include: • Targeting astrocyte survival pathways to prevent primary injury INTERNATIONAL JOURNAL OF PHARMACEUTICAL SCIENCES 643 | P a g e Varaganti Sai Chitra Prathyusha, Int. J. of Pharm.

    Comprehensive Elucidation of Immunopathogenic Cascades, Astrocytopathy, and Complement-Mediated Neuroinflammation in Neuromyelitis Optica Spectrum Disorder: Integrating Molecular Biomarkers, Advanced Neuroimaging, and Emerging Monoclonal Antibody-Based Therapeutic Strategies · 2026 · DOI
  • responses and Although multiple disease-modifying therapies (DMTs) are currently approved for MS, most primarily target peripheral immune activation and inflammatory cell trafficking rather than directly interrupting OS-driven injury within the CNS. Among approved agents, DMF is the most closely linked to the OS context because, in addition to its immunomodulatory effects, it can enhance cellular antioxidant suppress inflammatory signaling (Blair, 2019; Peng et al., 2012). In contrast, most other approved therapies may reduce oxidative damage only indirectly by attenuating inflammation, but they are not specifically designed to target persistent reactive oxygen and nitrogen species production, mitochondrial dysfunction, ironassociated oxidative injury, or chronic microglial activation. Consequently, although current DMTs effectively reduce relapse rates and inflammatory activity, ongoing neuroaxonal injury and disability progression may still occur in a subset of patients despite treatment (Dendrou et al., 2015; Jayaraman and Jayaraman, 2022; Gharibani et al., 2025). These limitations underscore the need for therapeutic strategies that more directly restore redox homeostasis and interrupt the self-perpetuating cycle between OS and inflammation in MS.

    The oxidative stress-inflammation self-perpetuating cycle in multiple sclerosis: from mechanisms to emerging antioxidant strategies · 2026 · DOI
  • Several important limitations should be considered when interpreting the findings of this study. First, the estimates rely on modeled data from the GBD study, which, like all large-scale epidemiological models, faces particular constraints in regions with less developed health systems. In such settings, limitations in disease reporting, diagnostic access, and registry completeness can affect the accuracy of burden estimates and influence cross-regional comparisons. Second, because the GBD provides populationlevel rather than individual-level data, this analysis could not adjust for person-specific factors such as comorbidities, education, or detailed socioeconomic circumstances. This may obscure variations in risk and outcomes within broader populations. Third, the clinical differences between dementia subtypes create diagnostic challenges. These are the difficulties inherent in the data underlying and can lead to uncertainty in the burden estimates of the subtype. Fourth, the study has chosen a subgroup of adults (55 years and above) with the purpose of analyzing the disease burden in late adulthood, but it inevitably misses other types of these diseases at an earlier age, including multiple sclerosis. Consequently, the results fail to represent the entire clinical spectrum of the diseases. Lastly, the forecasts forwarded presuppose that the current trends will persist and lacks outlook attitudes to the possible future developments of the disease-modifying specifications that could adjust the long-term path and load of the examined diseases. Combining these points, the set of future research should be empowered in several ways to better its impact in the burden field. Finer data collection, combination of each risk factor individually and continuous optimization of diagnostic standards would enhance usefulness of such studies in informing responsive and specific health policies.

    The burden and trends of late-onset multiple sclerosis, Parkinson’s disease, Alzheimer’s disease and other dementias among adults aged 55 and older, spanning from 1990 to 2021, with projections through 2050 · 2026 · DOI
  • [3]Despite its high prevalence and clinical significance, depression often goes underrecognized and untreated in MS populations, partly due to overlapping symptoms such as fatigue, cognitive decline, and sleep disturbances.

    Fatigue, Insomnia, and Disability as Independent Predictors of Depressive Symptoms in Multiple Sclerosis: A Prospective Observational Study · 2025 · DOI
  • Previous tools for assessing MS pathology have focused on conventional histopathological techniques10,11,24, which are limited by the number of antibodies to distinguish cell types.

    Cell type mapping reveals tissue niches and interactions in subcortical multiple sclerosis lesions · 2024 · DOI
  • Although the aetiology of Flammer syndrome and multiple sclerosis or the causes underlying the clinical correlations between them have not been clarified so far, expanded research may contribute to better care for those at increased risk of developing multiple sclerosis, as well as improved therapy and support for patients, with consideration given to challenges that may arise from the coexistence of both diseases.

    Flammer syndrome – characteristics and prevalence among multiple sclerosis patients · 2022 · DOI
  • This difference warrants further research into MS epidemiology in Croatia and calls for a rational allocation of funds and human resources to provide adequate care and support to MS patients.

    Prevalence of multiple sclerosis in Croatia: data from national and non-governmental organization registries · 2018 · DOI

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