Diagnosis And Treatment
What are signs that I may be developing multiple sclerosis?
Loss of vision in one eye is a common presenting finding. Coordination difficulties. If the spinal cord is involved, urgency or frequency of urination. Numbness, weakness of a limb; so your arm is weak or your leg is weak. Vertigo. Double vision is another one.
If I think I have signs of multiple sclerosis, when should I see a neurologist?
Neurologic function change requires investigation. If they're of the age where they're going to have a stroke, that has to be done within minutes. If they're young, then it certainly should be done within days.
How is multiple sclerosis diagnosed?
Usually the first episode is what brings the person to the neurologist and we have criteria which are internationally agreed upon which, even though there may only be one episode, we can still use to make the diagnosis of MS if there are supporting laboratory data. So, for instance, if there is a specific MRI change elsewhere in the brain from what the patient came in with. Let's just say you have an optic neuritis, but when we do an MRI we find lesions elsewhere in your brain or in your spinal cord. So, even though you're only coming in because of the optic neuritis, there is evidence of multiple lesions elsewhere. Or, if your spinal fluid is abnormal or if some of the electrophysiology is abnormal, we can then make the diagnosis of probable MS and we would treat that person. In other words it's what we call clinically isolated syndrome, and some of those will never have MS, but we can't tell which is which. So, for instance, somebody comes in with vertigo. They have a lesion in the MRI of their brain. We make the diagnosis of clinically isolated syndrome, and we say, "Well, this is a patient that probably has a 70-80 percent, maybe 90 percent chance of developing MS, which means they have about a 10 or 15 percent chance of not having it with one event." They come in with a transverse myelitis or a spinal cord syndrome in which they have weak legs or they're not walking at all. They get better from it and they have some lesions in their brain, which means they have lesions elsewhere. We will make the diagnosis of likely MS and we will treat that patient. So, those are the major features. The diagnostic tools are the MRI, spinal fluid exam, and electrophysiology which we call evoked potentials. If the patient has all of those things, we will make the diagnosis and we will treat the patient.
Is there a cure for multiple sclerosis?
There's no cure, but there are treatments, just like there are treatments for hypertension, for congestive heart failure, for cardiac disease, for diabetes. It's the same kind of thing; there are life-long treatments for multiple sclerosis. Now, hopefully some day, there will be a cure. The more we learn about this, we may be able to influence things. There is a drug that we're about to test which is given once a year. You're not going to be cured, but it's a lot better than injecting yourself every day, or every other day or once a week or whatever, and it's much better than the chemotherapeutic agents, which have their own dangers and so forth. But there's no cure for MS. There are, as I say, six licensed treatments, all of which are immune modulating drugs. So if you modulate the immune response, you will prevent disability, or delay it, and you will prevent relapses.
What are the treatments for multiple sclerosis?
The earlier you treat MS (multiple sclerosis) patients, the less likely it is that they're going to get into trouble. The current six medicines are licensed. Three interferons - copaxone, mitoxantrone, and a monoclonal antibody, and there are now about half a dozen that are being tested and are looking good. So I think we will probably have a whole host of treatments for this disease, but a great deal depends on treating the patient as soon as you make the diagnosis. Having this disease for five or ten years before treatment is bad. We know that, we have evidence for that now. Because the damage is done and you cannot undo it. None of these chemicals get into the brain. All their effects are in the peripheral blood. So if you change the peripheral blood, you will modulate the disease in the brain. One way is to prevent the substances, the lymphocytes, from getting into the brain by altering the blood-brain barrier. One of them is a chemotheraputic agent which is developed for cancer, and it basically knocks out everything. You can only use it for about two and a half years, becase it has a toxic effect and it has complications, cardiac complications, but we use it as a rescue therapy in people who have failed other treatments. And it works. It's got more side effects so we don't use it in a twenty-five year old, young, person. And the third and final one is a monoclonal antibody, which is a humanized antibody, which essentially blocks the blood-brain barrier. In other words, lymphocytes can't get into the brain, they can't produce disease. It is at the moment the most effective of these drugs, but it's had some complications. One of the major complications has been viral infection of the brain, of which two of three people died. So it's been reissued, and we are studying it, we monitor those patients very closely so we will be able to see how that works out. But the concept of not letting lymphocytes into the brain is important.
What is the effect of treatments for multiple sclerosis?
Before treatment, if you did natural history, in other words, if you followed patients for ten, fifteen, or twenty years, what happened to them? Well, at the end of ten years fifty percent of them would disabled. They would be blind, they would be unable to walk, or they would have cognitive difficulties. So they would be disabled. With these treatments disability after ten years is somewhere between eight percent and twenty-five percent. Which means ninety-two percent are not disabled, or eighty percent are not disabled. So that's the major impact. Some of the drugs we haven't been able to study for ten years yet, we don't know, but quite clearly the ones we have studied have made a major impact on disability which is really very, very critical. Disability is associated with axonal damage, with nerve damage and if you can prevent that you will not have disabled patients. My feeling right now is that if a patient is diagnosed now, with their first episode and they're put on treatment they have a very little chance of being disabled. About a ten percent chance of being disabled, which I would not have said five years ago or ten years ago.
What are the effects of exercise on multiple sclerosis?
We think that exercise is almost as important as their drug that they are going to get for the treatment. So everybody with Multiple Sclerosis has to exercise six days a week, but whether they do or not is a different story. We are very vigorous and there's plenty of reasons to do that. First of all, there is evidence that when you exercise, a lot of the symptoms are better. You certainly stimulate stem cells when you exercise, and are certainly making your immune response less responsive when you exercise regularly and it's certainly good for depression which does occur.
What is the effect of major depression on multiple sclerosis?
When a multiple sclerosis sufferer has major depression, this can lead to negative effects because generally speaking there can be issues with compliance, in other words, the patient won't always take the medicine they should when they're depressed. They're usually having spousal or marital problems and the other thing is that we don't know what it does for the immune system, but sufferers of both multiple sclerosis and major depression just don't seem to do as well. So treatment of that is very agressive, initially counselling may work, they can go to a psychologist, talk about their disease and how it is impacting them and so on and so forth, and there are a number of psychologists around big cities that are really familiar with MS that patients can be recommended. If the patient doesn't respond well to psychological treatment then pharmacologic agents can be used. Usually, if it is what we call a reactive depression to the multiple sclerosis disease, they don't have to be treated for more than six months or a year, and they basically seem to adjust to it when they see they are doing well. If they are reacting poorly then you it must be deal with further, but so many of the patients do so well after the initial episode that they generally don't need to be treated for depression for very long.
How does a person deal with the permanent or lasting effects of multiple sclerosis?
The first thing that you tell them is that they are the same person they were when they came in before their diagnosis. They are not a different person. Having a diagnosis of MS, having to inject yourself are life- changing experiences. They need to realize that that should not interfere with their goals. They may need support. They may need to get through the rough spots in terms of emotional things but they can do it. They need to exercise. They have to be optimistic. They cannot be depressed and they have to recognize when they are depressed because they won't do as well. They have to be compliant with their medicines. When they have anything that goes wrong they have to contact their doctor because you can get other things. 90% of the time I get contacted by a patient it is not related to their MS. So they think that every little thing that happens is their MS and that produces even more anxiety. So if you can tell them no you must have eaten something last night because that's not your MS. You have to confirm the fact that they are going to be around. The life expectancy is normal and with recurrent treatments and what's coming along they should never be disabled. And they have to think of themselves that they will be the kind of patient if they do everything they will not become disabled. They will have a normal life.
Are there support groups for people who have multiple sclerosis?
There are lots of support groups. The major ones are the National MS Society, which is the ones that we deal with, which is NMS, the National MS Society, which is based in New York, but has Southern California branches. It has branches all over the country. There are other local groups that are involved, and some of them I'm familiar with that are good. But I think that, for the most part, all of the MS centers, in universities particularly, will have a support group system.
