Ask a Doc: Multiple Sclerosis

• By:  Emily Adamek
• Posted:  February 21, 2020
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Multiple sclerosis (MS) is a potentially disabling disease of the central nervous system that affects approximately 1 million people in the U.S. There are uncertainties around the cause of MS, but the result is damage to the myelin sheath which surrounds and protects nerve cells. This slows down or blocks messages between the brain and body, leading to a range of symptoms, including visual disturbances, muscle weakness, loss of balance, and thinking and memory challenges. MS is categorized as an autoimmune disease, since it is felt to be the immune system that causes damage to the central nervous system.

In the worst cases, people with MS may develop severe mobility issues. However, even with mild cases, people living with the disease must contend with the frustration of highly individualized and unpredictable symptoms.

To learn more about the complexities of MS, and advances in treating it, I talked with neurologist Troy Desai, MD, from the Allegheny Health Network (AHN). He says that MS and MS-related conditions make up the highest percentage of his practice — approximately 90% of office visits these days. Other common conditions his practice treats include migraines, dementia, tremors, seizures, and strokes.

The challenges of diagnosing multiple sclerosis

Emily Adamek (EA): Is it true that we don’t really know what causes multiple sclerosis?

Dr. Troy Desai (TD): There is no known cause. But we do know some things that increase the risk of developing MS. If there is a family history, the risk is higher. Childhood obesity is a factor, as is being overweight. Smoking — firsthand and secondhand. Low vitamin D levels. We think eating too much salt may be a risk factor as well.

EA: I know that MS can have many symptoms — does that also make it difficult to diagnose?

TD: It is difficult not just because of different symptoms but because so many of the symptoms are nonspecific. In other words, these are symptoms that could have many possible causes, not just MS.

MS is now thought to have a prodrome — a set of early symptoms or signs that tend to occur before diagnosis. When you look at records of people eventually diagnosed with MS, you see that in the years leading up to their diagnosis, they often see doctors more or even end up in emergency rooms. They might be telling their doctor that they’re tired all the time, or perhaps they have mild cognitive problems.

Again, many symptoms are nonspecific — if you say you’ve been feeling tired, your doctor has many possibilities to explore before thinking about MS.

EA: Can you give an example of how a diagnosis might play out for a patient?

TD: MS affects the optic nerve, the brain, and the spinal cord. Often, the first thing that brings someone to a neurologist is vision loss, sometimes called optic neuritis. Usually people will complain of blurred vision or a blind spot. They might experience pain behind their eyes with eye movement. Colors may seem washed out.

MS can also cause double-vision, weakness or numbness in one part of the body, trouble with coordination or cognition, fatigue, bowel and bladder dysfunction, sexual dysfunction, problems with mood, anxiety, depression, and sleep disorders.

So, let’s say someone comes in because they’re experiencing numbness. It’s the neurologist’s job to figure out what is causing the symptoms. Is it stemming from the brain or spinal cord? Or is it maybe a pinched nerve in their foot or leg? Maybe it’s something else entirely.

In terms of MS, during an exam, I’m looking for evidence that the brain and spinal cord have been affected. It’s not always possible to determine early on. Since many conditions look and act like MS but aren’t, another common step would be to order blood work. Although no blood test shows whether you have MS, we can test for many conditions with similar symptoms. If we rule out the mimics, then it becomes more likely that we’re looking at MS.

We also turn to MRIs to look for lesions in a typical place and shape for MS. However, not all lesions are created equal. People can have them from high blood pressure, diabetes, and smoking. Even “typical” MS lesions are sometimes caused by other things.

Another step is to do a thorough review of body systems — joints, lungs, and so on — to see if there is something else that might explain the symptoms. For example, lupus can affect pretty much any organ, including the brain.

As you’re going through all these steps and this process of elimination, if you still are not clear, you may decide to do a spinal tap to help diagnose.

Improvements in treating multiple sclerosis — and hope for the future

EA: How do you treat MS? Is there a cure?

TD: MS is a lifelong condition with no cure. Up until 1993, there was no treatment, and as late as 2006, there were only two classes of what are called Disease Modifying Therapies (DMT). Now there are more than 15 available drugs and they have many different mechanisms of action. Progress is only speeding up.

The diversity of treatments is important, because now I can reassure people that if something doesn’t work for them, I’m not going to keep them on it. Back in the day, some patients complained that medication made them feel like they had a flu — but that was their only option! Fortunately, we have plenty of options now.

EA: What are you most excited about in terms of future treatment?

TD: Treatments that rebuild myelin around the nerves. Right now, our bodies can regenerate damaged myelin, but it’s not always 100% effective. In about 40% of all current MS relapses, people don’t fully recover. They’re left with residual problems because their body either didn’t remyelinate perfectly, or because they lost some axons that were transected. Remyelination could potentially return lost function to individuals with MS.

EA: Is there any one piece of advice that you tend to give to your MS patients?

TD: I think technology is a good thing — it enables people to find information quickly and easily. However, we need to make sure they find reliable resources. When people are first diagnosed with MS, I tell them, “Don’t read blogs.”

One reason I emphasize that is because if you’re reading something on a blog, it may not be scientifically proven. And, with MS, even if something has evidence behind it, what works for one person may not work for another.

MS symptoms also tend to improve slightly on their own after a relapse — but people may think the improvement is because of something they’ve done. As a result, many dubious treatments have been proclaimed effective on the internet — everything from bee-stings to dangerous surgery to put stents into the veins and drain blood from the brain.

EA: One of your MS patients, John Platt, runs marathons despite the disease. When I interviewed him, it seemed that exercise had really transformed how he was living with MS. Is there evidence that exercise is important in managing MS and slowing its progression?

TD: Stress causes inflammation, as does being overweight, and we know that exercise can help reduce stress. There is some thought that exercise can help to directly reduce inflammation and control the immune system — so yes, in that respect I believe exercise can potentially help control the immune system and slow the progression of MS.

One way neurologists measure MS progression is something called the Expanded Disability Status Scale (EDSS), which is a scale from 0 to 10 in 0.5 increments. Progression is indicated when that number goes up — so, the lower the number, the better. Part of that EDSS score is dependent on how well people are walking — whether they’re walking independently, and how far they can go. Regular movement and exercise can potentially help to keep that EDSS number low.

The science and mystery of neurology

EA: What motivated you to pursue medicine as a career?

TD: Science has always interested me, especially anatomy and physiology. The way our bodies work is just amazing; everything has form and function.

EA: What attracted you to neurology specifically?

TD: When I first went into medicine, I thought I wanted to do preventive medicine. I soon realized that this meant I would need to know a little bit about a lot of things, whereas I wanted to concentrate my energy on one area. That’s where neurology came in.

There’s a rational side to neurology, where everything is structured like an electric circuit. Then there’s all the unknown where we really don’t understand how the brain works. Because of advances made in immunology and genetics and other sciences, we’re now better understanding its intricacies.

EA: Even though we’ve learned so much, is there still a level of mystery to the field?

TD: There’s always another layer. Think of it this way — a few hundred years ago we didn’t know about atoms and molecules. Now we have a grasp on that, and we are wondering about subatomic and quantum particles. What we know about the brain, or about MS, is always connected to something else that we still need to figure out.

EA: Is neurological diagnosis a bit like detective work?

TD: You could say that. I do love the way the process works. You can start to figure something out — where the problem lies — just from examining and talking to someone. You might say, ok, the problem seems to be in the spinal cord. From there, you come up with a differential diagnosis — is it inflammation, stroke, tumor, herniated disc? Then, based on a patient’s age, complaints, and other medical conditions, you start to categorize potential causes from most likely to least likely. Next comes the diagnostic plan — deciding which tests will be most effective to rule out this or that. You’re putting things together and progressing toward “solving the mystery,” to use your analogy, so that then you can develop a treatment plan and help the person.