In a NeurologyLive® Peer Exchange series, experts on the care of patients with multiple sclerosis offer recommendations for selecting and sequencing therapies used to treat patients with relapsing disease.
OVER THE COURSE OF THE PAST DECADE, the care of patients with multiple sclerosis (MS) has evolved rapidly, with the need for a more comprehensive care model taking hold. Aside from clinical disease progression, this patient population faces many additional challenges brought on by MS, including cognitive and mobility issues among others.
This shift has widened the scope of the MS team, providing a bigger role for the advanced practice providers (APPs) to offer their insight and expertise on patient management. As such, the perspective of nurse practitioners and physician assistants has become more essential to the ongoing conversations surrounding clinical care decisions.
In a recent NeurologyLive® Peer Exchange, a group of APPs came together to offer their views on the care of patients with MS, decisions in therapeutic approach, and several other topics. Moderated by Amy Perrin Ross, MSN, MSCN, APN, CNRN, Neuroscience Program coordinator at Loyola University Medical Center, a portion of the conversation focused on looking at nontherapeutic lifestyle interventions that can be applied to MS care regimens, as well as assessments of what the future holds for patients.
Nontherapeutic approaches in MS management can include several interventions, ranging from diet and exercise to vitamin supplementation. These interventions are mostly leveraged as complementary methods, aimed at adding value to the benefit derived from a given patient’s disease-modifying therapy (DMT) regimen.
Specifically, Patricia Melville, MSN, MSCN, RN, NP-C, a nurse practitioner at the Multiple Sclerosis Comprehensive Care Center, Stony Brook Neurosciences Institute, noted the importance of addressing diet in patient conversations. Although the topic often comes up several times over the course of a patient visit, she explained that it can be tricky to navigate.
“There is no scientifically validated diet that we can speak to our patients about [adopting],” Melville said. “What I generally recommend is that they eat a healthy, well-balanced, and sensible diet; eliminate—or at least minimize—proinflammatory foods such as red meat; increase fruits, vegetables, [and] whole fiber; and minimize processed foods and…foods high in sugar and…salt. Hydration is critically important. Many of our patients, particularly if they have bladder problems, will limit the number of fluids that they take in.”
She added that, inevitably, these conversations often lead to discussion about vitamin D intake. Its role in the immune system is apparent. Thus it is important to make patients aware of the need to measure their level of vitamin D and how they can boost their diet with it through food or a supplement, which may be prescribed occasionally. Stephanie Agrella, PhD, APRN-BC, a nurse practitioner specializing in MS at Central Texas Neurology Consultants, agreed, adding that she often has discussions about the Mediterranean diet and its cardiovascular benefits.
“Then maybe touching on some of the research regarding more of an anti-inflammatory diet is another discussion that we can talk about,” Agrella said. “I also highlight vitamin D and the importance of it, not only in the immune system’s ability to function, but also in its effects that could potentially happen in the setting of MS. Highlighting the fact that this is something they have control over then motivating them to take that control can be helpful for them.”
Exercise is another lifestyle facet in MS that is often brought into patient conversations. Christen Kutz, PhD, PA-C, director of research and head of the Huntington’s Disease Clinic at Colorado Springs Neurological Associates, pointed out that most patients are aware of the need for exercise. But emphasizing its importance in increasing their strength and balance, helping prevent falls, and improving spasticity is worthwhile.
“Potentially, [it can] even improve bowel or bladder function, it can help with fatigue, and it can help with mood,” Kutz said. “As far as what exercise we advise, that oftentimes depends on the patient’s physical and cognitive abilities, but we have a lot of patients that enjoy yoga or tai chi, just being outside walking, swimming, biking, or hiking. I have one patient that likes to do Zumba videos online. Whatever they find enjoyable that helps with their overall health and well-being [is good].”
Ultimately, even something is better than nothing when it comes to exercise, according to Bryan Walker, MHS, PA-C, a physician assistant in the Department of Neurology at Duke University School of Medicine. “That’s where I tell my patients to start off— with getting up and walking around their home. Even if it’s with an assisted device, or a walker, it’s going to be better than just sitting there not doing anything,” Walker said.
For those individuals who have fewer mobility challenges, Walker noted that exercise can be as simple as a 20-minute walk most days of the week. Study findings have suggested that even light housework offers benefits to patients, he added. He also expressed his belief in the advantages of activities that work on not only core strength, but balance, flexibility, and stretching.
“To tie back into diet, that’s also important. You are what you eat, and the fuel you put in your tank is going to be important to figure out what type of energy you’re going to have,” Walker said. “There [has been] a lot of input recently on the MIND [Mediterranean- DASH Intervention for Neurodegenerative Delay] diet, … [referring] to Pat’s point earlier. [This involves] avoiding certain things that we know are not great for us and introducing things that are more beneficial and healthier for us. Eating healthily is expensive, but there are ways to do that for every budget. These things are important. When you start to think about…fatigue and cognition, [for example,] there are interventions that patients can [make] themselves to help with both….”
As the field of MS care advances toward the ultimate goal of offering precision intervention, the integration of a more holistic approach is essential. Incorporating facets of care such as nonpharmacologic interventions in diet, exercise, physical and occupational therapy, and neuropsychiatric care should be considered. Additionally, more investigations into the effect of such strategies and whole-patient approaches will help these efforts bear fruit.
With all of that in mind, no clinician can predict the future evolution of care, but examining the trends over the past few years may lend some insight into at least the near future. Ross asked each member of the panel to “take out [your] crystal ball and think about what the future looks like with MS.”
“The future is looking bright. We have so much research that’s been done just in MS over the past 25 years or more,” Agrella said. “It’s brought us 19 different therapies. We have a variety of different administration options. We have a variety of different mechanisms of actions that we can provide to our patients. As more research [is done] in the field—specifically looking at those biomarkers, remyelination, neuronal repair, and neurofilament light chains—[it will] help us expand our knowledge base, likely expand our treatment options, and ultimately benefit our patients’ outcomes.”
Walker agreed, noting that the MS field will likely “borrow” ideas and advances from efforts to address similar demyelinating disorders, particularly regarding the importance of the complete cascade of disease. “We’re going to be rehashing some of the old and maybe tweaking some of what we have now, and we’re going to be looking at what some of the other possible interventions are that could take us to the next step,” he said.
Kutz expressed her desire to further elucidate the root causes of MS to build out a more complete understanding of the disease’s pathophysiology. As for treatments, she is particularly excited about the trials of remyelination agents, the new class of Bruton tyrosine kinase inhibitors, and the potential for cell-based therapies to enter the landscape. For Melville, advancing care for progressive MS offers a particular challenge for the future. The variety in choice of available agents for relapsing disease induces a look into the need for more biomarkers, with the goal of individualizing therapies for specific patients.
“I’m hoping for prevention of damage. Once we identify that the cascade has started, what can we do beyond our current DMTs to hold the disease in its tracks? People are always talking about remyelination and how important that is. I agree that it is, but...if we let axonal transection continue to progress, what are we going to remyelinate?” Ross said. “My hope is that we move along the continuum somewhere in the concept of prevention and what we can do to at least stop this disease in its tracks if not reverse things, with respect to the future. That offers a great deal of opportunity for hope for patients, and that’s incumbent upon us.”
You can view the entire series, "Optimal Management of Relapsing Multiple Sclerosis: Advanced Practice Providers’ Perspectives," at www.neurologylive.com/ms-app