IJMSC Insights: Francois Bethoux on 10 Years With IJMSC

One of the celebrations at the 2025 annual meeting of the Consortium of Multiple Sclerosis Centers (CMSC) had Francois Bethoux, MD, at its center. 2024 marked a decade of his service as editor in chief of the International Journal of MS Care (IJMSC). At the journal's editorial board meeting, he received a plaque and a round of applause from his colleagues. It proved to be only the first recognition Bethoux would receive as he went on to be recognized as a Giant of Multiple Sclerosis® the next night. To add to the celebrations, the entire IJMSC team also received the Thumbs Up award from the International Organization of Multiple Sclerosis Nurses at the meeting's closing ceremony.

Francois Bethoux, MD, accepting a 2025 Giants of MS in the area of rehabilitation. Image Credit: CMSC

As the journal of the CMSC, the mission of IJMSC is "to promote multidisciplinary cooperation and communication among the global network of MS health care professionals, with the goal of maximizing the quality of life of people affected by MS." It is a free publication for authors, researchers, and all those interested in advancing MS care, charging no publishing, processing or subscription fees.

Francois Bethoux, current IJMSC editor in chief, with M. Alissa Willis, current IJMSC associate editor, with founding IJMSC editor in chief Robert M. Herndon, Sr, at the 2024 CMSC annual meeting. Image credit: M. Alissa Willis

At its founding in 1998, the journal's first editor in chief was Robert M. Herndon, Sr, MD. He passed the torch to Lael Stone, MD, in 2007. In 2014, before her untimely death in 2019, she passed the torch to Bethoux, making his current 10 years the longest tenure thus far.

Bethoux is chairman of the Cleveland Clinic Department of Physical Medicine and Rehabilitation and director of Rehabilitation Services at the Cleveland Clinic Mellen Center for Multiple Sclerosis Treatment and Research. He also serves as medical director of the Cleveland Clinic's Arts and Medicine Program.

Before the CMSC meeting, IJMSC sat down with Bethoux to get his perspective on his career path, his involvement with the journal, and his opinion on hot topics in the field of MS care.

International Journal of MS Care: Tell me about your journey to medicine. How did you get involved in the field of rehabilitation?

Francois Bethoux, MD: My brother was in a car accident when he was 5 years old, so I was exposed to the field of rehabilitation pretty early. He had a severe traumatic brain injury and a long rehab journey, and [that experience led me] into medicine. I had an interest in neurology first and wanted to know everything related to the brain. I was passionate about that, but along the way, when I did my rotations, I felt that the neurorehabilitation field was the best fit, following people with chronic neurological disability for a long time and trying to promote function and quality of life. That’s how I ended up in the field of neurorehabilitation.

IJMSC: How old were you when your brother was in his accident?

FB: I was 8 years old at the time. There’s a whole area of literature on being the sibling of a child with a disability, and I would say [the experience] was very formative for me, and I was grateful. I probably wanted to avoid making the obvious choice and going straight [into the field of neurorehabilitation], but it felt very comfortable.

IJMSC: How did you make the move from France to the United States?

FB: It was an interesting evolution. I was on an academic track in France, and as a part of that, it’s customary to spend a year abroad. My mentor had a friend in Cleveland, Ohio, at the time that I was ready to spend that year abroad, so I applied for a research fellowship with Metro Health Medical Center and Case Western Reserve University. It was a rehabilitation research fellowship. I did some research on functional electrical stimulation, particularly in people who had had a stroke, and I was interested in the medical scene in Cleveland. I interviewed around and had to go back to France. Then, I received an opportunity to enter an MS [multiple sclerosis] fellowship at the Cleveland Clinic’s Mellen Center for Multiple Sclerosis. And my family was ready to make the move, so I jumped at the opportunity, came back, and never left. That was 27 years ago.

I received an opportunity to enter an MS [multiple sclerosis] fellowship at the Cleveland Clinic’s Mellen Center for Multiple Sclerosis. And my family was ready to make the move, so I jumped at the opportunity, came back, and never left.

IJMSC: Was that fellowship your first exposure to MS rehab, or had you seen it elsewhere?

FB: I had seen it in my practice in France, but sporadically, because typically, people with MS [are] not a large percentage of patients in neurorehabilitation. In my area of France, there’s a hospital that specializes in the rehabilitation of people with MS. I knew of that hospital, and I knew colleagues who worked there, but I didn’t directly work there. So when I came to Cleveland, I really had, if you wish, a crash course in MS, MS 101. That fellowship provided me with the neurological background to really understand MS, know how it is managed with medications and MRIs, and understand how to integrate rehab. Generally, the model of rehabilitation is that if you have a severe disease, surgery, or an injury, then your ability to function is limited, so you go through a period of rehabilitation and hopefully reintegrate your environment as close as possible to the level of function you had beforehand, or learn adaptations with equipment, etc. With a chronic disease that, in many people, gets worse over time, the role of rehabilitation wasn’t as obvious. I think now the role of rehab in chronic disease is more understood and accepted. We have examples of rehabilitation in many other chronic conditions, from Parkinson disease to cancer. After the fellowship, I felt prepared to stay on as a rehab physician. At first, I was in the [Mellen] MS center, only seeing people with MS. Then I grew my practice outside of MS but stayed physically tied to the MS center for my clinic, and of course, also great ties and collaborations with the neurologists in the MS center.

IJMSC: How much of your practice now is people with MS?

FB: I would say my clinical practice is really focused on spasticity management and, being in the MS center, probably 40% of the patients I see have MS, which is pretty high for a physical medicine and rehabilitation practice. Then we also see people with strokes, spinal cord injuries, brain injuries, adults with cerebral palsy, so a wide variety of diagnoses, but a strong core of people with MS. I have also been doing clinical research for the past 20-plus years, and that research is 90% focused on people with MS.

IJMSC: I’m curious: Is spasticity the same across chronic diseases, or are there particular parts of spasticity that you see in people with MS, stroke, or cerebral palsy?

FB: At the core, we could say that spasticity is spasticity, no matter what the underlying condition is. However, how it manifests and how we manage it will vary. With MS, spasticity is one piece of the puzzle, one part of the symptoms, and it’s not always bothersome, so it doesn’t always need to be aggressively treated. When it needs to be treated, there are many factors to keep in mind. First is the evolution of the disease. Is the disease progressing quickly or is the person having multiple relapses? Fortunately, it’s less and less the case now with the powerful medications that we have to treat MS. Second, what other symptoms, what other limitations is the person facing? And what has been the evolution of the spasticity over time?

...we could say that spasticity is spasticity, no matter what the underlying condition is. However, how it manifests and how we manage it will vary. With MS, spasticity is one piece of the puzzle, one part of the symptoms...

With MS, you have symptoms that fluctuate from day to day, from morning to afternoon, and also over the years, gradually. It is important to keep this in mind when we manage it. I would say it is different. We use the same types of treatments, but how they’re coordinated when they are being prescribed or recommended depends. A big emphasis in MS, as in other conditions, is keeping up with physical activity and exercise. It is amazing what a difference it can make, although it’s hard, right? There are so many barriers to exercise when somebody has MS. Just keeping up with regular physical activity when you have fatigue, depression, difficulty moving, abnormal sensations, pain [is difficult]. It seems that everything is conspiring to not let people with MS be physically active, so it needs to be purposeful, and [the person needs] to be engaged. Some people were athletic before having MS, and so they know how to go about it. Others were not, so they need to be [coached], and we need to pay attention because they can’t just go to the gym or watch any video on the internet and just start doing it. That may lead to them saying, “Well, I really don’t like exercise. It’s not really appropriate for me.” We also have to keep in mind that exercise, physical activity, doesn’t really cause MS relapses or progression of the disease but can cause some symptoms to get worse for up to a few hours or some symptoms to reappear, also for a limited time, and that can be very scary.

IJMSC: I’ve come across the idea of prehabilitation, rehabilitation before you need it essentially, as a part of clinical care, realizing that exercise and being physically active helps with the management of the disease and the symptoms. Is that a new thing? Has that always been a part of MS care?

FB: I think that the view that rehabilitation should be involved as early as possible, of course whenever indicated, has led to the development of multidisciplinary MS centers and the idea of comprehensive care of MS, which, as you know, the CMSC [Consortium of Multiple Sclerosis Centers] and IJMSC are promoting. The idea has been around for a long time. As usual, the devil is in the details of how to implement it. We do have to take into account the cost of care, so we don’t want to systematically involve every professional just because we think it could be useful, but there are so many symptoms of MS where the first line of management is nonpharmacological and can be handled by rehabilitation professionals.

The idea is that these rehabilitation professionals will, say, help the person establish an exercise program, or help them manage their energy over the course of the day, or help the person with MS realize how they can do the same task while expending less energy. That doesn’t necessarily require intensive, prolonged rehabilitation. It might be a few exercise training pointers, and then the person goes home, does it on their own, and then they may touch base again with their rehab professional. It’s initiating a dynamic there to try to change behaviors early, when it’s relatively easy, as opposed to later on in the disease, when it may not be as easy. It is also to empower people with MS to say, “Well, that overwhelming fatigue, that difficulty with my foot and my balance....” You know, we need to acknowledge that, and we need to give people the tools to either work around it or to overcome it, and above all, to keep functioning, have a great quality of life, even though there are some symptoms. Sometimes symptoms and what we call neurological deficits, like a foot drop, that we consider mild can have a significant impact. Someone who’s a young adult, maybe raising children, trying to have a career, sometimes running through airports to catch a plane. Many people say that keeping an active job, for example, while dealing with the consequences of MS isn’t necessarily that simple. Maybe each symptom is mild, but the combination of them is difficult to deal with, especially in the demanding world that we have today, where it seems that we have to go faster and faster and faster.

IJMSC: Yes, and the literature about MS and employment supports that idea as well, showing that it is difficult to sustain employment after diagnosis.

How did you first hear about the Consortium of Multiple Sclerosis Centers?

FB: I heard about the CMSC very early in my MS fellowship because the Mellen Center at the Cleveland Clinic is very involved with the CMSC and has been for a long time. I think one of the early meetings of the CMSC was held in Cleveland. I submitted abstracts to the CMSC annual meeting, and after attending and networking there, I really became more involved. Before that, I was aware of the CMSC and felt it was a very unique organization, obviously promoting the multidisciplinary care of MS, but also looking into the future and trying to build the workforce to help people with MS. That’s a great mission to have.

IJMSC: And did your involvement with CMSC lead to your introduction to IJMSC?

FB: It did. IJMSC started as an online-only journal, then became print and online, and now is back to online only. I am very proud of the fact that it remains open access at no cost to authors or those who want to access the research. It is a model that is difficult to follow long term, but the CMSC has been incredibly supportive. Dr Lael Stone, who was a colleague of mine, became the second editor in chief of IJMSC after founding editor Dr Robert Herndon, and she started to involve me as a reviewer, and then invited me to join the editorial board. That’s really when I got more intimately acquainted with IJMSC and all of the contributors, which led to my being comfortable taking on the editor in chief role just a few years ago.…

IJMSC: Just a short decade ago, right? And how did that come about?

FB: When Dr Stone wanted to transition from her role as editor in chief, there were several candidates who were considered, and there was an interview process. I was chosen, and I was grateful for that, and a little scared, of course, at the same time. It’s a responsibility. Dr Stone had initiated transformative initiatives for the journal, particularly the inclusion of IJMSC in PubMed Central. I took over about that time, and all of a sudden, we saw the number of submissions skyrocket. Over the course of 2 years, I think they increased to the level we have today. And so, for me, it was exciting to see that transformation [that led to] IJMSC being cited more and known outside of the relatively small group of the CMSC.

IJMSC: What has the past decade been like?

FB: It’s been like a French movie whose title is Life Is a Slow, Peaceful River, and the movie is everything but slow and simple. It’s not chaos all the time, but I would say it’s been very eventful. There have been some initiatives that the journal has launched, and there were also changes in the scholarly publication field, and IJMSC tries to adhere to the highest standards of publication ethics. As Dr Stone said when I became editor, “Well, you’re going to stretch another part of your brain.” I definitely did, and I keep stretching it now. The role forced me out of my comfort zone to attend, say, a meeting on publication ethics and to see what other journals were doing with the changes to open access models or the peer review model and see what seemed to be acceptable or not. And, as the CMSC is a professional organization, it seemed important to me to involve people with MS in some way with our publication, and so that’s also something we’ve been pursuing over time.

As Dr Stone said when I became editor, “Well, you’re going to stretch another part of your brain.” I definitely did, and I keep stretching it now.

IJMSC: What do you think about the development of research that IJMSC has published from when you started to today? Have you seen any trends?

FB: I would say that there’s been a welcome evolution. Early on, IJMSC published a mix of original research and updates on topics that were relevant to the readership. The readership of IJMSC is composed of many clinicians who are not necessarily in an academic setting yet want to know the latest and greatest about MS care, so publishing these updates was important. We’ve shifted toward publishing more original research and systematic or narrative reviews. These are helpful and more comprehensive and really provide, for example, the state of the art of what it is to manage fatigue and maybe aspects of fatigue management, such as exercise.

I’m also very proud of the fact that we address topics that are not commonly addressed in other journals because they are underrepresented or because the research is considered emerging. The studies remain small, and they derive hypotheses but cannot necessarily provide answers that can be generalized to the entire population of people with MS. Another big focus has been on the caregivers of people with MS, the family members, the friends, the spouses who really help on a day-to-day basis. That evolution, I think, has helped us mature into a journal that is hard to classify. Are we a neurology journal? A nursing journal? Is it a rehabilitation journal or a multidisciplinary care journal? We are unique. We’ve also evolved into being a great supporter of early investigators and trainees who want to publish. To me, it’s a great contribution to the future of MS care and research because we get people very early in their career and support them in publishing, maybe their first manuscript or their early manuscripts, and we address topics, again, that are very relevant to multidisciplinary MS care but are not necessarily very mainstream.

IJMSC: What has been the biggest challenge for IJMSC in the past decade?

FB: A very practical challenge is finding reviewers, and we constantly have a call on our editorial board, on [CMSC] membership, to review the articles so that the authors can get great quality reviews from experts in many, many fields. That’s been a practical challenge. Another challenge, I would say, is the fast pace. The publishing field has intensified over the past few years, which, in a way, is great as we get new research in front of an audience much faster. But it’s very important to note that, at the same time, it collides with the difficulty of finding reviewers or giving authors the time to revise the manuscript. That pace is an ongoing challenge, but I would say it is a good challenge that keeps us on our toes.

IJMSC: What would you cite as one of the successes of IJMSC’s past 10 years?

FB: I have already listed [becoming] more [known] and the articles being cited [more]. I started seeing IJMSC research in theses, which is a great success. My personal best is involving people with MS through the cover art. To me, that speaks deeply to the fact that we’re all here for people with MS and their families, to provide them with options, support, and guidance, while also empowering them to be the most important part of the care team. Being able to showcase the art and say a little bit about the artist is thanks to our collaboration with the Multiple Sclerosis Association of America and their wonderful Art Showcases. That’s very dear to my heart because it puts the patient back in the center on the cover of the journal. I know that it keeps me grounded. I have a secret passion for arts and medicine as well. It’s a secret that is not so secret. But it’s very niche, and I feel like any time we can remind people how the arts can be helpful when you’re dealing with a chronic condition, or when you’re taking care of people with chronic conditions, that’s also great, and so that’s why I’m particularly proud of this success.

I have a secret passion for arts and medicine as well. It’s a secret that is not so secret. But it’s very niche, and I feel like any time we can remind people how the arts can be helpful when you’re dealing with a chronic condition, or when you’re taking care of people with chronic conditions, that’s also great...

IJMSC: In the field of MS research, rehab or otherwise, what has had the most impact in the past 10 years?

FB: It’s a tricky question because so many things have happened. This is going to date me, but when I did my fellowship, we had 3 approved medications for MS, and now it’s hard to count how many. There are so many coming out every year. And then, you know, the goal of the disease-modifying therapies has evolved. We talk about no new disease activity, no evidence of disease activity. We have now also discovered that there can be progression between relapses or progression independent of relapse activity. I feel like there’s so much more that is known about the disease process and also so much more attention to small but significant changes that can impact the person with MS.

At the same time, there’s been tremendous growth in evidence in the other disciplines involved in the management of MS; the field of exercise and rehabilitation is a great example. More and more technology is available for rehabilitation and directly to patients, but do we have the evidence to show how to use it to get the most benefit? We need research for that. Do we know whether it’s safe? We need research for that, and that has been growing exponentially. We now have a very solid body of evidence that exercise is not harmful when it’s done properly and is helpful in MS. We also have more evidence on all the psychological consequences of MS and how some treatments can help, like cognitive behavioral therapy, which can be applied for many of the consequences of MS. And in the field of caregiver research, [we have more on] caregiver involvement and all the consequences on the caregiver’s health by being involved in giving care, for example. There has also been the development of qualitative research. Quantitative research is important, and it can be done on large samples of people with MS, but qualitative research goes in-depth, trying to understand what [the numbers] really are telling us. What do people feel and experience in their daily lives? What are the themes that can be extracted? I find it fascinating. We’ve also seen [continued] growth of social media and the internet over the past 10 years. We need to understand how people with MS are using social media and how caregivers and health care professionals can use it as well.

So all this knowledge is coming together and coalescing into a model of care, and that model of care, of the comprehensive care of MS, is as relevant, if not more relevant, now than it was before, particularly at a time when we’re trying to use health care dollars wisely. We also have to take into account the fact that not everyone has access to MS care…. Now we have online care. I don’t like to say virtual care because it sounds like you have a virtual doctor talking to a virtual patient, but I’m willing to embrace it. Online care gives access to MS specialists to patients who live in an area where they don’t have access to an MS clinic.

I’m sure I’m missing a lot of important developments that have happened.... I haven’t mentioned basic research. IJMSC does not publish basic research because that is not our mission, but we’ve seen more and more of that basic research being translated, and that becomes relevant to the clinical care of people with MS. That is great, and, as we all know, people with MS are hungry for this information to know what they can do: For example, when is that research going to come to the clinic? It’s fascinating.

IJMSC: I hesitate to pick one thing in the next 10 years because I feel like the next decade will also be a very important one for MS research and clinical care developments. But what do you have your eye on? What are you following in MS research?

FB: One thing that I’d like to talk about is the advent of artificial intelligence [AI] and how it can permeate MS clinical care and research. You’re talking to somebody who had a flip phone until a couple of years ago, is not on social media or has very limited access to social media, and has just tinkered with the most easily accessible AI probably a total of 5 times over the past few years. But the health care system I work for is talking about integrating AI into visits so that we can spend more time face to face with our patients instead of typing on the computer, but also to avoid what is sometimes called pajama time. You know, late in the evening after the kids are in bed, finishing notes because we wanted to spend more time with our patients, and so the consequence was doing overtime to finish the notes. If [AI] delivers on its promise, it will be transformative in the day-to-day experience of caring for people with MS. That’s just one example. Could AI help with reading MRIs? Help with basic decision-making as well to help guide the first steps of decision-making? Help generate hypotheses for research and deal with massive amounts of data? We now have the capacity to collect massive amounts of data and store it, but how do we handle it? AI seems to be a promising [way] to help sift through data and tease out some of the meaningful conclusions, or at least meaningful leads. To me, AI has the potential to permeate every aspect of MS care and research. Of course, it is a little scary. We’ve already seen some of the drawbacks, and we see that AI needs to learn more, but the beauty of AI is that it keeps learning, so I am very interested in seeing [what happens].

To me, AI has the potential to permeate every aspect of MS care and research. Of course, it is a little scary. We’ve already seen some of the drawbacks, and we see that AI needs to learn more, but the beauty of AI is that it keeps learning, so I am very interested in seeing [what happens].

IJMSC: As a journal editor, are you wary of researchers using AI when writing articles?

FB: I’ve lost a few nights’ sleep over this, but just a few because, at some point, I was like, will I be able to tell if somebody used AI to write a scientific article or not? And, I heard teachers say the same thing: Will I be able to tease out if a student has used AI to write their paper from start to finish? Then I started turning the premise around a little bit, saying, “First, we’re going to ask the authors to be upfront about it, to tell us if they used AI to write the paper.” You know, we have the word international in IJMSC and that's not for nothing. We work on papers from many countries, particularly in countries where MS research is emerging, researchers or clinicians who want to publish don’t necessarily have access to translators, and sometimes that hinders the publication of their manuscripts. If AI could help organize the content and assuage some of the [translation] issues, then that could be a good use of it. As with many new technologies, it’s watchful optimism. That’s kind of my position right now: Ask everybody to be transparent and keep learning because humans can keep learning. It’s not only AI that can keep learning.

We work on papers from many countries, particularly in countries where MS research is emerging, researchers or clinicians who want to publish don’t necessarily have access to translators, and sometimes that hinders the publication of their manuscripts. If AI could help organize the content and assuage some of the [translation] issues, then that could be a good use of it. As with many new technologies, it’s watchful optimism.

IJMSC: Thank goodness. [We just attended] CMSC 2025 in Phoenix, Arizona. What did you enjoy?

FB: As with each annual meeting of the CMSC that I have attended, it’s the networking. Everybody who attends is passionate and comes to the meeting with a different experience, different expertise, different desires. So literally, the conference is teeming with ideas, and there are some new people in the field that we get to meet in person. Sometimes I’ve interacted with people by email or via online meetings, but then I get to spend time with them, discuss in person. [Over the years,] there have been many opportunities to discuss the embryo of a project. Being able to meet in person, spend time together, that sometimes helps coalesce ideas in a very quick exchange and outline next steps…. That’s really what [I enjoy].

This interview has been edited for clarity.