Both the busy clinician and the overwhelmed patient benefit from a pointed approach to disease management.
Aaron Boster, MD
As the field of neuroimmunology evolves at an unprecedented rate, keeping up with the latest advancements in diagnosis and treatment of multiple sclerosis (MS) proves challenging. Many neurologists—even those who spend most of their time in the MS space—are overwhelmed in their clinical practice and research endeavors. Therefore, I intend to set aside interleukins and cytokines, pathophysiology, and immunopathogenesis and instead share some clinical pearls to help both simplify and advance your care for patients and families affected by MS.
My goal is to share a simple approach that will serve you and your patients well, with the aim of helping patients with MS be the best version of themselves possible despite their condition. The following recommendations are based on my formal fellowship training; my 13 years of experience dedicated to MS clinical prac- tice; my review and contributions to the canon of MS literature; my participation in over 65 MS clinical trials; and, most important, the things my patients have taught me.
My rubric is straightforward. The goal is for patients to be “4 for 4” in key factors that have a significant impact on this condition. Here’s what you can do:
As the clinician, you should help the patient choose the most effective DMT they are comfortable taking. Forgo the flawed escalation model, in which providers prescribe mildly effective drugs and allow patients to accrue neurological disability before escalating them to a more effective agent. Brain lost is never regained, and early brain and spinal cord damage sets a poor long-term trajectory. It is not the clinician’s job to be paternal and decide what risk a patient should or should not be exposed to. Instead, it is the clinician’s ethical obligation to educate the patient on the seriousness of untreated or undertreated MS and help their family understand how to place the risks and benefits of the given therapeutic in the context of the disease. I cannot stress this point enough.
Once you’ve initiated treatment with an effective medication, monitor the patient by listening to them, examining them to iden- tify disability progression, and reviewing serial neuroimaging.
At each visit, ask the following treatment-related questions:
All ambulatory patients should perform a timed 25-foot walk at each visit. This single test is more predictive of progression of disability than the entire traditional neurological examination. A 20% change in timed walk is both statistically and clinically signif- icant.1,2 Also, each patient should be screened for cognitive impairment. I’m partial to the Symbol Digit Modalities Test because the 90-second matching quiz is extremely sensitive; in fact, a 4-point drop is statistically and clinically significant.3
In addition, a magnetic resonance imaging (MRI) scan of the brain should be performed annually based on The Consortium of Multiple Sclerosis Centers protocol.4 I suggest that you personally review the scan, comparing it with the previous year’s results, and look for (1) new enhancing lesions, (2) new or enlarged T2 bright lesions, and (3) new T1 black holes and visual evidence of accelerated central atrophy (via measurement of the width of the third ventricle). I recommend imaging the cervical spinal cord every few years, even in the absence of new symptoms attributable to the spinal cord.
If the patient experiences breakthrough disease activity (new MRI lesions or clinical attacks), then discuss switching to a different highly effective DMT. Therapeutic inertia—identifying a clinical problem and not making changes to address it—contributes to poor outcomes, and both patients and practitioners are guilty of participating. I urge you to not sit idly by as your patient accrues brain damage and neurological disability.
It is equally important to not forget about invisible symptoms. If a highly effective DMT slows disability but the patient is miserable, then the clinician has not done the best job. The goal is to both slow disease activity and improve quality of life. Much of MS pathology is invisible and easily missed during a rushed clinic visit. Therefore, I recommend inquiring about invisible symptoms, including cognitive impairment, depression, fatigue, and bladder function, at each visit. When these symptoms are uncovered, I recommend they be aggressively treated.
At each visit, ask patients the following symptom-related questions:
The remaining 3 of 4 factors have to do with patient empowerment. It is now known that untreated cardiovascular risk factors drive MS disease progression faster.5 Sedentary lifestyle, obesity, hypertension, hyperlipidemia, and prediabetes must all be considered in the management of patients with MS.6
Although it’s safe to assume that no one in the health care community promotes the smoking of tobacco, I am amazed at how passive our community of treaters is in fighting against tobacco use. It is imperative to educate patients that smoking increases
the risk of developing MS and, if they already have MS, speeds up disability progression.7 Smoking is the single most impactful modifiable risk factor in MS, so help patients who smoke quit by engaging them in a dialogue and connecting them with resources.
Encourage patients to move. Physical activity improves cognition, mood, energy levels, sleep quality, spasticity, and ataxia and buttresses patients against future attacks.8 Exercise programs should be customized to each patient’s interests and limitations but, ideally, address cardiovascular fitness (eg, stationary recumbent bike), balance (eg, chair yoga), core strengthening (eg, Pilates), and flexibility. In my experience, water-based exercises are excellent for patients with MS: A person weighs less in water, so moving on a weak leg is easier; if balance is off and the patient falls to the left, the water pushes back to the right. In addition, heat sensitivity is less of an issue because convection pulls heat off the body. If you are unsure where to start, consider sending the patient to a qualified neurological physical therapist who can introduce appropriate physical activity.
Although no diet to date has proved to slow MS disease progression, many diets can help improve cardiovascular disease; combat obesity; and, importantly, boost energy levels.9 I recommend a heart-healthy diet and avoiding fast food, sugar-laden foods, processed foods, and nearly unpronounceable/unrecognizable ingredients. Eating clean can lead to some amazing changes in a patient.
At each visit, ask patients the following lifestyle-related questions:
As an experienced clinician, I stand by this simple rubric to optimize the health and quality of life of a person affected by MS. If you help the patient and family embrace these 4 factors, you have changed their lives for the better.
1. Schwid SR, Goodman AD, Mcdermott MP, Bever CF, Cook SD. Quantitative functional measures in MS: what is a reliable change? Neurology. 2002;58(8):1294-1296. doi: 10.1212/wnl.58.8.1294.
2. Kragt JJ, van der linden FA, Nielsen JM, Uitdehaag BM, Polman CH. Clinical impact of 20% wors- ening on timed 25-foot walk and 9-hole peg test in multiple sclerosis. Mult Scler. 2006;12(5):594-598. doi: 10.1177/1352458506070768.
3. Benedict RH, Deluca J, Phillips G, LaRocca N, Hudson LD, Rudick R; Multiple Sclerosis Assessments Consoritum. Validity of the Symbol Digit Modalities Test as a cognition performance outcome measure for multiple sclerosis. Mult Scler. 2017;23(5):721-733. doi: 10.1177/1352458517690821.
4. 2018 revised guidelines of the of the Consortium of MS Centers MRI protocol for the diagnosis and follow-up of MS. The Consortium of Multiple Sclerosis Centers website. mscare.org/page/MRI_ protocol. Updated February2018. Accessed October 10, 2019.
5. Moccia M, Lanzillo R, Palladino R, et al. The Framingham cardiovascular risk score in multiple scle- rosis. Eur J Neurol. 2015;22(8):1176-1183. doi: 10.1111/ene.12720.
6. Jakimovski D, Weinstock-Guttman B, Gandhi S, et al. Dietary and lifestyle factors in multiple scle- rosis progression: results from a 5-year longitudinal MRI study. J Neurol. 2019;266(4):866-875. doi: 10.1007/s00415-019-09208-0.
7. Wingerchuk DM. Smoking: effects on multiple sclerosis susceptibility and disease progression. Ther Adv Neurol Disord. 2012;5(1):13-22. doi: 10.1177/1756285611425694.
8. Motl RW, Sandroff BM. Benefits of exercise training in multiple sclerosis. Curr Neurol Neurosci Rep. 2015;15(9):62. doi: 10.1007/s11910-015-0585-6.
9. Katz Sand I. The role of diet in multiple sclerosis: mechanistic connections and current evidence. Curr Nutr Rep. 2018;7(3):150-160. doi: 10.1007/s13668-018-0236-z.
10. Sintzel MB, Rametta M, Reder AT. Vitamin D and multiple sclerosis: a comprehensive review. Neurol Ther. 2018;7(1):59-85. doi: 10.1007/s40120-017-0086-4.