Questions and Answers With Doctor Nitin Sethi, Neurologist
Doctor Sethi has graciously agreed to answer some questions posed by readers and here they are:
1. This first question comes from _Franklin Catholic _
Is it possible to have MS and also have an abnormal nerve conduction test?
That is an interesting question you ask. Classically multiple sclerosis is defined as a demyelinating disease of the central nervous system (CNS). The CNS includes the brain and the spinal cord. So in multiple sclerosis the pathology lies in the brain and spinal cord (meaning that the lesions or plaques as we refer to them lie in the white matter of the brain and/or the spinal cord).
Multiple sclerosis does not involve the peripheral nervous system (PNS). The peripheral nervous system consists of the nerves which carry the impulses to the muscles. So in multiple sclerosis typically the nerve conduction studies are normal (nerve conduction studies determine the conduction in peripheral nerves which are unaffected in multiple sclerosis).
Of course there is always the possibility that one may have two diseases. Let me explain with the aid of a simple example. Let us assume that you have MS but also have a pinched nerve in your neck. Well in this case the nerve conduction study in the upper limb may be abnormal.
2. The following question was asked by an anonymous caregiver:
I am a caregiver to a loved one with MS. It is the remitting type and so of course there are good days and not so good days. I have often wondered if there are triggers to the bad days. I have read about heat and so we know to watch out for the real hot days and try to plan accordingly. Sometimes other things seem to trigger onsets, certain foods, stress, and so forth. Is this just our imagination or would you agree that such things do trigger episodes and if so, what would you recommend we watch out for in planning our days?
Thank you for writing in. Taking care of a loved one with MS is indeed challenging and demanding. My patient's care-givers never fail to inspire me. They bring their loved ones to see me, act as their advocates and their love and devotion is apparent. Care giver stress and burn out is common especially when confronting a chronic and debilitating condition such as MS.
Now to your question. The relapsing remitting form of MS (RRMS) is characterized by acute episodes of MS exacerbation, which then remit over time. At times no neurological deficit is left behind and the patient returns to baseline. Things remain fine till another attack strikes!!.
We now know that there are certain factors which may worsen pre-existing neurological symptoms in patients with MS. Uhthoff's phenomena is the name given to the worsening of neurological symptoms in patients with MS usually when their body temperature rises (as when they have fever) or when the ambient temperature goes up ( such as when they are in a hot environment, after a hot shower etc). Infact many times patients come to the ER thinking they are having an acute MS exacerbation (such as increased weakness, increased blurring of vision, they feel more unsteady), only to find they have a fever due to a urinary tract infection or a pneumonia. We treat the infection and lo and behold they are back to their baseline with respect to their MS symptomatology. Hence exacerbations like the above are actually not true exacerbation rather we refer to them as pseudo-exacerbation.
MS patients also by and large fare better when the environmental temperature is slightly low. I tell my patients to avoid places with high temperature such as a sauna and also advise them not to take baths/ showers with hot water (lukewarm is better).
You may ask why MS patients do poorly when the temperature rises. There is an explanation to this and I shall try to make it simple. MS as you know causes demyelination of the central nervous system. Myelin coats the nerves of the central nervous system and acts as an insulation and also performs a role in conduction of nerve impulses down the length of the nerve fiber. When nerves of the central nervous system are stripped off this insulation, there is cross talk. Nerve signals may jump from one nerve to another. When the temperature rises, this cross talk increases and also we notice increased conduction blocks (there is block in conduction of nerve impulses down a nerve fiber). This all leads to worsening of pre-existing neurological symptoms.
Stress and food do not play a direct role in worsening MS symptomatology. I do though advise my patients to attempt to reduce the stress in their lives and eat a balanced nutritious diet.
This next question comes from Julie who writes:
Hi Merelhanks for taking these questions!** Here's the one that continually perplexes me: How do I know if my new symptom is serious enough to call my neurologist? Most often I use the litmus test of: Would I be willing to go on steroids right now to get rid of this or can I live with it? Is that a good method or stupid? Are there any symptoms that are red flags and must not be ignored? Most of the time, I just live with it knowing that solumedrol is so hard on the body.**** Thank you!- Julie**
Thank you Julie. That is a great question and a practical one which patients with MS are frequently confronted by. Your litmus test is actually not a bad idea. As I stated in my response above, many times MS patients have pseudo-exacerbations (transient worsening of pre-existing neurological deficits either due to a fever or an intercurrent infection). Not all these "exacerbations" warrant acute treatment with intravenous steroids such as Solumedrol. You are right when you say steroids are not innocuous medications. True they are wonder drugs when it comes to MS but they do have their own side-effects (many of which are not pleasant and some can actually be dangerous). I would advise patients to call their doctors or seek medical attention if they have an acute attack of optic neuritis (sudden loss of vision in one eye), if they develop sudden weakness in both their legs or urinary incontinence (this may be indicative of an acute MS lesion in the spinal cord, a condition called transverse myelitis).
I know of one doctor who gives his MS patients some steroid pills to keep at home and advises them to take them if they feel they are having an acute MS exacerbation. This approach has its own advantages and disadvantages. It may help a patient tide over a MS exacerbation and avoid a visit to the ER. It is ill-advised though if you attempt this without consulting your physician.
The next question comes from Lanette who has a blog called Chain Reaction:
**Hi! I wanted to see if you would inquire with Dr. Sethi which disease modifying drugs he felt worked best for someone who has several Spinal Lesions after 5 years of MS with no previous DMD's. If they cannot tolerate interferon's what would be his next course of action?
I'd appreciate it! (Lanette also wants to add that she has 4-5 brain lesions and the same in her spine.)**
Hello there. Thank you for asking that question. Spinal MS (a patient with MS who has predominantly MS involvement of the spinal cord, the brain is relatively spared) is at times associated with high morbidity and mortality rates. The reason is that all the tracts which carry nerve impulses to and from the brain are concentrated in a relatively small area in the spinal cord. So even a small strategically placed lesion in the spinal cord can cause significant neurological impairments. Patients with spinal MS present with slightly different clinical signs and symptoms. They may present with what is called transverse myelitis (this is an involvement of the spinal cord usually at the cervical or thoracic level). Transverse myelitis can be devastating because all the descending motor fibers from the brain and the ascending sensory tracks are packed in the small diameter of the spinal cord. So any involvement of the spinal cord has the potential to affect all these tracks. Depending upon the level of cord involvement patients may have either weakness of just the legs (paraparesis or paraplegia) or all the four limbs may be involved (quadriparesis or quadriplegia). Usually the bladder and bowel are involved too and patients may have complaints of urinary incontinence. Sexual dysfunction is also commonly reported.
Spinal MS is treated in much the same way with traditional disease modifying drug therapies such as interferons. If a patient cannot tolerate one particular interferon, it may still be worthwhile attempting therapy with another interferon (for example if you cannot tolerate interferon beta 1 b, interferon beta 1a may be tried). The other option for RRMS would be to use glatimer acetate (copaxone) or Nataluzimab. Nataluzimab can at times have very serious side-effects and potential complications. Hence there are strict criteria which determine which MS patient can receive this drug.
Merely Me's question for Doctor Sethi:
**What percentage of people who have a clinically isolated incident such as optical neuritis go on to have MS? For me it took over ten years for my clinically isolated incident (optical neuritis) to manifest to becoming MS. After how many years following the one incident are you safe from getting MS? ** You ask a very valid question. I want to stress that not all patients who have a clinically isolated syndrome (CIS) go on to develop MS. But I am getting ahead of myself here. What does it mean when a doctor says you have a CIS? Let us assume you present to the doctor because you suffer an attack of optic neuritis. Optic neuritis is inflammation of the optic nerve and hence the patient seeks medical attention for acute loss of vision and pain in the eye. To be certain that your presentation is indeed isolated, your doctor shall have to take a thorough history to make sure you have never had any other attacks suggestive of MS in the past. MRI of the brain and spine as well examination of the cerebrospinal fluid is carried out to rule out any other silent lesions of MS. If no other lesions/ plaques of MS are found in the brain or spinal cord on MRI, the spinal fluid studies are normal and so are the results of other tests such as evoked potentials then and only then one has a _clinically isolated syndrome _.
Not all patients with a CIS go on to develop MS (there are other causes of optic neuritis besides MS). Patients who have a CIS do not warrant treatment with MS specific drugs like interferons. Your doctor might give you a short course of IV and oral steroids to hasten the recovery of eye function.
The problem though arises in prognosticating patients who have a CIS. What are the odds that they would develop MS in the near future? Unfortunately we still cannot answer this question with 100% accuracy. There are though certain clues which suggest to us that the CIS is actually the first attack of MS. If the MRI scans show silent plaques ( by silent I mean clinically silent and not causing any neurological deficit to the patient) in the brain or spinal cord, if the spinal fluid studies come back abnormal or if the evoked potential are delayed they all hint at the possibility of future MS. It is imperative that we as doctors try our best to rule in or rule out MS because if the patient does have MS, we want to catch it early and treat it effectively with disease modifying drugs.
Our next question comes from Carole who has a blog called, Carole's MS Blog:
Can you please ask Dr, Sethi, why doctors seem less concerned about the psychological, emotional, and cognitive effects of MS, compared to the physical symptoms? Depression being the exception.** Thanks Carole**
We now have ample evidence that suggests, MS involves not just the white matter tracts (meaning the nerves carrying impulses to and from the brain and the spinal cord), but the grey matter is also affected. Hence MS patients complain of cognitive difficulties. They also have a slightly higher risk of depression and at times suicide and it cannot all be explained by the fact that they are suffering from a chronic disabling neurological condition. Studies have shown that higher the plaque burden (meaning that more the number of MS plaques/ lesions in the brain), more are the cognitive deficits.
But you are not entirely right in saying that doctors do not give as much attention to the psychological, emotional and cognitive effects of MS patients. If you seek care in a comprehensive MS facility (you can find MS centers in most of the big university hospitals), you shall find ancillary staff such as MS nurses and social workers dedicated to treating the MS patient as a whole, not just the motor deficits but the entire gamut of MS symptomatology.
Our last question comes from Nadja who also has an MS blog.
Thanks for sending me this info.
I am wondering
one thing. Is it normal and common for MSers to suffer regular fatigue
and illness (like weekly) even if they are not in a relapse?
I think I alluded to this in my interview with Merely me. Yes fatigue is a common symptom of MS. It is frequent and often debilitating. It occurs even when patients are not having a MS relapse. Patients may not tell their doctors about it since they may attribute it to drug side-effects. We now have some effective drugs for this MS symptomatology.
I hope you find my answers useful. I thank you all for your questions.
Nitin Sethi, MD