Who Is at Risk for Multiple Sclerosis (MS)? (podcast)

Well, that's the $64,000 question. We don’t know what causes multiple sclerosis. We believe it’s caused by a viral infection, possibly Epstein-Barr virus, the virus that causes infectious mononucleosis, probably acquired when you’re very young in your adolescence. Then it remains dormant for all those years until it comes out when you’re 30, 35 years of age.

There are many symptoms of MS and that’s part of the reason why it’s sometimes difficult to diagnose. It’s because the symptoms can be so different from person to person. But the common ones are fatigue, urinary symptoms, bowel symptoms, erectile dysfunction in men and failure to climax in women. Sometimes pain is a big issue for some patients, problems walking, balance, slurred speech, swallowing issues. The list goes on. It’s quite a long list.

It’s all location, location, location. It depends where the spots occur. One person will present with blurred vision, with pain in the eye as first symptoms. Another one will present with numbness from the waist down, two totally different presentations. It really depends where the spots of MS are.

MS causes attacks that leads to damage, especially of the myelin sheath, the insulation of the nerve fibers, and those damaged areas produce the symptoms. It all depends where the damage is occurring. That’s why location is so important.

With MS, you have attacks where the immune system invades the central nervous system, the brain, the spinal cord, the optic nerves and causes damage, which may or may not cause a symptom. Then, somehow the attack turns off after a couple of weeks typically, and then the area heals and becomes asymptomatic, which means no symptoms anymore.

The reason that it is asymptomatic is because perhaps the damage wasn’t strong enough to produce a scar, just cause some inflammation that healed. Or perhaps the nervous system worked around the damaged area. We know that the healthy parts of the brain and spinal cord and optic nerves can compensate for damage near where the spot is and can make the spot not any more symptomatic.

Young women who are white. The most common person to get multiple sclerosis is a Caucasian woman.

The ratio of female to male is currently about 3 to 1. When I was in training in the 1970s and early 80s, the ratio was 1.4 to 1. What’s happened over the years is that women have become more and more vulnerable to getting multiple sclerosis, possibly because of hormonal differences between men and women. We just don’t know the answers.

MRI is the most important diagnostic tool in multiple sclerosis. We do an MRI on the brain and the spinal cord. What we’re looking for is spots with the characteristic shape, a characteristic appearance as far as where they are and how they’re oriented. If they seem to make sense for multiple sclerosis, and we’ve ruled out other mimics, then we can say multiple sclerosis is the diagnosis.

Well, there are two aspects to this question. Number one, you treat the disease process, so it won’t progress and cause disability down the road. The second thing we do is we look at the symptoms. The person has to try and help them with that to improve their quality of life.

So, the first treatment is disease course modification. We select one of the many medications that we have that will address the immune attack that’s leading to the disease progress. Once that’s done and the person is stable and confirmed to be stable, then we start managing, coincidentally as well, the symptoms that a person has.

Symptom management is a difficult aspect because none of the therapies really work 100%. But we try to manage those symptoms that have a solution, such as spasticity, bladder control, fatigue and so on. Then, we refer patients to physical therapy, and occupational therapy, and speech therapy as needed so that we get them to be functioning as best as they can be.

Alas, no, but I must say that the more recent treatments are now producing responses that are about 95% effective. We call this NEDA, no evidence for disease activity. If we have achieved NEDA and we can maintain it, then the patient is essentially cured. I mean, there is no more disease progression.

It’s important to realize that there are so many therapies out there that help MS. And surely there’s one that’s right for the vast majority of MS people. So, unlike in the past where I would tell a person when there was no therapy to hope for the best, now I can say that we can beat this, that we can be positive about this because we will try whatever treatment we need to do to get you having a normal full life. There is a life after a diagnosis of MS unlike there was in the past.