Melanie Cole (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole. And joining me is Dr. Matt Kniss. He's a neurologist at Neurology Associates, a part of Bryan Health. And he's here to tell us about multiple sclerosis. Dr. Kniss, it's a pleasure to have you join us today. I'd like you to start by telling us a little bit about MS today. What do we know about the causes and the different types? Tell us a little bit about how common it is. Kind of give us a little bit of a summary.

Dr Matt Kniss: Sure. And thank you for having me, Melanie. I appreciate the time. So, multiple sclerosis, we call it MS for short. A little background on how it was named. Basically, multiple means multiple and sclerosis means scars. When they first diagnosed this, what they saw in the brain was multiple scars. So, that's how it got its name.

And as far as the cause, that's probably the holy grail of questions for multiple sclerosis. We really don't know. We have a lot of theories about environmental exposures. Could there be a virus? There's genetics that play a role in this. So ultimately, what we think at this time is that it's probably multifactorial causes, but there's really not one thing that I would say that we've really honed in on that would give us that answer for sure.

As far as the types of multiple sclerosis, we have three major types. The most common would be what's called relapsing-remitting multiple sclerosis where somebody will get a neurologic symptom. It lasts maybe a few weeks up to a few months and then relapses, meaning that they have improvement, and that makes up about 80% of newly diagnosed multiple sclerosis patients. A lot of those will go on to what's called secondary progressive, where we no longer have the relapses, but they will have a progressive course over time. And then, we have what's called primary progressive MS, which really doesn't have the relapses. It just has a slow course of progressive neurologic symptoms over a lifetime.

Melanie Cole (Host): Well, thank you so much for that definition and explanation, Dr. Kniss. So, tell us a little bit about the average age of onset. And also, is there a gender difference when you look at prevalence? Are more women than men getting MS? Tell us a little bit about when you see this.

Dr Matt Kniss: So, we think of MS as typically a younger person's condition. So, most common age of onset or initial presentation is around age 20 to 40. We'll see it much more commonly in females as probably two to three times that in males, and that is predominantly with the relapsing-remitting. There's a slight male predominance when you talk about primary progressive MS. But mostly younger females is when we see that. Right now, the prevalence or how often we're seeing it, last numbers I saw was about 350 per 1000. So if you look at the population of Lincoln, for example, which is around 300,000, it's probably about a thousand patients that we have in that area. So, not terribly common, but certainly not uncommon.

Melanie Cole (Host): So Dr. Kniss, let's talk about symptoms. Do they occur in predictable patterns? Are there times of life when they're more likely to experience these symptoms? And then, I'd like you to speak about diagnoses because it's not always easy, yes? So, speak about why it's sometimes challenging to diagnose based on the symptoms that people will come to see a neurologist for.

Dr Matt Kniss: So, symptom-wise, MS is quite variable. The things that we key in on as neurologists, we always get more concerned about what are called focal neurologic symptoms. This may be numbness or weakness on one side of the body or one limb. Those are always a little more concerning, the more generalized symptoms. We typically see some visual changes. And again, if it's one eye visual change, a little more concerning than if you have bilateral vision changes. We can see things like balance difficulty, incoordination, bladder changes, people will come in with vertigo. You can have cognitive changes where they feel like their memory may not be quite as good. So, anything that I think you could think about the nervous system that can be a symptom of MS, now that is a lot. And so, yeah, you're right, the diagnosis can be challenging because there is not one lab test, there's not one imaging test that really diagnoses MS.

What we use is a combination. You take a very good clinical history. You try to find are they having focal neurologic symptoms. Can we localize those symptoms to part of the nervous system where we might think there might be one of these, you know, scars or a lesion that we see? Then, we move on and we say, "Well, if that's consistent," then we say, "Well, the next step is we usually do some imaging, which is typically an MRI scan," and that will be of usually the brain and the spinal cord. So, we think of MS as more of a central nervous system disorder, affecting the brain and spinal cord, so that's what you image. And we have certain criteria for that. Radiologists help us with that. But we kind of count up the number of spots we see and say, "Well, if these are in the right spots and they make sense, then you know, this could be consistent with MS." Sometimes we use a few other tests. There's a lumbar puncture or a spinal tap. Sometimes we'll look at the fluid and that might help us out. And sometimes when you don't have enough information, we kind of wait. We say, "Well, you have this symptom. It sounds like MS, but we don't meet the diagnostic criteria." So, we may follow up with them in six months. We may get another scan in six months and we look for changes. It's challenging, but sometimes it's straightforward, sometimes it's not. But we have to use what's at our disposal.

Melanie Cole (Host): Well, certainly, and thank you for that. So, tell us a little bit about how a patient's health is overall affected by MS as you get into telling us about some of the treatments that you're looking to and some of the exciting advancements in your field. There are other specific health areas that they need to pay attention to and some you might see them maybe neglecting, maybe health appointments, well visits because they're so focused on their MS. Can you tell us a little bit about lifestyle and what's that like for somebody living with MS?

Dr Matt Kniss: Because it's a variable condition, we see lots of different things that can play a role with lifestyle. Number one thing we focus on is treatment. And the reason we treat MS is to decrease disability. Over time, we know that since we don't have a cure per se for MS, there is a chance of progression and we try to treat that in order to decrease progression of disability. So, you'll see all different types of people. They may look perfectly normal or they may be in a wheelchair, so everybody's a little bit different.

Every appointment that we see an MS patient, we also ask about how are you doing? There's a higher chance of depression. There's a higher chance of mental health issues with people with MS. And we think that has to do with just possibly the disease itself causing some of that versus just the disability and the fact that they may not be able to do the things they used to be able to do. It can have an impact on fertility. We ask about family. It has an impact on their ability to exercise. We always want our MS patients to be exercising, we have really good studies that show that people that are more active are the ones that stay active. So, we really try to encourage those types of things. We want them to maintain their weight. We know that people that may be a little overweight have a slightly increased risk of more progression and more disability later in life. We preach that we should stop smoking. Smoking has actually been identified as a risk factor for MS. So, we really make sure that we're doing all we can to get them to stop smoking if they're there. There's always a lot of questions from females about pregnancy and those types of things. So, there's a lot of education that goes on at those visits when we talk about lifestyle changes.

Melanie Cole (Host): Well, there certainly is a lot of education. As an exercise physiologist, Dr. Kniss, I've learned so much over the years about that lifestyle and, as you say, exercise and nutrition and some of those behaviors and stress and the mental health toll that having MS can take. So, speak about some of the exciting, hopeful treatments that are out there and why shared decision-making is such an important part of MS treatment.

Dr Matt Kniss: It is exciting. I think that over the past five years, we've had a lot of new treatments come out for MS, compared to when I started 18 years ago. We maybe had four medications at that time. So yeah, at this point, we probably have over 20 different treatments that we have to choose from. You know, not all of them are for everybody, but it's certainly nice to have a lot more options for people. In a nutshell, I think that these treatments that we have, they all are based on sort of the immune system. We try to alter the immune system. It's a little scary to use those words for patients. But honestly, you know, it's not scary. We get people through it, but there's a lot of education that goes on prior to that. And you're right, shared decision-making with these medications is very important. When we talk about the medications, we try to guide them in saying, "Well, this is what I think you may do well with, but here's some other options. We need to have you look at it and see what you're comfortable with and what I'm comfortable with."

And part of that also has to go with what is also approved by their insurance because MS is probably one of the most expensive conditions to treat. So insurance, unfortunately, does have to play a role in some of this decision-making as well. But, typically, we get people on good treatment, people tolerate treatment well. There is a bit of a maintenance that goes on that we have to look at labs and we have to do some other imaging to make sure things are working like they should. But for the most part, I think that we've come a long way in being able to treat MS very effectively to try to decrease that disability that we're trying to prevent. It is an exciting field. I think we’re making a lot of progress, there's a lot of research that goes into it. And so, we've been very lucky to have these newer treatments available and it really seems to make an impact on patients' lives and being able to keep that patient doing what they want to do later in life.

Melanie Cole (Host): What a wonderful philosophy of care, Dr. Kniss. As we wrap up, I'd like you to offer your best advice for listeners and how they can go about managing their health, side effects from treatment, maintaining that healthy lifestyle, what you'd really like them to know about living with MS. And the treatments and exciting advances available at Bryan Health.

Dr Matt Kniss: So, I think my goal, our neurologist's goal, doctor's goal is really to live a normal life, even if you have MS. So, it may take a little more work on the doctor's part, on the patient's part to live a pretty normal life. But the ultimate goal is to have somebody look at that patient and say, "Well, I can't even tell you have MS," and that's a pretty successful treatment. But it does take some work. I mean, there are medications that you have to manage. You have to see the doctor every once in a while. You have to get labs, you have to get images done. You have to work on your exercise. There is definitely some dietary things that we recommend, which is basically just a normal, healthy diet. But you know, you have to remind people to do that sometimes. We recommend exercise, routine exercise, and I think that the best patients I have are the ones that really stick to that plan. They're consistent with their medications, they're consistent with their exercise and they're consistent with their diet and maintaining a healthy weight. Those are really the ones that I would say you probably can't even tell that they have MS at this point. So between the medications and the patient and the counseling and the education and just the therapists that may be involved. It's kind of this multifactorial approach and multi-specialty approach that gets them to that goal.

Melanie Cole (Host): Well, it certainly is, that multidisciplinary approach. Thank you so much, Dr. Kniss, for joining us today. I'd also like to thank our Bryan Foundation partner, Sampson Construction.

Thank you for listening to Bryan Health podcast. To listen to more podcasts from our experts. You can visit bryanhealth.org/podcasts and always remember to subscribe, rate, and review this podcast and all the other Bryan Health podcasts. I'm Melanie Cole. Thanks so much for joining us today.

 Melanie Cole (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole. And joining me is Dr. Matt Kniss. He's a neurologist at Neurology Associates, a part of Bryan Health. And he's here to tell us about multiple sclerosis. Dr. Kniss, it's a pleasure to have you join us today. I'd like you to start by telling us a little bit about MS today. What do we know about the causes and the different types? Tell us a little bit about how common it is. Kind of give us a little bit of a summary.

Dr Matt Kniss: Sure. And thank you for having me, Melanie. I appreciate the time. So, multiple sclerosis, we call it MS for short. A little background on how it was named. Basically, multiple means multiple and sclerosis means scars. When they first diagnosed this, what they saw in the brain was multiple scars. So, that's how it got its name.

And as far as the cause, that's probably the holy grail of questions for multiple sclerosis. We really don't know. We have a lot of theories about environmental exposures. Could there be a virus? There's genetics that play a role in this. So ultimately, what we think at this time is that it's probably multifactorial causes, but there's really not one thing that I would say that we've really honed in on that would give us that answer for sure.

As far as the types of multiple sclerosis, we have three major types. The most common would be what's called relapsing-remitting multiple sclerosis where somebody will get a neurologic symptom. It lasts maybe a few weeks up to a few months and then relapses, meaning that they have improvement, and that makes up about 80% of newly diagnosed multiple sclerosis patients. A lot of those will go on to what's called secondary progressive, where we no longer have the relapses, but they will have a progressive course over time. And then, we have what's called primary progressive MS, which really doesn't have the relapses. It just has a slow course of progressive neurologic symptoms over a lifetime.

Melanie Cole (Host): Well, thank you so much for that definition and explanation, Dr. Kniss. So, tell us a little bit about the average age of onset. And also, is there a gender difference when you look at prevalence? Are more women than men getting MS? Tell us a little bit about when you see this.

Dr Matt Kniss: So, we think of MS as typically a younger person's condition. So, most common age of onset or initial presentation is around age 20 to 40. We'll see it much more commonly in females as probably two to three times that in males, and that is predominantly with the relapsing-remitting. There's a slight male predominance when you talk about primary progressive MS. But mostly younger females is when we see that. Right now, the prevalence or how often we're seeing it, last numbers I saw was about 350 per 1000. So if you look at the population of Lincoln, for example, which is around 300,000, it's probably about a thousand patients that we have in that area. So, not terribly common, but certainly not uncommon.

Melanie Cole (Host): So Dr. Kniss, let's talk about symptoms. Do they occur in predictable patterns? Are there times of life when they're more likely to experience these symptoms? And then, I'd like you to speak about diagnoses because it's not always easy, yes? So, speak about why it's sometimes challenging to diagnose based on the symptoms that people will come to see a neurologist for.

Dr Matt Kniss: So, symptom-wise, MS is quite variable. The things that we key in on as neurologists, we always get more concerned about what are called focal neurologic symptoms. This may be numbness or weakness on one side of the body or one limb. Those are always a little more concerning, the more generalized symptoms. We typically see some visual changes. And again, if it's one eye visual change, a little more concerning than if you have bilateral vision changes. We can see things like balance difficulty, incoordination, bladder changes, people will come in with vertigo. You can have cognitive changes where they feel like their memory may not be quite as good. So, anything that I think you could think about the nervous system that can be a symptom of MS, now that is a lot. And so, yeah, you're right, the diagnosis can be challenging because there is not one lab test, there's not one imaging test that really diagnoses MS.

What we use is a combination. You take a very good clinical history. You try to find are they having focal neurologic symptoms. Can we localize those symptoms to part of the nervous system where we might think there might be one of these, you know, scars or a lesion that we see? Then, we move on and we say, "Well, if that's consistent," then we say, "Well, the next step is we usually do some imaging, which is typically an MRI scan," and that will be of usually the brain and the spinal cord. So, we think of MS as more of a central nervous system disorder, affecting the brain and spinal cord, so that's what you image. And we have certain criteria for that. Radiologists help us with that. But we kind of count up the number of spots we see and say, "Well, if these are in the right spots and they make sense, then you know, this could be consistent with MS." Sometimes we use a few other tests. There's a lumbar puncture or a spinal tap. Sometimes we'll look at the fluid and that might help us out. And sometimes when you don't have enough information, we kind of wait. We say, "Well, you have this symptom. It sounds like MS, but we don't meet the diagnostic criteria." So, we may follow up with them in six months. We may get another scan in six months and we look for changes. It's challenging, but sometimes it's straightforward, sometimes it's not. But we have to use what's at our disposal.

Melanie Cole (Host): Well, certainly, and thank you for that. So, tell us a little bit about how a patient's health is overall affected by MS as you get into telling us about some of the treatments that you're looking to and some of the exciting advancements in your field. There are other specific health areas that they need to pay attention to and some you might see them maybe neglecting, maybe health appointments, well visits because they're so focused on their MS. Can you tell us a little bit about lifestyle and what's that like for somebody living with MS?

Dr Matt Kniss: Because it's a variable condition, we see lots of different things that can play a role with lifestyle. Number one thing we focus on is treatment. And the reason we treat MS is to decrease disability. Over time, we know that since we don't have a cure per se for MS, there is a chance of progression and we try to treat that in order to decrease progression of disability. So, you'll see all different types of people. They may look perfectly normal or they may be in a wheelchair, so everybody's a little bit different.

Every appointment that we see an MS patient, we also ask about how are you doing? There's a higher chance of depression. There's a higher chance of mental health issues with people with MS. And we think that has to do with just possibly the disease itself causing some of that versus just the disability and the fact that they may not be able to do the things they used to be able to do. It can have an impact on fertility. We ask about family. It has an impact on their ability to exercise. We always want our MS patients to be exercising, we have really good studies that show that people that are more active are the ones that stay active. So, we really try to encourage those types of things. We want them to maintain their weight. We know that people that may be a little overweight have a slightly increased risk of more progression and more disability later in life. We preach that we should stop smoking. Smoking has actually been identified as a risk factor for MS. So, we really make sure that we're doing all we can to get them to stop smoking if they're there. There's always a lot of questions from females about pregnancy and those types of things. So, there's a lot of education that goes on at those visits when we talk about lifestyle changes.

Melanie Cole (Host): Well, there certainly is a lot of education. As an exercise physiologist, Dr. Kniss, I've learned so much over the years about that lifestyle and, as you say, exercise and nutrition and some of those behaviors and stress and the mental health toll that having MS can take. So, speak about some of the exciting, hopeful treatments that are out there and why shared decision-making is such an important part of MS treatment.

Dr Matt Kniss: It is exciting. I think that over the past five years, we've had a lot of new treatments come out for MS, compared to when I started 18 years ago. We maybe had four medications at that time. So yeah, at this point, we probably have over 20 different treatments that we have to choose from. You know, not all of them are for everybody, but it's certainly nice to have a lot more options for people. In a nutshell, I think that these treatments that we have, they all are based on sort of the immune system. We try to alter the immune system. It's a little scary to use those words for patients. But honestly, you know, it's not scary. We get people through it, but there's a lot of education that goes on prior to that. And you're right, shared decision-making with these medications is very important. When we talk about the medications, we try to guide them in saying, "Well, this is what I think you may do well with, but here's some other options. We need to have you look at it and see what you're comfortable with and what I'm comfortable with."

And part of that also has to go with what is also approved by their insurance because MS is probably one of the most expensive conditions to treat. So insurance, unfortunately, does have to play a role in some of this decision-making as well. But, typically, we get people on good treatment, people tolerate treatment well. There is a bit of a maintenance that goes on that we have to look at labs and we have to do some other imaging to make sure things are working like they should. But for the most part, I think that we've come a long way in being able to treat MS very effectively to try to decrease that disability that we're trying to prevent. It is an exciting field. I think we’re making a lot of progress, there's a lot of research that goes into it. And so, we've been very lucky to have these newer treatments available and it really seems to make an impact on patients' lives and being able to keep that patient doing what they want to do later in life.

Melanie Cole (Host): What a wonderful philosophy of care, Dr. Kniss. As we wrap up, I'd like you to offer your best advice for listeners and how they can go about managing their health, side effects from treatment, maintaining that healthy lifestyle, what you'd really like them to know about living with MS. And the treatments and exciting advances available at Bryan Health.

Dr Matt Kniss: So, I think my goal, our neurologist's goal, doctor's goal is really to live a normal life, even if you have MS. So, it may take a little more work on the doctor's part, on the patient's part to live a pretty normal life. But the ultimate goal is to have somebody look at that patient and say, "Well, I can't even tell you have MS," and that's a pretty successful treatment. But it does take some work. I mean, there are medications that you have to manage. You have to see the doctor every once in a while. You have to get labs, you have to get images done. You have to work on your exercise. There is definitely some dietary things that we recommend, which is basically just a normal, healthy diet. But you know, you have to remind people to do that sometimes. We recommend exercise, routine exercise, and I think that the best patients I have are the ones that really stick to that plan. They're consistent with their medications, they're consistent with their exercise and they're consistent with their diet and maintaining a healthy weight. Those are really the ones that I would say you probably can't even tell that they have MS at this point. So between the medications and the patient and the counseling and the education and just the therapists that may be involved. It's kind of this multifactorial approach and multi-specialty approach that gets them to that goal.

Melanie Cole (Host): Well, it certainly is, that multidisciplinary approach. Thank you so much, Dr. Kniss, for joining us today. I'd also like to thank our Bryan Foundation partner, Sampson Construction.

Thank you for listening to Bryan Health podcast. To listen to more podcasts from our experts. You can visit bryanhealth.org/podcasts and always remember to subscribe, rate, and review this podcast and all the other Bryan Health podcasts. I'm Melanie Cole. Thanks so much for joining us today.