Jaime Lewis (Host): ​Living with multiple sclerosis means managing a wide range of symptoms that can affect everything from physical mobility to cognitive function and emotional well-being. The good news is there are many strategies and treatments available to help people with MS live full active lives.

Here to discuss the practical side of symptom management is Dr. Ann Cabot, a neurologist with Elliot Health System, who works closely with MS patients to develop comprehensive care plans. This is Elliot Health Talks. I'm your host, Jamie Lewis. Dr. Cabot, welcome.

Dr. Ann Cabot: Hi. Thanks. Nice to be here.

Host: Let's talk about daily life with MS. What are the most common symptoms your patients deal with on a day-to-day basis?

Dr. Ann Cabot: Managing symptoms is really one of the most rewarding parts of the job. And I think what I express to patients, because I see MS patients all day every day, is that it's never the same. Every patient is so different when they walk in. So, some patients may have very few symptoms, and some patients may have a whole bunch of symptoms. So really, we just focus on a very personal one-on-one basis to try to pick through what patient's symptoms are at the time of the appointment, make sure it's an MS symptom or if it's something else, we treat that. And then, focusing on what our team plan is, because really this is a multidisciplinary approach moving on to treat symptoms.

As far as sort of what the most common symptoms are, MS is a disease of the central nervous system. So if you think about episodes of demyelination in the brain and the spinal cord, these symptoms could be anywhere in that territory. So, it's just a huge geography. So, some of the most common complaints that we see really are, believe it or not, fatigue. Fatigue is a really common complaint of MS. So if we wanted to focus on that most common complaint, we really start by making sure a whole bunch of things. Are we seeing fatigue as a result of, you know, sleep issues or vitamin deficiencies or even medications that we might have prescribed for something else as a side effect, or is it true MS fatigue? And then, we work with a whole team of people, including PT and OT, to try to help manage that fatigue. So, we usually try to do things without medication first. But if that doesn't work, then we oftentimes will lean on sometimes symptom management medications. So, yeah, fatigue, believe it or not, is one of the most common complaints of MS, even though it's not something that you can see.

Host: Well, I know that mobility and balance issues are prevalent or can be. When patients start having those kinds of problems, what tools and strategies do you recommend?

Dr. Ann Cabot: So, there is a symptom that is actually visible to other people, right? So, if you see someone with weakness, maybe their gait is impaired or they're having problems transferring or things like that. So, what we first do is evaluate them in the office and see where the issues arise. And then, we're very fortunate to have a wonderful rehab team to work with, this multidisciplinary rehab team. And then, they will be referred there to have a full evaluation. So, sometimes balance can be from loss of sensation, it can be from other things like weakness, it can be from vestibular problems. So, the balance can be a complicated one. And then, we work with a combination of techniques and exercises. Exercise is a big foundation of how we treat mobility issues. So, giving them the right exercise is key. And that's where we really work with our outstanding rehab team here at Elliot.

Host: Can you address cognitive symptoms? I'm thinking things like memory loss, brain fog, those kinds of things that are so frustrating. How do you approach managing those?

Dr. Ann Cabot: Yes, exactly. I couldn't agree more, Jamie. It's so frustrating for patients, because we're all fearful of that, right? We don't want to lose our memory and things like that. And the good thing is most of the time, the memory issues are not severe with MS. And a lot of times, my patients are very reassured when we do cognitive testing. So, we work again as a group. And again, this is where the multidisciplinary approach to treating MS really is incredible. So, we have a teammate in the office who will do cognitive testing for us.

And the important part of cognitive testing is not only to see where the patient stands, but also to rule out other things that can interfere with our cognition, because sometimes it's the fatigue. When you're really tired, it's hard to process. Sometimes it's depression or mood issues that can interfere with your cognitive function. Sometimes there's another medical issue or stressors that we can address as well. Stress is really common with MS, because nobody wants MS and sometimes it throws some curve balls at us. You know, maybe it changes roles in the family or things like that, or just life stress. So, we also work on ways to help manage stressors to help improve cognitive issues.

I think one thing that's frustrating for patients is when we try to use exercise or tools like that to help fatigue, because they just told us they're tired, right? And it almost sounds like we're not listening, and we are listening. So, that's where getting the right types of exercise to help with those things come in handy. And there's even cognitive exercises and cognitive behavioral therapy that can be really helpful.

More severe cognitive issues are definitely more problematic. Fortunately, much less common with MS. But again, we would work with our multidisciplinary team. And again, I feel very fortunate to have the team that we do here at Elliot to assist our patients.

Host: You mentioned depression, anxiety, how are those emotional components connected to MS itself? Is it a direct correlation or is it sort of a byproduct of other things going on?

Dr. Ann Cabot: You know, I think we have to look at all of our patients very holistically. A lot of people have anxiety and depression. But then, you throw in an autoimmune disease that requires treatment and appointments and imaging, it's expensive to get all those tests done. It's a little frightening to get those tests done, especially at first if you're not sure what's happening.

So, yeah, I think it's a very interlaced problem, like a lot of these things are just sort of linked together. But it's important to treat them because if we don't treat depression and anxiety, and if you don't feel like your head's on right, then it's really hard to tackle the rest of the issues that MS may throw at you. You know, we want our patients to be strong and resilient. And so, we need to give them the tools to help treat the anxiety and depression.

Now, that being said, I'm not a psychiatrist. So, I have to help patients find the right tools. So, I think a lot of my job is really coordinating that kind of care and effort and working with patients to get the best outcome.

Host: I'm thinking about assistive devices as well. Do those help patients with maintaining independence?

Dr. Ann Cabot: So, there's a whole lot of different things that we can do. So depending on what the patient is experiencing. So if we're thinking about like mobility or weakness, sometimes we'll have a patient who has maybe like foot drop or sometimes it's hard for them to raise part of their foot. So, we have different options for them. We have bracing, there's electronic devices, all kinds of options for people. So, those things can help because they can treat the weakness, sometimes it helps aid in spasticity. Spasticity is a big problem with MS.

And then, a lot of our patients do get musculoskeletal issues as sort of a secondary byproduct of the MS, it's not directly from the MS. But, you know, if you're weak on one side and you've been walking that way for 30 years, you might get some back pain, right? So, we do work a lot with physical therapy in that realm as well, sometimes the orthopedics.

And then, bladder and bowel, I think, bladder and bowel symptoms are, again, really common in MS and often really important to talk about. Sometimes patients are a little shy when they are discussing bladder and bowel concerns or sexual health, but it's really important to address those things, because they also can contribute to lack of socialization and things like that. And they're often so very treatable. I often use the example of, you know, if someone has some incontinence, they have anxiety about leaking, then they don't want to go to the gym and maybe they don't want to go out on social events, and then it's like a spiral and they get a little more sad because they're not participating in their community. And when you're not participating in your community, it's not good for your mood. It's not good for your cognitive function. So if we don't treat that one thing, it really makes a whole lot of things worse. So, it's really important to pay attention to all the symptoms.

Host: Tell me about the arc of a person's MS journey. Do you create a different symptom management approach depending on the type or the stage of MS that somebody has?

Dr. Ann Cabot: Yes. And I think that's so important. I'm so glad you mentioned it, because we talk a lot about wellness and symptoms. And sometimes honestly, patients will have very few symptoms at all, and I think they're waiting for the other shoe to drop. And it may never drop. Especially if you're a newly diagnosed patient who's been treated with a high efficacy therapy, you may not ever have these symptoms, which is remarkable.

And then, we have other patients who may have had MS for 30, 40 years and has a whole lot of symptoms that we're treating. So, their arc is different because they didn't have the benefit of treatment or at least high efficacy therapies. And so, their disease was sort of set in play early and now we're managing a whole lot of things. So, it's just very unique for everybody. And I think until a person feels confident in their pathway, which I think that takes a year or two to really feel confident in their path, that these things can be a bit of a challenge because it's always in the back of their mind when is that going to happen? But it may never happen. So, it's a bit of a mind game at first, so it's important to have good communication with the office and make sure you're asking your questions.

Host: Well, Dr. Cabot, this has been so informative, I would imagine, for anybody dealing with day to day management of MS. So, thank you.

Dr. Ann Cabot: You bet.

Host: That was Dr. Ann Cabot, a neurologist at Elliot Health System. To learn more about comprehensive MS care and symptom management at Elliot Health System, visit elliothospital.org and search neurological specialties. If this episode was helpful to you or someone you know, please share it on your social media channels. And thank you for listening.