Multiple sclerosis (MS) only affects at least 1,000,000 individuals nationwide. This disorder is highly variable from one individual to another, and impacts on the central nervous system can result in a broad range of symptoms and functional impairments. Confirming the diagnosis of MS can be complicated and challenging, as other disorders can have similar symptoms. That is why it is incredibly important to seek a physician who has a strong understanding of the diagnostic criteria for MS as there is no single test for the disease.
Infirmary Health’s multidisciplinary Neuroscience Center of Excellence has decades of experience in helping properly diagnose individuals with MS. Dr. Elizabeth Minto, a neurologist with Coastal Medical Group, is a designated Partner in MS with the National Multiple Sclerosis Society. She joins us to discuss symptoms, guidance on obtaining a proper diagnosis and the importance of choosing a care provider with expertise in MS.
Selected Podcast
Multiple Sclerosis: What It Is, and What It Isn’t
Featuring:
Elizabeth Minto, M.D.
Elizabeth Minto, M.D. has served the Gulf Coast Region for more than 15 years. She is a graduate of the University of Alabama at Birmingham and completed her residency in neurology with Vanderbilt University. She is a recent recipient of the Leonard Tow Humanism in Medicine Award for demonstrating outstanding compassion to patients and their families. She is a designated Partner in MS Care by the National Multiple Sclerosis Society indicating expertise in diagnosing and treating individuals with MS. Transcription:
Prakash Chandran: Multiple sclerosis or MS only affects 400,000 individuals nationwide. However, the impacts on the central nervous system result in a broad range of symptoms and functional impairments. Infirmary Health's Multidisciplinary Neuroscience Center of Excellence has decades of experience in helping properly diagnose individuals with MS.
Dr. Elizabeth Minto, a neurologist with Coastal Medical Group, is a designated partner in MS Care with the National Multiple Sclerosis Society. She joins us to discuss symptoms, guidance on obtaining a proper diagnosis and the importance of choosing a care provider with expertise in MS.
Welcome to LIFE Cast by Infirmary Health. My name is Prakash Chandran. Dr. Minto, thank you so much for joining us today. I really appreciate your time. Let's get started with the basics. What exactly is multiple sclerosis?
Dr. Elizabeth Minto: Hello, and thank you for having me. MS is a complicated and relatively mysterious diagnosis that affects the nervous system, so the brain, the spinal cord, and the optic nerve, which is the stalk that connects the eyes to the brain. It is thought to be because of an immune system dysfunction whereby your immune system that should be protecting you from outside influences like splinters and viruses and bacteria for some reason cross-reacts and starts to attack your own body's nervous system tissues. It is a chronic disorder that can be managed with medications and other treatments to try to help suppress the inflammation and the damage done by the immune system.
Prakash Chandran: Okay. And before we get into signs and symptoms and diagnosis, I'd love to understand a little bit more around if there are risk factors or common risk factors for multiple sclerosis.
Dr. Elizabeth Minto: So, as I mentioned, MS is somewhat mysterious, meaning that we don't know of any particular thing that causes it or triggers it to happen in individuals. MS attacks something in the nervous system called myelin. Myelin is the insulation around our nerve fibers. I think of it kind of like our phone charger cable. There's a wire inside that's wrapped by rubber, so that we don't get shocked. The insulation or the myelin is what gets damaged in MS. And so, that immune system going haywire is thought to be caused by some immune reaction, probably with a prior viral infection.
There's a lot of mounting evidence that prior infection with something called Epstein-Barr virus maybe what triggers the immune system dysfunction that causes MS. There is also a lot of evidence that this triggering of the immune system by a viral infection probably happens prior to adolescence.
And this is some really interesting data, people who live farther from the equator have a higher incidence of developing multiple sclerosis, and people that live closer to the equator have a lower incidence of developing MS. We think that has something to do with vitamin D levels and sun exposure. Obviously, if you live closer to the equator, you're in the sun more so your vitamin D levels are higher. But there are a lot of studies that have shown that patients who move from areas closer to the equator to areas farther from the equator pick up that increased risk of living farther from the equator if they moved prior to puberty, but they retain that lower risk of developing MS if they moved after puberty. So, there's some kind of circumstantial evidence, if you will, that MS is triggered by some exposure to probably a viral infection prior to puberty, and then the immune system damage starts to become apparent a little later in life, typically in your 20s or 30s is when first MS symptoms appear.
Prakash Chandran: I wanted to ask a little bit more about potentially the signs or symptoms that lead people to start a conversation with their physician in the first place. Like what are the most common things that we see?
Dr. Elizabeth Minto: This is such an important question because I think there are so many various symptoms that MS can cause that a lot of times I'll see a patient for a possible diagnosis of MS and they've looked up their symptoms on the internet and have become convinced that MS is the explanation for all of their symptoms.
The symptoms of MS are incredibly variable for one patient to the next. Depending on where the inflammatory damage from this disease occurs in the brain, that's going to determine what symptoms a patient has. So, if a patient develops inflammation in their optic nerve, they would be expected to have loss of vision in that eye for some days or weeks before it starts to get better. If a patient develops inflammation in what's called the brain stem, which is the stalk that connects the brain to the spinal cord, they may be expected to have completely different symptoms. They may have vertigo. They may have double vision. They may have difficulty with weakness or numbness on one side versus the other. And so, really where the lesions occur in MS is what dictates what symptoms it causes. What is not typical for someone with MS are what are called generalized or vague symptoms, so just being dizzy or just having headaches, or having generalized fatigue and malaise. Those are symptoms that patients with MS do experience, but just those symptoms alone shouldn't cause concern that MS is the explanation. So, it can be a really complicated and difficult disease to get an accurate diagnosis for.
It's also important to note that symptoms like vision loss or weakness or numbness on one side or the other can be caused by lots of other different disorders, strokes, brain tumors, infections. Lots of other explanations for these symptoms have to be considered and excluded before we arrive at MS as an accurate diagnosis, so it can be really complicated and it's important to be under the care of someone with experience diagnosing MS and undiagnosing MS when it has been inaccurately diagnosed before embarking on a treatment plan.
Prakash Chandran: Yeah, I'd love to expand on that a little bit. Because it is typically so complicated to diagnose MS, given the varied symptoms, how does one get traditionally diagnosed? Like, can you explain at a high level what combination of signs and symptoms might tell you that someone does in fact have it?
Dr. Elizabeth Minto: So, there are some symptoms that we consider to be "typical delineating symptoms". So, a common presenting symptom of MS, as I mentioned, might be loss of vision in one eye or double vision. Another common symptom might be weakness or numbness or both on one side of the body versus the other, since the brain works in halves. The right side of the brain controls the left side of the body and vice versa.
For any patient who presents with symptoms that may be suggestive of MS, the first thing I'm going to order is an MRI scan of the brain and usually also of the spinal cord because there is a formal diagnostic criteria for MS called the McDonald criteria, and the very first points on that diagnostic criteria are that a patient with MS has more than one MRI lesion in more than one location in the central nervous system. And so, if I get an MRI and there are no lesions, then I know without a doubt that MS is not the explanation for this patient's symptoms.
Another test that is commonly ordered is called a lumbar puncture, and that really strikes fear into a lot of patient's hearts. But at the end of the day, it is basically collecting spinal fluid through a small needle at the base of the back, and it's basically no more complicated than a blood draw. It's just drawing different fluid, but looking at various proteins and cells in the spinal fluid can support or not support the diagnosis of multiple sclerosis. So, anyone who's being considered as possibly having MS should absolutely be having an MRI, a lumbar puncture, plus or minus some other lab work, depending on what other symptoms might suggest other workup.
Prakash Chandran: Now, I want to move on to how MS is treated. So, can you broadly speak about this and also address if MS can actually be cured?
Dr. Elizabeth Minto: So, at this point in human history, there's not a cure for MS. We know that if we start MS treatment sooner, so getting an accurate diagnosis sooner, we can definitely stave off some of the disease progression that is a natural part of this diagnosis, is progression. When I first entered practice, there were four FDA-approved treatments for multiple sclerosis. And today, there are 20. So, I think that's one of the most exciting things about being in a multiple sclerosis care provider, is that the treatment options have amazingly expanded in a relatively short time. Unfortunately, all of our disease treatments at this point are approved to prevent future disease activity. But we haven't reached a point where we have a treatment that can reverse the established deficits that have already occurred from MS. So, that's why it's so important to start treatment early.
Treatments vary along a spectrum of safety and efficacy. There are first line, second line, third line, even fourth line treatments. So basically, it's recommended that each patient with MS have a detailed discussion with their neurologist regarding which treatment makes the most sense to best balance, safety, and efficacy for their particular MS symptoms and MRI findings. And then, that patient and their neurologist are basically in a long-term relationship to follow their symptoms, follow their surveillance imaging. And if their MS is flaring up or their MRI is changing despite the treatment that they're on, it would be recommended that they escalate to the next tier of MS therapy. So, there are oral therapies or pills, there are injectable therapies or shots, and there are IV therapies or infusions. And so, each patient really has to have their therapy tailored to their particular disease severity and how it's behaved over the years.
Prakash Chandran: So, one of the last things I wanted to ask you is what does it mean to be a partner in MS care, and why is it important to choose a provider with knowledge and expertise in caring for MS?
Dr. Elizabeth Minto: Well, as I mentioned, multiple sclerosis can be a difficult disorder to get an accurate diagnosis for. There are textbooks filled with all of the various conditions that can cause white spots to form on a brain MRI. And so, it's critically important that we not misdiagnose a patient as having MS as the explanation for their symptoms and their MRI findings because the last line of the diagnostic criteria is the most important one in my opinion. And it says that symptoms are not better explained by an alternative diagnosis.
So, the designation of being a partner in MS Care is basically a title given by the National Multiple Sclerosis Society, just indicating that they have vetted me and my office staff and the other partners in MS Care as having experience in diagnosing and treating patients with MS, and also having a priority that not only are we just prescribing medication and ordering surveillance MRIs and lab work, but also really treating and helping support the whole patient and their family and caregivers by creating a multidisciplinary team that may include physical therapists, urologists, neuropsychologists, to make sure that all of the patient's symptoms are being managed and not just their medication needs.
Prakash Chandran: You know, there's probably going to be people listening to this who might have themselves or for a loved one have a relatively new MS diagnosis, and I was wondering if you could broadly speak to living with MS and what patients can expect.
Dr. Elizabeth Minto: I'm really glad you asked that question. It's a really complicated one. But when I diagnose a patient with MS for the first time, you can imagine it's a bit overwhelming and the patient wants to know, "Am I gonna be in a wheelchair? Should I have children? Am I going to be able to work?" And those are very fair questions.
My first reassurance to any patient who has been newly diagnosed with MS is, yes, you are going to be able to live with this disease. it is a heavy psychological burden to carry to know that you have an unpredictable and progressive neurologic disease, but it is also comforting to know that there are so many treatment options. And that there's going to be a partner walking this walk with you to make sure that you're on the right treatment. And if things change, then your treatment changes.
Patients with MS likely early in their disease don't show any outward signs. So, in a lot of cases, a patient with newly diagnosed MS is not going to have anyone that they work with or live with know that they have MS unless they tell them. and so it is my goal that we keep it that way for as long as we can. Patients with MS are encouraged to maintain physical activity levels to continue to work as long as they feel physically and mentally able; to have children. Believe it or not there is data that patients who have more children who are living with MS actually have less disease progression because the condition of pregnancy seems to lower the autoimmune disease activity of MS. So, the more often and the longer you're pregnant, the less active your MS can be.
So, I try to share with patients that all of these things are still very feasible while living with ms. Um, it's important to be compliant with medications and to discuss any side effects with your neurologist rather than just stopping medication. And I think my biggest encouragement to patients when they receive this diagnosis, is there's really two ways that I see people handle this. One is that it becomes their identity and it's all that they think about and it really reshapes the way that they see the world and the way that they see themselves. And another reaction is to see it as an inconvenience and something that they are going to get through and that they are going to treat and that they're going to fight. And so, I really encourage people to do the best that they can to go with that latter approach of it being an inconvenience, but something that we're going to tackle.
Prakash Chandran: Dr. Minto, I think that is the perfect place to end. Thank you so much for your time.
Dr. Elizabeth Minto: Thank you for having me.
Prakash Chandran: That was Dr. Elizabeth Minto, a neurologist with Coastal Medical Group and a designated partner in MS Care with the National Multiple Sclerosis Society. Thanks so much for listening to this episode of Infirmary Health's LIFE Cast. Visit infirmaryhealth.org to learn more about our multidisciplinary neuroscience program or to find a physician near you. My name's Prakash Chandran. Thanks again for listening, and we'll talk next time.
Prakash Chandran: Multiple sclerosis or MS only affects 400,000 individuals nationwide. However, the impacts on the central nervous system result in a broad range of symptoms and functional impairments. Infirmary Health's Multidisciplinary Neuroscience Center of Excellence has decades of experience in helping properly diagnose individuals with MS.
Dr. Elizabeth Minto, a neurologist with Coastal Medical Group, is a designated partner in MS Care with the National Multiple Sclerosis Society. She joins us to discuss symptoms, guidance on obtaining a proper diagnosis and the importance of choosing a care provider with expertise in MS.
Welcome to LIFE Cast by Infirmary Health. My name is Prakash Chandran. Dr. Minto, thank you so much for joining us today. I really appreciate your time. Let's get started with the basics. What exactly is multiple sclerosis?
Dr. Elizabeth Minto: Hello, and thank you for having me. MS is a complicated and relatively mysterious diagnosis that affects the nervous system, so the brain, the spinal cord, and the optic nerve, which is the stalk that connects the eyes to the brain. It is thought to be because of an immune system dysfunction whereby your immune system that should be protecting you from outside influences like splinters and viruses and bacteria for some reason cross-reacts and starts to attack your own body's nervous system tissues. It is a chronic disorder that can be managed with medications and other treatments to try to help suppress the inflammation and the damage done by the immune system.
Prakash Chandran: Okay. And before we get into signs and symptoms and diagnosis, I'd love to understand a little bit more around if there are risk factors or common risk factors for multiple sclerosis.
Dr. Elizabeth Minto: So, as I mentioned, MS is somewhat mysterious, meaning that we don't know of any particular thing that causes it or triggers it to happen in individuals. MS attacks something in the nervous system called myelin. Myelin is the insulation around our nerve fibers. I think of it kind of like our phone charger cable. There's a wire inside that's wrapped by rubber, so that we don't get shocked. The insulation or the myelin is what gets damaged in MS. And so, that immune system going haywire is thought to be caused by some immune reaction, probably with a prior viral infection.
There's a lot of mounting evidence that prior infection with something called Epstein-Barr virus maybe what triggers the immune system dysfunction that causes MS. There is also a lot of evidence that this triggering of the immune system by a viral infection probably happens prior to adolescence.
And this is some really interesting data, people who live farther from the equator have a higher incidence of developing multiple sclerosis, and people that live closer to the equator have a lower incidence of developing MS. We think that has something to do with vitamin D levels and sun exposure. Obviously, if you live closer to the equator, you're in the sun more so your vitamin D levels are higher. But there are a lot of studies that have shown that patients who move from areas closer to the equator to areas farther from the equator pick up that increased risk of living farther from the equator if they moved prior to puberty, but they retain that lower risk of developing MS if they moved after puberty. So, there's some kind of circumstantial evidence, if you will, that MS is triggered by some exposure to probably a viral infection prior to puberty, and then the immune system damage starts to become apparent a little later in life, typically in your 20s or 30s is when first MS symptoms appear.
Prakash Chandran: I wanted to ask a little bit more about potentially the signs or symptoms that lead people to start a conversation with their physician in the first place. Like what are the most common things that we see?
Dr. Elizabeth Minto: This is such an important question because I think there are so many various symptoms that MS can cause that a lot of times I'll see a patient for a possible diagnosis of MS and they've looked up their symptoms on the internet and have become convinced that MS is the explanation for all of their symptoms.
The symptoms of MS are incredibly variable for one patient to the next. Depending on where the inflammatory damage from this disease occurs in the brain, that's going to determine what symptoms a patient has. So, if a patient develops inflammation in their optic nerve, they would be expected to have loss of vision in that eye for some days or weeks before it starts to get better. If a patient develops inflammation in what's called the brain stem, which is the stalk that connects the brain to the spinal cord, they may be expected to have completely different symptoms. They may have vertigo. They may have double vision. They may have difficulty with weakness or numbness on one side versus the other. And so, really where the lesions occur in MS is what dictates what symptoms it causes. What is not typical for someone with MS are what are called generalized or vague symptoms, so just being dizzy or just having headaches, or having generalized fatigue and malaise. Those are symptoms that patients with MS do experience, but just those symptoms alone shouldn't cause concern that MS is the explanation. So, it can be a really complicated and difficult disease to get an accurate diagnosis for.
It's also important to note that symptoms like vision loss or weakness or numbness on one side or the other can be caused by lots of other different disorders, strokes, brain tumors, infections. Lots of other explanations for these symptoms have to be considered and excluded before we arrive at MS as an accurate diagnosis, so it can be really complicated and it's important to be under the care of someone with experience diagnosing MS and undiagnosing MS when it has been inaccurately diagnosed before embarking on a treatment plan.
Prakash Chandran: Yeah, I'd love to expand on that a little bit. Because it is typically so complicated to diagnose MS, given the varied symptoms, how does one get traditionally diagnosed? Like, can you explain at a high level what combination of signs and symptoms might tell you that someone does in fact have it?
Dr. Elizabeth Minto: So, there are some symptoms that we consider to be "typical delineating symptoms". So, a common presenting symptom of MS, as I mentioned, might be loss of vision in one eye or double vision. Another common symptom might be weakness or numbness or both on one side of the body versus the other, since the brain works in halves. The right side of the brain controls the left side of the body and vice versa.
For any patient who presents with symptoms that may be suggestive of MS, the first thing I'm going to order is an MRI scan of the brain and usually also of the spinal cord because there is a formal diagnostic criteria for MS called the McDonald criteria, and the very first points on that diagnostic criteria are that a patient with MS has more than one MRI lesion in more than one location in the central nervous system. And so, if I get an MRI and there are no lesions, then I know without a doubt that MS is not the explanation for this patient's symptoms.
Another test that is commonly ordered is called a lumbar puncture, and that really strikes fear into a lot of patient's hearts. But at the end of the day, it is basically collecting spinal fluid through a small needle at the base of the back, and it's basically no more complicated than a blood draw. It's just drawing different fluid, but looking at various proteins and cells in the spinal fluid can support or not support the diagnosis of multiple sclerosis. So, anyone who's being considered as possibly having MS should absolutely be having an MRI, a lumbar puncture, plus or minus some other lab work, depending on what other symptoms might suggest other workup.
Prakash Chandran: Now, I want to move on to how MS is treated. So, can you broadly speak about this and also address if MS can actually be cured?
Dr. Elizabeth Minto: So, at this point in human history, there's not a cure for MS. We know that if we start MS treatment sooner, so getting an accurate diagnosis sooner, we can definitely stave off some of the disease progression that is a natural part of this diagnosis, is progression. When I first entered practice, there were four FDA-approved treatments for multiple sclerosis. And today, there are 20. So, I think that's one of the most exciting things about being in a multiple sclerosis care provider, is that the treatment options have amazingly expanded in a relatively short time. Unfortunately, all of our disease treatments at this point are approved to prevent future disease activity. But we haven't reached a point where we have a treatment that can reverse the established deficits that have already occurred from MS. So, that's why it's so important to start treatment early.
Treatments vary along a spectrum of safety and efficacy. There are first line, second line, third line, even fourth line treatments. So basically, it's recommended that each patient with MS have a detailed discussion with their neurologist regarding which treatment makes the most sense to best balance, safety, and efficacy for their particular MS symptoms and MRI findings. And then, that patient and their neurologist are basically in a long-term relationship to follow their symptoms, follow their surveillance imaging. And if their MS is flaring up or their MRI is changing despite the treatment that they're on, it would be recommended that they escalate to the next tier of MS therapy. So, there are oral therapies or pills, there are injectable therapies or shots, and there are IV therapies or infusions. And so, each patient really has to have their therapy tailored to their particular disease severity and how it's behaved over the years.
Prakash Chandran: So, one of the last things I wanted to ask you is what does it mean to be a partner in MS care, and why is it important to choose a provider with knowledge and expertise in caring for MS?
Dr. Elizabeth Minto: Well, as I mentioned, multiple sclerosis can be a difficult disorder to get an accurate diagnosis for. There are textbooks filled with all of the various conditions that can cause white spots to form on a brain MRI. And so, it's critically important that we not misdiagnose a patient as having MS as the explanation for their symptoms and their MRI findings because the last line of the diagnostic criteria is the most important one in my opinion. And it says that symptoms are not better explained by an alternative diagnosis.
So, the designation of being a partner in MS Care is basically a title given by the National Multiple Sclerosis Society, just indicating that they have vetted me and my office staff and the other partners in MS Care as having experience in diagnosing and treating patients with MS, and also having a priority that not only are we just prescribing medication and ordering surveillance MRIs and lab work, but also really treating and helping support the whole patient and their family and caregivers by creating a multidisciplinary team that may include physical therapists, urologists, neuropsychologists, to make sure that all of the patient's symptoms are being managed and not just their medication needs.
Prakash Chandran: You know, there's probably going to be people listening to this who might have themselves or for a loved one have a relatively new MS diagnosis, and I was wondering if you could broadly speak to living with MS and what patients can expect.
Dr. Elizabeth Minto: I'm really glad you asked that question. It's a really complicated one. But when I diagnose a patient with MS for the first time, you can imagine it's a bit overwhelming and the patient wants to know, "Am I gonna be in a wheelchair? Should I have children? Am I going to be able to work?" And those are very fair questions.
My first reassurance to any patient who has been newly diagnosed with MS is, yes, you are going to be able to live with this disease. it is a heavy psychological burden to carry to know that you have an unpredictable and progressive neurologic disease, but it is also comforting to know that there are so many treatment options. And that there's going to be a partner walking this walk with you to make sure that you're on the right treatment. And if things change, then your treatment changes.
Patients with MS likely early in their disease don't show any outward signs. So, in a lot of cases, a patient with newly diagnosed MS is not going to have anyone that they work with or live with know that they have MS unless they tell them. and so it is my goal that we keep it that way for as long as we can. Patients with MS are encouraged to maintain physical activity levels to continue to work as long as they feel physically and mentally able; to have children. Believe it or not there is data that patients who have more children who are living with MS actually have less disease progression because the condition of pregnancy seems to lower the autoimmune disease activity of MS. So, the more often and the longer you're pregnant, the less active your MS can be.
So, I try to share with patients that all of these things are still very feasible while living with ms. Um, it's important to be compliant with medications and to discuss any side effects with your neurologist rather than just stopping medication. And I think my biggest encouragement to patients when they receive this diagnosis, is there's really two ways that I see people handle this. One is that it becomes their identity and it's all that they think about and it really reshapes the way that they see the world and the way that they see themselves. And another reaction is to see it as an inconvenience and something that they are going to get through and that they are going to treat and that they're going to fight. And so, I really encourage people to do the best that they can to go with that latter approach of it being an inconvenience, but something that we're going to tackle.
Prakash Chandran: Dr. Minto, I think that is the perfect place to end. Thank you so much for your time.
Dr. Elizabeth Minto: Thank you for having me.
Prakash Chandran: That was Dr. Elizabeth Minto, a neurologist with Coastal Medical Group and a designated partner in MS Care with the National Multiple Sclerosis Society. Thanks so much for listening to this episode of Infirmary Health's LIFE Cast. Visit infirmaryhealth.org to learn more about our multidisciplinary neuroscience program or to find a physician near you. My name's Prakash Chandran. Thanks again for listening, and we'll talk next time.