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Multidisciplinary Care for Multiple Sclerosis (MS)

Dr. Jai S. Perumal discusses what patients should know about multidisciplinary care for Multiple Sclerosis (MS). She gives an overview of what MS is and how the condition is diagnosed and treated. She highlights the comprehensive and collaborative care available for people living with MS at the Weill Cornell Medicine Multiple Sclerosis Center.

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Multidisciplinary Care for Multiple Sclerosis (MS)
Featured Speaker:
Jai S. Perumal, M.D
Jai S. Perumal, M.D., is an Assistant Professor in the Department of Neurology and Neuroscience at Weill Cornell Medicine and Attending Neurologist at New York-Presbyterian Hospital/Weill Cornell Medicine (NYPH/WCM). She is faculty at the Weill Cornell Multiple Sclerosis Center at NYPH/WCM. She is the Director of the Madlyn Borelli MS Center at Nyack Hospital. She is board certified in Neurology and has additional specialized fellowship training in demyelinating disorders including multiple sclerosis. 

Learn more about Jai S. Perumal, M.D

Melanie Cole (Host): Welcome to Back To Health, your source for the latest in health, wellness, and medical care. Keeping you informed, so you can make informed healthcare choices for yourself and your whole family. Back To Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And joining me today is Dr. Jai S. Perumal. She's an Assistant Professor in the Department of Neurology and Neuroscience at Weill Cornell Medicine and she's an attending neurologist at New York Presbyterian Hospital Weill Cornell Medicine. She's here to highlight today multiple sclerosis multidisciplinary care.

Dr. Perumal, thank you so much for being with us today. As we start this topic, such an important topic, I'd like you to tell us a little bit about MS. What are the different types and the average age of onset?

Dr Jai S Perumal: Hi, Melanie. Thank you for having me on this podcast. It's a pleasure being here and I very strongly believe in education, so I'm glad to participate in this series. Starting out with what is MS, MS is an autoimmune disorder, which means that somehow your immune system gets a little bit dysregulated or goes out of control, so it's your own immune system attacking your brain or your spinal cord. So it belongs to the group of autoimmune disorders. Some of the other disorders are lupus, rheumatoid arthritis, they also belong to the same group. What differentiates these different disorders is what triggers and what kind of cells are activated and what tissue or organ is attacked. So in the case of MS, it is your brain or spinal cord, or even the optic nerves, which help us see.

With regard to the types of MS, there are three or four different types. The most common form is called relapsing-remitting. This is where a patient has an attack or a relapse. And over the next several days, they get better. And then they have a relatively stable course clinically, meaning outwards, they don't have any, symptoms or they could have healed from their previous relapse completely. And over time, they may have another event. This happens in about 85% of the population. Again, this doesn't describe the disease fully because relapsing-limiting just corresponds to what the patient is doing outside. When a patient is in a so-called remission outwardly, we don't know if they're still developing lesions in the brain because every single lesion they develop in the brain may not translate to symptoms. That's why even if a patient is in so-called remission in terms of how they're doing clinically, you still need to treat the patient continuously so that we can keep the immune system under control and the disease remains stable. So that's the most common form of MS.

The other form of MS is called primary progressive of MS. This happens where a patient doesn't start out with a clear cut relapse, rather the disease kind of steps in very slowly over time without a clear cut start. This may be somebody who has been noticing problems with walking. You know, they get more fatigued. They're not able to walk as long as they used to before. They're noticing some problems with balance. So this kind of creeps in. It doesn't have a clear onset. And the differences here, the symptoms don't kind of go away like a relapse. It keeps adding up, so that slowly over time, patients tend to keep getting worse. So this is the less common form of MS. It's about 10%, 15% of patients who get diagnosed with MS.

And the other form that is described is called secondary progressive MS. This is what happens to patients who start out with relapsing. So the disease changes pattern from an up and down state to one where it's slowly getting worse. That is called secondary progressive.

Now, distinguishing these kinds of MS is not just an academic exercise. It actually has implications for treatment, because the relapsing forms of MS is what responds to treatment very well. We have gotten really good at controlling the disease and delaying the so-called disability or preventing disability or progression. The progressive forms of MS, especially primary progressive MS, may not respond to treatment that well. However, having said that, the sooner we start treatment, the earlier we start treatment, the bigger the impact we make in terms of long-term outcomes and disability.

And the average age, usually MS is diagnosed in patients in their mid-20s. There is a preponderance of women. The ratio of women to men is almost 2.5 or 3:1. With primary progressive MS, these patients tend to get diagnosed later. So usually, that diagnosis is made in their mid-40s or 50s. And there, the ratio of men to women is almost 1:1. So there are a few different characteristics that help us distinguish these different forms of MS.

Melanie Cole (Host): Wow. That was a very comprehensive answer. You are just an excellent guest, doctor. So for a person living with MS, physical wellness involves much more than disease and symptom management. The research has shown that healthy diet, exercise, not smoking, ongoing preventive care. They can all contribute to the overall health and impact the person's progression and lifespan. So as we're talking about the importance of this multidisciplinary care, why is shared decision-making such an important part of MS treatment so that the patient and their doctor work together to find the treatments that work the best?

Dr Jai S Perumal: I'm so glad you asked that because the concept of care and physician-patient relationship has changed a lot and it is evolving. The old paternalistic kind of attitude where the doctor came in and just told the patient, "This is what you have, and this is what you need to do" is completely not feasible anymore, neither should it be. Patients are more knowledgeable. They are more involved in their care and they need to know what's going on, so they understand the disease and the implications and why they are doing what they're doing to keep the disease under control.

With regard to MS, this is, like I had mentioned earlier, an autoimmune disease, so this is where once own immune system is triggered. So the treatment for MS is controlling or stopping the immune system from causing damage. So that's a long-term commitment. It's not a medication that you just take for a few days, and then you are done. This is long-term treatment and it has implications and it has potential side effects and adverse events because you're doing something to the immune system.

Now, depending on the medication, it can be something that just mildly alters the immune system, or if it is a more aggressive medication, it can suppress the immune system. So we owe it to the patients to go over all the details of the disease and treatment and why we are advising a particular patient to, let's say, start a more aggressive treatment, what our concerns are and, if we did not start the treatment, what we expect their disease to do to them. So I have found that explaining all this to the patient, telling them, it's not a one-solution-fits-all, correct? Because MS is a very wide spectrum. You have patients at the mild end of the spectrum, where even years into the disease, you don't expect them to get into trouble, so you could get away with starting a milder drug. On the other hand, you have patients who have very aggressive disease and if we did not get that under control right away, unfortunately, they're going to have significant problems. So it is our job to explain all this to patients about the diversity and presentation of the disease, the way it manifests, how to find the best drug for that person sitting in front of us. So if we explain to them that, "These are my concerns, that based on how you presented, what your relapse was, what your MRI looks like, I want you to do this so that we can prevent what might happen 10 years, 20 years down the road." And I find that once you explain this to patients and then recommend, "I want you to consider this or this medication," they understand it. They know why they're taking it and they know why that risk of the potential side effects is worth taking. I've had several patients come to my office tell me that, "Doc, if somebody had explained this to me, I would've gone and done what they asked me to do. I did not follow through with that because I didn't know why I was doing this." So it is a joint venture. We work together to ensure that patient's long-term health and care. So I absolutely believe in communication. It makes a better doctor and it makes a better patient as well.

Melanie Cole (Host): What a lovely lady you are. I can hear how compassionate you are with your patients. And doctor, as we're talking about how a patient's overall health can be affected by MS and the specific health areas that they need to pay extra attention to, for these people, how important is that multidisciplinary approach? Tell us what kinds of providers. I, myself, am an exercise physiologist. So I know that that exercise and exercising in the heat, that sort of thing is so important to pay attention to, smaller class sizes, but there are so many providers that can help a person living with MS to have a better quality of life.

Dr Jai S Perumal: There are two ways to look at it, Melanie. One is in terms of medical expertise, what are the kinds of issues a patient with MS might have and how do we get them the right medical care? And the second part is lifestyle. And I think both are equally important with regard to MS because the brain and spinal cord control pretty much all of the functions. So, patients with MS can have symptoms with bladder. They may have increased frequency or problems with the urination. So we need to have a urologist on board who understands the nuances of taking care of patients with MS. We need to have a neuro-ophthalmologists because MS can affect the optic nerve, problems with vision. And then a rehab specialist, we need to have physical occupational therapists and physiatrists to understand MS.

One of the points you touched was the heat sensitivity, right? So patients with MS, they're mostly very sensitive to heat. So their body cannot tolerate that rise in body temperature, whether it's external or internal. So you cannot just have them do this vigorous workout and expect that they will be able to keep up. So some of the things are you'd exercise in a pool or advise swimming because it keeps the body temperature down. Or when they're exercising indoors, you keep the AC turned up so that the temperature is lower. So we need to have rehab specialists to understand this. Then, patients are on infusion treatment. So you need to have either an infusion center at your facility or easily accessible so that we can work with them.

The other important aspect is pregnancy and MS, because MS is diagnosed in young folks and predominantly they are women. So pregnancy and childbearing comes up often both in terms of how do patients with MS manage that? And also treatment, because we may not be able to continue these treatments continuously while patients are trying to conceive or while they're pregnant. So we need to work closely to integrate all this. So we need to have specialists who will understand and work with us.

The other aspect is the general health aspects you mentioned because, while we keep emphasizing medications, something we really don't bring up enough and discuss on a regular basis with patients is diet, exercise, and healthy lifestyles. Again, you had also said this, that yes, there are several studies that show that BMI and healthy diet are related to better outcomes in MS. And the other thing that has been looked at is regular exercise. It has an impact on both the physical and even cognitive aspects of MS. So we have to reiterate these things with patients. We have also looked at studies that examine stress and inflammation. Patients, many times when they go through periods of stress, their MS symptoms get more pronounced. And it's real, it's not just their perception of everything being bad because they don't feel that great psychologically. It does seem to have an impact on inflammation. So we have to address all this so that the patient's overall sense of wellbeing and managing this disease and living as normal a life as possible is we make it happen and we can sustain it.

Melanie Cole (Host): Such a comprehensive approach. And doctor, tell us a little bit about the Judith Jaffe Multiple Sclerosis Center at New York Presbyterian Hospital Weill Cornell Medicine, and really how it's helping those living with MS to manage their health in both of physical and psychosocial sense, as you just mentioned, and what makes this program at Weill Cornell Medicine stand apart.

Dr Jai S Perumal: Thank you for asking that, Melanie. I'm so proud to be part of the Weill Cornell MS Center. We have five physicians here and, recently, we had a nurse practitioner join us as a clinician as well. And all of us have interests in different aspects of MS, whether it is clinical care or research. So I feel, as a group, we are well-rounded and we constantly discuss patients and new research and papers and whichever aspect. If one or more of us is weaker, then the other one can fill in because we all have very diverse interests in multiple aspects of the disease. So I find that extremely helpful to me and helpful for us functioning as a group.

I had earlier alluded to the different specialties that are involved and different aspects to MS care, like infusions or lab, so we are all located in this same building or a building across the street. And we work closely with all of these specialists. So if a patient needed, let's say, to see a urologist, we have a urologist who has an interest in MS patients and has experience taking care of patients with MS. We have the neuro-ophthalmologist who is a few floors above us. So we can integrate all this care almost like under the roof, so we know, and everybody has access to the same system. We can get patients in quickly. So that is very, very helpful. Everybody's here.

Our nurse practitioner recently came on board and she's focusing a lot on cognition because, usually, when you have a 30-minute followup and we do a brief exam, we don't dedicate that much time to go into an in-depth cognitive evaluation. And we know that cognitive symptoms are very, very common in MS. And they may be very subtle, so you don't catch it on your regular visit. So now, we are having patients do this detailed cognitive exam every year, so we can monitor for it and even subtle changes we'll be able to catch.

So I think in terms of interest, in terms of expertise, in terms of knowledge, we are well-rounded with us having very diverse and undiverse interests. So we know, as a group, we talk to one another, we update one another on what is happening in each of our fields. So I think we are well-rounded, we know, and we can always ask someone else to educate us and inform us on things and access to all the care is here. We have integrative medicine, it's not a new, new department, but it is relatively recent. And we have had patients go there to talk about nutrition or diet and even therapies like acupuncture or things like that that, again, can help with the symptom management. So the fact that we have access to this, we have folks who are interested in this, adds to the strength of our program.

Melanie Cole (Host): What an informative uplifting podcast this was. Dr. Perumal, thank you so much for joining us today. And Weill Cornell Medicine continues to see our patients in person as well as through video visits and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back To Health. We'd like to invite our audience to download, subscribe, rate, and review Back To Health on Apple Podcast, Spotify and Google Podcast. And for more health tips, go to and search podcasts. And parents, don't forget to check out our Kids Health Cast. I'm Melanie Cole.

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