Health Chats
Multiple Sclerosis: Understanding the Disease and Managing Symptoms
Tuesday Aug 16, 2011, 06:00PM - 07:00PM (EST)
Jonathan Howard, MDBlank
Multiple Sclerosis is a challenging disease to treat. Symptoms vary greatly from one patient to the next and can often wax and wane. Knowing what to expect and how to cope with the overall progression of the disease goes a long way toward living the highest possible quality of life with MS. Join us with Dr. Jonathan Howard, an attending physician at the NYU multiple sclerosis center, where he will provide answers to your questions about the complexities of MS and how to best manage the disease.<br><br> Doctor Jonathan Howard graduated from the University of Southern California Keck School of Medicine in 2003. After this, he completed a dual residency in both neurology and psychiatry at New York University Langone School of Medicine and Bellevue Hospital. He is currently board certified in both psychiatry and neurology. After residency, Dr. Howard completed a fellowship in multiple sclerosis at the New York University Multiple Sclerosis Care Center.<br><br> Currently, he is an attending physician at the NYU multiple sclerosis center where he practices both psychiatry and neurology. Dr. Howard believes that it is just as important to treat the mind as well as the body, especially for chronic neurological illnesses such as MS. He also established a weekly MS clinic at Bellevue Hospital, the oldest public hospital in the United States. He is working on publishing several books for medical students using modern media to educate about the brain and neurological disorders.
Wingy8:
After each Copaxone injection, I experience what I would categorize as extreme bruising at the shot site--extreme meaning an area about the size of a lemon. The area itches for days after the shot, and the bruise lingers for at least 3 weeks. Is this a "normal" reaction? I am always careful to make sure that the dial on the autoinjector is set to the proper level.
Jonathan Howard, MD:
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Jonathan Howard, MD:
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MedHelp:
Hi Everyone! Welcome to the Multiple Sclerosis Health Chat. We'll be getting started soon but in the meantime, feel free to submit your questions.
MedHelp:
Welcome Dr. Howard and thank you for taking the time to answer questions today.
Jonathan Howard, MD:
Hi everyone.  Thanks for joining me today.  I hope that I am able to help give everyone some useful information.
Jonathan Howard, MD:
The first question I will answer is the one about Copaxone.  Copaxone is generally a very well-tolerated medication.
Jonathan Howard, MD:
However a number of people do have the side effect that you mention.  In cases like this the "cure can be worse than the disease."
Jonathan Howard, MD:
Some people find that either cooling or warming their skin prior to an injection can decrease the injection-reactions that you describe.  However, ultimately, it might be necessary to change to another medication.  I have a handful of patients who cannot tolerate those medications either, so I suggest the inject Copaxone 3 times per week.  There is no solid evidence it is as effective, but there have been some reports that it works at this dose.
NikkiColorado:
I am recently diagnosed with MS and have lesions in my spine but not in my brain.  I am currently taking Copazone but noticed on their web site they said Copazone has not been clinically proven to treat spinal lesions.  Is this the same with all of the other medications or is there a medication that has been proven to help with spinal lesions?
Jonathan Howard, MD:
So let me take another Copaxone question.  Firstly, almost all MS patients have lesions on their spine at some point.  It is somewhat unusual not to have any in the brain, but this is not unheard of.
Jonathan Howard, MD:
Fortunately, the medication is "stupid."  It does not know where you have lesions and should be effective in all kinds.  Usually in the studies, brain lesions on MRIs are studied more than spinal lesions.
Jonathan Howard, MD:
This is because the brain has so much more white matter than the spinal cord.  But the medicine should work well for either brain or spinal lesions.  I would just add in your case that the diagnosis should be carefully confirmed.  There are some MS mimics such as Devic's disease that can be confused with MS.  But I would have to know more about your case to comment on that specifically.
kel1lost:
What are the chances of my little boys developing this Disease.  I have RRMS.  I was adopted and I do know that my biological mother's side does not have this in her family.  I don't know about my bio. father's side.  And is their anything I can do like certain vitamins, or anything at all I can do to lessen the chances.  Thank You
Jonathan Howard, MD:
This is a very common question.  MS is indeed increased in families.  However the role of genes is not strong.  It is considered a "polygenetic" disease, meaning that many genes play a small role in developing the illness, rather than a single gene.
Jonathan Howard, MD:
Simply put the odd of a child getting it if a parent does are still quite small- perhaps 3%.  Even if identical twins, if one twin has the disease, the chances that the other will have it are about 33%.  So clearly something besides genes is important.
doublevision1:
How frequently should RRMS patients who are on a DMD have an MRI?  If a RRMS patient on a DMD is clinically stable and hasn't had a relapse in > 2 years, should they have a routine follow up MRI, and if the MRI shows disease progression (new lesions), should they change therapies?  
Jonathan Howard, MD:
This is a question that will get many neurologists fighting.   The role of the MRI in diagnosis MS is quite clear.  However once someone has been diagnosed with MS, the role of the MRI is not as clear.
Jonathan Howard, MD:
There is something in MS called the "clinical radiographic paradox."  Briefly, this means that some patients with MS can have a lot of symptoms, but not much on their MRI.  Alternatively, I have seen some patients with a lot of lesions on their MRIs, but with few symptoms.
Lulu54:
Would you address the reliance of neurologists on the MRI to give a definite dx of MS as opposed to the use of clinical observations?  We have a number of people we call "limbolanders" who exhibit all the symptoms of MS, but lack a dx due to not enough MRI evidence.  
Jonathan Howard, MD:
Having said that, I think that most MS docs would order an MRI every year or two at a minimum and if there are a lot of changes would consider changing treatment.  The MRI is a VERY powerful machine and will reveal new lesions at some point in most MS patients.
txpete:
What types of alternative therapy is available and most effective?
Jonathan Howard, MD:
Many of my patients use so-called alternative therapies.  I am not 100% sure what to make of that word "alternative."  If a treatment has been shown to work, I would not call it "alternative."
Jonathan Howard, MD:
Over the years, there have been many claims made about different supplements and vitamins to cure MS.  Most of them are harmless, probably, but some have been harmful.  Mostly, I am worried that a lot of patients spend a lot of money on things that they cannot afford.
Jonathan Howard, MD:
Most of the "alternative" treatments have not been studied properly, and probably never will be since it is a huge undertaking to do a properly controlled study.  Let me not sound too arrogant though.  Many mainstream treatments that I use all the time have not been "properly" studied either.
twopack:
What do you suggest is the best course for people to take when they have many signs and symptoms of MS but no objective diagnostic testing that allows for the diagnosis?
Jonathan Howard, MD:
I erased a similar question by accident, so I am glad you asked this.  First of all, the possible symptoms caused by MS is so large that there are bound to be many people who experience symptoms of MS for other reasons.
Jonathan Howard, MD:
Many other illnesses can mimic the symptoms of MS, and some of the symptoms, such as fatigue and cognitive slowing, are reported by a large number of people in the general population.  
Jonathan Howard, MD:
You say that there is no objective evidence of you having the illness.  I assume that you mean you have a normal exam, normal MRI, and a normal spinal tap.  In this setting MS is VERY unlikely.  Technically, a person can have MS with a normal MRI, but this is rare.  I would suggest repeating the MRI annually on such a person, and if the MRI  remains stable, then the diagnosis of MS can be ruled out.  Certainly, it would be a mistake to treat someone with an expensive medication that causes side effects for a disease they don't have.
Lulu54:
re: no lesions in the brain.  Is it possible the lesions are there but just not visible with the technology we have readily available today?  That brings another question  - can you talk about the evolution of the MRI and what you think might be the next step in this diagnostic tool and it's use for MS.  
Jonathan Howard, MD:
So the MRI is a VERY powerful machine.  Usually we have to opposite problem- meaning that it detects too many lesions.  Often we are confronted with patients whose brains have lesions, but they have no clear symptoms, they just happened to get an MRI for some reason.  
Jonathan Howard, MD:
MRIs do come in different strengths based on the size of the magnet- this is what an MRI is after all.  So one could always request a 3 Tesla machine.  More powerful ones are available for research purposes.  Currently, people are working on other ways of viewing the brain using MRIs.  I just attended a talk about seeing venous abnormalities in the brain using MRIs.  Interesting stuff.