Health Chats
Multiple Sclerosis: Understanding the Disease and Managing Symptoms
Tuesday Aug 16, 2011, 06:00PM - 07:00PM (EST)
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.
I have several members in my family who have been diagnosed with MS from their MRI's which showed brain lesions.   One took MS meds for approximately eight years and passed away before we learned that in fact all suffered from CADASIL a genetic disorder resulting from a mutation on chromosome 19.  I am glad that the NMSS has now added MS as a disorder to be ruled out first.  What can you offer patients in the line of good questions to ask their Dr.s before or after a diagnosis so that this misdiagnosis does not happen.  Thank you
Jonathan Howard, MD:
Well, the first clue that this was not MS was that it seemed to run strongly in your family.  CADASIL is a rare genetic disorder that causes strokes and can mimic MS for sure.  I would like to think that I would not confuse CADASIL and MS, but there are so many diseases like CADASIL that are very rare, it is easy for doctors to become confused.
Dr. Howard, I am wondering about a connection between migraine headaches and MS.  When I have migraine attacks, they occur for several days for a week.  I am wondering if this is a signal that I could be developing new lesions.  
What is on the horizon for understanding our disease and managing it?
Jonathan Howard, MD:
Many of these diseases have similar clinical symptoms- numbness, weakness, poor coordination.  And many of them appear similar on MRI, at least at the start.  As I said, the MRI is a VERY powerful tool.  But still, it is black and white pictures.  So many illnesses can look the same.  I am sure that some of the patients seen in every MS center do not have MS, even if they are being treated for it.  Since the treatments for MS are safe, at least the older ones, we tend to error on the side of treating borderline patients.
Are sinus infections common for people with multiple sclerosis?  I seem to be getting them a lot - at least 4-5 times a year.  I know in my MRIs my neurologist said it shows I have sinus disease, so I was wondering if they kind of go hand-in-hand.  Thank you!
hi- what % of the population is diagnosed with MS. My cousin was newly diagnosed and this is a helpful tool. Thanks!
Jonathan Howard, MD:
As far as I know, there is no connection between sinus infections and MS.  Some of the medicines used to treat MS- usually immunosuppressants that are not often used in the US- could cause that in theory.
What are spinal taps supposed to show? I had one and it was inconclusive... although it showed banding, they couldn't tell if it was in the blood or in the spinal fluid?
Jonathan Howard, MD:
The most important part of the spinal tap is indeed the oligoclonal bands.  From what you say, it sounds like the lab made a mistake.  The lab should compare the number of bands in your spinal fluid to the number of bands in your blood.  If there are bands in your spinal fluid that are not in your blood, this is suggestive of MS.  It should be noted that other illnesses can have bands and about 10% of patients with MS do not have bands.
What explains a lack of disease progression visible on MRI despite progression of disability?
Jonathan Howard, MD:
As I said before, there is something called the "clinical radiographic paradox" where people can have worsening of their symptoms without MRI changes. This is most common in the later stages of the illness.  During the secondary progressive phase, disability slowly accumulates due to chronic injury to the nervous system.  There is rarely new inflammation, so the MRI does not change as much.
What about SPMS? there seems to be very little available and very little being done about it. Are there new, existing or coming treatments?
Jonathan Howard, MD:
You are right that SPMS (secondary progressive MS) has little in the way of treatment.  This is also true of primary progressive MS.  Repair of the nervous system- whether it be damaged by stroke or Parkinsons or Alzheimers- is the holy grail of neurology.
Jonathan Howard, MD:
Unfortunately, once the nervous system has been damaged, it is hard to repair.  This might sound harsh, but people who have lost a finger don't ask when it is going to grow back.  This is why it is important to try to stop MS as early as possible.
Jonathan Howard, MD:
Having said that, companies are investing repair of damaged axons, and such a treatment would be a revolution in MS.  One treatment that looks promising is something called anti-LINGO-1.  It is still in the early stages, but you can read more about it online.  We'll keep our fingers crossed.
i am a 14 year old boy suffering from relapsing and remitting neurological illness and demyelinating disorder..the doctor told that i ve few signs of multiple this possible at my age?
Jonathan Howard, MD:
Sadly yes, children do get MS.  14 is young, but possible.  There is a pediatric MS center in NY at Stony Brook University.  I have no idea where you live, but you should go there if possible.  Usually MS progresses more slowly in children than adults.  Also, if you have MS, you will likely start treatment right away- something that many adults could not do, since the first treatments came out in 1993.  Many new treatments are coming out as well, so you really cannot compare yourself to someone older than you.
My mom has M.S., she found out she had it in her 40's.  I'm now in my 40's and experiencing numb toes, so I looked up numb toes on the internet and it's a symtom of M.S. Should I be concerned?
Jonathan Howard, MD:
You should be mildly concerned.  MS does run in families- but very weakly.  The vast majority of parents with MS have children without the disease.  Also numb toes could be a symptom of many other conditions.  You should see a doc though, have a neurological exam, and get an MRI and maybe a lumbar puncture too.
Why are some doctors so reliant on tests and not clinical symptoms when it comes to a diagnosis of MS?
Jonathan Howard, MD:
There are several answers to this question. First of all, doctors SHOULD be very concerned with the clinical symptoms.  The problem is that the clinical symptoms of MS are so myriad that they can often be experienced by people with many different disorders.
Jonathan Howard, MD:
Secondly, the MRI and the lumbar puncture are so powerful.  It is very unusual to have a normal MRI is MS.  It is very unusual to have a normal spinal tap. In someone with a normal MRI and normal spinal tap, the possibility of MS is very low.
Jonathan Howard, MD:
Let me just say, these are all great questions.  I am sorry I will not get to answer them all tonight. I am sure we'll do this again.
How soon is it likely that the recent discoveries of several genes involved in MS will have a direct impact on MS treatment options?
Jonathan Howard, MD:
I don't think there is anything imminent of the horizon.  Other neurological disorders which are caused by one gene (like CADASIL or Huntington's) have no cure.  The gene for Huntington's has been known since 1994, I think.  It has not led to a treatment.  
Jonathan Howard, MD:
The MS society just released a list of something like 52 genes that have been implicated in MS.  Wow.  It is going to take scientists a long time to untangle how they all work together.
Dr. Howard, the most concerning problem for me is dealing with cognitive issues.  I especially have a hard time with my short term memory.  Is there anything that can be done to help with this?
Jonathan Howard, MD:
Great question.  Cognitive issues have long been under-valued as a cause of disability in MS.  Sadly, there is no "cognition" pill.  Studies of medicines like Aricept used in Alzheimer's disease, failed to show an improvement.
Jonathan Howard, MD:
So I think the best thing to do is control MS using the standard medications, remain as cognitively active as possible, get a good night's rest if possible.  Depression can cause cognitive problems and is common in MS.  Finally, some patients have noticed improvements with stimulants like Adderall and Ritalin.  I use these at times.
I have many MS-like symptoms, but nothing 'sinister' on the  MRI of brain and spine.  When at their worst, my symptoms make it difficult for me to manage at home and at work.  This and my MRI result, what next steps should be taken by my health care team?
Jonathan Howard, MD:
I would have to see the MRI myself to comment.  However, your pain should be treated regardless. It is certainly worth repeating your MRI periodically so see if something "sinister" and more concerning for MS develops.