Ask the Doctor
Q: What
is transverse myelitis and how is it related to MS?
A: "Myelitis" means inflammation in the spinal cord. While it can be part of an attack of multiple sclerosis, it can also occur as an isolated event with no future attacks. Then it is called transverse myelitis (TM) and is identified as "myelitis," a separate disease from MS.
Confusion can arise because spinal cord inflammation can be the first attack of MS. In this situation, the neurologist looks for other areas of damage in the brain and tries to illicit a history of previous neurological episodes that might be indicative of MS. The MRI can be helpful at this point.
TM may occur after a viral infection or after a vaccination, but many cases have no known preceding event. TM is often seen in children, which is unusual for MS. Both diseases may be treated with high doses of intravenous steroids. However, conclusive proof is lacking as to whether or not steroids make much difference in TM, since TM patients may get better without steroid therapy and others do not recover in spite of massive doses of steroids.
Q: Are individuals with MS at greater risk of cancer? What issues are involved when treating both MS and cancer?
A: I have seen many MS patients who also have cancer. However, that does not mean that cancer is more frequent in MS, since both are relatively common diseases. Some people have postulated that cancer occurs less frequently in MS because the hyperactive immune system in MS may actually reduce the chances of cancer.
When an MS patient develops cancer, patients may have less MS symptoms when they are on chemotherapy for their cancer. In fact, Novantrone® (mitoxantrone), Cytoxin® (cyclophosphamide), Imuran® (azathioprine), and methotrexate are all anti-cancer drugs that have been touted to help individuals with MS. Conversely, some interferons have also been used in the treatment of cancer.
The decision to combine one of the MS drugs (Avonex®, Betaseron®, Copaxone®, or Rebif®) with anti-cancer agents is a decision for the patient’s neurologist and cancer specialist. One study has shown that the cancer drug Novantrone can be taken safely with interferon beta1b (Betaseron). However, the final decision is made on a case-by-case basis by the physicians involved.
Q: What is the best way to manage pain from MS?
A: We have come a long way in understanding pain in multiple sclerosis. Only a few years ago patients were often told that pain was not attributed to one’s MS. We now know that up to 75 percent of MS patients can suffer from pain.
I divide MS "pain" into two categories. The first I call "neurogenic pain," which causes burning, lightning-like sensations, or severe numbness and tingling. This pain is believed to be caused by the myelin damage in the brain or spinal cord. The anti-seizure medications help most of these patients. Neurontin® (gabapentin) is often my first choice of therapy. However, other medications such as Tegretol® (carbanazepine) and other anti-seizure medications can also help.
I refer to the second type of pain as "musculo-skeletal pain," which is caused by the stresses and strains of having weakness, poor coordination, muscle stiffness, and other MS-related problems, but not directly from myelin damage. Symptoms may include neck pain, lower back pain, and joint pains. I recommend physical therapy as the initial treatment. Often stretching and muscle strengthening programs can help stabilize the muscle-related pain. Yoga and relaxation therapies may also be helpful. Sometimes muscle relaxants and pain medications can provide relief, but they may cause drowsiness, reduced coordination, and cognitive problems.
If painful symptoms arise, see your physician as soon as possible so the pain can be treated early. Since individuals with MS may be very sensitive to medications used for muscle relaxation and pain, I begin with a low dose of medication and increase the dose slowly. I do not recommend narcotics. Narcotics are addictive, often sedating and disrupting of sleep, cognition, and balance, as well as impairing bowel, bladder, and sexual functions. None the less, each patient’s situation is different and your physician is your best guide to therapy.
Marijuana has been touted for MS muscle spasticity and pain. However, objective testing on the effects of marijuana on muscle spasticity was negative, i.e., it did not work. Despite this fact, patients perceived that they felt better (just like people who don’t have MS who smoke marijuana). One of my major concerns about marijuana and MS is short-term and long-term additional brain damage and cognitive dysfunction. In MS, the brain experiences damage, and I fear that marijuana may be another toxin that could intensify that damage.
Therefore, I do not recommend marijuana, especially since other ways are available to treat pain and spasticity. The other treatments mentioned have been well tested and are not associated with the side effects of marijuana.
