Ask The Doctor
Dr. Jack Burks
Vice President & Chief Medical Officer for MSAA
Q: I have been diagnosed with MS and I take an immunomodulating medication for its treatment. A recent MRI didn't show any new, active lesions, and I have not experienced any new symptoms. How often should a patient have an MRI done?
A: The "official" recommendation by neuroradiologists states that MRI's should not be done routinely on MS patients. MRI's should only be considered if a change in therapy is contemplated and the MRI will help in making a treatment decision. Many neurologists, however, feel that an MRI is a valuable tool to evaluate disease activity that may not be evident during routine checkups. Therefore, many MS experts recommend an MRI every one to three years. One rationale is that MS medications cost between $15,000 and $20,000 per year, so why not spend $1,000 on an MRI to see how well the therapy is working? Opponents of this position point out that an MRI can change dramatically from month to month, and a single MRI may not accurately reflect ongoing brain damage. On the other hand, a very recent presentation from Italy indicates that new damage on the brain MRI (using a contrast material known as gadolinium) may predict a sub-optimal response to treatment. So, the debate continues.
Q: Is there any research about how MS affects various ethnicities differently?
A: Ethnicity issues in MS have been recognized for several decades. For example, Caucasians are at a greater risk for MS than African-Americans, Asians, Native Americans, and others. Northern European heritage is a risk factor. Therefore, genetics are clearly related to risks of getting MS. However, the overall risk is still small in the population at large. Recent research has shown that those of African descent, while less likely to get MS, may have more aggressive clinical disease course (and may not respond to treatments as well as Caucasians). Also, while Asians may have less MS, they get another diagnosis more frequently (neuromyelitis optica or Devics syndrome). This disease involves myelin damage in spinal cord and optic (visual) nerves. In the near future, research should add more clarity to these important issues.
Q: What medications are available to manage pain and when should someone move on to pain patches and opiate therapy (without risk of sleepiness or addiction)? How can acute pain be brought under control?
A: I divide MS pain into two categories. The first is "neuropathic" pain, which is often described as "burning," "painful pins and needles" feeling, "lightning-like" sensations, and/or "stabbing," and "searing" sensations. The cause is myelin damage and/or inflammation in the brain and spinal cord. Medications used for this pain usually begin with anti-seizure drugs, although this pain is not associated with epilepsy. Neurontin® is often the first line of treatment, followed by Tegretol®, Dilantin® or Depakate®. Tricyclic antidepressant drugs, such as Elavil® can also be tried. Biofeedback is helpful with some patients. Narcotics and pain patches (lidocaine) are usually not very helpful. Steroids for acute attacks of MS may provide relief, and sedation may "take the edge off" temporarily. Usually "neuropathic" pain lessens after a few months.
The second type of pain is "neuromuscular," secondary to imbalances from poor coordination, tremors, stiffness, and weakness, but not from direct myelin damage. This pain is best treated by rehabilitation techniques as well as medications for stiffness, for example. Stretching, cooling, warming, strengthening, and balance programs may be helpful. Assistive devices such as a cane or walker may reduce joint pain from limb weakness. Muscle relaxants are used cautiously because of potential side effects such as sedation, fatigue, and fuzzy thinking, etc. Narcotics and pain patches are usually not the long-term answer for most patients, but they may help decrease the acute pain in selected patients. Exercise programs under the supervision of a physical therapist trained in MS are usually recommended.
Jack Burks, MD, is a neurologist who specializes in MS. He is vice president & chief medical officer for MSAA, as well as president of the Multiple Sclerosis Alliance. Additionally, Dr. Burks is a clinical professor of medicine in neurology at the University of Nevada School of Medicine in Reno, Nevada, and a member of the Medical Advisory Board of the National MS Society. He has edited two textbooks on MS, and in the 1970s, Dr. Burks established the Rocky Mountain MS Center in Colorado, one of the nation's first comprehensive MS centers.
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