Episode Transcript
[00:00:01] Speaker A: From Riverside Health System. This is the healthy you podcast where we talk about a range of health related topics focused on improving your physical and mental health. We chat with our providers, team members, patients and caregivers to learn more about how to maintain a healthy lifestyle and improve overall physical and mental health. So let's dive in to learn more about becoming a healthier you.
[00:00:30] Speaker B: All right. I'm really excited to have with me in the healthy you studio today, Dr. Kermit Lloyd. Dr. Lloyd is a neurologist with Riverside Neurology specialists. We are going to be talking about and decoding multiple sclerosis risks, symptoms and breakthroughs in care.
Welcome back. I'm Frankie Myers, your host today and we're talking about a condition that impacts nearly 1 million people in the United States alone, multiple sclerosis or Ms. Joining us today to unpack that again is Dr. Lloyd, neurologist with Riverside Neurology specialist and together we explore all things Ms. Thank you for joining me.
[00:01:14] Speaker C: Thank you for having me. I'm very happy to be here and excited, excited to talk with you all about multiple sclerosis and teach you some stuff about this fairly common neurological disease.
[00:01:24] Speaker B: Absolutely. Let's start out. How did you end up in medicine and then more specifically neurology. Neurology.
[00:01:34] Speaker C: Oh, let's see.
I was not one of those people that wanted to be a doctor all my life. I frankly was in biology classes and had good grades and I thought, ooh, what am I going to do with this? Right. Do I want to be a biologist? Right. And then ultimately decided that wanted to go into the medical profession. And then when in medical school, I was just fascinated by neurology, particularly immunology. And multiple sclerosis is the quintessential neuroimmunological disease. It brings them both together and the advances that have been made in multiple sclerosis in the time since I've came out of training in 1993 until now, just amazing. It's one of the sort of the hottest areas of research and neurology and we've gone from having no treatments for it. When I first came out and then we had one medication that came out shortly after I finished, finished up my training to about a dozen 15 that are currently available. So we have just a wide array of medications that work quite well. We can't cure it, but we can slow it down pretty well these days. And just very nice. Heartening with all the advances that have been made and what we can do for people now.
[00:02:49] Speaker B: Yeah. So for our viewers, just define what multiple Sclerosis, what is it?
[00:02:56] Speaker C: It's an autoimmune disease. It's yet another example of a condition where your body, seemingly thinking is doing something good, inappropriately mounting an attack upon itself. It's in the family with some other autoimmune diseases. Rheumatoid arthritis, psoriasis, Crohn's disease. And these 10 autoimmune diseases tend to run together, as we say. So if you have one, you're at somewhat higher risk of another. So a lot of my patients with Ms. Also suffer from these other diseases such as that.
But anyway, it's an autoimmune disease characterized by areas of inflammation in the central nervous system. There'll be little clumps of inflammation, variable locations in the central nervous system, which is the brain and the spinal cord, also the optic nerves. And wherever the areas of inflammation occur, that's where the symptoms or the clinical manifestations are. You can have a lot of areas of inflammation in the brain, sometimes without any obvious symptoms from it. Other times just one or two can be devastating. Just depends on where they are. Like, for example, you don't want to have an Ms. Plaque or an area of inflammation at the top of the cervical spinal cord because everything has to go there. It's a bottleneck. So it can cause a lot of difficulty or the brain stem.
But it's pretty common. Like you say about a million people in the United States, it's 1 in 400 people have multiple sclerosis. There is an increased familial risk. So if you have a first degree relative with it, a sibling, a parent, for example, the risk is about 1 in 25.
We think it is caused by three things that have to come together. There's a genetic predisposition. There are over 200 genetic links to this disease.
Vitamin D deficiency. That's the key thing. You have to have a vitamin D deficiency to really get things going. And then the trigger is the Epstein Barr virus. So we think that you encounter the Epstein Barr virus at some point in your childhood.
[00:04:56] Speaker B: Right.
[00:04:57] Speaker C: And then. And then when you reencounter it, the body thinks it's going after it and it gets.
[00:05:01] Speaker B: Is there another name for the Epstein Barr virus?
[00:05:04] Speaker C: It's just one of the human herpes viruses.
They're all generally bad. There's a lot. They tend to. You get them and they stay in your body forever. But it can cause infectious mononucleosis. They determine this looking at it. There was a big military study. Exactly. Mononucleosis, the kissing disorder. Exactly.
[00:05:25] Speaker B: We often Ask in high school.
[00:05:26] Speaker C: Yes.
[00:05:27] Speaker B: Your parents say, don't kiss anybody.
[00:05:29] Speaker C: Absolutely. But we often ask people if they had mono. But you can have mono and not know that you've had it. Because people often think, well, I can't have Ms. I never had mononucleosis. But it can be an asymptomatic illness. So that's just something to keep in mind. And of course, at its worst, it's devastating with enlargement of the spleen. Very sick. But there's a whole spectrum, and that's why this disease most commonly occurs in people from 20 to 40 years of age. Of course, mononucleosis comes around usually in the teens or early 20s. I myself had it when I was about 20, but that's what seems to get it going.
[00:06:05] Speaker B: The numbers seem staggering to me.
Is it on the rise? Is that a misconception? But it seems to be. You're hearing more often of people that have it.
[00:06:18] Speaker C: Absolutely. In the past, it was very hard to diagnose before we had mri. MRI is the main diagnostic test that we use to diagnose this condition. But prior to MRI, CT scans would show it sometimes, but it had to be pretty bad. Lumbar puncture would help, but they probably, frankly didn't really know the right things to look for. So a lot of it has increased just because we have better diagnostic acumen. But there may be some environmental changes in that. You know, probably maybe all the bad foods that we eat, the ultra processed foods, the avoidance of sunlight, I think has a lot to do with it.
[00:06:54] Speaker B: Because we're not outside as much.
[00:06:56] Speaker C: Right, Exactly. The low levels of vitamin D are just a. Astounding that we see it. We see just abysmally low, low levels. And that's largely, you know, people just don't get outside.
[00:07:07] Speaker B: In addition to not getting video so much things, so many things to do inside now.
[00:07:12] Speaker C: Absolutely. It's more fun inside.
[00:07:14] Speaker B: Yes.
Wow. Okay.
Talk about some of the signs and symptoms that you may see early if you have Ms.
[00:07:27] Speaker C: It depends on where the lesion is.
Commonly people have optic neuritis as a first manifestation of multiple sclerosis. That's loss of vision. Unilateral, usually every now and then is bilateral. But more commonly, unilateral loss of vision, often with pain, there'll be pain, with eye movements, there'll be a hole in the vision. We call that a scotoma. Sometimes weird things such as loss of color vision or visual impairment, blurring of vision, that worsens with heat exposure. That's one of the Classic features of Ms. Is to worsen when you get hot. So back in the old days, before they had MRIs and tried to diagnose it, allegedly they would put people into a warm bath and see if that made their symptoms worse, if it made them tingle more, for example, or get weak. So you can have optic neuritis, commonly seen, but not everyone gets that.
The most common symptom, by the way, is fatigue, this overwhelming sense of fatigue that is not relieved by rest. We have medications that can help it, but they're not perfect. So it's often very challenging to deal with that focal weakness or numbness.
So often when I'll have a new Ms. Patient and they come in with an obvious manifestation of it and I'll get my history and it'll turn out that they thought they slept, slept wrong like 10 years ago. And they said my arm was numb for about a month. And that was, that was the first attack. And they just didn't realize it. For all they knew it was just a pinch in the neck doing that. There can be bowel or bladder disturbance, someone who urinates a lot. The classic features of that are constipation because it generally slows the gut or hyper excitability of the bladder. So they tend to urinate very frequently.
The There can be some cognitive impairment. About 50 to 60% of patients have some mild cognitive impairment. At times it can be quite severe. I have a number of patients that look totally fine, seemingly have no symptoms. They just have cognitive impairment. They move everything okay, but they just can't hold down a job because of that.
Whenever patients have to seek disability because of multiple sclerosis, that's the most common cause for disability is the cognitive impairment seen with it.
Okay, but yeah, just an array of symptoms. They have some. Another thing that's unusual about ms, they have what's called the Ms. Hug. If they get a lesion in the thoracic spinal cord, they'll have a tight feeling under the ribs. And it's just very strange, you know, and they think it's their stomach and they get a big GI workup and it ultimately turns out to be the Ms. Hug.
But an array of symptoms though. But the most common being is whenever someone has some weakness or numbness and we always ask them, did you feel more tired? Because that's another thing that you will see as a manifestation of a flare up. This disease is characterized by remissions and exacerbations where people will have a flare up and they'll have increased inflammation and they'll have new symptomatology or a recurrence of old symptomatology over days to weeks.
We generally treat those with steroids. Otherwise steroids have no place in the management of multiple sclerosis. But we calm down the acute inflammation with a course of steroids iv, usually sometimes oral, but we do that for the acute bouts. It's not always relapses and remissions with this disease. There are different forms of Ms.
There's clinically isolated syndrome, which is basically one attack, not meeting the standard criteria. Not the multiple part, just the one. But that's now being folded into the definition of multiple sclerosis. There's always changes in the terminology and classification over time.
Relapsing, remitting, multiple sclerosis is the most common type. 85% of patients have that at onset. There's also secondary progressive Ms. There's an active form of that where you have relapses still, but there's an overall gradual worsening and then there's primary progressive Ms. Primary progressive Ms. Is the hardest to diagnose because it just sort of slowly worsens over time. They too can have relapses, though, just to make it even more complicated. But we have diagnostic criteria that we use to diagnose this disease, primarily the brain. MRI is our main tool. We also do an MRI of the cervical and thoracic spines, looking for lesions there. Lumbar puncture helps a lot. 80 to 90% of patients with multiple sclerosis have oligoclonal bands in their spinal fluid. It's unique to the spinal fluid. It's not also in the serum. So we also have to check a serum sample as well. So you can rule in multiple sclerosis with a lumbar puncture, but you can't rule it out. So people often think, is there a definite test for this? No, we don't have ultimate test for it. You just have to meet what we call the McDonald criteria. But the spinal fluid analysis is an important part of making the diagnosis. I like to, if I can, to make the diagnosis without spinal fluid analysis because, not surprisingly, people don't like to have lumbar punctures.
But most of the time we do have to do it. But every now and then it's just such a classic presentation that we can get by without getting a lumbar puncture. And then we do our MRI studies of the brain on average, every year, year and a half, just to make sure the medication is working properly.
No rules about these things, but generally that's about what it is, the spine, lesser intervals.
Some patients never have their spine imaged at all when they have multiple sclerosis. Just depends on where the symptoms are. Most of the decision making is based on the brain mri, but we certainly, you know, I just told you that the worst place to have one is the top of the circle cord. So there's a lot of decision making involved with that. But if the person doesn't have any findings on exam to suggest that they need an MRI of the spine, then we'll forego that. But it's highly variable though, this disease. About half of my patients with ms, you couldn't tell they have anything wrong with them.
Many are employed, working full time, long hours, lots of times.
It's important to keep up with everything. Yeah, exactly. So we do a lot of neurocognitive testing with them just because with the tendency to cognitive impairment, sometimes pretty subtle, we just need to document it and follow it over time. And because if there's a reason for them to go out of work, as I told you earlier, then that's the most common reason. So we like to get a nice baseline. We have a new tool that we've been using in our clinic called the Octave Ms. Disease Activity Biomarker Panel. It's 18 different biomarkers that have been selected to correlate with Ms. Disease activity. So it's given us another way to follow this disease, an alternative to the MRIs and the clinical history and exam. So that's. We're just in the first year or so of having it, but it's proven to be very helpful. We'll just check that and get a number from 1 to 10, with 1 to 4.0 being low level of Ms. Disease, inflammatory activity, 4.5 to 7.0 moderate, and then 7.5 or above is high. And yes, we get patients sometimes that will seem to be doing pretty well and will have a high level. And that sort of sets the alarms off. And like, okay, we don't do anything differently, but we watch them more closely, we'll scan them more often. And because it seems to have some prognostic value in that the numbers will go up before a clinical event.
[00:14:51] Speaker B: That's great information. Are women more prone than men?
[00:14:55] Speaker C: Absolutely.
[00:14:56] Speaker B: Talk a little bit about that.
[00:14:58] Speaker C: At least two to one. Women to men.
[00:15:00] Speaker B: Okay.
[00:15:03] Speaker C: Hormonal effects have a role here. Certainly, for example, during pregnancy, it tends to be quiet, thankfully. So we, we always like to start treatment early. The key thing with multiple sclerosis, the best outcomes are with early treatment. And we have, as I alluded to earlier, a wide variety of medications to use for it. But you want to start them early in the course of the disease because outcomes are far better if you start them early. But we usually stop them during pregnancy. In certain cases we do continue them. There are some that seem that they look relatively safe during pregnancy, but for the most part we try to avoid those because basically we get more and more information over time. People have babies despite being on medications, and that's how you find out that things are okay. Like now. The beta interferons, the oldest class of Ms. Treatments from the 1990s. There have been enough babies born on that that are fine, that we allow those. We also allow glatiramer acetate, also known as copaxone, to be continued throughout the pregnancy. Also because of just experience and clearly nothing.
[00:16:06] Speaker B: It doesn't really cross the.
[00:16:08] Speaker C: Exactly.
[00:16:08] Speaker B: The blood brain barrier. Okay, Very, very good. It's a lot of great information.
So late stage, it sounds like to me this could be missed.
[00:16:21] Speaker C: Oh, absolutely, yeah.
[00:16:22] Speaker B: That there, that there could be a period of just ruling out a lot of things. And so are most of your referrals coming from primary care? And I would just think that that relationship is so important as we talk about disease prevention and health promotion. We talk a lot about getting a primary care physician, keeping up with your annual checks and then they can link you and refer you when things come up when you're having these various signs and symptoms.
[00:16:48] Speaker C: Oh, absolutely, yeah. The referrals from primary care, the main thing that we have, we also get referrals from other neurologists. We get second opinions, that kind of thing in the neurology clinic.
But because there are so many different ways that this can present, we get a lot where people just aren't thinking clearly and have a little numbness, which could be neuropathy. Many things such as that people think.
[00:17:11] Speaker B: It'S the normal course of age, right?
[00:17:14] Speaker C: Absolutely. We get a lot from migraine patients.
If someone has just common migraine, migraine with. Without aura, you don't have to get a scan, but people get scans. Sometimes they feel very strongly about making sure there's nothing bad going on in the brain. And sometimes they find abnormalities.
You can get abnormalities on the brain scan associated with migraines. Generally when you see spots on the brain. The most common cause would be hypertension related microvascular ischemic changes. But there are lots of other things, but migraines among them. And sometimes we'll have a patient that has the only risk factor for the spots on the brain is migraines. They don't have a lot of spots.
[00:17:53] Speaker B: Right, right.
[00:17:54] Speaker C: They end up getting a spinal tap to try to sort them out. We have something called radiologically isolated syndrome. I mentioned briefly clinically isolated syndrome. That's when you have one Ms. Like event but haven't had the second one to clinch the diagnosis. But radiologically isolated syndrome is when it looks like Ms. On the scan but they don't have any symptoms of it. Otherwise. I've picked up two or three patients, interestingly over the years that were radiology technicians and they told them, we need to check out this new scanner, climb up in there and we'll take some photos of your brain and see how it looks. And then, oh no.
So it's very strange that it had more than one, but it's not. We get all sorts of things like that.
[00:18:35] Speaker B: So for some of our viewers who may they think about scan, talk a little bit about what that diagnostic process looks like.
[00:18:43] Speaker C: Ah, so the scan, the MRI scan, it's about 45 minute procedure.
We still have a little bit of problem with claustrophobia with them, but they're more open than they were in the past. I remember having one for my shoulder or something years ago in one of the mobile units and thinking, oh, this.
[00:19:08] Speaker B: Is a little tight, I'm claustrophobic.
[00:19:09] Speaker C: I didn't realize I was claustrophobic and not getting in here. But then I've had one since and it seemed very roomy. And I remember think this is. So they're good. But there are open scanners around. We can do the scans with sedation. Takes longer the scans with sedation. At Riverside we're only doing them on Fridays and so they're booked out.
[00:19:30] Speaker B: Do they have to have any iv, Is it with contrast?
[00:19:32] Speaker C: Oh, they do.
The standard for Ms. Patients is with and without contrast because the with is to look for areas of enhancement which indicate active lesions and that's caused by a breakdown of the blood brain barrier and therefore you get the enhancement in the brain or the spinal cord.
People who have had it a long time, after a while, sometimes you're Frankie, you're not expecting any enhancing lesions and getting the dye administration every time there's a little bit of risk, tiny amount of risk, but it's not no risk. So for that reason we sometimes do them without contrast if the person's had it for a while. But in general we like to do them with and without contrast because you just get the best information and you don't want to have an enhancing lesion that you don't see because you didn't give the approval properly.
[00:20:24] Speaker B: Right, right. You talked a little bit about the, you know, early detection and early starting medication early.
In contrast to someone who doesn't and finds out very late stage what, what is the differences look like in treatment and outcome as it relates to that?
[00:20:41] Speaker C: It's tough. The people that start treatment late because it's one of those horses out of the barn situations, often they're already pretty devastated.
Speaking of the patients with dementia, I have just a lovely woman in my practice that I've taken care of her for 15 years and she's received one of the high potency forms of disease modifying therapy. That's our shorthand for it by the way, dmt.
But she's on one of those and she has not progressed one iota since going on this. But I just so wish that I could have gotten her earlier in the course with a good drug and her life would have been completely different. But yeah, but once it's advanced and there's a significant cognitive impairment.
Weakness spasticity is a big problem with Ms. Patients. They get stiff, particularly their legs will get stiff and they have difficulty walking because of that. It's not just the weakness, but it's also the stiffness. But you can't get it back. Every now and then with the high potency drugs, maybe 10 or 15% of patients will improve a little. But we tell them going into it that you should not expect to improve. We just want to slow the progression of it, ideally stop the progression of it. Our little catch word for that is neda. For no evidence of disease activity.
[00:21:54] Speaker B: I like that.
[00:21:55] Speaker C: We're going for. Exactly, we're going for neda. If we get a little bit of improvement, wonderful. But we're just trying to slow this progressive neurological disease down.
[00:22:05] Speaker B: All right, talk a little bit about for someone who's newly diagnosed, lifestyle changes and what lifestyle changes need to occur to help.
[00:22:17] Speaker C: I like to think that because Ms. Overall cut some years off the life because. But I think that's just more of an average type thing because there are a few people that get such a devastating form they sort of blow the curve for everyone else. It's like getting a zero on a test. You're still going to probably pass fail the course because if you get 100 on your next two, you still have a failing score. So not many early deaths from it, but that pulls down the overall average. But it can certainly occur.
So once you get the diagnosis of ms, we see These changes in lifestyle that I think, frankly, I know that in years to life, because smoking cigarettes, for example, is a risk factor for Ms.
[00:23:03] Speaker B: Many things.
[00:23:03] Speaker C: Exactly. So we do the best we can to get them away from that. We try to get them exercising. Exercise is extremely important for this. You want to make the best of your body, you want it to be at its best. And a lot of them are just exercise junkies, so to speak, there I have a few that like, you spend too much time in the gym. But regular exercise is very important. Proper eating, they go from eating just all the garbage that we tend to eat in our culture to a much healthier diet. The Mediterranean diet, by the way, is the recommended diet for multiple sclerosis, as it is for most everything else. There has been some experimentation with different types of diet that are questionable, frankly.
There's some decent data on the, on the keto diet. Interestingly, of all things, it looks like that's reasonable, but still the best overall. I mean, if someone is using that for weight loss for short periods of time, we're okay with that. That's not going to mess things up.
[00:24:03] Speaker B: Absolutely.
[00:24:04] Speaker C: But in general it's just regular exercise. Stretching is important. We particularly enjoy patients and getting involved with, or encourage patients getting involved with tai chi or yoga. Yoga. Yoga is the best of all. So we like yoga, Stress reduction, mindfulness, biofeedback, meditation is encouraged. So, and that's why I think with a lot of these people, you know, if you don't have a bad case, I think it probably does add years to your life just because they take better care of themselves and they start thinking about these things and stop doing all the bad things that they were.
[00:24:39] Speaker B: They were doing, which is so important. Sounds like there's a multi team approach, or would be a multi team approach to managing a disease of this nature. And just thinking about the emotional aspect of a diagnosis.
[00:24:53] Speaker C: Good point. The emotional aspect is very important.
There's a lot of depression with this disease.
Getting back to my 50% number, about that percentage of patients with Ms. Have depression, which is higher than you see with other forms of chronic disease. And that's not just because of the dealing with the chronic disease, but also the location of the lesions within the brain, down in the limbic system, deep, deep in the brain. But it's not so cut and dried that you can say, oh, you've got a lesion here, you're going to be therefore depressed. So it's not quite that tidy. But there's absolutely more depression that can occur with this disease. And the general population. And so something that we have to keep in mind to your point, a comprehensive approach is very important.
We have a. Here at Riverside, we have a comprehensive care multiple sclerosis clinic, and we're designated as such by the National Multiple Sclerosis Society. I think there are four or five in the state of Virginia. And we have to fulfill pretty rigorous criteria that comes up every three, four years.
[00:25:55] Speaker B: Yes, yes. Awesome. Are there support groups?
[00:25:58] Speaker C: There are, yes. We indeed we have a support group. Like all support groups, they were set back a bit by the COVID pandemic, but we've got.
[00:26:08] Speaker B: Coming together now a little bit going again.
[00:26:09] Speaker C: Yeah, just had. We have a very dynamic leader, Erica, that's doing a lot of work with that and just had our holiday party.
[00:26:19] Speaker B: Hi, Erica.
[00:26:20] Speaker C: Yeah, we meet monthly at the cancer center for that and getting good turnout. And she has different things. She'll have like an attorney come in to talk about disability. She'll have an occupational therapist come in to talk about what they have to offer. Just all sorts of things. A urologist talking about the challenges that are presented in that realm. And just lots of specialists that are pertinent to living with this disease.
[00:26:48] Speaker B: Yes. Well, thank you for your commitment. A lot of great information. If someone wants to reach out to you, would you please tell our viewers how to contact you?
[00:26:58] Speaker C: Absolutely. Just contact our office, Riverside neurology specialist in Newport News. Have your primary care physician or whichever physician make a referral to us, and we will get you in and get you checked out and evaluate for Ms. And get you started on treatment if appropriate. And I want to give people hope that have this disease.
There's never a good time to have ms, but this is a way better time to have Ms. Than any other time in our history.
[00:27:28] Speaker B: More information.
[00:27:29] Speaker C: So many different options. We have a lot of good medications for treatment of it. We do sometimes struggle with trying to get exactly the medicine we want because there are cost constraints that we have to take that into account. But we do the best we can to get the person on the best drug tailored for their condition.
We also have research opportunities at Riverside. We've had a long standing history of clinical research. And so we.
[00:27:55] Speaker B: That's important.
[00:27:56] Speaker C: At any given time. We always have some research study and we now have a new commitment to that. We're going to be collaborating with the University of Virginia regarding research. So we're very excited about that. We'll be having a meeting in the next. Next couple weeks about that.
[00:28:10] Speaker B: Yes, well, please come back. You're always welcome.
You know, come back and keep us updated on how things are going as it relates to research.
Thank you for your time. Thank you for your commitment and dedication.
[00:28:26] Speaker C: Okay, thank you so much Frankie. This was likewise nice opportunity to spread the word about Ms. And then Great.
[00:28:35] Speaker B: Thank you so much.
[00:28:39] Speaker A: Thank you for listening to this episode of Healthy Youth. We're so glad you were able to join us today and learn more about this topic. If you would like to explore more, go to riversideonline.com thank you for listening to this episode of Healthy Youth. We're so glad you were able to join us today and learn more about this topic. If you would like to explore more, go to riversideonline.com.
