MS: When should you refer to an MS center vs. general neurology?
There is a perception among some physicians that little can be done to help patients with multiple sclerosis. But the treatment landscape has changed dramatically in recent years, and early diagnosis and treatment can help patients stay functional and enjoy a much better quality of life. That makes it important for primary care physicians to know which MS symptoms to watch for and when to refer for specialized MS care at places like the Eastside Neuroscience Institute (ENI) at EvergreenHealth.
Multiple Sclerosis: What to Watch for
MS can present in a variety of ways that are connected to dysfunction within the central nervous system.
“Because at least 90% of people have a relapsing form of MS, their first presentation will be a relapse. By definition, that’s a new symptom that’s attributable to the central nervous system and lasts for 24 hours,” says Theodore Brown, MD, a physiatrist at ENI who specializes in MS.
Initial MS symptoms can include:
- Numbness
- Vision changes such as double vision
- A shock-like sensation that occurs when patients bend their spine.
- Urinary retention, incontinence or urge incontinence
- Loss of balance, coordination and walking
Keep in mind that MS follows certain patterns. Symptoms usually emerge as a rapid change, not as a slowly evolving condition. And symptoms are usually asymmetric.
“If your patient’s symptoms or reflexes are symmetric, and at no point are they consistently asymmetric, the differential broadens and MS becomes overall less likely. These patient maybe better seen in general neurology,” says Jason Poon, MD, a neurologist who specializes in MS at ENI.
Physicians should also consider the patient’s gender and age.
“MS happens more in women than in men and usually emerges when they’re in their 30s or 40s,” Dr. Poon says. “If a patient is in their 60s or 70s, it’s much less likely that they have MS.”
When Should You Refer to an MS Specialist Versus a General Neurologist?
For an initial referral, physicians have a choice between a general neurologist and one who specializes in MS. Which one is appropriate?
Imaging is the number one factor to consider.
“If a patient’s imaging is normal, general neurology is typically the best place to start,” Dr. Poon says. “But if an MRI suggests demyelinating disease, it’s appropriate to send them directly to an MS specialist – especially if they have a neurological history that indicates the potential for MS or another demyelinating disease.”
At ENI, we will route the patient to the appropriate neurologist as part of our screening.
“There are some patients who are referred to ENI neurology, who are then moved directly to the MS center because of the presenting history and findings,” Dr. Brown says. “Likewise, there might be some patients who are referred to the MS center who we end up sending to general neurology instead.”
Benefits of Early MS Diagnosis and Treatment
There are now approximately 20 FDA-approved drugs for MS. Most of them are monoclonal antibodies that aim to reduce the disease’s autoimmune attacks. These drugs are becoming increasingly affordable, in part because some generic options are available.
Getting a patient started on an appropriate drug, early in the course of disease can significantly improve their long-term outcome.
“There’s strong evidence that aggressive, early treatment makes a huge difference,” Dr. Poon says. “By treating the disease in its earliest, most active phase, you can potentially diminish that activity so the patient will have less disability in future years.”
Early diagnosis also means patients can start the journey of accepting their disease and preparing for the future.
“When patients think they might have MS, they feel like their world has been turned upside down – they worry about things like whether they’ll still be able to work, take care of their family and keep enjoying life,” Dr. Brown says. “The sooner we can give them a definitive diagnosis, the sooner we can give them a sense of control that they can manage the disease and still have a fulfilling life.”
How Personalized, Multidisciplinary MS Care Makes a Difference
Once a patient is referred to ENI we do our best to see them as soon as possible – usually within two weeks. We take time to understand each patient’s lifestyle and goals, so we can identify treatment options that best match their needs.
If they’re a newly diagnosed patient, we walk them through their medication options, and the pros and cons of each one. This includes educating them on how certain MS drugs are administered – options include oral medications, self-injectable subcutaneous medications and infusion treatments.
If the patient has already been undergoing MS treatment, we evaluate their disease activity, their current medication regimen, how well it’s working and whether it matches their lifestyle and financial needs. If the drug isn’t working for them, we identify potential alternatives.
“With the right drug, many patients can get to a point where they stop progressing clinically and their MRI is stable and not showing more abnormalities,” Dr. Brown says. “That’s our goal for each patient and if we’re not achieving it with one drug, there are a variety of others we can turn to.”
ENI at EvergreenHealth offers access to a comprehensive, multidisciplinary MS team. This team includes a dedicated MS nurse and a dedicated MS social worker, as well as a pharmacist and neuropsychologists, physical therapists, speech therapists, occupational therapists and neuro-ophthalmologists that have years of experience with MS patients. We also work closely with our urology and gastroenterology departments, and we have a strong prior authorization team that is familiar with getting drugs started. Our care team stays with each patient long-term, so we can help them manage the disease when it relapses and at every stage in their life.
“We take a whole-patient approach and we spend significant efforts to ensure we’re setting each patient up to be as functional as possible, for as long as possible,” Dr. Poon says. “This includes figuring out things like how we’re going to help a patient maintain their bone health, what support they need at home, how we’re going to use occupational therapy to help them be able to care for themselves on a daily basis, and how we’re going to help them prevent falls.”
We also communicate closely with each patient’s primary care physician.
“Primary care physicians can play a huge role in helping patients maintain things like bone health, cardiovascular health and a healthy body weight,” Dr. Poon says. “They also help with smoking cessation and with vaccinations, which are especially important for MS patients because most MS medications are immunosuppressive.”
Taking a team approach and including every provider’s voice is essential to our approach – and we’re available to trade ideas and answer questions any time.
“We strive to be very accessible to our patients and referring providers,” Dr. Brown says. “We’d much rather be talking and collaborating with other physicians, instead of having them feel like they need to figure out how to support an MS patient on their own.”
To refer a patient:
Bellevue Location 1-425-635-6560
Kirkland Location: 1-425-899-3135