Here is my question:
I am being put under general anesthesia tomorrow to remove my wisdom teeth but am unsure if I should take my Extavia shot tonight or wait until after the surgery.

Answer:
It makes little difference if you take the Extavia tonight or wait until after you recover. If a person experiences side effects with interferon injections, I usually suggest that they hold their injection until after they recover from surgery. Check with your physician and I suspect he or she will agree. Good luck.

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is My Question:
There is a device called the Biocharger; https://biocharger.com/persona/alternative-therapies/

Could this help manage MS symptoms?

Answer #1:
There is no real scientific evidence that this biocharger helps with disease or symptoms of disease.  In fact, the disclaimer on the website states it does not diagnose or mitigate any disease. The research presented on the website is hypotheses (over 100 years old) without any practical data to support its use in the management of disease. They do reference recipes to be used but it remains unclear to me if these incorporate herbs.  This device is being marketed as a product that emits electromagnetic energy within a radius of ~3-5 feet and that somehow treats people for a myriad of different (and unrelated) diseases. I would recommend a “buyers beware” caution to anyone with MS thinking about shelling out $14,000 for this.

A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente

Answer #2:
Thanks for the question. I checked out the website thoroughly. There are comments about “proven benefits” and even “testimonials” (whatever they are worth), but the company provides no peer reviewed references and I can find no references on the BioCharger in PubMed or any other search engine; this and the cost, which is $14,000, should make anyone pause and move on. Unless you are a millionaire with money free to throw around, do not even think twice.

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is My Question:
Does spasticity hurt? Can the pain in my hamstrings be due to spasticity?

Answer:
Patients tend to report painful spasticity but there are exceptions.  Spasticity can present in any muscle or muscle group, but also tend to follow other signs of central nervous system involvement that your neurologist can confirm on the neurological exam.  If spasticity is the cause of symptoms, various medicines could be used, but I typically recommend deep stretching of the affected muscles frequently first as this can be helpful while avoiding medication side effects.  

A. Scott Nielsen MD MMSc
​Neurologist and MS Specialist at Kaiser Permanente

Here is My Question:
I think my SPMS is being made more uncomfortable by arthritic changes and I'm wondering what meds will help?

Answer:
This is a really good question. MS never exists in a vacuum; instead it co-exists with everything else life throws at you, including old age and arthritis. In most cases your joint problems are a result of osteoarthritis, especially if the pain involves knees, hips, shoulders and/or spine. You can think of this as a form of wear and tear arthritis that can be accelerated by the muscle weakness and sensory alterations associated with Multiple Sclerosis.

There is no single treatment for osteoarthritis . You need to take an integrated approach that involves exercise (especially Tai Chi and Yoga), mindfulness/meditation and relief of pain with non-steroidal anti-inflammatory medications (think motrin). Additional approaches may include corticosteroid injections in several different types of joints for short term relief of pain and injections of the knee joint with hyaluronic acid for more long term pain reduction. Glucosamine and chondroitin sulfate may also be beneficial for knee pain in some people. More recently, platelet rich plasma injections have been used to treat joint, tendon and ligament injuries.

For patients with more advanced osteoarthritis involving the hip and knee and, in some cases, the shoulder, your doctor may recommend total joint replacement surgery even if you have more advanced progressive disease. This type of surgery done in the right hands in well selected patients can dramatically improve function and quality of life

In my experience it is best to be evaluated by specialists in sports medicine and pain medicine  for relief of joint, bursa (the lining around the joint), ligament and tendon pain. The correct diagnosis is of utmost importance. They will refer you to an orthopedic surgeon if they believe surgery is a good option

Good luck

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is My Question:
Can MS cause a low grade fever? My doctor can’t seem to find a reason for why I keep having one.

Answer:
Fever is not a known issue in MS, in fact, on average patients can have a slightly lower body temperature

Benjamin M. Greenberg, MD, MHS
Vice Chair of Translational Research and Strategic Initiatives
Cain Denius Scholar of Mobility Disorders
Distinguished Teaching Professor
Department of Neurology and Neurotherapeutics
Department of Pediatrics
UT Southwestern Medical Center
Dallas, Texas

Here is My Question:
As my MS advances, (RRMS 17 years-on glatopa daily shots) my gut seems to get worse. Especially since I had C-Diff a couple of years ago. I have had 2 short courses of flagyl for tooth abcesses recently. It was really awful then. But now it won't go away even when not on antibiotics. Is nausea and vomiting now an MS symptom that will not go away?

Answer:
In general those symptoms are usually not due to MS inflammation, although we do see constipation that can cause symptoms.

Benjamin M. Greenberg, MD, MHS
Vice Chair of Translational Research and Strategic Initiatives
Cain Denius Scholar of Mobility Disorders
Distinguished Teaching Professor
Department of Neurology and Neurotherapeutics
Department of Pediatrics
UT Southwestern Medical Center
Dallas, Texas

Here is My Question:
Has Siponimod been FDA approved?

Answer:
Siponimod has not been approved by the FDA yet but they are supposed to announce their decision sometime this month (March 2019)

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

Here is My Question:
Can Copaxone be used to treat PPMS?

Answer:
Copaxone has been FDA approved for RRMS and does not for PPMS (no evidence for effectiveness in PPMS).  The b-cell biologicals do have data to support use in PPMS.

A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente

Here is My Question:
Is SPMS worse than PPMS? I’m feeling I’m better off with PPMS because I have sudden things occur.

Answer:
The general course of PPMS and SPMS are very similar and the rate of progressive disability are also similar.  SPMS is different in that it is preceded by a relapsing-remitting course while PPMS does not.  The individual’s experience with MS can vary.

A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente

Here is My Question:
I was recently diagnosed with relapsing-remitting MS my doctor gave me the choice of medicine and I decided to go with Ocrevus. Being JC virus positive should I be concerned about PML?

Answer:
Risk of PML has been observed in MS patients on b-cell biological when there is combined or overlapping immunotherapy (ie, coming off Tysabri and onto Ocrevus or Rituximab for instance).  Since you were recently diagnosed I assume you are not on another therapy but this would be your first exposure to an immunotherapy.

A. Scott Nielsen MD MMSc
Neurologist and MS Specialist at Kaiser Permanente

​PLEASE NOTE:  The information/opinions on this site should be used as an information resource only.  This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment.  Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.

Here is My Question:
I have a paralyzed right diaphragm with resulting atelectasis of the right lower lobe and part of middle lobe. My last MRI in 8/18 didn't show any disease C3-5. I have been off Aubagio since 7/18 due to side effects (abnormal low WBC) and will be restarting it this month. Will be repeating MRI to assess for new disease. How often does MS cause phrenic nerve damage?

Answer:
Unilateral paralysis of a diaphragm is relatively rare in MS, although studies performed years ago suggested subclinical involvement of diaphragm function in a larger number of patients. This paralysis does not require involvement of the cord segments with the anterior horn cells supplying innervation to the diaphragm through the phrenic nerve (C3,4 and 5). This can also be the result of involvement of central motor pathways above this level in the brainstem.

Good luck

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

​Here is My Question:
I'd like your opinion about the findings from my latest MRI. These are from the radiologist at the hospital, not my neurologist. I'd like to know how concerned I should be about the level of atrophy (I am a 52 yr old female) and whether I can interpret the note about imaging stability to indicate that my DMT (Ocrevus, started 2 yrs ago, about 9 months post diagnosis) is working. Also, does the location of the subtle T2 signal indicate what functions might be / become impaired? Here are the findings:
FINDINGS: The brain is mildly atrophic. There is no diffusion abnormality indicative of no acute ischemic infarct. Redemonstrated is subtle asymmetric hyperintense T2-FLAIR signal in the periventricular white matter of the left frontal lobe. There is no new signal abnormality. There is no evidence of acute or chronic extravascular blood products. There is no mass and no mass effect. Corpus callosum and pituitary gland have a normal appearance. Following gadolinium administration, there are no areas of abnormal enhancement. There is no cerebellar tonsillar ectopia with the craniovertebral junction normal. Orbital structures are unremarkable. Paranasal sinuses and mastoid air cells are clear.

IMPRESSION: MR imaging of the brain shows no acute neuroimaging finding with imaging stability when compared to the exam 26 months ago.

Answer:
It is hard to provide an opinion about an MRI based on a radiologists report. I can however provide some explanations

1. The radiologist could see no changes since the last scan 26 months ago. This is a qualitative judgement and generally means there has not been a big enough change for the eye to perceive.
2. The comment about mild atrophy is meaningless without quantitative measurement; mild compared to what? 
3. The report does not provide enough information about the location of “lesions” to make any comment regarding associated symptoms. Generally speaking there is little if any relationship between the location of “lesions” in the cerebrum (main part of the brain) and symptoms or exam findings

I would emphasize the lack of change over 26 months as good news.

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego

​PLEASE NOTE:  The information/opinions on this site should be used as an information resource only.  This information does not create any patient-HCP relationship, and should not be used as a substitute for professional diagnosis and treatment.  Please consult your health care provider before making any healthcare decisions or for guidance about a specific medical condition.