Here is My Question:
I’ve recently started getting cramps in my feet. At first the weren’t bad but now it feels like someone crushing my foot. I’m on a mild muscle relaxer but it works a little.

Answer:
For the purpose of answering this question I will assume you have Multiple Sclerosis and no other problems associated with either cramps or spasms.
There are three basic principles to follow for relieving muscle spasms in particular muscle groups.

1. Make sure there is no noxious stimuli ( source of pain) causing or worsening the spasms. Often people are not aware of the source of pain because of the lack of sensation in the affected body part. This is particularly true of the feet. We see individuals with serious infections or fractures that they were not aware of because of their lack of adequate sensation.
2. Make sure you are stretching the involved muscle regularly and avoiding positions that provoke spasms if possible. You can find stretching regimens on-line or see a physical therapist for a stretching program individualized for your needs. Leg spasms are often worse when lying down at night to sleep. Certain positions of the feet may provoke spasms. Finding ways to avoid these positions can be helpful
3. Use anti-spasticity medications appropriately to decrease the spasms. I often find that anti-spasticity medications are prescribed according to the package insert instead of your individual needs. For instance, the package insert will tell you to take Baclofen (a common anti-spasticity medication) three times a day, but this is often not necessary. Daytime doses can increase drowsiness and mental fogginess and decrease your balance unnecessarily if you only need the baclofen to limit evening or nocturnal spasms  that interfere with sleep. If your problems with spasms are mostly at night and you can manage the spasms during the day with stretching and movement, only take baclofen in the evening and use enough to accomplish your goal. Some people do very well with a dose of 20 to 30 mg taken just in the evening as one dose. If baclofen doesn't work at an acceptable and tolerated dose given at the right time of day, move on to other medications until you find one that works. It helps to try medications with different mechanisms of action ; a common sequence is baclofen, then gabapentin then tizanidine then a benzodiazepine (e.g. diazepam). This assumes you have already tried standard muscle relaxants like cyclobenzaprine. If the spasms involve a particular group of muscles in the feet, botox can be effective in refractory cases.

Good luck

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#footcrampsandms #MS #multiplesclerosis #footcramp

Here is My Question:
I don't have a diagnosis of MS, but am having multiple symptoms that make me worried I might have this condition. I don't have health insurance so I can't see a doctor unless I can really justify sinking thousands of dollars into testing. I was just wondering if these symptoms are concerning so I can be sure it's worth going into medical debt to get checked out.

At first I thought this was probably just a pinched nerve or something but I have been in constant pain/discomfort for over three months so I'm starting to get worried that this is something else.

Here is a (very long, so sorry) list of my symptoms:

- pain in upper back between my shoulder blades going down left arm. The pain is burning, stabbing, or shocking (though sometimes is a persistent deep aching) and sometimes I can feel the muscles in the neck/back/shoulder contracting (feels like "locking up") and becoming hard and painful. Worst overnight and right after waking up in the morning.

-Tried ice, heat, icyhot, massage, rest, Tylenol, ibuprofen, stretching, etc. But nothing has helped

-I can feel a nerve pulling when I try to look down, bend down, turn my head, or move my arm. I cannot tilt my head back to look up at the ceiling. Sometimes it just hurts but other times I physically can't do it and need to tilt my head with my hands. At it's worst I also need to physically tilt my head to the side or turn my head down with my hands.

-with both the pain from my muscles and the nerve pulling sensation, my body jolts forward slightly when I feel them, almost like wincing but more pronounced. It usually stops after a few seconds.

-If it's not pain then it's numbness and tingling and generally uncomfortable. 24/7. It never stops. It just gets either better or worse depending on the day/week.

-I can't sleep for more than a couple of hours at a time because there is no comfortable position to be in, no matter if it's standing or sitting or laying down. The pain isn't unbearable (though at times I couldn't even raise myself up to get out of bed and had to have my wife physically lift me out of bed, so the worst of it comes and goes).

-even though I do have strength in my left arm it feels weaker than usual and gets fatigued almost immediately when I raise it up, or I can't lift/grip things as easily when my muscles do that contracting thing, due to pain. Example: I couldn't lift a pan out of the sink this morning with my left arm but could with my right. (this post was shortened as it is unable to fit due to word length constraint)

Answer:
Thank you for the in-depth observation of your symptoms. The diagnostic process in neurology is complex and depends a great deal on your age, past medical, surgical and family history and examination; but at a minimum it sounds like you have a problem involving the lower part of your cervical spine on the left side. This could be as simple as arthritis or a disc compressing a nerve root or even the spinal cord, or as complex as MS or even a tumor. Most of the common causes I've mentioned are very treatable, especially when evaluated early before the condition progresses too much. It is not too late to purchase health insurance on the exchange in your state or sign up for Medicaid if you fall under the income limit. Open enrollment through the affordable care act is underway until the middle of December, so you will need to hurry. For Medicaid you can sign up at any time during the year. Neither option will exclude you because of a pre-existing condition. 
Good luck

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego

Here is My Question:
I was recently diagnosed with MS my MRI shows 2 lesions and my CFS OLIGOCLONAL BAND PROFILE shows 4 bands and abnormal, what stage is this? 

Answer:
We currently stage MS by clinical criteria (see below), not by MRI or CSF results. MRI and CSF results are used for diagnosis and prognostication.

Most people newly diagnosed with MS under the age of 40 have relapsing MS and those over 40 have a mix of relapsing and progressive forms of MS.

Relapsing MS is characterized by acute or subacute onset of new neurological symptoms and findings consistent with MS that variably improve over weeks to months. 80 % of people with MS relapses reach their nadir (worse point) within 2 weeks and 90 % within 4 weeks. Improvement typically takes 3 to 6 months following a relapse.
Progressive MS is characterized by steadily worsening neurological symptoms and findings over a year or more without remission

Two lesions on an MRI of the brain would be considered a low lesion burden. 
Similarly, 4 oligoclonal bands in cerebrospinal fluid (CSF) would not be considered an additional risk factor for subsequent disease worsening, although this finding is certainly useful for assisting in the diagnosis of MS.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#multiplesclerosis

Here is My Question:
What do you think about taking Duavee as hormone replacement therapy in MS patients? I have an early onset menopause, and have come across some research about Duavee. Thanks!

Answer:
We have no current information about the use of Duavee in menopausal women with MS at this time.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego

Here is My Question:
I started Kesimpta treatment last Friday, I’m due to inject this Friday, can I have a small tattoo done on Saturday.

Answer:
I see no reason to delay your Kesimpta injection because of a tattoo, but as always check with your physician. I would not inject at the tattoo site.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#tattooandmultiplesclerosis #MStattoo #tattooandMS #MS #multiplesclerosis #Kesimpta

​PLEASE NOTE: This information/opinions on this site should be used as an information source 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 been on Ocrevus for 2.5 yrs now. About 8 weeks prior to each infusion, my physician has me complete a set of labs. The labs are usually things like Vitamin D, IGg, WBC, RBC, etc. They also require a urinalysis. The urinalysis is what I am curious about. What are they looking for with that? Infection? What things are typically checked prior to an infusion of Ocrevus?

Answer:
I would ask your physician what she or he is looking for in any test they order. If the test is not easily explainable there is no reason for the test.  We usually obtain a urinalysis to check for infection although I do not do this testing prior to Ocrevus infusions unless I suspect an infection.

Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#multiplesclerosis #MS #Ocrevus

Here is My Question:
I have MS and I got Avonex treatment. I want to know about one thing, is there an obligation to get Avonex once or twice a week? If we do it, for example, once a month, what can happen?

Answer:
There was an initial reason for dosing Avonex injections once a week that was established prior to the pivotal clinical trial started over 30 years ago. Pre-clinical studies showed that downstream activation of interferon sensitive genes (ISGs) after injection of Avonex 30 ug in normal controls, and subsequently people with MS, led to secretion of certain proteins (MxA and neopterin) easy to measure in a blood test that persisted for up to 5 days. This information was used to select a dosing interval of once a week. It is important to note that there is no clinical evidence that secretion of MxA or neopterin after Type 1 interferon injections (e.g. avonex, betaseron or rebif) is at all responsible for any benefits of this therapy; this was simply an easy to measure marker of activation of ISGs.  

The phase III clinical trial of Avonex demonstrated the known benefits of Avonex with once weekly dosing and the rest is history. 

Since the original approval of Type 1 interferons to treat relapsing forms of MS, there has been continued debate about the effects of different doses and dose intervals of all Type 1 interferons. If all patients with a diagnosis of MS exhibited similar dysregulation of type I interferon responsiveness, then it is likely that higher doses would benefit people with MS not responding to standard dosing. However, Richard Ransohoff and Tony Reder, two prominent experts on interferon signaling, demonstrated years ago that approximately 20 % of relapsing MS patients exhibit an overactive response to Type I interferon injections that is associated with continued disease activity or even an increase in pre-treatment MS disease activity on standard dosing. This overactive response to Type I interferon signaling is similar to what we observe in patients with lupus (SLE) and neuromyelitis optica (NMO), two conditions known to worsen when treated with Type I interferons. Therefore, it would not make sense to increase the dose or dose frequency of type 1 interferons in relapsing MS patients experiencing breakthrough disease on these therapies unless there was a validated method to predictably determine their interferon responsiveness.

Of course, one could argue for increasing doses or dose intervals of interferons if there was controlled clinical trial evidence that this strategy was effective. Unfortunately, this type of study was never done and would not be considered ethical in the current environment of readily available, highly active, well tolerated disease modifying therapies with treatment effects far larger than those observed with interferons. However, this study would be ethical if you could reliably exclude those MS patients with an overactive response to Type I interferon signaling.

Great question. 
​
Revere P (Rip) Kinkel, MDProfessor of Neurosciences
Director of the Multiple Sclerosis Program
University of California San Diego
#Avonex #multiplesclerosis #MS