What Does a Diagnosis of MS Mean Today

"We are keeping myelin"
by Ann Crickmer, MSW

At the Consortium of MS Centers Annual Meeting held in September in Atlanta Patricia K. Coyle, MD (SUNY, Stonybrook) noted that the recent reclassification of MS has clinical relevance, as well as it's intended purpose of diagnostic standardization to facilitate multi MS Center research studies. There is data that suggests that different types of MS may have distinct biologic features and have a different response to therapies, with implications for more accurate prognosis and for therapeutic options. Certain factors have been related to a favorable vs. unfavorable prognosis in MS. These factors are gender, age of onset of disease, type of disease, type and pattern of initial relapse, relapse rate and degree of recovery and extent of disability several years after disease onset. Prognosis is, of course, a major concern to both the person with MS and their families. This will influence both therapy and other important life and financial planning decisions. As MS has recently become a treatable neurologic disease, the whole question of prognosis is opened up. With these new treatments, if there is an early diagnosis and a low attack rate in the first two years post-diagnosis, we decrease the probability of medical disability interfering with work and family life at 5 and 10 years. For those diagnosed as RRMS the fact that we are "keeping myelin" today significantly improves the probabilities for maintaining one's pre-diagnosis quality of life.

The Poser Committee Criteria used since 1983 required two distinct attacks to obtain a clinically definite diagnosis, an abnormal brain MRI does not diagnosis MS since there could not be a definite diagnosis at a single attack, or only one symptom according to this system of diagnosis. With the availability of the new treatments which have the potential of slowing the progression of MS, many physicians are questioning if the Poser Criteria are appropriate today as they may delay initiation of treatment.

In fact, Biogen is seeking people who don't have clinically definite MS, but are at risk. They must have multiple brain lesions on their MRI, and have had a recent, isolated occurrence of one demyelinating neuralgic sign or symptom, including optic neuritis, spinal cord syndrome (sensory problems, urine of fecal incontinence or retention, or dystonia), or a brain stem/cerebellar syndrome (vertigo, trigeminal neuralgia, nystagmus, ataxia, tremor). Taken individually, each of these signs and symptoms suggest MS but each alone is insufficient to make a definite diagnosis according to the Poser Criteria, which requires a second, different clinical sign or symptom for a definitive diagnosis. Those who are eligible for the medication trial will receive intravenous and oral steroid treatment. Then, within 13 days, half of the participants will receive weekly injections of Avonex for a maximum of 3 years, and the other half will receive a placebo. [To determine if you are eligible, ask your physician to call 1-800-324-2454 for more information.]

Revised MS Categories

The National MS Society Advisory Committee on Clinical Trials sought a consensus from physicians on defining the types of MS in a more accurate, specific way than the former categories had done. They received questionnaires from 125 physicians and agreed on the following types [Lublin & Reingold, NEUROLOGY 1996;46:907-911].

Relapsing-remitting (RR) MS: "clearly defined disease relapses with full recovery or with sequelae and residual deficit upon recovery; periods between disease relapses characterized by a lack of disease progression". 85% have this diagnosis at onset, with a relapse rate of 1.2/yr. Benign MS (10% of RRMS) is a subset of this type in which the patient remains fully functional in all neurologic systems 15 years after disease onset. Biologically, their disease is being controlled. Secondary-progressive (SP) MS: "initial RR disease course followed by progression with or without occasional relapses, minor remissions, and plateaus".

Once the baseline between relapses begins to progressively worsen, an initially diagnosed RRMS becomes SPMS. This does not imply an inexorable decline, one can stabilize for years, even though there is a gradual worsening of baseline functional capacity. 40-65% ultimately fell in this category before the interferon and 4 amino acid, antigen-stimulating therapies and methylprednisilone were recognized to slow disease progression in RR type of MS. This suggests that it is possible that more than 30% of RRMS will maintain baseline functions for a longer period of time. As Robert Herndon, MD said, "we are keeping myelin" [see Nov & Dec 1996 Contact].

Primary-progressive (PP) MS: "disease progression from onset with occasional plateaus and temporary minor improvements allowed. There is a gradual nearly continuously worsening baseline". 15% of those diagnosed with MS have this type. MRI evidence shows this form of MS to be biologically different than the other three types. The MS Society Clinical Trials committee recommended that the term chronic progressive be abandoned as it is too broad and included forms of MS that differ in both MRI evidence and clinical course.

Progressive-relapsing (PR) MS: "Progressive disease from onset, with clear acute relapses, with or without full recovery; periods between relapses characterized by continuing progression. This course of MS is rare, accounting for less than 5% of diagnoses."

To see a video interview on early treatment of MS with MS specialists Frederick Munschauer, MD and Heidi Crayton, MD, click here: http://www.healthology.com/multiple-sclerosis/video3857.htm.

Was this information helpful? Then please consider making a donation. We are a small, independent nonprofit agency and are dependent on donations from our supporters. Thank you from all the staff at the MSA.




	What Does a Diagnosis of MS Mean Today "We are keeping myelin" by Ann Crickmer, MSW At the Consortium of MS Centers Annual Meeting held in September in Atlanta Patricia K. Coyle, MD (SUNY, Stonybrook) noted that the recent reclassification of MS has clinical relevance, as well as it's intended purpose of diagnostic standardization to facilitate multi MS Center research studies. There is data that suggests that different types of MS may have distinct biologic features and have a different response to therapies, with implications for more accurate prognosis and for therapeutic options. Certain factors have been related to a favorable vs. unfavorable prognosis in MS. These factors are gender, age of onset of disease, type of disease, type and pattern of initial relapse, relapse rate and degree of recovery and extent of disability several years after disease onset. Prognosis is, of course, a major concern to both the person with MS and their families. This will influence both therapy and other important life and financial planning decisions. As MS has recently become a treatable neurologic disease, the whole question of prognosis is opened up. With these new treatments, if there is an early diagnosis and a low attack rate in the first two years post-diagnosis, we decrease the probability of medical disability interfering with work and family life at 5 and 10 years. For those diagnosed as RRMS the fact that we are "keeping myelin" today significantly improves the probabilities for maintaining one's pre-diagnosis quality of life. The Poser Committee Criteria used since 1983 required two distinct attacks to obtain a clinically definite diagnosis, an abnormal brain MRI does not diagnosis MS since there could not be a definite diagnosis at a single attack, or only one symptom according to this system of diagnosis. With the availability of the new treatments which have the potential of slowing the progression of MS, many physicians are questioning if the Poser Criteria are appropriate today as they may delay initiation of treatment. In fact, Biogen is seeking people who don't have clinically definite MS, but are at risk. They must have multiple brain lesions on their MRI, and have had a recent, isolated occurrence of one demyelinating neuralgic sign or symptom, including optic neuritis, spinal cord syndrome (sensory problems, urine of fecal incontinence or retention, or dystonia), or a brain stem/cerebellar syndrome (vertigo, trigeminal neuralgia, nystagmus, ataxia, tremor). Taken individually, each of these signs and symptoms suggest MS but each alone is insufficient to make a definite diagnosis according to the Poser Criteria, which requires a second, different clinical sign or symptom for a definitive diagnosis. Those who are eligible for the medication trial will receive intravenous and oral steroid treatment. Then, within 13 days, half of the participants will receive weekly injections of Avonex for a maximum of 3 years, and the other half will receive a placebo. [To determine if you are eligible, ask your physician to call 1-800-324-2454 for more information.] Revised MS Categories The National MS Society Advisory Committee on Clinical Trials sought a consensus from physicians on defining the types of MS in a more accurate, specific way than the former categories had done. They received questionnaires from 125 physicians and agreed on the following types [Lublin & Reingold, NEUROLOGY 1996;46:907-911]. Relapsing-remitting (RR) MS: "clearly defined disease relapses with full recovery or with sequelae and residual deficit upon recovery; periods between disease relapses characterized by a lack of disease progression". 85% have this diagnosis at onset, with a relapse rate of 1.2/yr. Benign MS (10% of RRMS) is a subset of this type in which the patient remains fully functional in all neurologic systems 15 years after disease onset. Biologically, their disease is being controlled. Secondary-progressive (SP) MS: "initial RR disease course followed by progression with or without occasional relapses, minor remissions, and plateaus". Once the baseline between relapses begins to progressively worsen, an initially diagnosed RRMS becomes SPMS. This does not imply an inexorable decline, one can stabilize for years, even though there is a gradual worsening of baseline functional capacity. 40-65% ultimately fell in this category before the interferon and 4 amino acid, antigen-stimulating therapies and methylprednisilone were recognized to slow disease progression in RR type of MS. This suggests that it is possible that more than 30% of RRMS will maintain baseline functions for a longer period of time. As Robert Herndon, MD said, "we are keeping myelin" [see Nov & Dec 1996 Contact]. Primary-progressive (PP) MS: "disease progression from onset with occasional plateaus and temporary minor improvements allowed. There is a gradual nearly continuously worsening baseline". 15% of those diagnosed with MS have this type. MRI evidence shows this form of MS to be biologically different than the other three types. The MS Society Clinical Trials committee recommended that the term chronic progressive be abandoned as it is too broad and included forms of MS that differ in both MRI evidence and clinical course. Progressive-relapsing (PR) MS: "Progressive disease from onset, with clear acute relapses, with or without full recovery; periods between relapses characterized by continuing progression. This course of MS is rare, accounting for less than 5% of diagnoses." To see a video interview on early treatment of MS with MS specialists Frederick Munschauer, MD and Heidi Crayton, MD, click here: http://www.healthology.com/multiple-sclerosis/video3857.htm. Was this information helpful? Then please consider making a donation. We are a small, independent nonprofit agency and are dependent on donations from our supporters. Thank you from all the staff at the MSA.
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