Measuring MS Progression: Biomarkers, Comorbidities, and Rehabilitation

In "Measuring MS Progression: Biomarkers, Comorbidities, and Rehabilitation," the panel takes up the question of how to detect change in patients who have no relapses.

Dr. Nair asks how clinicians can measure the two phases of disability accrual when patients present without relapses. Dr. Longbrake says she dislikes the labels relapsing MS and progressive MS. Inflammatory and neurodegenerative biology occur together in the same patient, and the labels only describe which one looks dominant from a 20,000-foot view. In her view, the buckets are artificial and do not tell clinicians how to treat.

Dr. Newsome agrees that MS is one spectrum, with two trains running in parallel from the start. Powerful therapies can shut down inflammatory activity while progressive biology continues, and current tools may not show it early. He points to digital wearables, fluid biomarkers such as GFAP, and novel imaging such as paramagnetic rim lesions. Progressive biology tends to surface later, when neurological reserve is lower.

Dr. Longbrake then raises comorbidities that can compound apparent progression. Reflecting on perimenopause, she suspects she has missed those symptoms in her patients for years, because they overlap with progression symptoms. Her approach is to find and treat every aspect of worsening that is treatable.

Dr. Freeman adds that progression in a person with MS may not be due to MS at all. Perimenopause, sleep apnea affecting cognition, and orthopedic problems in older patients are examples. She wants tools that measure MS-specific biology alongside a checklist of other contributors.

Dr. Newsome stresses rehabilitation as part of treatment. He once mistook deconditioning for progression and considered switching therapy, but patients returned stronger after physical therapy and core exercises. Dr. Longbrake closes by noting that MS brains are inefficient, so small additional insults have outsized effects.

Up next, in "MS Phenotypes, ICD-10 Codes, and Payer Barriers to Treatment," Dr. Nair asks how the continuum view of MS squares with phenotype-based coding and payer rules.