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[00:00:00] Pete Waggoner: This is Neurology Now. The podcast that explores the fascinating and complex world of neurology. Join us as we explore the human brain and beyond with expert guests who share their knowledge and insights. Welcome to the neurology now podcast. And on today’s show, we welcome Victoria Levasseur from the Minneapolis Clinic of Neurology.
[00:00:21] Pete Waggoner: Dr. Victoria Levasseur is a board certified neurologist with specialized fellowship training in multiple sclerosis and neural inflammatory disease. Good morning to you, doctor. It’s a pleasure to meet you.
[00:00:33] Victoria Levasseur: Good morning. Thanks for having me.
[00:00:35] Pete Waggoner: Thanks for taking the time out to join us on, on this topic. And we have a really nice program schedule here that we’re going to go through a lot of topics and really kind of explore your vast mind and experience in this world.
[00:00:48] Pete Waggoner: And before we get into that I’m just curious to know what your path to this was. What led you through your educational journey to really focus in on this?
[00:00:57] Victoria Levasseur: Well, it started at a younger [00:01:00] age, kind of like most neurologists, we find some level of fascination with the brain at, in school or through an interaction with someone who’s affected by illness.
[00:01:09] Victoria Levasseur: And for me, it was in high school, I took a psychology course and was really intrigued by the anatomy behind, what each part of the brain is responsible for. And then I kind of dug into it more. And college ended summer research in between each year of undergrad, and that led me into different labs where I learned about Parkinson’s disease, migraine and then later on multiple sclerosis.
[00:01:36] Victoria Levasseur: I started research in that area as a medical student and decided to go for neurology residency. And was working with a mentor that would later become one of my mentors I worked with in fellowship. So, kind of a long road, but the interest was there from the very beginning. So.
[00:01:55] Pete Waggoner: Well, all of those things you learned along the way will be for another podcast.
[00:01:59] Pete Waggoner: Cause I would love to [00:02:00] dig into that personally, cause I find that super fascinating. But on the topic here today of multiple sclerosis, also known as MS for, for those that are just new to this and don’t know anything about it, how does it, what is it, and how does it affect the body?
[00:02:15] Victoria Levasseur: That’s a great question.
[00:02:16] Victoria Levasseur: We’re still not fully understanding the exact underlying mechanism of the condition, but we know it’s a chronic immune mediated disease that affects the brain and the spinal cord, which together are called the central nervous system. It typically happens to people between the ages of 20 to 40. It affects about 1 million people in the U.S.
[00:02:38] Victoria Levasseur: And so far a single antibody hasn’t been identified to implicate an exact target within the nervous system. So it’s not technically considered an autoimmune condition for that reason. We think that the peripheral immune system, which are the cells in our bloodstream that fight off infection are a signal to enter through a barrier [00:03:00] that protects the nervous system from the rest of the body, called the blood brain barrier.
[00:03:04] Victoria Levasseur: This leads to an attack on the nerve cells in the brain and spinal cord. Nerve cells are also called neurons and they’re cells that conduct electricity throughout the brain and spinal cord and that signals us to navigate the world around us. So if you think about it, when you damage these cells that can impact the body in multiple different ways depending on the location of the attack.
[00:03:25] Victoria Levasseur: And so, for example, damage to the nerve cell sheath called myelin around the optic nerve could lead to vision loss and discomfort when moving the eyes. And that’s a common sign of multiple sclerosis. So we’ve learned that attack on the myelin is only one component of change in the immune environment that occurs after an attack.
[00:03:46] Victoria Levasseur: And we can actually visualize inflammation on the magnetic resonance imaging scan that we do when we are looking into this as a possible diagnosis for a patient. And we also sample the spinal fluid, which is [00:04:00] a test that we use to diagnose and detect inflammation in somebody’s nervous system. And so it’s a very complex condition and we don’t know why it starts and it’s going to affect each person very differently.
[00:04:14] Victoria Levasseur: So that’s important to also note.
[00:04:16] Pete Waggoner: That must be interesting in your field where when you don’t know exactly what it is, and it’s kind of a fluid situation. I suppose from year to year, month to month, week to week, there may be things that you lean on as a group that say, well, this is taking us down a path.
[00:04:33] Pete Waggoner: Have you seen much change in that regard? As far as what you’re learning and knowing over time as far as, what it is and how it affects the body. Cause what I heard in there was a little bit of, we have an idea of what it is, but so it seems fluid to me.
[00:04:49] Victoria Levasseur: Yeah, yeah, I think well, a lot of it depends on definitions and how they change over time. The more research that we have on the topic and the [00:05:00] more advanced our research tools become, the more likely we’ll be able to figure out exactly where this is coming from and potentially tease apart whether it’s truly the same condition in each person.
[00:05:13] Victoria Levasseur: Before we had some of these techniques and research, we actually considered a few other diseases as part of multiple sclerosis, and they’ve been teased apart as other autoantibody conditions. So one of those is neuromyelitis optica, and the other one is something called myelin oligodendrocyte glycoprotein associated disease.
[00:05:32] Victoria Levasseur: So it’s a tough one to say out loud, but yeah, those are two that have kind of been siphoned off and put into a different category.
[00:05:40] Pete Waggoner: Got it. So then could you break down the different types of MS and how they differ?
[00:05:46] Victoria Levasseur: Sure. So clinically speaking, we are kind of considering two main manifestations of MS.
[00:05:52] Victoria Levasseur: One being relapsing, remitting, and the other progressive. So there are components of progression in all [00:06:00] individuals with MS. And so in a case of relapsing MS, a person will develop a neurologic impairment like numbness over one side of the body. And those symptoms can lessen over time or remit. And then if untreated, another symptom can occur at a different time point.
[00:06:16] Victoria Levasseur: And so, we know that the impact of these relapses can still accumulate and lead to more changes and difficulties for a patient over time. And so we see a shift away from this relapsing phase to a more progressive phase, and we would call that a secondary progressive MS. And then in primary progressive MS, we don’t really see that relapsing remitting phase, we tend to see a more slow development of symptoms. Like weakness on one side of the body that gets worse over a few months. And sometimes we don’t identify it right away for that reason.
[00:06:52] Victoria Levasseur: When we look at this, I guess you could say under the microscope, the story is more complex than that. [00:07:00] With a typical MS plaque, when people have looked at this under a microscope, the pathology, we see inflammation, the presence of immune cells that are kind of engulfing myelin debris and attacking the nerve cell that we talked about earlier. But the plaques themselves change over time.
[00:07:19] Victoria Levasseur: And so we see a few different stages of plaque evolution, and that can impact a person clinically over time. And we don’t have a perfect correlation between what we see in the plaques and clinical outcomes, but our therapeutics kind of target the preventative lesion formation. And so they reduce that relapse risk.
[00:07:40] Pete Waggoner: What are the causes or the known risk factors that you’re aware of?
[00:07:45] Victoria Levasseur: So there are multifactorial. And that’s kind of the case with a lot of medical conditions, especially in neurology, where we don’t really have a clear positive factor. But we know that there’s genetic influence [00:08:00] and also environmental influence, so we can’t predict the future for our patients.
[00:08:05] Victoria Levasseur: But we’re continuing to advance diagnostics and apply different tools like RNA sequencing to further delineate the causes underlying each person’s condition. We’ve known for a while that there are variants in susceptibility genes within building blocks of the immune system. So some of those are called human leukocyte antigens.
[00:08:27] Victoria Levasseur: And they encode proteins that differentiate self and non self, and there’s other genes that are like this linked to the immune system that we think may predispose a patient to developing MS. A lot of my patients will kind of ask or come in concerned they have a family member with MS and wondering, what their risk is.
[00:08:45] Victoria Levasseur: So, in identical twins, there’s about a 17 percent risk in developing MS if you’re an unaffected twin. And, and then in first degree relatives, which would be parents, siblings and offspring, there’s only about a 2 percent risk. So [00:09:00] that leaves a lot of room for environmental and epigenetic influence. Other environmental factors are things like proximity to the equator.
[00:09:10] Victoria Levasseur: So there’s a link between decreased exposure to the sun and low vitamin D to susceptibility. And then tobacco use is considered inflammatory to the body. So that likely increases risk of relapse and severity of one’s condition. And then among others, exposure to certain viruses can harbor potential molecular mimics to components of the nervous system.
[00:09:33] Victoria Levasseur: And then finally, overall health can really impact outcomes. So examples of that would be obesity and presence of cardiovascular disease.
[00:09:42] Pete Waggoner: And then when you get into these causes and these risk factors, obviously, there are probably some warning signs that come in. Are there any early warning signs of MS that people should be aware of?
[00:09:55] Victoria Levasseur: It’s tough to call out specific signs, before that initial [00:10:00] relapse. But there are some really great researchers out there who are studying a prodromal period in MS. So, we think that five to 10 years prior to first relapse, patients may be spending more time seeking healthcare. Data indicates an increase in the diagnosis of things like depression, anxiety, headache, gastrointestinal and bladder issues, and sleep disturbances.
[00:10:27] Victoria Levasseur: So there may be something going on in the body that we can’t quite pin down. There’s also interestingly a population of people with something called radiologically isolated syndrome. And so in these individuals, we find MRI lesions while we image the brain for something else, and we find lesions that look like what we see in people who have MS.
[00:10:48] Victoria Levasseur: Some researchers are studying this population to help us understand if there are certain factors that could be leading to developing clinical symptoms. And then on [00:11:00] other end of the spectrum, when we’re looking at a possible MS diagnosis, relapse symptoms tend to include loss of vision, double vision, loss of balance or coordination, loss of sensation, loss of strength, urinary urgency or incontinence or constipation.
[00:11:19] Victoria Levasseur: And then it’s important also to know that these symptoms typically develop over the course of about 24 or 48 hours and persist for weeks to months.
[00:11:28] Pete Waggoner: How about treatments that are out today? What are the most promising ones that you see? And then can you follow that up with anything new that’s potentially available on the horizon as well?
[00:11:39] Victoria Levasseur: So the treatments that we have available now, when it comes to modifying the course of someone’s disease, are designed to alter the immune system. So, at the beginning, we talked about how we don’t have a, an antibody or a real target at this point. But the drugs are designed to help shift the [00:12:00] immune system, shift its activity, or by targeting specific cell types in the immune system. And either keeping them from entering into the peripheral blood, or by targeting them and actually killing them off. So there are 21 different options that are approved by the FDA for the treatment of M.S.
[00:12:19] Victoria Levasseur: Some of them have overlap or similar mechanisms of action, and some of them are quite different from one another. So they all require safety screening prior to starting an ongoing monitoring. And they’ve all been studied in randomized control trials. And they have shown to significantly reduce the risk of relapse to varying degrees.
[00:12:39] Victoria Levasseur: So, continued studies are ongoing to look at how these drugs affect people over time, and when it might be safe to stop treatment in some patients. And so the medications that I would say are most effective at reducing this risk of relapse are the more targeted treatments known as monoclonal antibodies. [00:13:00] And these are ocrelizumab, ofatumumab, ubutuximab, and natalizumab.
[00:13:05] Victoria Levasseur: And then there are also ongoing trials looking to address an unmet need, which is the progression of symptoms in MS. And so that’s something kind of on the horizon too, that we’re all looking for. And hoping that there’ll be something to really make an impact.
[00:13:22] Pete Waggoner: The lifestyle, the daily management, this is probably my favorite question of the whole podcast.
[00:13:28] Pete Waggoner: I know a few people with MS, one is, one is a coach and he’s very active and you wouldn’t even know another, maybe can’t be as mobile as the other. In terms of that, lifestyle and daily management of that, what are some of the strategies for people living with MS? And there’s a kind of a spectrum, isn’t there?
[00:13:50] Pete Waggoner: Based off of what we spoke earlier.
[00:13:52] Victoria Levasseur: Definitely. There are a lot of different strategies out there, and I like to keep it as simple as possible [00:14:00] and encourage patients to think about what they are doing every day and what their goals are. But if you think about it, the brain and spinal cord are conductors of everything that we do every day.
[00:14:12] Victoria Levasseur: So depending on where someone has an attack, it can really influence how they feel. And there’s also a lot of fluctuation that can happen. So if there’s life stress or an infection or another illness or injury that can make someone feel like they’re having a relapse all over again. So, number one, find a great primary care provider, establish regular wellness visits, and then also needed screenings for infection, if you feel like, you’ve had a cold or maybe a urinary tract infection, those are things to really check for as soon as you can. And then help managing other chronic health conditions and also keeping up with age appropriate cancer screenings.
[00:14:53] Victoria Levasseur: Our disease modifying therapies actually alter the immune system, so this can impact the body’s ability to screen and [00:15:00] regulate for things like infection and abnormal cell growth. And then number 2, finding a neurologist with fellowship training in MS is really important for neurologists who spend an additional 1 to 3 years.
[00:15:12] Victoria Levasseur: Much is after our 4 year neurology residency, learning how to diagnose, treat and manage these types of conditions. So there are dedicated fellowships led by experts in the field, and there’s often a component of research involved. And then thirdly, physical and occupational therapy or services that can really help people get back on their feet.
[00:15:33] Victoria Levasseur: Get some education on mobility and then some assistance with things like cognitive difficulties. And then a support network of trusted family and friends is super important because it’s all about, getting the support you need to work through issues that come up on a day to day basis. And also talking to your workplace about accommodations that you might need.
[00:15:54] Victoria Levasseur: Because MS can certainly impact your ability to perform tasks at work, and that may look [00:16:00] different for you than it used to. So it’s, it’s really useful to have those conversations soon. And then lastly, is just making sure you carve out time for yourself. Making it a daily routine to spend at least an hour just resting and trying to recharge and regain some of that energy that gets lost.
[00:16:18] Pete Waggoner: Great stuff there. And then we come along the lines kind of on the same vein of, of this, we all know the diet matters and are there specific dietary changes that could benefit those that are working through MS?
[00:16:32] Victoria Levasseur: Well, this has been studied extensively. We know that good cardiovascular health leads to better outcomes.
[00:16:39] Victoria Levasseur: And so we feel like a diet that tends towards leafy and green vegetables is, very beneficial to overall health. And so we think that benefits multiple sclerosis as well. The problem with some of the research on diet is that, a lot of the trials are small and they’re not blinded. People know if which [00:17:00] diet they’re usually eating. And the studies are typically short duration, so it’s hard to generalize some of this data and apply it to everybody. And so I just usually suggest limiting consumption of highly processed foods, which includes things that are packaged, or fast foods. And then trying to incorporate nutrient dense foods and also trying your best to eat at home as much as you can.
[00:17:26] Pete Waggoner: Then we hear that and I remember when I was young, I’m a little bit older that it was a fatal disease that it was a lifespan influencer. Can you talk to that today?
[00:17:38] Victoria Levasseur: Yeah, so the reasons you may have heard this may be partly due to the fact that our treatments have improved over the years. But for the most part, most research suggests that lifespan is affected in MS by about five to seven years.
[00:17:56] Victoria Levasseur: It’s really, really tough to say [00:18:00] why that is for everybody. There’s lots of things that play into life span and also a wide range of disease severity. But we know that chronic conditions like MS tend to have a really big impact on quality of life. So that’s why it’s just really important to take time to address your underlying health conditions and work closely with your neurologist to identify resources that are specific to your needs.
[00:18:23] Victoria Levasseur: So your provider should really help you weigh the pros and cons of different disease modifying therapies, and that will help you develop an individualized care plan to address ongoing symptoms that can affect your quality of life and also sometimes lifespan as well.
[00:18:39] Pete Waggoner: Well, then leading into it having been considered a fatal disease, there’s also a stigma, I would say, that followed with inevitable wheelchair use.
[00:18:49] Pete Waggoner: Can you go into that a little bit?
[00:18:50] Victoria Levasseur: Of course, yeah. So, this diagnosis does not equate to needing an assistive device. So, that’s true that some people may rely on [00:19:00] a cane or walker or wheelchair during a relapse or, later on in life years down the line. But they may also regain motor function and be able to walk without assistance.
[00:19:11] Victoria Levasseur: So, just to kind of hone in the advent of disease modifying therapies have really improved outcomes in this regard. The fewer relapses one person has usually indicates that they won’t need a device at all, but that really depends. So, we really do need better predictors to help understand, what’s going to happen to an individual.
[00:19:32] Victoria Levasseur: But I think things are, looking more positive than they used to.
[00:19:36] Pete Waggoner: We all know support matters in any type of situation that we encounter. And when we get into loved ones, how can they support with those with MS and what resources are available for families and friends to be able to assist?
[00:19:51] Victoria Levasseur: Oh, I think the number one show of support would be coming with your loved one, to those doctor visits.
[00:19:57] Victoria Levasseur: So, especially those first two or [00:20:00] three visits are really, really hard for the patient. Because they’re not sure what’s going on, they’re undergoing all these tests and are trying to figure out if they have, what we think they might have. And so it’s really helpful to have somebody in the room hearing the same things and helping to weigh the pros and cons of what’s going to happen next.
[00:20:20] Victoria Levasseur: So you can help by coming to those visits, taking notes. And then as far as resources, I really enjoy the National M.S. Society’s organized web page. I think they keep their information up to date. And so if my patients are looking things up on the internet, I always direct them to that website.
[00:20:39] Victoria Levasseur: They have local chapters throughout the United States and they’re continuing to expand their community events and offerings. So I think they’re a great place to lean on. And Then also keeping in mind, that if you have a family member who’s affected by this disease, it’s a condition that can impact memory, [00:21:00] cognition, energy levels, and that can be different every day.
[00:21:03] Victoria Levasseur: So it’s important to really show your compassion.
[00:21:06] Pete Waggoner: Understand that every day might not look the same, right? You just have to be open to that. We’ve talked about things. Maybe we’re it was misunderstood that maybe it was fatal or you go to a wheelchair immediately. And then those are some misconceptions, but there’s even more out there.
[00:21:21] Pete Waggoner: And I’d like to wrap up the podcast, having you kind of dispel some of those. Can you go ahead and do that? There’s some big ones, I think that you’d like to talk about.
[00:21:30] Victoria Levasseur: Yeah. So, there are a lot of things out there that we hear and may or may not be true. And I just, we’ll mention a couple here. So the first is that MS was thought to be a condition primarily impacting white individuals of Northern European descent.
[00:21:46] Victoria Levasseur: On the contrary, we think this is likely incorrect. MS prevalence was assumed to be low in black and hispanic individuals. But now we’re seeing the incidents and prevalence is likely much higher [00:22:00] than was previously recognized. Also, the disease course was thought to be more severe in these individuals, but we’re still looking into reasons behind this.
[00:22:09] Victoria Levasseur: And just overall, we’re noticing the lack of diversity in clinical research. So we hope that, over time, we’ll change that and be able to kind of understand what we’ve missed. The second is that it’s possible and safe to become pregnant. So if you’re a young woman who’s been diagnosed with MS, it’s possible.
[00:22:26] Victoria Levasseur: It’s definitely a possibility and just requires a little bit extra planning and communication with your neurologist. So that your therapy, if you’re on it, can be paused and then resumed safely afterwards. And then lastly, MS does involve a change with the immune system, but it’s not infectious and you can’t pass it on to anybody else.
[00:22:48] Pete Waggoner: You know, It’s really great to hear these things from you specifically, it’s one thing to kind of dig on the internet and read about it. And, is that really what I should be reading or not? And I feel like hearing this come from your [00:23:00] words in your mouth really helps to go through all of the components of this.
[00:23:04] Pete Waggoner: And I find this very informative. Great information, as we like to say in the business, great content, if you will. It was really, really good. So thank you for taking the time to dig into what you do and sharing it with all those that would like to know more.
[00:23:18] Victoria Levasseur: Awesome. Well, thanks so much for having me.
[00:23:20] Pete Waggoner: Thank you. That’s Dr. Victoria Levasseur. She joins us once again, and thank you for joining us for this episode of Neurology Now. We hope you found it informative, engaging, and if you enjoyed this episode, please subscribe to our podcast to stay up to date and help us educate our community and beyond. We welcome your feedback, comments, and suggestions for future topics.
[00:23:42] Pete Waggoner: So please feel free to reach out to us through our website or social media channels. That’s going to do it for today’s program. Thanks for joining us. I’m Pete Waggoner. So long, everybody.