What is the best approach to taking a multiple sclerosis (MS) disease history for a stable patient?

Comprehensive Approach to Taking a Multiple Sclerosis Disease History for a Stable Patient

A comprehensive MS disease history for a stable patient should focus on systematically assessing disease activity, progression, treatment response, and quality of life through structured evaluation of symptoms, imaging findings, and functional status.

Key Components of MS Disease History

1. Disease Characteristics Assessment

• Relapse History:

  • Frequency, severity, and duration of relapses
  • Last relapse date and symptoms
  • Recovery status from previous relapses
  • Need for steroid treatment or hospitalization 1

• Symptom Progression:

  • Changes in existing symptoms (better/worse/stable)
  • New symptoms since last assessment
  • Particular focus on:
    • Sensory symptoms (numbness, tingling, pain) - most common in stable RRMS (76.1%) 2
    • Fatigue levels (73% prevalence) 2
    • Motor symptoms (weakness, spasticity) - more common in progressive forms 2
    • Visual disturbances
    • Balance and coordination issues
    • Bladder/bowel function
    • Cognitive changes

2. MRI Monitoring and Disease Activity

• MRI Findings Review:

  • Compare with previous scans for new/enlarging T2 lesions
  • Presence of contrast-enhancing lesions
  • Brain volume changes (atrophy progression) 1
  • Lesion topography (infratentorial lesions have higher prognostic value) 1

• Brain MRI should be performed:

  • Using the same MRI system and protocol as baseline scan
  • With contrast-enhanced T1-weighted sequences to detect acute inflammation
  • At least annually for stable patients 1

3. Disability Assessment

• EDSS (Expanded Disability Status Scale) Score:

  • Current score and change from previous assessments
  • Document specific functional system scores (pyramidal, cerebellar, brainstem, sensory, etc.)

• Functional Assessment:

  • Ambulation status (distance walked without rest/assistance)
  • Need for assistive devices (cane, walker, wheelchair)
  • Hand function and fine motor skills
  • Impact on activities of daily living

4. Treatment Evaluation

• Current Disease-Modifying Therapy (DMT):

  • Adherence to prescribed regimen
  • Tolerance and side effects
  • Patient's perception of efficacy
  • Duration on current therapy

• Treatment Response Indicators:

  • Clinical stability (absence of relapses)
  • MRI stability (no new/enlarging lesions)
  • Stable disability measures
  • Consider brain volume changes as treatment response marker 1

5. Symptom Management

• Current Symptomatic Treatments:

  • Effectiveness of current symptom management
  • Side effects of symptomatic medications
  • Need for adjustment of symptomatic treatments

• Untreated Symptoms:

  • Identify symptoms not adequately addressed
  • Prioritize symptoms most affecting quality of life

6. Quality of Life Assessment

• Cognitive Function:

  • Subjective cognitive complaints
  • Impact on work/daily activities
  • Consider formal cognitive assessment if concerns arise

• Psychological Status:

  • Screening for depression and anxiety
  • Sleep quality
  • Coping strategies and stress management

• Social Functioning:

  • Employment status and work accommodations
  • Social support system
  • Recreational activities and participation

Practical Implementation

1. Begin with open-ended questions:

   • "How have you been feeling since your last visit?"
   • "Have you noticed any new or worsening symptoms?"

2. Use structured assessment tools:

   • EDSS for disability progression
   • Patient-reported outcome measures for symptoms
   • Quality of life questionnaires

3. Review MRI findings systematically:

   • Compare with previous scans for new/enlarging lesions
   • Assess for brain atrophy progression 1
   • Document lesion topography (infratentorial lesions have higher prognostic value) 1

4. Document treatment response:

   • Clinical stability (absence of relapses)
   • MRI stability (no new/enlarging lesions)
   • Stable disability measures

Common Pitfalls to Avoid

• Overlooking subtle disease progression: Even in "stable" patients, careful assessment for gradual worsening is essential
• Focusing only on physical symptoms: Cognitive and psychological symptoms significantly impact quality of life
• Neglecting brain volume changes: Brain atrophy can progress even in clinically stable patients and correlates with long-term disability 1
• Assuming all symptoms are MS-related: Consider comorbidities and alternative explanations for new symptoms
• Relying solely on patient recall: Supplement with objective measures and previous documentation

By systematically addressing these components, clinicians can effectively monitor disease status, optimize treatment, and improve quality of life for stable MS patients.