Should a patient with multiple sclerosis (MS) be followed by a neurologist?

Should Patients with Multiple Sclerosis Be Followed by a Neurologist?

Yes, patients with multiple sclerosis should be followed by a neurologist, as they are significantly more likely to receive disease-modifying therapy, undergo appropriate rehabilitation, and benefit from specialized monitoring that directly impacts disease progression and disability outcomes.

Evidence Supporting Neurologist-Led Care

Treatment and Management Advantages

Patients with MS who receive care from neurologists demonstrate substantially better treatment outcomes compared to those managed by other providers:

• Disease-modifying therapy utilization: Neurologist-managed patients are significantly more likely to receive disease-modifying agents (DMAs), which reduce relapse rates by approximately one-third and slow disability progression 1, 2
• Multidisciplinary coordination: Patients under neurologist care have significantly higher rates of referral to physical therapists, occupational therapists, and urologists—specialists critical for managing MS-related complications 2
• Rehabilitation access: Neurologist-managed patients are more likely to attend outpatient rehabilitation programs, which address mobility, coordination, and functional independence 2

Specialized Diagnostic and Monitoring Expertise

The complexity of MS diagnosis and monitoring requires specialized neurological expertise:

• MRI interpretation: Diagnosis and monitoring require interpretation by trained neuroradiologists or clinicians deeply familiar with MS features and differential diagnoses 3
• Structured monitoring protocols: Neurologists implement standardized MRI monitoring every 3-6 months initially, then every 6 months for 1-2 years after treatment initiation, using specific sequences (T2-weighted, T2-FLAIR, gadolinium-enhanced T1-weighted) to detect new lesions and treatment response 4, 5, 6
• Cognitive assessment: Regular cognitive monitoring using the Symbol Digit Modalities Test (SDMT) every 6 months requires neurological expertise to interpret and integrate with other disease markers 4

Disease-Specific Treatment Decisions

Neurologists are essential for navigating the complex treatment landscape of MS:

• Risk stratification: Presence of infratentorial lesions, spinal cord lesions, or contrast-enhancing lesions requires immediate treatment decisions that neurologists are trained to make 6
• Treatment escalation: Identifying breakthrough disease activity (two or more new T2 lesions between scans, or relapses with contrast-enhancing lesions) and escalating to higher-efficacy DMTs requires specialized knowledge 6
• Relapse management: Intravenous methylprednisolone remains the treatment of choice for relapses, with plasmapheresis reserved for steroid-refractory cases—decisions requiring neurological expertise 7, 8

Barriers to Neurologist Access

Despite clear benefits, significant access disparities exist:

• Economic barriers: Patients lacking health insurance or living in poverty have significantly lower probability of seeing neurologists 2
• Geographic barriers: Rural residents face reduced access to neurologist care 2
• Racial disparities: African American patients are significantly less likely to see neurologists 2
• Disease stage: Patients with advanced disability (wheelchair/scooter users or bedbound) paradoxically have lower neurologist access, despite potentially benefiting from specialized symptom management 2

Role Throughout Disease Course

Early Disease (Relapsing-Remitting MS)

• Immediate intervention: High-risk MRI features (infratentorial lesions, spinal cord lesions, contrast enhancement) require immediate DMT initiation 6
• Frequent monitoring: First follow-up MRI at 3-6 months after DMT initiation, then every 6 months for 1-2 years 6
• Treatment optimization: Women and patients with 1-2 relapses in the preceding year particularly benefit from neurologist management 2

Advanced Disease

Even patients with severe disability continue to value neurologist involvement:

• Source of hope: Neurologists provide information about therapeutic advances and clinical trials 9
• Disease education: Ongoing education about disease progression and symptom management remains critical 9
• Supportive care: Neurologists coordinate management of bowel/bladder dysfunction, depression, fatigue, movement disorders, and pain 7, 9

Critical Pitfalls to Avoid

• Delayed referral: Patients with clinically isolated syndrome or radiologically isolated syndrome should be referred immediately to establish baseline monitoring and treatment plans 1, 7
• Inconsistent follow-up: Even asymptomatic patients with radiologically isolated syndrome require consistent MRI monitoring every 3-6 months to detect subclinical progression 5
• Abandoning care in advanced disease: Patients with severe disability still benefit from neurologist involvement for symptom management and supportive care, despite limited disease-modifying options 9