RealTalk MS
RealTalk MS
Navigating multiple sclerosis is easier when you understand the science behind it. Join host Jon Strum each week as he translates complex MS research, treatment breakthroughs, and healthcare news into clear, accessible language. Whether you’re living with MS, caring for a loved one, or looking for answers, RealTalk MS connects you with top neuroscientists, advocates, and the information and insights that matter most to your MS journey.
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Aug. 24, 2026

Episode 469: Maintaining and Even Improving Cognitive Function If You're Living with MS with Dr. Anna Kratz

Episode 469: Maintaining and Even Improving Cognitive Function If You're Living with MS with Dr. Anna Kratz
RealTalk MS
Episode 469: Maintaining and Even Improving Cognitive Function If You're Living with MS with Dr. Anna Kratz
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Season 9 Research Insights Mental Health

Key Takeaways

  • A newly proposed framework by the International Advisory Committee on Clinical Trials in Multiple Sclerosis aims to replace outdated clinical categories with a dynamic, biologically informed profile to guide precision medicine.
  • A major international study revealed that finding even a single silent lesion on an annual MRI can increase future relapse and disability progression risks, challenging the concept of tolerable minimal disease activity.
  • Researchers have identified advanced MRI markers—specifically paramagnetic rim lesions and choroid plexus volume—that can predict future cognitive decline in early relapsing-remitting MS independent of physical relapses.
  • Dr. Anna Kratz explains that cognitive challenges in MS often affect processing speed, memory, and executive function, and that daily ups and downs are frequently influenced by sleep, pain, and fatigue.
  • Using real-time smartphone-based testing, Dr. Kratz's research captures day-to-day cognitive fluctuations in a person's lived environment, providing a more comprehensive snapshot than a single in-clinic assessment.

Cognitive changes in MS—fluctuations in processing speed, memory, and executive function—can significantly impact daily life, yet they're often misunderstood or overlooked in routine clinical exams. This week, we are joined by Dr. Anna Kratz, clinical psychologist and Professor in the Department of Physical Medicine and Rehabilitation at the University of Michigan, to discuss actionable, evidence-based ways to navigate cognitive challenges.

Dr. Anna Kratz

Dr. Kratz breaks down the latest findings from the CogDetect-MS study, exploring how daily symptom fluctuations, complex medication regimens, and common substances like caffeine and cannabis influence brain fog. She also shares practical compensatory workarounds and introduces a no-cost digital self-management resource, My MSToolKit.

We'll also explain the new framework for describing MS that's been proposed by the International Advisory Committee on Clinical Trials in Multiple Sclerosis.

We're sharing study results that reveal why detecting even a single silent lesion on an MRI should trigger an immediate conversation about stepping up to high-efficacy therapy.

And we'll tell you about 2 advanced MRI markers that can predict future cognitive decline — even in the absence of any relapses or new lesions on MRI.

We have a lot to talk about! Are you ready for RealTalk MS??!

This Week: Maintaining and improving cognitive function :22

The International Advisory Committee on Clinical Trials in Multiple Sclerosis calls for updating the way MS is described 1:12

A study provides evidence for switching your DMT when there's even a single silent lesion on your MRI 6:53

Scientists identify two MRI markers that can predict future cognitive decline in early relapsing-remitting MS 10:53

Dr. Anna Kratz discusses maintaining and improving cognitive function 15:33

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Next week 42:33

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LINKS

If your podcast app doesn't allow you to click on these links, you'll find them in the show notes at www.RealTalkMS.com

PAPER: Towards a Biologically Informed Description of Multiple Sclerosis Disease Course -- A Roadmap for Transition
https://rdcu.be/fxBw1

STUDY: Treatment Escalation After Clinically Silent MRI Lesions in Relapsing-Remitting Multiple Sclerosis
https://academic.oup.com/brain/advance-article/doi/10.1093/brain/awag252/8741305

STUDY: Paramagnetic Rim Lesions and Choroid Plexus Volume at Diagnosis Are Associated With Cognitive Progression Independent of Relapse and MRI Activity in Early Relapsing-Remitting Multiple Sclerosis
https://onlinelibrary.wiley.com/doi/10.1002/acn3.70448

REGISTER: ECTRIMS Patient Community Day
https://ectrimspatientcommunity.eu

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RealTalk MS Episode 469
Guest: Dr. Anna Kratz

Frequently Asked Questions

What is the CogDetect-MS study?

The CogDetect-MS study, led by Dr. Anna Kratz, explores actionable and evidence-based ways to navigate cognitive challenges in multiple sclerosis using real-time smartphone assessments.

What are paramagnetic rim lesions in MS?

Paramagnetic rim lesions are active brain MRI borders where inflammation continually simmers around old lesions, slowly expanding and damaging myelin even in the absence of new physical relapses.

Why is a silent lesion on an MRI important?

Even a single silent lesion—a new lesion appearing without symptoms or relapses—is linked to a significantly higher risk of future relapses and disability progression, suggesting a potential need to escalate disease-modifying therapy.

How do daily fluctuations affect MS cognitive testing?

Cognitive function in MS can fluctuate based on factors like sleep quality, pain, and stress, meaning a single, one-time test in a doctor's office may not reflect a patient's true day-to-day abilities.

WEBVTT

00:00:18.020 --> 00:00:21.410
It's August 25th, and we have a lot to talk about.

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When we talk about cognitive function that can be affected by MS,

00:00:26.470 --> 00:00:30.940
we could be talking about several different things, including processing speed,

00:00:31.230 --> 00:00:35.550
memory, or the mental skills that we use to plan, focus,

00:00:35.950 --> 00:00:38.050
organize, and make decisions.

00:00:38.760 --> 00:00:43.210
This week, we're talking about the steps people living with MS can take to manage

00:00:43.380 --> 00:00:45.370
and even improve their cognitive function.

00:00:45.990 --> 00:00:50.180
Joining me is one of the leading researchers and experts in how people with

00:00:50.180 --> 00:00:52.280
MS can best function day to day.

00:00:52.820 --> 00:00:56.700
Clinical psychologist and professor in the Department of Physical Medicine and

00:00:56.700 --> 00:01:00.900
Rehabilitation at the University of Michigan, Dr. Anna Kratz.

00:01:01.370 --> 00:01:06.550
But before we get to my conversation with Dr. Kratz, there are a few other things

00:01:06.900 --> 00:01:08.080
that you should know about.

00:01:12.820 --> 00:01:18.310
Since the 1990s, multiple sclerosis has been organized into three very familiar

00:01:18.310 --> 00:01:22.890
clinical categories, relapsing remitting, secondary progressive,

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and primary progressive.

00:01:25.250 --> 00:01:30.330
And since the 1990s, these labels have guided virtually everything that has

00:01:30.330 --> 00:01:35.850
to do with MS, including clinical trials, insurance approvals, and treatment choices.

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They've also defined the way people living with MS understand their own disease.

00:01:41.480 --> 00:01:45.340
Now, if you're a regular listener, you've probably heard me rant about the fact

00:01:45.580 --> 00:01:51.530
that between the 1990s and today, scientists have learned a lot more about MS.

00:01:51.870 --> 00:01:56.340
And we've reached a point where the labels we've always used to describe MS

00:01:56.590 --> 00:01:58.000
have stopped working for us.

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Now, a landmark paper published by a working group on behalf of the International

00:02:03.620 --> 00:02:07.070
Advisory Committee on Clinical Trials in Multiple Sclerosis,

00:02:07.550 --> 00:02:12.350
makes the case that these clinical descriptors are increasingly out of step

00:02:12.350 --> 00:02:19.900
with modern biology, and it's time to build a new, biologically informed framework to describe MS.

00:02:21.030 --> 00:02:25.620
This is an important topic that will ultimately affect everyone in the MS community.

00:02:26.200 --> 00:02:30.570
And before we get into it, for the sake of transparency, I want to let you know

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that I am a member of the working group that wrote this paper,

00:02:34.270 --> 00:02:36.840
and you'll see my name listed as a co-author.

00:02:37.750 --> 00:02:43.520
The central issue highlighted in the paper is that MS is not a collection of separate conditions.

00:02:44.100 --> 00:02:50.100
It's a complex immune-mediated disease where inflammation, demyelination,

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axonal injury and neuronal loss, and tissue repair can all be happening at the same time.

00:02:56.780 --> 00:03:00.970
Because these processes occur at different intensities in different people,

00:03:01.580 --> 00:03:07.030
two individuals who may have the exact same clinical label for their MS might

00:03:07.030 --> 00:03:11.560
have completely different biological drivers operating under the surface.

00:03:12.360 --> 00:03:17.310
Individuals diagnosed as relapsing-remitting MS may feel stable while their

00:03:17.310 --> 00:03:19.310
MS is technically in remission.

00:03:19.860 --> 00:03:25.740
But focal inflammatory damage or silent neurodegeneration can continue accumulating

00:03:25.950 --> 00:03:29.180
and go completely unnoticed between relapses.

00:03:29.760 --> 00:03:35.110
And the transition from relapsing to secondary progressive MS happens gradually,

00:03:35.500 --> 00:03:39.790
And today, it can only be identified retrospectively, that is,

00:03:39.790 --> 00:03:41.640
once it's already happened.

00:03:42.250 --> 00:03:47.600
In clinical practice, pinpointing that exact moment someone shifts from relapsing

00:03:47.600 --> 00:03:52.880
remitting to secondary progressive MS is extremely difficult to define.

00:03:53.510 --> 00:03:58.030
And when it comes to primary progressive MS, now this label identifies people

00:03:58.220 --> 00:04:01.980
whose disability worsens from the very onset of MS.

00:04:02.240 --> 00:04:04.440
There are no so-called remissions.

00:04:04.920 --> 00:04:08.960
But it doesn't represent a single specific biological pathway.

00:04:09.930 --> 00:04:14.660
So rather than defining MS as a fixed sequence of static stages,

00:04:15.050 --> 00:04:20.270
our working group has proposed moving toward dynamic, multidimensional descriptors

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that are updated over time as things change.

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The long-term vision is to create a living biological profile for each individual

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by tracking continuously updated dimensions, including active inflammatory activity,

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and that includes both clinical relapses and subclinical MRI lesions.

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It includes tracking progression independent of relapse activity,

00:04:45.640 --> 00:04:50.330
or PIRA, and the underlying neurodegeneration that goes with it.

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It means tracking fluid biomarkers, including markers of axonal injury and glial

00:04:56.630 --> 00:05:02.350
activation, and the individual's overall degree of neurological impairment and

00:05:02.350 --> 00:05:03.760
their response to treatment.

00:05:04.650 --> 00:05:09.720
Now, just to be clear, the traditional terms we use today to describe MS aren't

00:05:09.720 --> 00:05:10.870
disappearing overnight.

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These terms are still important and necessary for everyday communication and

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for interpreting decades of clinical trial data.

00:05:19.800 --> 00:05:23.410
Instead, the proposed framework is designed to evolve.

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Clinical labels will increasingly be supplemented with biological measurements,

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and new descriptors or biomarkers would have to first be validated and standardized

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across clinics worldwide.

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And any new system would have to remain practical. It would have to be clearly

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understandable not only for clinicians but for patients as well,

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and it would have to be directly useful for improving treatment decisions so

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we're not just swapping one set of rigid classifications for another.

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The ultimate goal of this roadmap is precision medicine, bringing clinical language

00:06:02.130 --> 00:06:05.430
into alignment with actual disease biology.

00:06:06.290 --> 00:06:11.580
By moving toward a dynamic living profile, clinicians will catch disease activity earlier.

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They'll be in a position to intervene with greater precision and tailor therapies

00:06:16.500 --> 00:06:21.980
to what is truly happening in the central nervous system of the person standing in front of them.

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I'll also mention that from the beginning, this work has involved people affected

00:06:26.790 --> 00:06:32.650
by MS, and that will continue as this roadmap continues to be defined and disseminated.

00:06:33.440 --> 00:06:36.750
Now, this is going to be a marathon, perhaps an ultra-marathon,

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certainly not a sprint, so you can be sure we'll continue talking about this

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important next step into the future.

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Meanwhile, if you'd like to review this paper, you'll find a link in today's show notes.

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When someone with relapsing-remitting MS is on a disease-modifying therapy and

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they undergo their annual MRI exam, a new, enlarging, or contrast-enhancing

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lesion might appear on that MRI scan.

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And that can happen even when that person hasn't had a recent relapse or experienced

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any noticeable worsening of their symptoms.

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And because there are no immediate outward signs, these are called clinically silent lesions.

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In fact, a single lesion, which accounts for about 40% of all breakthrough MRI

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activity, is often labeled minimal evidence of disease activity,

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and clinical guidelines don't recommend any escalation in treatment.

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Well, the results of a large international study suggest that finding even a

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single silent lesion on an MRI could be a clear signal to consider stepping

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up to a higher-efficacy disease-modifying therapy.

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In this study, researchers analyzed real-world data from more than 10,000 adults

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with relapsing-remitting MS across 26 different countries between the years 2007 and 2025.

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Using the global MS-based neuroimmunology registry.

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And here's what the numbers revealed over approximately two years of follow-up.

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Compared to having zero silent lesions, having just one silent lesion was linked

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to a 59% higher risk of a future relapse.

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And for those people with multiple silent lesions, that risk jumps to 94%.

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The adjusted risk of confirmed disability worsening was 35% higher in people

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with a single silent lesion and 42% higher for those with multiple silent lesions.

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The researchers then ran an emulated clinical trial using data from 2,264 participants

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taking platform or moderate-efficacy DMTs

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to evaluate what happens when treatment is escalated,

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after silent lesions appear.

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They found that patients who escalated to a moderate or high-efficacy DMT,

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within six months of detecting at least one silent lesion cut their four-year

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relapse risk by more than half compared to those patients who waited for an

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actual clinical event like a relapse before escalating.

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And this benefit held true whether someone had developed one silent lesion or

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multiple silent lesions.

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However, early escalation to a high-efficacy DMT did not significantly reduce

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the risk of confirmed disability worsening during that two-year follow-up window.

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Now, the researchers noted that this could be due to the relatively short follow-up period,

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or a low overall rate of disability worsening, or the fact that current DMTs

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target acute central nervous system inflammation rather than the drivers of

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progressive neurodegeneration.

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The researchers concluded that the results of their study challenged the concept

00:10:10.450 --> 00:10:16.500
of what's considered to be quote-unquote tolerable minimal disease activity on routine imaging.

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So, if you're taking a low- or moderate-efficacy disease-modifying therapy,

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and your routine MRI shows even one new silent lesion, this is a meaningful

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conversation to have with your healthcare team.

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While risks and benefits associated with any DMT should always be weighed carefully,

00:10:36.780 --> 00:10:41.260
this study suggests that you shouldn't necessarily wait to experience a relapse

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before considering a switch to a stronger treatment.

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And if you'd like to review the details of this study, you'll find that link in today's show notes.

00:10:53.470 --> 00:10:58.030
If you're living with relapsing-remitting MS, you're likely used to the typical routine.

00:10:58.500 --> 00:11:04.170
You get your regular MRI scans, and your neurologist looks for new or active lesions.

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And if the scan looks stable and you haven't had a recent symptom flare or relapse,

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you breathe a sigh of relief.

00:11:12.270 --> 00:11:16.980
But many people living with MS know all too well that how they feel cognitively

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doesn't always align with what those standard lesion counts show.

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As we just discussed in the last segment, there can be silent progression taking

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place behind the scenes.

00:11:28.280 --> 00:11:33.310
A fascinating new study out of Europe is shedding light on exactly what may be happening.

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Researchers have identified two specific brain MRI markers that can predict

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cognitive decline in early relapsing-remitting MS with roughly 80% accuracy.

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Even when there are absolutely no new lesions or physical relapses.

00:11:52.650 --> 00:11:56.150
To understand this breakthrough, we have to talk about what some scientists

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are calling PERMA, or progression independent of relapse and MRI activity.

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This describes low-grade chronic inflammation that slowly damages nerve fibers

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over time, but completely flies under the radar of our standard tracking tools.

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By following 87 newly diagnosed relapsing-remitting patients for over six years,

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researchers discovered that nearly two-thirds experienced meaningful cognitive decline,

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and for 80% of those people, that decline happened without a single clinical

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relapse or a single new lesion.

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When the research team looked closely at advanced imaging, two culprits stood out.

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First, they identified paramagnetic rim lesions, or PURLS.

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You can think of these as active borders.

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While the center of an old lesion might look quiet, a paramagnetic rim means

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inflammation is actively simmering around the edges, slowly expanding and eating away at myelin.

00:13:02.000 --> 00:13:06.630
Patients facing cognitive decline had a significantly higher number of these

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paramagnetic rim lesions.

00:13:09.360 --> 00:13:13.470
Then the researchers identified choroid plexus enlargement.

00:13:14.310 --> 00:13:18.780
Now the choroid plexus is an important network of blood vessels that produces

00:13:18.780 --> 00:13:21.430
the fluid surrounding your brain and spinal cord.

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When it gets enlarged, it acts like an open highway, letting traffic lanes of

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damaging immune cells flood straight into the central nervous system.

00:13:31.870 --> 00:13:33.620
This study found a direct link

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between increased choroid plexus volume and worsening cognitive function.

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And here's why these discoveries are so important.

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Historically, cognitive impairment in MS has often been looked at as a static, late-stage symptom.

00:13:50.170 --> 00:13:54.840
This study completely refutes that. It proves that cognitive changes are an

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active window into the earliest, quietest moving parts of MS.

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If clinicians can spot these two hidden markers right at the time of diagnosis,

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it changes the entire treatment playbook.

00:14:07.780 --> 00:14:12.450
Instead of waiting for brain fog or memory gaps to disrupt your daily life,

00:14:12.880 --> 00:14:15.490
your medical team can proactively step in.

00:14:16.180 --> 00:14:21.640
This means doctors can use these indicators to bypass milder foundational treatments

00:14:21.860 --> 00:14:26.850
and reach directly for highly effective high-efficacy therapies designed to

00:14:26.850 --> 00:14:29.970
aggressively put out those inflammatory fires

00:14:30.310 --> 00:14:33.100
before permanent myelod damage occurs.

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The big takeaway from this study is that no new lesions doesn't automatically

00:14:39.380 --> 00:14:41.820
mean your MS is completely asleep.

00:14:42.740 --> 00:14:47.610
If you or a loved one are noticing changes in memory, processing speed,

00:14:47.610 --> 00:14:54.760
or focus, even if your doctor tells you your standard MRI looks completely unchanged, you can speak up.

00:14:55.310 --> 00:14:59.640
Ask your neurologist about advanced imaging markers like paramagnetic rims.

00:15:00.320 --> 00:15:04.330
Your cognitive health is every bit as critical as your physical mobility,

00:15:04.690 --> 00:15:10.190
and catching these silent signs early is your best strategy in maintaining your quality of life.

00:15:10.730 --> 00:15:15.930
If you'd like to review the details of this study, you'll find that link in today's show notes.

00:15:16.690 --> 00:15:19.440
And while we're talking about preserving cognitive function,

00:15:19.970 --> 00:15:23.930
it feels like the perfect time to bring in our guest who works at the forefront

00:15:23.930 --> 00:15:26.950
of developing new ways to do exactly that.

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In a moment, we'll meet Dr. Anna Kratz.

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Dr. Anna Kratz is a clinical psychologist and professor in the Department of

00:15:38.070 --> 00:15:41.520
Physical Medicine and Rehabilitation at the University of Michigan.

00:15:42.020 --> 00:15:47.230
Dr. Kratz's work focuses on understanding how people living with chronic symptoms

00:15:47.230 --> 00:15:49.750
of MS can best function day to day.

00:15:50.220 --> 00:15:52.990
And today, we're talking about cognitive function.

00:15:53.600 --> 00:15:55.600
Welcome back to the podcast, Dr. Kratz.

00:15:56.210 --> 00:15:57.260
Thanks for having me, Jon.

00:15:58.250 --> 00:16:04.160
When we talk about cognitive function in MS, we're looking at a wide range of mental abilities.

00:16:04.750 --> 00:16:08.760
What are the specific cognitive domains like processing speed,

00:16:08.760 --> 00:16:13.410
memory, or executive function that are most commonly affected by MS?

00:16:14.120 --> 00:16:19.050
Yeah, this is a very good question. And the answer I'll give is one that is

00:16:19.050 --> 00:16:20.520
familiar to people with MS.

00:16:20.520 --> 00:16:26.590
And it's that, you know, what's common for everyone may not be your situation.

00:16:26.590 --> 00:16:34.770
So there are very individual what aspects of cognition are affected for any person.

00:16:35.270 --> 00:16:40.780
But I will say that research has been done to sort of find out what's most commonly affected.

00:16:41.230 --> 00:16:45.060
And it seems to be, especially in the areas of processing speed,

00:16:45.060 --> 00:16:49.450
so that is how fast you're able to think, how fast your brain works.

00:16:50.330 --> 00:16:56.650
Different aspects of memory. So this might be memory for new words,

00:16:58.210 --> 00:17:02.240
learning new words, memory for things you've seen,

00:17:02.550 --> 00:17:06.960
memory for experiences you've had, as well as working memory,

00:17:06.960 --> 00:17:13.630
which is the kind of memory where you have to hold some information in mind and sort of work on that.

00:17:13.630 --> 00:17:18.500
So maybe remembering two numbers and then adding them together, that's working memory.

00:17:18.950 --> 00:17:22.810
And then also executive functioning, what we call executive functioning.

00:17:22.810 --> 00:17:28.300
So this is kind of higher, more complex types of cognitive functioning.

00:17:28.700 --> 00:17:34.720
This might be things like planning out your day or making decisions or switching

00:17:34.720 --> 00:17:40.400
between different tasks kind of at the same time. So that flexibility can be

00:17:40.400 --> 00:17:42.220
really affected in people with MS.

00:17:43.420 --> 00:17:47.570
Do we know why MS targets these different cognitive domains?

00:17:48.530 --> 00:17:54.120
Well, it's a little bit unclear. You know, MS can be associated with brain changes

00:17:54.120 --> 00:17:56.170
in both the white matter.

00:17:56.170 --> 00:18:01.860
So that's the cells in the brain that kind of connect and transmit signals.

00:18:01.860 --> 00:18:08.700
And, you know, in MS, white matter is often the focus, often where the myelin

00:18:08.700 --> 00:18:13.180
is actually being damaged, as well as the gray matter.

00:18:13.180 --> 00:18:18.180
So when you think about a brain, you know, people think of it as maybe this gray organ.

00:18:19.510 --> 00:18:28.390
But it's a little bit unclear about exactly what is, how MS is affecting cognitive function.

00:18:29.340 --> 00:18:34.380
One of the things I'm really interested in looking at is how symptoms that are

00:18:34.380 --> 00:18:37.280
related to MS, So things like pain,

00:18:38.260 --> 00:18:46.580
fatigue, depressed mood, anxiety, those sorts of things are affecting cognitive function.

00:18:48.230 --> 00:18:53.910
When you are depressed or have pain, your cognitive function tends to be a little hard compromised.

00:18:54.580 --> 00:18:58.290
And then there are behaviors that are affected in MS, right?

00:18:58.290 --> 00:19:01.930
So sleep problems are very common in MS.

00:19:02.300 --> 00:19:08.240
That includes just kind of poor sleep quality, as well as obstructive sleep

00:19:08.240 --> 00:19:10.850
apnea and central sleep apnea.

00:19:11.200 --> 00:19:16.070
So there's all these kinds of ways that MS can affect cognitive functioning,

00:19:16.070 --> 00:19:20.980
both directly through changes in the body and brain, through these behaviors,

00:19:20.980 --> 00:19:25.090
and through the experience of new symptoms that might be impacting cognition.

00:19:26.140 --> 00:19:31.450
Many people with MS report that their cognitive abilities can fluctuate,

00:19:31.450 --> 00:19:34.670
sometimes pretty wildly, from morning to night.

00:19:35.460 --> 00:19:41.640
Can you explain how your lab's use of real-time smartphone-based tracking helps

00:19:41.640 --> 00:19:47.460
create a more complete picture of these daily ups and downs compared to a one-time

00:19:47.460 --> 00:19:49.140
test in a doctor's office?

00:19:49.770 --> 00:19:54.730
Yeah, thank you for asking about this. I get excited talking about our real-time

00:19:55.030 --> 00:19:57.280
data collection on real-time MS.

00:19:58.780 --> 00:20:05.570
So we use smartphone apps that administer the very brief and kind of easy to

00:20:05.570 --> 00:20:07.130
complete cognitive tests.

00:20:08.250 --> 00:20:13.350
And this is in contrast to what many people with MS experience when they get

00:20:13.570 --> 00:20:15.520
their cognition tested, right?

00:20:15.520 --> 00:20:22.280
They might go into a very quiet room with an examiner who's administering these

00:20:22.280 --> 00:20:25.080
tests. It's long. Maybe you're there all day.

00:20:25.620 --> 00:20:30.750
Um, but the reason we do these, uh, these short tests and we'll do them for

00:20:30.750 --> 00:20:35.750
two weeks at a time, four times a day, believe it or not, people in our studies,

00:20:35.930 --> 00:20:39.620
people with MS are happy to do it because I think they recognize

00:20:40.120 --> 00:20:43.470
that their cognitive function might change throughout the day.

00:20:43.470 --> 00:20:48.810
You know, maybe you're a little fresher in the morning and then you have like an afternoon slump.

00:20:49.520 --> 00:20:51.110
Maybe you're a little better before bed.

00:20:53.000 --> 00:20:58.190
And it addresses the issues of things like if you've had a poor night of sleep,

00:20:59.000 --> 00:21:04.090
we know that sleep is really, really affects cognitive function.

00:21:04.550 --> 00:21:11.440
So we not only can sort of get a better assessment of cognitive change over

00:21:11.760 --> 00:21:17.700
years by taking these multiple days of little assessments and sort of averaging them,

00:21:18.190 --> 00:21:24.920
sort of washes out the effects of poor night of sleep or a day of high stress

00:21:25.410 --> 00:21:31.060
or a day of really low symptoms where maybe you're functioning at your best.

00:21:31.390 --> 00:21:36.970
And sort of gives an overall, a broader snapshot versus that one day.

00:21:36.970 --> 00:21:41.510
You know, if you go in and you've been waiting nine months to see this neuropsychologist

00:21:41.510 --> 00:21:45.290
and get the test, and then you wake up that day and you haven't had good sleep,

00:21:45.290 --> 00:21:49.140
your pain is really bad, you know, you get lost on the way to the clinic,

00:21:49.140 --> 00:21:50.520
you're super stressed out.

00:21:50.800 --> 00:21:53.840
Maybe that's not really what your cognitive function looks like.

00:21:54.160 --> 00:21:57.470
And it's not what your cognitive function looks like in your daily life,

00:21:57.730 --> 00:22:01.800
Which is another way that it's different to be doing it on a phone when you're

00:22:02.330 --> 00:22:07.680
in Target or, you know, you're in your lived environment.

00:22:07.790 --> 00:22:13.000
So we think it's a much better way of assessing actual cognitive functioning

00:22:13.270 --> 00:22:15.810
for a person in their lived environment.

00:22:16.950 --> 00:22:21.370
And, you know, we're just at the very beginning of sort of using these methods

00:22:21.590 --> 00:22:26.830
to try to get a better sense of cognitive functioning in people living with MSK.

00:22:27.370 --> 00:22:30.940
Well, thinking about that test you take in a doctor's office,

00:22:31.590 --> 00:22:36.080
have you found that there's a difference between what a patient feels is happening

00:22:36.080 --> 00:22:40.620
to their memory and what the standardized tests actually show?

00:22:41.510 --> 00:22:48.090
Yes. People might be surprised to hear that what you perceive in terms of your

00:22:48.090 --> 00:22:53.700
cognitive function, so how you feel your brain is working, is not highly related

00:22:53.700 --> 00:22:55.900
to how your brain is actually working.

00:22:56.220 --> 00:23:02.050
So, we have found some evidence that when we do these smartphone tests,

00:23:02.650 --> 00:23:07.220
that, you know, if you had one score in the morning and then another score in

00:23:07.220 --> 00:23:11.390
the afternoon, that you can actually say, you know, I think my cognitive function

00:23:11.390 --> 00:23:12.730
has changed a little bit.

00:23:13.130 --> 00:23:15.250
But it's very, very subtle.

00:23:16.700 --> 00:23:25.370
And people tend to report bigger, noticeable changes in their cognition if they

00:23:25.370 --> 00:23:28.570
started off with very high cognitive function.

00:23:28.570 --> 00:23:32.050
So that's the other thing is I always say, like, if you've had a very sharp

00:23:32.050 --> 00:23:36.140
knife and it dulls just a little bit, you notice versus if

00:23:36.950 --> 00:23:41.210
somebody, you know, is not challenging themselves cognitively,

00:23:41.430 --> 00:23:45.080
they may not notice those changes as dramatically.

00:23:45.690 --> 00:23:50.730
But, yeah, I think, you know, things like depression and anxiety,

00:23:51.350 --> 00:23:58.030
especially if you're anxious about your cognitive function, can really affect your perception.

00:23:58.830 --> 00:24:05.110
And I think, you know, slight changes in cognitive functioning that is maybe

00:24:05.650 --> 00:24:06.860
socially embarrassing.

00:24:06.860 --> 00:24:11.500
So like a lot of times we hear people complaining that like,

00:24:11.500 --> 00:24:16.500
I can't find my words and that, you know, that kind of social contact can make

00:24:16.500 --> 00:24:19.430
that problem seem bigger than it actually is.

00:24:20.130 --> 00:24:24.410
And I think the other thing is like cognitive flip ups happen to everybody.

00:24:24.730 --> 00:24:30.100
But I think when you are living with MS, it can be really easy to say like, oh, this is my MS.

00:24:30.880 --> 00:24:35.960
Sometimes it is and sometimes it isn't. And I think that that's one of the reasons,

00:24:35.960 --> 00:24:40.550
too, that there's like this disconnect between people's perception of their

00:24:40.550 --> 00:24:43.240
cognitive function and how their brains actually work.

00:24:44.670 --> 00:24:49.230
You and your team have published the results of the COG-Detect MS study.

00:24:49.660 --> 00:24:55.520
Your research showed that 63% of the participants in that study were using five

00:24:55.520 --> 00:24:58.100
or more medications to manage their MS.

00:24:58.920 --> 00:25:02.570
Since disease-modifying therapies are only part of that equation,

00:25:03.250 --> 00:25:07.780
what are the most common symptom management medications that people are taking

00:25:08.170 --> 00:25:11.810
that might quietly be piling up for someone?

00:25:12.520 --> 00:25:18.550
Uh-huh. Yeah, so some of the medications, well, and before I go into that,

00:25:18.550 --> 00:25:24.190
I just want to thank you for bringing up the topic of multiple medications.

00:25:24.630 --> 00:25:28.820
You know, the more medications you take, the harder it is to sort of track the

00:25:28.820 --> 00:25:34.560
interaction with those medications and any side effects that might emerge from those interactions.

00:25:35.140 --> 00:25:40.300
And so what we found is that, you know, lots of people are taking medications

00:25:40.300 --> 00:25:44.990
that are not super negative in terms of cognitive function.

00:25:44.990 --> 00:25:50.450
These are things like antidepressants, which we found a benefit in processing

00:25:50.450 --> 00:25:58.480
speeds of how fast your brain is working with the type of antidepressant and SSRI.

00:25:58.480 --> 00:26:04.740
SRI, that's the Selective Serotonin Reuptake Inhibitor, things like Zoloft or Lexapro.

00:26:06.000 --> 00:26:11.530
But, you know, thankfully, some of the medications that are most detrimental

00:26:11.530 --> 00:26:17.040
to cognitive function, these are things like opioids, benzodiazepines,

00:26:17.870 --> 00:26:20.790
those are less frequently taken in MS.

00:26:20.790 --> 00:26:25.940
And I think physicians have gotten the word that, like, a lot of these medications

00:26:25.940 --> 00:26:30.990
that are really bad for cognitive functioning, um, should not be used long term.

00:26:30.990 --> 00:26:34.240
So I think that that, you know, if we had done this study 20 years ago,

00:26:34.240 --> 00:26:38.490
I think it probably would have been different as even 10 years ago. Um,

00:26:39.330 --> 00:26:42.300
The other thing is, is there are some medications that, you know,

00:26:42.300 --> 00:26:44.640
may be used pretty frequently.

00:26:44.640 --> 00:26:52.690
These are things like gabapentin or corticosteroids that may or may not have

00:26:52.690 --> 00:26:58.420
a very strong effect on cognitive function, depending on what else you're taking and who you are.

00:26:59.010 --> 00:27:02.790
You know, take the example of gabapentin. Sometimes we hear complaints that,

00:27:02.790 --> 00:27:06.890
like, I just feel kind of out of it or foggy when I'm on gabapentin.

00:27:07.960 --> 00:27:11.680
But having a conversation with your doctor about all of your symptoms,

00:27:11.680 --> 00:27:17.050
and sometimes MS presents with pretty complex symptom burden,

00:27:17.560 --> 00:27:22.360
it's like, you know, are you better with a little bit of fogginess and not the

00:27:22.360 --> 00:27:25.300
bad fact that you see? So it's definitely fascinating.

00:27:26.270 --> 00:27:30.920
You know, you should bring up your cognitive concerns with your doctor and put

00:27:30.920 --> 00:27:37.030
them on par with whatever concerns you have, you know, just have that conversation.

00:27:37.530 --> 00:27:41.730
If you don't express the concern, your physician won't know that,

00:27:42.140 --> 00:27:47.930
you know, your domesticity is being managed really well, but maybe you're experiencing

00:27:47.930 --> 00:27:49.630
some new cognitive symptoms.

00:27:49.630 --> 00:27:52.900
So I think bringing it up and asking questions like, I don't know,

00:27:52.900 --> 00:27:55.710
does this medication affect cognitive function?

00:27:56.120 --> 00:28:00.490
Would it affect my cognitive function in combination with the other thing you're giving me?

00:28:00.850 --> 00:28:06.520
And just really asking a lot of questions, being curious, and initiating that

00:28:06.520 --> 00:28:08.710
conversation with your doctor.

00:28:09.560 --> 00:28:13.080
I think you've already started to answer my next question. I'm wondering,

00:28:13.080 --> 00:28:18.450
when someone is taking a complex cocktail of drugs, like something to manage

00:28:18.450 --> 00:28:21.520
spasticity, something else for bladder issues,

00:28:21.970 --> 00:28:25.290
and then there are often pain relievers in that mix,

00:28:25.830 --> 00:28:30.140
How do these drugs interact to compound cognitive fatigue?

00:28:30.870 --> 00:28:35.630
There's no one answer for that, right? Like, it really depends on the person

00:28:35.630 --> 00:28:37.370
and the specific medication.

00:28:37.900 --> 00:28:41.870
You know, and you mentioned pain medications. We actually have found evidence

00:28:41.870 --> 00:28:48.370
across different populations that non-steroidal anti-inflammatory drugs,

00:28:48.370 --> 00:28:50.470
So this is Motrin or ibuprofen,

00:28:51.210 --> 00:28:56.570
you know, that if that is a medication that works well for your pain management,

00:28:56.570 --> 00:29:02.210
that maybe that would be helpful for for your, you know, for managing both pain

00:29:02.210 --> 00:29:04.940
and not having an effect on your cognitive function.

00:29:06.280 --> 00:29:13.260
On the other hand, if you're taking hydrocodone or an opioid and that's all

00:29:13.260 --> 00:29:18.220
that's managing your pain, you might expect cognitive side effects.

00:29:19.270 --> 00:29:24.550
The interactions, though, are hard. And I think it's much easier for doctors

00:29:24.550 --> 00:29:29.620
to add new medications to address the new symptoms you're coming in with.

00:29:31.010 --> 00:29:35.670
I think it's very hard to wean people off of meditations, especially if they're

00:29:35.670 --> 00:29:39.470
working for one thing, but you think they might be affecting something else.

00:29:39.470 --> 00:29:45.220
So if something is managing your pain, you know, it might be sort of a cost

00:29:45.220 --> 00:29:48.940
benefit analysis and it might be a trial and error.

00:29:49.330 --> 00:29:52.730
I don't think you really know until you try to make some changes.

00:29:53.850 --> 00:29:58.550
Obviously, in concert with your doctor. Would not recommend dropping anything

00:29:59.090 --> 00:30:02.760
just because you're noticing some changes without talking to your doctor.

00:30:02.760 --> 00:30:07.640
And also know that especially when starting a new medication or changing a dose,

00:30:08.120 --> 00:30:13.700
there might be like a short-term adjustment period where your symptoms kind of go up.

00:30:13.700 --> 00:30:17.940
Like maybe you feel foggy for a while when you start a new med or increase your

00:30:17.940 --> 00:30:21.330
dose. So, you know, getting in contact with your doctor and say,

00:30:21.330 --> 00:30:23.760
I'm noticing this. Should I be concerned?

00:30:24.250 --> 00:30:28.790
Can we adjust it? And sometimes two doctors will be able to give you a similar

00:30:28.790 --> 00:30:32.340
medication that just has a slightly different risk profile.

00:30:32.340 --> 00:30:37.500
So I think, you know, exploring those options and having a conversation and

00:30:37.500 --> 00:30:42.320
being willing to try out some alternative plans.

00:30:43.210 --> 00:30:46.360
Are there certain red flag combinations

00:30:46.360 --> 00:30:50.110
of medications that clinicians and patients should watch out for?

00:30:51.170 --> 00:30:57.280
I think the highest risk medications right now, and this is really well recognized

00:30:58.410 --> 00:31:01.640
in medicine, are the benzodiazepines.

00:31:01.640 --> 00:31:06.780
So these are, were traditionally used mostly for anxiety, but are sometimes

00:31:06.780 --> 00:31:09.440
used for sleep disorders and MS.

00:31:10.450 --> 00:31:14.230
And again, the opioid medications are really risky.

00:31:14.830 --> 00:31:21.390
The one thing I'll bring up is that we don't really know the effects of cannabis

00:31:21.390 --> 00:31:26.480
or marijuana on cognitive function, especially in combination with any of these meds.

00:31:27.870 --> 00:31:34.000
As you probably know, marijuana is either medically or recreationally legal in many states,

00:31:35.370 --> 00:31:42.960
but is really understudied largely because of federal limitations on our ability to study it.

00:31:43.630 --> 00:31:48.320
But I think, you know, that is sort of an unknown. I will say that in older

00:31:48.320 --> 00:31:53.900
adults, there is some evidence that some cannabis use could be beneficial,

00:31:54.360 --> 00:31:58.620
but that is very preliminary and there's real risk.

00:31:59.110 --> 00:32:03.410
So I think, you know, the research needs to catch up to what people are doing

00:32:04.950 --> 00:32:08.790
and we don't have the full answer yet. Hopefully we'll know in the next few years.

00:32:11.180 --> 00:32:15.300
You've studied how common substances like cannabis, caffeine,

00:32:15.300 --> 00:32:18.640
alcohol, impact MS symptoms in real time.

00:32:19.240 --> 00:32:23.150
Caffeine, for example, it's the ultimate pick-me-up for MS fatigue,

00:32:23.420 --> 00:32:28.270
but your study showed it also predicts a near-future spike in stress.

00:32:28.800 --> 00:32:34.350
So what should people know about the hidden cognitive or symptomatic costs of

00:32:34.350 --> 00:32:38.150
relying on what have really become everyday substances?

00:32:38.670 --> 00:32:45.110
Yeah, I think really paying attention. And you may even start tracking or logging

00:32:46.000 --> 00:32:50.250
your intake of certain substances and what happens to you after the fact.

00:32:51.390 --> 00:32:55.690
You know, I know for me, I drink coffee every morning, but there's definitely

00:32:55.690 --> 00:32:58.780
a tipping point, right? Like it helps perk me up in the morning.

00:32:58.780 --> 00:33:04.900
But if I have just an extra cup, then I'm very stressed out and not functioning at my best.

00:33:05.480 --> 00:33:11.970
So I think people with MS, especially if you're sort of knowingly taking any

00:33:11.970 --> 00:33:16.650
of these substances to manage symptoms or to feel better, you know,

00:33:17.190 --> 00:33:22.510
I know that people will sometimes drink alcohol to manage stress or pain.

00:33:23.770 --> 00:33:27.290
And so it might have some benefits. But what are the downsides?

00:33:27.600 --> 00:33:33.440
And just paying attention to both the benefits and the risks and the good part

00:33:33.570 --> 00:33:37.970
of any of these substances and then the negatives is, I think, really important.

00:33:39.010 --> 00:33:43.610
I think caffeine is a really interesting one, right? Because like I just said,

00:33:44.250 --> 00:33:48.780
with my own life, it sort of reduces the fatigue but increases the stress.

00:33:49.260 --> 00:33:53.880
Fatigue and stress both affect cognitive function. Do you have like a potentially

00:33:53.880 --> 00:33:58.370
positive effect and a potentially negative effect? Do they just gamble out?

00:33:58.870 --> 00:34:00.210
We don't know the answer to that.

00:34:01.280 --> 00:34:05.980
If someone is listening to this conversation and suspects that their medication

00:34:05.980 --> 00:34:11.810
regimen is making their brain fog worse, how should they initiate that conversation

00:34:12.060 --> 00:34:14.960
with their neurologist or primary care physician?

00:34:15.790 --> 00:34:21.930
I think it depends on how severe the change is. If you're noticing big changes,

00:34:22.050 --> 00:34:27.120
I do think that calls were a very urgent message to your physician

00:34:29.240 --> 00:34:37.680
to suss out what's going on. I do think any kind of changes should be brought up.

00:34:38.760 --> 00:34:43.920
You may call for a special appointment to talk about them or wait for your regular

00:34:44.520 --> 00:34:47.710
routine visit if it's more modest.

00:34:48.400 --> 00:34:52.720
You might also think about collecting some information to bring to your doctor

00:34:52.720 --> 00:34:55.720
about, you know, patterns you see.

00:34:56.820 --> 00:35:04.220
You know, they may be asking some additional questions about exactly what kinds of cognitive problems.

00:35:04.220 --> 00:35:09.550
So, you know, especially if your brain feels foggy, making some documentation

00:35:09.550 --> 00:35:12.090
of it so that when you go into the appointment, you're not like,

00:35:12.090 --> 00:35:13.750
oh, I don't really remember.

00:35:13.750 --> 00:35:19.560
Um, I think the other thing to think about is that your physician might be able

00:35:19.560 --> 00:35:22.550
to, uh, screen out for some additional

00:35:22.550 --> 00:35:26.490
things that might be affecting your cognition beyond medication.

00:35:26.940 --> 00:35:33.980
Um, one great example is sleep apnea can really affect your cognitive function.

00:35:33.980 --> 00:35:36.910
We've done some early research showing that and, um,

00:35:38.700 --> 00:35:43.260
Sleep apnea is really underdiagnosed in MS, but it's very common.

00:35:43.260 --> 00:35:47.170
So, for instance, if you're finding that you're kind of falling asleep during

00:35:47.170 --> 00:35:51.320
the day or you're waking up feeling really unrefreshed, even though you've slept

00:35:51.320 --> 00:35:55.920
through the night, or if somebody tells you you snore a lot or stop breathing in the night,

00:35:57.230 --> 00:36:03.320
it's very worth asking for a sleep study from your physician to see if you have

00:36:03.320 --> 00:36:06.140
sleep apnea, how bad is it and should it be treated?

00:36:06.140 --> 00:36:11.470
Because that is another treatment that your doctor can help you with in terms

00:36:11.470 --> 00:36:13.750
of improving your cognitive function.

00:36:14.510 --> 00:36:18.630
Beyond looking at the impact of medications on cognitive function,

00:36:18.950 --> 00:36:24.410
your lab has also researched how people use compensatory cognitive strategies

00:36:24.710 --> 00:36:27.000
or workarounds in their daily lives.

00:36:27.860 --> 00:36:32.340
What are some of the most effective mental habits or tools you've seen patients

00:36:32.340 --> 00:36:36.050
use to successfully get around their cognitive challenges?

00:36:36.720 --> 00:36:41.070
That's a great question. You know, when it comes to addressing cognitive function

00:36:41.070 --> 00:36:45.630
and MS, there's really two sort of ways that we're thinking about this.

00:36:46.290 --> 00:36:50.140
Can we do anything to sort of improve the cognitive function?

00:36:50.540 --> 00:36:56.120
And then alternatively, can we teach people to sort of improve their life,

00:36:56.120 --> 00:36:59.780
even if their cognitive function doesn't change, right? Like you can't approve

00:36:59.780 --> 00:37:03.970
the cognitive function. And that's what those compensatory strategies are.

00:37:04.400 --> 00:37:10.760
And it's really remarkable the number of ways that people just naturally sort

00:37:10.760 --> 00:37:15.100
of figure out how to work around their cognitive challenges.

00:37:16.050 --> 00:37:21.820
Many people will start to use ways of recording.

00:37:21.820 --> 00:37:25.320
So this might be a notebook or now everybody has a smartphone,

00:37:25.320 --> 00:37:30.940
you can leave yourself, like, voice messages, that sort of thing.

00:37:30.940 --> 00:37:37.820
So really using the tools that you have at your disposal to remember things.

00:37:38.850 --> 00:37:45.840
Another big tool that is used oftentimes is day planning. So planning out the

00:37:45.840 --> 00:37:49.690
day and tracking your activities.

00:37:50.410 --> 00:37:55.420
Partly, this helps people not overdo it, helps people pace.

00:37:56.770 --> 00:38:00.690
So, you know, there's a lot of different sort of strategies people can use.

00:38:01.050 --> 00:38:04.140
I'd say that the day planning is one of the big ones.

00:38:05.460 --> 00:38:10.230
And, you know, just find out what works for you. And the strategy that you will

00:38:10.230 --> 00:38:15.550
use will depend on what you're struggling with. Like, are you struggling with attention?

00:38:16.320 --> 00:38:20.520
You know, maybe in that case, you want to limit the amount of time you need

00:38:20.520 --> 00:38:22.350
to attend to any given thing.

00:38:23.400 --> 00:38:27.490
You know, if you want to watch a movie, maybe break it up into sections so you

00:38:27.490 --> 00:38:30.030
don't sort of lose the thread partway through.

00:38:30.380 --> 00:38:35.330
Versus memory issues where you might want to use some of these tools like a

00:38:35.330 --> 00:38:38.020
notebook, like post-it notes.

00:38:39.000 --> 00:38:40.780
Like a calendar or a day planner.

00:38:42.090 --> 00:38:45.790
Looking ahead, when you think about the future of MS rehabilitation,

00:38:46.220 --> 00:38:52.010
do you see us moving toward more personalized digital toolkits like your My

00:38:52.010 --> 00:38:56.790
MS Toolkit project to help people manage their invisible symptoms from home?

00:38:57.560 --> 00:39:00.340
I think it's part of the answer, right? I think

00:39:01.740 --> 00:39:09.670
we are developing web-based and app-based tools that people can use to self-manage

00:39:09.820 --> 00:39:14.150
symptoms like pain, fatigue, depressed mood, et cetera.

00:39:15.840 --> 00:39:21.580
But I don't think it's the full story. And I think one of the real struggles with digital tools

00:39:22.680 --> 00:39:27.710
that people don't really engage with them as much as they engage with a person.

00:39:28.560 --> 00:39:33.870
However, I do think that it can be sort of a way to fill the gap, right?

00:39:33.870 --> 00:39:38.820
There's not enough healthcare providers, there's not enough physicians,

00:39:38.820 --> 00:39:43.680
psychologists, social workers, occupational therapists to go around.

00:39:43.870 --> 00:39:49.340
And there's real barriers for people. Maybe you have to drive have a long way to see somebody.

00:39:49.730 --> 00:39:55.420
Maybe there are financial barriers to getting person-to-person care.

00:39:55.800 --> 00:40:02.400
So I do think, especially for people who are sort of really comfortable with

00:40:02.400 --> 00:40:07.310
digital technology and digital tools, these can be great.

00:40:08.910 --> 00:40:11.750
And then, you know, maybe use in combination

00:40:14.270 --> 00:40:21.290
With providers. In fact, we have a study, one of my collaborators at the University

00:40:21.290 --> 00:40:22.960
of Washington, Don Eady,

00:40:23.770 --> 00:40:30.950
and I are working on a project to sort of look at the combination of the MyMS

00:40:30.950 --> 00:40:37.670
toolkit with a coach, a very light touch, you know, checking with a person, and comparing that

00:40:38.840 --> 00:40:41.450
to pull-on therapy with a psychologist.

00:40:41.450 --> 00:40:46.090
So I think one of the things we're doing besides developing these tools is testing

00:40:46.090 --> 00:40:50.210
how best to use them and how we can get people

00:40:50.680 --> 00:40:56.690
to have, you know, the best quality of life and to take on some of these self-management skills.

00:40:57.220 --> 00:41:00.510
Like, is it just enough to give them a website? Do they need a coach?

00:41:00.510 --> 00:41:03.490
Do they need full therapy to kind of understand?

00:41:03.850 --> 00:41:06.630
So we're testing those things out right now.

00:41:07.700 --> 00:41:11.800
Well, I remember the first time I had you join me on the podcast,

00:41:11.800 --> 00:41:17.240
we talked about My MS Toolkit, but that's been a minute. So please remind us,

00:41:17.240 --> 00:41:20.000
where can people find My MS Toolkit today?

00:41:20.880 --> 00:41:33.080
Yeah, great question. So it is online at www.mymstoolkit.com.

00:41:33.660 --> 00:41:39.160
I will say we are right now in the process of updating and improving the website,

00:41:39.160 --> 00:41:41.510
so stay tuned for a whole new look.

00:41:41.900 --> 00:41:51.020
It's a refresh that is much needed, but the version one of my MS Toolkit is

00:41:51.020 --> 00:41:54.770
currently available and will be for the foreseeable future.

00:41:55.570 --> 00:42:00.110
Dr. Anna Kratz, as always, I appreciate all you do to improve the lives of people

00:42:00.110 --> 00:42:03.040
living with MS. Thanks so much for talking with me today.

00:42:03.790 --> 00:42:05.680
Thanks for having me on, Jon. Good to see you.

00:42:06.680 --> 00:42:11.390
That's going to wrap up this episode of Real Talk MS. Real Talk MS is powered

00:42:11.390 --> 00:42:13.080
by the National MS Society.

00:42:13.520 --> 00:42:17.600
And you can share this episode of the podcast by letting your friends or family

00:42:17.600 --> 00:42:25.390
members know that all they have to do is point their web browser at realtalkms.com slash 4006. 169.

00:42:26.020 --> 00:42:30.040
You'll find that link in today's show notes so you can easily copy and paste

00:42:30.040 --> 00:42:32.510
it right into an email or a text.

00:42:33.260 --> 00:42:38.160
In next week's episode, you'll meet Benji Wilkins. Benji is a magician in the

00:42:38.160 --> 00:42:40.930
UK and Benji's mom lives with MS.

00:42:41.290 --> 00:42:46.800
Like many other people, MS has had a real impact not only on her health but on her finances.

00:42:47.440 --> 00:42:52.010
So Benji had an idea for what I have to call an epic fundraiser.

00:42:52.480 --> 00:42:56.830
I hope for planning to join me next week because this is a story you won't want to miss.

00:42:57.810 --> 00:43:04.290
I'm John Strum. Thanks for listening. Stay safe and make healthy choices.