Episode 458 -- From the 2026 CMSC Annual Meeting: Part Two with Dr. Stephen Krieger

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It's June 9th, and we have a lot to talk about.

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This week, we're continuing our coverage of the Consortium of MS Centers annual

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meeting, a meeting that took place just a couple of weeks ago in Charlotte, North Carolina.

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Now, typically, I'd be sharing interviews with two or three of the world-class

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MS experts that it's always my privilege to meet up with at conferences like

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this one. But this week is a little different.

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This week, my sole guest is Dr. Stephen Krieger. And the reason Dr.

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Krieger is my sole guest is because at this year's CMSC meeting, Dr.

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Krieger seemed to be everywhere, talking about all the important things as they

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relate to people living with MS.

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But before we get to my conversation with Dr. Stephen Krieger,

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there are a few other things that you should know about.

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If you're living with multiple sclerosis, you already know that managing your

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symptoms is a bit of a balancing act.

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You wake up, you gauge your energy, you determine where your pain levels are,

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check in with your other symptoms, and then you adjust.

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And for many people, that adjustment includes reaching for things in their pantry

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or medicine cabinet to help them cope.

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Maybe it's an extra cup of coffee to fight off fatigue, a glass of wine at night

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to unwind from the stress, or maybe cannabis or prescription opioids to take the edge off the pain.

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Well, researchers from the University of Michigan and the University of Washington

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took a super close look at exactly how this plays out in real time.

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They tracked over 250 adults with MS who were asked to report in using their

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smartphones four times a day.

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The research team wanted to see the immediate, almost hour-by-hour relationship

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between the substances people with MS use and their symptoms.

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And what they found provides a clear snapshot of the daily habits of people who live with MS.

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The researchers call it a bidirectional relationship.

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In plain English, it's a two-way street. Your symptoms change what you reach

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for, and what you reach for changes your symptoms later in the day.

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Let's break down a few of the most surprising twists they found because,

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well, it's not always what you might expect.

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First, let's talk about alcohol and stress.

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The data showed that when people felt a sudden spike in momentary stress,

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they actually had lower odds of reaching for a drink.

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However, when they did have a drink, it succeeded in reducing their stress.

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So it works to lower stress, but stress itself isn't always the trigger pushing people to alcohol.

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Patients with higher overall pain averages were less likely to drink alcohol,

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but they were significantly more likely to use prescription opioids,

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which makes complete sense for pain management.

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But here's where that two-way street starts getting tricky.

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It's what we call the hidden tax.

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The study found that while caffeine did what it was supposed to do,

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it boosted energy and it lowered fatigue, it also predicted higher stress levels later in the day.

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And substances like alcohol, nicotine, and cannabis were actually linked to

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greater fatigue afterward.

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Even more surprising, cannabis use was actually tied to higher momentary pain later in the day.

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Now the point of the study isn't to judge anyone or tell you to throw away your

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morning coffee or change your routine.

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Living with MS is tough, and symptom regulation is what gets you out of bed

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every day, or at least most days.

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What the scientists are trying to show us is that our bodies are in a constant dynamic feedback loop.

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Sometimes the very thing you reach for to fix a symptom right now might be sending

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you a bill that becomes due a few hours later with a different symptom.

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If you use caffeine for energy, you might be trading it for an anxiety or stress spike later.

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If you use cannabis or alcohol to relax, you might be digging a deeper fatigue

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hole that you'll find yourself standing in tomorrow.

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So here's an opportunity for each of you to become your own scientist.

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For the next few days, just pay attention to the timing.

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When you have that afternoon coffee or that evening drink, look at how you feel

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three or four hours later.

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Understanding your personal feedback loop is one of the most powerful ways to

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take control of your health.

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Talk with your care team about what you notice, because finding a balance that

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doesn't cost you later, that should be the ultimate goal.

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

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If you're a parent living with multiple sclerosis or navigating any kind of

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progressive mobility challenge, then you know about that unique layer of emotional

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weight that comes with raising kids.

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You worry about what they're witnessing.

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You worry if or how your changing body could be affecting their childhood.

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You wonder about how to explain a wheelchair, a scooter, or a walker to a five-year-old

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without making them feel sad or afraid?

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Well, I want to tell you about a children's book that handles this subject with

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grace, heart, and honesty.

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It's called My Superhero with Wheels, and I think it's a book that deserves

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a place on the bookshelves of every parent of young children in the MS community.

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My Superhero with Wheels was written by Lawrence Morello, who's been living with MS for 32 years.

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But the story itself is told through the eyes of a young child looking at their father.

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And to this child, the wheels their dad uses to move through the world aren't

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a limitation at all. Quite the opposite.

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They're part of what makes him a superhero.

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When an adult transitions to

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their first assistive device, it often comes with a lot of complex grief.

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That wheelchair or walker becomes a symbol of what's been lost.

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But kids don't have that baggage.

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To a child, a mobility aid is just an adaptation.

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It's that thing that lets dad roll fast so he can get to the park.

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My Superhero with Wheels beautifully normalizes disability.

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It shows kids that being strong doesn't have to mean standing up or running.

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Sometimes true strength is just showing up, adapting to the day, and loving fiercely.

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It teaches kids that disability isn't something to hide, fear, or explain away.

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It's just one part of a full, incredibly loving family life.

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If you're a parent who's managing MS, I think you're going to see yourself deeply

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reflected in these pages.

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It completely validates the realities of mobility challenges,

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but it keeps the spotlight exactly where it belongs, on your presence,

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your care, and that unbreakable bond you have with your kids.

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And the book gives children the pride and the language they need to talk about

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their family's story with total confidence on the playground or in the classroom.

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Whether you're looking for a bedtime story for your own kids,

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a gift for a family navigating a new diagnosis,

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or even a book to donate to a local classroom or therapist's office to spread

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disability awareness early, this is the one.

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The book is My Superhero with Wheels. You'll find the link in our show notes so you can grab a copy.

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So let's keep changing the narrative, one bedtime story at a time.

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And speaking of changing the narrative, new narratives are being written when

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it comes to subjects like how disease-modifying therapies can effectively manage MS,

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what's really needed when it comes to caring for people with advanced MS,

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and identifying some of the potential potholes on the road to getting an early

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and accurate MS diagnosis.

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My guest, Dr. Stephen Krieger, has thoughts to share on all of these topics.

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And in just a moment, we'll meet Dr. Krieger.

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Dr. Stephen Krieger is a professor of neurology at the Icahn School of Medicine

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at Mount Sinai in New York and a multiple sclerosis specialist at the Corinne

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Goldsmith-Dickinson Center for MS. I learn something new every time I speak

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with Dr. Krieger, and it's great to see you.

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It's great to see you, John. Thanks again for doing this with me.

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This is a busy meeting for you.

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You're reporting the three-year results of the Phase II open-label extension for Frexalamab.

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So can you tell us what Frexalamab is? Sure.

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So, you know, there's been a lot of attention paid to other disease mechanisms

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and treatments in MS in these last few years, such as BTK inhibitors and CAR-T

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therapies, but sort of maybe hiding a little below the radar is what Frexalumab does.

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It's an anti-CD40 ligand monoclonal antibody, so it's a monthly infusion,

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takes about an hour, and it modulates the CD40 pathway,

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which the hope is it will regulate both active inflammation in MS,

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the inflammation that causes relapses, and also this more chronic innate immune

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processes that we think are responsible for progression.

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And so what I presented at this meeting is the three-year extension after their

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phase two trial. So, you know.

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Long-term data, like long-term follow-up from a trial is always important,

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but especially with a novel mechanism, a drug that we don't have otherwise. There's no other one.

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So the only data we have for how do people with MS do on Frexalumab for the

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long term is this extension trial. So this was the three-year extension.

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And the punchline is people did not have new lesions. They did not have new enhancing lesions.

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They did not have new relapses, EDSS, so disability, was stable across the board.

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And perhaps most distinctively compared with other things in our field.

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Frexalumab doesn't deplete cells. It doesn't drop the immune globulins over time.

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There doesn't seem like a cumulative negative consequence on the immune system

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with it. So all that is holding steady at three years.

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And no new bad news, no new adverse events of any note.

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So it's a good report that Open Label Extension keeps going.

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And now it's in two phase three trials, one for relapsing remitting MS and one

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for folks with secondary progressive MS. Those are ongoing.

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We've got about another year, year and a half probably before we'll see those results.

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Well, we'll keep our fingers crossed. This sounds exciting. Thank you for sharing

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those results. My pleasure.

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You're also presenting on the needs of individuals with advanced MS,

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specifically preserving function, reducing symptoms.

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You know, the term advanced MS is a term some of my listeners may understand,

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but it isn't a term they often hear.

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We talk about progressive MS.

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How do you define advanced MS? This is a great question.

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That was the opening portion of this program was, how do we define advanced MS?

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This was a course led by my dear friend and colleague, Rachel Stakem.

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Rachel's a nurse practitioner in MS in New York.

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She works at a program called Independence Care Systems, which endeavors to

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help people with disability live full lives, live in their homes,

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not have to be in an institutional type facilities, et cetera.

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So Rachel's been my close friend at MS for 20 years. We both got into this field together.

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But her career commitment is to people with significant disability.

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Let's put it in those terms.

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You know, folks who are wheelchair-confined or wheelchair users need power devices for mobility.

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And in MS, we focus so much on preventing disability, which is a noble goal,

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but perhaps we focus on it too much.

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Most of our clinical trials don't include people who can't ambulate.

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Most of our clinical trials don't include people of advanced age.

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And so there's been a blind spot in some ways in our field for the people who

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have developed real challenges from their MS. So that's what we mean by advanced MS.

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In essence, significant disability. But she points out at the beginning of her

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course, and I was just a speaker in her course, but she points out that there

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is no consensus definition for advanced MS.

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And without that, there's less of a sense of how big that unmet need is.

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What are the needs of this population?

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Population that needs a lot. And so one of the things she'd like to do is help

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to move forward a consensus definition, then estimate the size of the population,

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survey what their needs really are, aligned resources to meet those needs.

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But the theme of her course was, it takes a community, it takes an interdisciplinary

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team, which is very much aligned with the spirit of CMSC as a conference, that no one provider,

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certainly no one neurologist, can hit all the needs herself.

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But it is our responsibility to look for them and recognize them.

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And my principle that you may know that I talk about, but is very much a part

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of this course, is find the good that you can do.

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Look for the opportunities to do some good for people and to remind clinicians

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in general and neurologists in particular that there's never nothing I can do for you.

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There's always something we can do, and we need to lean into it, listen carefully,

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think about the person in her world and help her navigate her life and optimize

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her life and not just prevent disability, not just treat symptoms,

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but be very holistic and proactive about it.

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That's what Rachel's course was about, and that's what my talk was about.

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You know, I'm very familiar with that world. Until she passed away,

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my wife lived in that world.

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And I would only add, not only is it, or it should be, a neurologist,

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a specialist's responsibility to see that and to respond to it.

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When that doesn't happen, I'll say as a patient advocate, it is a patient's

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responsibility or their care partner's responsibility to advocate for it, to point it out.

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And I can tell you from personal experience very often, the answer is,

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yeah, I wish there was something I could do for you. I've heard that out loud.

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And my response was always, there probably is.

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And I had some notes ready for that meeting. So we can't fix everything, but what here can we fix?

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And what I used to do with my wife is, what are the three biggest things that

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are burdensome to you every day?

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So it wouldn't just be a list of stuff, but it would be organized by priority.

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And that way, it increased the

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chances that one of those things could get addressed, mitigated somehow.

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I realized as I was saying it how resonant this is going to be for you.

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And this whole course, it was myself, Elaine, and Renee talking about mobility,

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talking about access, symptom management, keeping people out of the hospital.

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Extending life when possible, making it meaningful. Yeah.

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The course was recorded. Not everything at CMSC is recorded,

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but Rachel Stakem's course on Advanced MS was recorded.

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So I do think it would be available for folks that watch you and listen to you

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if they want to hear about it. I found it very meaningful.

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I hope we get to do it again. But at least this one was captured by CMSC on

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video. So it's out there if folks want to see it.

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Well, I'm glad. I think the folks at CMSC recognize this was something that

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should be shared, so I'm glad it was recorded.

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You'll understand immediately where this question comes from.

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But when someone is living with advanced MS, how important does managing the

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emotional well-being of their care partner become?

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Yeah, well, when we talk about thinking about someone in their life with MS,

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the care partner, care provider, pillar of support is an awfully important part

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of that person's life and navigating that life.

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We talk about shared decision-making in MS, but how about just shared priority

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setting, shared well-being, and the sharing of that between,

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care partner and physician and nurse practitioner and occupational therapy,

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physical therapy, referral, psychosocial support, social work,

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psychology, psychiatry.

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I think these things go hand in hand.

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And when we say there's always something you can do, there's always someone who can do it.

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And it's about finding who that person is to provide the support for the person

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living with MS, for the people living with them and supporting them.

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When one leg of a chair falls off, the whole chair falls over.

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So we need all the legs to hold it up. Well put.

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You know, one of the topics either being discussed or underlying the discussions

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at this meeting are the latest iteration of the McDonald criteria.

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I've heard about that. That is a criteria used to diagnose MS.

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And although you aren't speaking on that topic directly at this meeting,

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you recently had a commentary published in a peer-reviewed journal where you

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shared some concerns about the most recent update to the McDonald criteria.

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Now, the updated criteria significantly lower the barrier to a formal MS diagnosis,

00:18:29.850 --> 00:18:34.730
meaning patients can be diagnosed much faster, at least That is the stated goal,

00:18:34.930 --> 00:18:41.270
sometimes after just a single anatomical lesion, if specific biomarkers are present.

00:18:41.570 --> 00:18:47.510
So in your essay, you raise a cautionary flag about this leap in diagnostic sensitivity.

00:18:48.230 --> 00:18:52.490
Historically, every time the McDonald criteria are relaxed to catch MS earlier,

00:18:52.690 --> 00:18:58.210
there is a corresponding surge in misdiagnosis, often confusing MS with migraines,

00:18:58.390 --> 00:19:03.010
small vessel disease, or neuromyelitis optica spectrum disorder, right?

00:19:03.170 --> 00:19:08.670
How concerned are you that these new criteria will amplify that misdiagnosis

00:19:08.670 --> 00:19:11.530
epidemic in non-MS specialist clinics?

00:19:13.080 --> 00:19:18.740
How much time have you got for that? So, you know, it's a couple of things.

00:19:19.120 --> 00:19:25.900
I think that the motivation of the McDonald criteria is to allow for MS to be

00:19:25.900 --> 00:19:28.400
diagnosed earlier and people in whom it might have been missed.

00:19:30.660 --> 00:19:36.360
So I applaud the principle. The challenge, I think, is a couple of fold.

00:19:36.520 --> 00:19:42.520
One is the one you raised, that if we're going to diagnose multiple sclerosis

00:19:42.520 --> 00:19:48.240
in people who've never had a symptom of it, who may have very little evidence

00:19:48.240 --> 00:19:50.560
of it on traditional MRI scans,

00:19:50.780 --> 00:19:57.120
it does open up the risk of overdiagnosis in someone who has a nonspecific brain spot.

00:19:58.920 --> 00:20:03.080
And misdiagnosis in general, confusing the disease for something else.

00:20:04.260 --> 00:20:10.660
I do think that's a concern. I also think there's a concern more deeply that

00:20:10.660 --> 00:20:16.480
we're saying someone who has a certain marker has a disease,

00:20:16.500 --> 00:20:20.140
as opposed to saying someone who has a certain marker in the blood,

00:20:20.280 --> 00:20:25.060
or in the spinal fluid, or even on a brain MRI, has a risk for the disease.

00:20:25.460 --> 00:20:29.680
Those are two very different things. So I think we've confused the two.

00:20:30.810 --> 00:20:35.070
Someone having a risk for having a disease might merit closer monitoring,

00:20:35.070 --> 00:20:39.250
maybe even treatment to prevent things from happening.

00:20:39.650 --> 00:20:44.490
That's what we've called radiologic isolated syndrome, RIS, all these years.

00:20:44.730 --> 00:20:49.430
It looks like MS on a scan, but the person has nothing to show for it.

00:20:50.030 --> 00:20:57.230
But in certain circumstances, these new criteria mean we're going to diagnose those folks with MS.

00:20:57.230 --> 00:21:01.630
And I think that there's something really risky about doing that,

00:21:01.910 --> 00:21:04.150
telling people they have a disease that they may never have,

00:21:04.330 --> 00:21:09.950
they may never develop for their whole lives, telling them they have it.

00:21:11.010 --> 00:21:14.910
So I wrote this letter. It touches on some other things, which maybe we'll get to.

00:21:15.070 --> 00:21:19.370
And the authors of the McDonald Criteria wrote a response to my letter and a

00:21:19.370 --> 00:21:20.230
couple of other letters.

00:21:20.390 --> 00:21:23.610
This is in Lancet Neurology. So the journal that published the criteria,

00:21:24.070 --> 00:21:26.970
which I'm pleased that this letter got there.

00:21:27.230 --> 00:21:30.250
A lot of people writing about the McDonnell criteria in all sorts of places,

00:21:30.250 --> 00:21:35.810
but the fact that I wrote something that is critical and the journal that published

00:21:35.810 --> 00:21:39.730
the criteria itself saw fit to publish it is gratifying to me because I think

00:21:39.730 --> 00:21:41.930
what I'm raising are important points.

00:21:42.210 --> 00:21:48.930
But one of the responses from the authors to my letter was, well,

00:21:49.030 --> 00:21:50.810
we're doing this in Alzheimer's disease also.

00:21:51.170 --> 00:21:56.310
You know, there's biomarkers in Alzheimer's disease. Now we're able to diagnose that.

00:21:57.170 --> 00:22:02.250
That's actually very controversial. And a lot of folks are very unsatisfied

00:22:02.250 --> 00:22:06.850
or unhappy about that, too, because many people who have these biological markers

00:22:06.850 --> 00:22:10.170
of Alzheimer's disease are never going to develop that either.

00:22:10.710 --> 00:22:15.450
So I think although they appealed to that as an example, I think that's a cautionary

00:22:15.450 --> 00:22:19.590
tale that we have now weighted ourselves into in the MS world.

00:22:19.890 --> 00:22:25.550
And I do think it's a setup for error. And that's not fair either to people

00:22:25.550 --> 00:22:29.410
living with uncertainty, to people who've had an MRI scan.

00:22:30.870 --> 00:22:34.310
So that's one of my concerns. I've got a couple, but that's one of them.

00:22:35.390 --> 00:22:40.010
We'll talk about another set of concerns. The updated criteria rely heavily

00:22:40.010 --> 00:22:46.390
on cutting-edge tools, checking for a select six threshold of central vein sign,

00:22:47.010 --> 00:22:53.130
on mapping PIRLS, PRLs, measuring kappa-free light chains and spinal fluid,

00:22:53.310 --> 00:22:56.410
or evaluating optic nerve involvement by OCT.

00:22:56.750 --> 00:23:01.670
Now, these are all advanced imaging techniques and lab assays that are routine

00:23:01.670 --> 00:23:04.990
at academic settings for the most part,

00:23:05.150 --> 00:23:10.870
or at least available in most academic settings, but they're rarely standardized

00:23:10.870 --> 00:23:14.410
or available at a local community neurological practice.

00:23:14.970 --> 00:23:19.870
How do we prevent these criteria from creating really a two-tier diagnostic

00:23:19.870 --> 00:23:24.730
system where patients are going to be staged and treated based on their zip code?

00:23:25.410 --> 00:23:29.430
Yeah. I mean, I think this is the biggest concern that I have.

00:23:29.430 --> 00:23:34.750
Um, and I wrote about this in the commentary, I posted it on LinkedIn,

00:23:34.770 --> 00:23:38.590
my only social media, and there was a whole conversation there about that,

00:23:38.690 --> 00:23:41.110
including the two-tiered system concern.

00:23:41.610 --> 00:23:48.550
Um, I'm no Luddite. I like technology and I like new science and I do think

00:23:48.550 --> 00:23:49.550
the field needs to advance.

00:23:51.250 --> 00:23:58.470
Problem is, the criteria were written by folks who've studied these techniques for 10 or 20 years.

00:23:58.650 --> 00:24:02.250
They live in that world of cutting-edge science, and they promoted those things

00:24:02.250 --> 00:24:09.410
into a diagnostic criteria, which the whole point of it is to be globally useful.

00:24:10.350 --> 00:24:14.510
Useful to general neurologists, broad-spectrum neurologists in practice.

00:24:14.750 --> 00:24:19.470
Useful to neurology residents and fellows who are training, people in rural

00:24:19.470 --> 00:24:25.050
communities, people in under-resourced areas, a diagnostic criteria that's global

00:24:25.050 --> 00:24:29.390
is supposed to be a bar that everybody can achieve so that every patient,

00:24:29.950 --> 00:24:34.830
every person who may or may not have MS can have that question answered.

00:24:35.110 --> 00:24:40.510
But by promoting these very specialized tools and techniques into the criteria,

00:24:40.790 --> 00:24:44.050
even though they kind of couch them as optional, if they're available.

00:24:45.190 --> 00:24:50.630
I do think that it's going to make it essentially impossible for broad-spectrum

00:24:50.630 --> 00:24:54.530
neurologists, neurologists in the community, in practice, in training,

00:24:54.750 --> 00:24:59.650
to apply these criteria to their patients. Impossible.

00:25:00.130 --> 00:25:04.770
You said, these techniques are available in academic centers,

00:25:04.770 --> 00:25:09.130
and I probably smirked a little bit. We don't have them.

00:25:10.030 --> 00:25:15.830
I've never seen a pearl. I've never seen a central vein sign on a clinical scan.

00:25:16.570 --> 00:25:23.650
Because we don't have them available to us at our well-resourced MS center.

00:25:25.830 --> 00:25:29.950
We don't have them. These criteria were announced in fall 2024.

00:25:30.430 --> 00:25:33.910
It is summer 2026. We don't have them.

00:25:34.770 --> 00:25:37.730
Many places don't have them. Now, I'm not saying we can't get them.

00:25:37.850 --> 00:25:39.210
We can get them in research.

00:25:40.230 --> 00:25:44.130
This is a thing I think that the community doesn't know, and maybe even the

00:25:44.130 --> 00:25:46.390
authors of McDonald underappreciate it.

00:25:46.710 --> 00:25:50.830
It's not just you bring in a new imaging technology, now the answer's on it.

00:25:51.830 --> 00:25:55.690
That imaging technology needs to be ready for prime time. It needs to be standardized.

00:25:56.390 --> 00:26:03.030
An institution or an office needs to purchase it, install it,

00:26:03.190 --> 00:26:07.690
implement it, train the radiologist to read it. It doesn't just pop up on the

00:26:07.690 --> 00:26:08.750
screen and say, this is MS.

00:26:08.930 --> 00:26:12.490
It's a technique. It's like art appreciation. You have to learn how to read

00:26:12.490 --> 00:26:14.730
what is a pearl, what is a central vein sign.

00:26:15.450 --> 00:26:21.230
I'm afraid that not only are these techniques not available to people making

00:26:21.230 --> 00:26:24.650
a two-tiered system, some haves and some have nots.

00:26:25.940 --> 00:26:30.500
It's going to cause new forms of error. People misreading these things,

00:26:30.700 --> 00:26:34.740
misreading an OCT scan and saying, well, this person has optic neuritis.

00:26:34.900 --> 00:26:37.200
You can't diagnose optic neuritis with an OCT.

00:26:38.360 --> 00:26:45.900
So I'm concerned that we're going to not only delay diagnosis because patients

00:26:45.900 --> 00:26:48.980
are going to wait to try to find a place that has these resources.

00:26:49.840 --> 00:26:54.980
It's going to shunt MS diagnostic workup from everyone, every neurologist,

00:26:55.120 --> 00:26:58.700
to only the specialized few, which is going to make the wait times longer.

00:26:58.980 --> 00:27:02.340
We just talked about how people don't have enough time to spend with their patients.

00:27:02.860 --> 00:27:05.860
The wait times might be months, might become years.

00:27:06.780 --> 00:27:10.360
So the criteria, as you said up front, intended to expedite,

00:27:10.480 --> 00:27:12.980
make the diagnosis earlier, sooner, faster.

00:27:13.740 --> 00:27:17.860
I think it's going to delay it because it's going to make the wait time for

00:27:17.860 --> 00:27:21.440
people to get to specialists who know how to navigate this criteria longer.

00:27:21.680 --> 00:27:24.700
It's going to delay the diagnosis it was intended to expedite,

00:27:24.700 --> 00:27:30.240
and it's going to cause new etiologies of error, new mistakes on top of the

00:27:30.240 --> 00:27:32.980
old mistakes, but not correct any of them.

00:27:33.360 --> 00:27:38.380
One of the things I wondered about with some of the advanced technologies being

00:27:38.380 --> 00:27:43.480
promoted as part of the criteria is not only that people might get it wrong.

00:27:43.820 --> 00:27:48.720
And not only that in community office settings, they're not available.

00:27:48.980 --> 00:27:53.740
It occurred to me, the community neurologist who reads that and just says,

00:27:53.860 --> 00:27:55.420
oh, this is not for me. I give up.

00:27:55.620 --> 00:28:01.100
I give up. I wrote in the paper that general neurologists will be hamstrung.

00:28:02.150 --> 00:28:07.450
And that's a loaded word, but I think it makes it not for them.

00:28:07.910 --> 00:28:12.130
And I don't know that that was intentional on the part of the McDonald criteria

00:28:12.130 --> 00:28:16.950
authors. I just think that they live and breathe that stuff and forget that

00:28:16.950 --> 00:28:19.550
not everybody can and not everybody does.

00:28:20.050 --> 00:28:24.290
So my thought is, you know, an operating system for a computer,

00:28:24.350 --> 00:28:27.270
they add features and then they add more features and more features.

00:28:27.270 --> 00:28:31.070
And after a few years of the development cycle, the thing gets so complicated

00:28:31.070 --> 00:28:33.910
that it doesn't work very well anymore, slows the whole thing down,

00:28:34.050 --> 00:28:35.330
doesn't run on your computer anymore.

00:28:36.110 --> 00:28:39.730
And then the next iteration of that operating system strips out all that stuff.

00:28:39.870 --> 00:28:43.770
They start over clean, right? A clean, new, fresh operating system,

00:28:43.930 --> 00:28:45.570
getting rid of all the noise that got added.

00:28:46.070 --> 00:28:51.030
I would love to see a version two of the McDonald's 2024 criteria,

00:28:51.030 --> 00:28:57.510
a revision, a cleaned-up version, strips away a lot of the unnecessary things, gets back to basics,

00:28:58.090 --> 00:29:01.070
cleans it up, makes it doable by anyone.

00:29:02.130 --> 00:29:06.790
And then we can bridge this gap from where we are to where we want to be with new technology.

00:29:06.790 --> 00:29:11.930
But it's bogged down in a way that I do think is going to cause a lot of people

00:29:11.930 --> 00:29:16.070
to throw up their hands and say, this disease isn't for me anymore.

00:29:16.070 --> 00:29:19.250
I don't understand what the MS community wants from me.

00:29:20.150 --> 00:29:24.210
And I think that does a real disservice to people, especially in under-resourced areas.

00:29:24.430 --> 00:29:31.850
I think it's going to worsen inequity of how health care is delivered in MS, which we don't need.

00:29:32.230 --> 00:29:33.810
We sure don't. Well, I feel like

00:29:33.810 --> 00:29:37.990
we've just been given a masterclass in contemporary issues in MS care.

00:29:38.370 --> 00:29:41.510
Dr. Steven Krieger, I want to thank you for all you do to improve the lives

00:29:41.510 --> 00:29:42.990
of people who are living with MS.

00:29:43.370 --> 00:29:46.890
Thank you for sharing your clear-headed thinking so transparently.

00:29:47.230 --> 00:29:49.870
Thanks for talking with me today. It's my pleasure. And listen,

00:29:49.970 --> 00:29:51.450
people can disagree with me on this stuff.

00:29:51.510 --> 00:29:55.350
This is my own perspective on it. And I'm okay to be wrong.

00:29:55.690 --> 00:30:00.210
I would like to be wrong about this last part. My hope is maybe the uptake will

00:30:00.210 --> 00:30:04.970
be faster than I realize, and these new MRI sequences will be easier to interpret

00:30:04.970 --> 00:30:10.450
than I realize, and we'll look back on this and think, ah, Krieger underestimated it.

00:30:11.110 --> 00:30:13.170
I hope I'm wrong. Well, let's see.

00:30:15.270 --> 00:30:19.970
That's going to wrap up this episode of Real Talk MS. Real Talk MS is powered

00:30:19.970 --> 00:30:21.570
by the National MS Society.

00:30:21.930 --> 00:30:26.430
And you can share this episode of the podcast by letting your friends or family

00:30:26.430 --> 00:30:33.550
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00:30:33.870 --> 00:30:38.270
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00:30:38.270 --> 00:30:40.550
it right into an email or a text.

00:30:41.430 --> 00:30:45.810
Next week, our coverage of the Consortium of MS Center's annual meeting continues.

00:30:46.070 --> 00:30:51.210
You'll meet two experts who are each changing or at least expanding the rules

00:30:51.210 --> 00:30:53.910
of the game when it comes to MS rehabilitation.

00:30:54.510 --> 00:30:59.690
You'll hear Dr. Brad Willingham talk about how artificial intelligence can be

00:30:59.690 --> 00:31:04.750
used as a decision support tool in MS rehabilitation, and Dr.

00:31:05.130 --> 00:31:06.950
Brian Sandroff discusses whether

00:31:06.950 --> 00:31:11.770
physical exercise can be used to treat MS-related cognitive issues.

00:31:12.390 --> 00:31:18.970
I'm John Strum. Thanks for listening. Stay safe and make healthy choices.