28. A Better Approach To Multiple Sclerosis and Neurological Autoimmunity with Dr. Erica Rivas

[00:00:00] It's important to listen, right, to our patients. And yes, they have an autoimmune condition, but they also, you know, they're humans, they have, you know, other symptoms, they have other social issues, right, that they're dealing with. So we need to be better listeners, right? And we need to help the patient with their mind, body, and soul.

[00:00:28] Hello, everyone. Welcome to the Better Medicine Podcast. My name is Dr. Omar Akhter, and I'm very excited today to be joined with Dr. Erica Rivas.

[00:00:37] Dr. Erica Rivas is the Medical Director of the Multiple Sclerosis and Neurology Institute of Austin.

[00:00:42] She is an expert in immunological disorders that affect the central nervous system, spinal cord, and brain.

[00:00:48] She completed her fellowship in Multiple Sclerosis and Neuroimmunology at the University of Southern California.

[00:00:54] She is board certified in neurology, and she's also the recipient of an educational grant award for the Americas Committee for Treatment and Research in Multiple Sclerosis.

[00:01:03] She's also been voted as one of the top doctors around Austin.

[00:01:08] So, Dr. Erica, welcome to the podcast and thank you for your time.

[00:01:12] Thank you, Dr. Akhter, for having me here. I'm really excited to be talking to you and our public today.

[00:01:18] This is a very important topic for me, you know, to be able to discuss neurological autoimmunity.

[00:01:26] I'm glad that we were able to connect and to talk about this topic.

[00:01:30] But first, I wanted to ask you a little bit about your story, your background in medicine, and how you came to neurology.

[00:01:37] Yeah, absolutely.

[00:01:38] So, I grew up in Puerto Rico, and I did my medical school there.

[00:01:45] And I knew I wanted to do bigger things, and I decided to come to Dallas.

[00:01:52] At UT Western, I did my neurology residency training.

[00:01:57] And the thing that sparked my interest in becoming a neurologist is I had great mentors during medical school.

[00:02:06] And that's when my first idea of, like, maybe I want to become a neurologist.

[00:02:12] So, that's when it all started.

[00:02:14] And from there, it's been just a great journey, getting to know people and mentors and just doing what I love.

[00:02:22] And subsequently, deciding to do the numerology part, right?

[00:02:27] So, again, it's all mentors that really guide you and make you see, right, the things that excite you, right?

[00:02:37] So, I was really fortunate to have good mentors throughout it all.

[00:02:42] And eventually made my way to Los Angeles, California, where I did my fellowship in neuromunology, like you mentioned, and multiple sclerosis.

[00:02:52] That's awesome.

[00:02:53] So, my experience with multiple sclerosis and a lot of these neurological conditions is mostly in the hospital.

[00:02:59] As a hospitalist, we generally will see patients there.

[00:03:04] And so, but it's really nice that you're able to, in a clinic setting, do this in a very specialized way,

[00:03:10] because I think those patients need a lot of specialized care.

[00:03:13] So, can you tell, for the average listener, what is multiple sclerosis?

[00:03:17] And maybe we can start there.

[00:03:19] Yeah.

[00:03:19] So, multiple sclerosis is an autoimmune and inflammatory disorder that affects the central nervous system.

[00:03:26] And the central nervous system is composed of the brain, the brainstem, and the spinal cord.

[00:03:31] So, because of the autoimmune injury, people can experience different neurological symptoms.

[00:03:39] And most people with MS would experience focal or, yeah, focal neurologic deficits or symptoms throughout their body.

[00:03:50] And it's important to notice that no single or no more than one individual can have the same symptoms.

[00:03:58] Everybody's different.

[00:03:59] And in the MS community, MS, people living with MS call themselves snowflakes, or they say we are like snowflakes,

[00:04:07] because each one of them is very different and unique from each other.

[00:04:12] Okay.

[00:04:14] And I'm curious as to, you know, we have kind of the conventional way that we take care of a lot of these conditions.

[00:04:21] And a lot of that revolves around various medications, prescriptions.

[00:04:24] What would you say is your way of approaching multiple sclerosis that might be unique to, say, the average neurologist or average person that's maybe dealing with multiple sclerosis?

[00:04:38] Multiple sclerosis is a very complex disorder.

[00:04:42] And, yes, we understand a little bit about it, right, that it's an autoimmune disorder, that it causes inflammation.

[00:04:50] We don't know exactly what causes MS, right?

[00:04:53] We have theories about the potential triggers or risk factors for developing MS.

[00:04:59] We know that, you know, perhaps a genetic predisposition or a family history might be risk factors or are risk factors for developing MS.

[00:05:10] So, like other disorders, right, we could control perhaps those risk factors.

[00:05:16] With MS, not so much necessarily.

[00:05:20] Yes, we can live a healthy lifestyle, so no smoking and eat a nice, clean diet.

[00:05:27] But the treatment for MS focuses on two aspects, right?

[00:05:32] So, one is preventing further illness or disability, and two, right, treating potential MS relapses that people can experience.

[00:05:42] So, in my practice, we focus on the FDA-approved medications or disease-modifying therapies for the treatment of MS,

[00:05:52] and that will help us slow down or stop the inflammation that we see with autoimmune disorders.

[00:05:58] And then the other part of this prevention is focusing on better medicine, right?

[00:06:05] So, lifestyle changes, diet and exercise.

[00:06:10] There are certain supplements and vitamins that we provide to our patients or we recommend our patients to take.

[00:06:17] And other interdisciplinary medicine as well, right?

[00:06:24] So, we work with our physical, occupational, cognitive therapists.

[00:06:31] Some people need to see, you know, other, or want to see other specialists in integrative medicine, for example,

[00:06:40] and they can benefit from massage therapy or acupuncture sometimes, just mainly to treat the symptoms associated with MS, right?

[00:06:50] Yeah.

[00:06:51] So, yeah.

[00:06:52] So, we want to take care of the whole person, right?

[00:06:55] And, very importantly, the mental health.

[00:06:59] So, people living with MS live with mood disorders, that they can live with mood disorders.

[00:07:07] Right.

[00:07:08] So, anxiety, depression are, in fact, more common in people living with MS than in people that don't live with MS.

[00:07:15] Right.

[00:07:15] So, that's also a very important part of our treatment care for those patients.

[00:07:21] Okay.

[00:07:21] You mentioned something very important, which is that whole person care, which I'm a big advocate for.

[00:07:26] And I think that's the intersection of where you and I come together is that kind of that integrative whole person approach,

[00:07:33] with obviously you being the specialist and me being more general.

[00:07:37] But I think that that's very important because one of my sort of pet peeves when it comes to autoimmune conditions is that it gets treated very system specifically.

[00:07:48] And what I mean by that is that, for example, MS is obviously a neurological condition and things like, you know, ulcerative colitis Crohn's disease is a GI-specific issue.

[00:08:00] But one thing that they have in common is that they're autoimmune problems.

[00:08:03] So, it's an immune system dysregulation going on at the heart of it.

[00:08:07] So, I tend to try and see a lot of these immune system issues with that basis in mind.

[00:08:13] And so, then I try to attack the autoimmunity at that source, which is the immune system.

[00:08:19] And I think you mentioned a lot of good points of improving diet, improving lifestyle, and that whole person approach because that is very important when it comes to autoimmune conditions.

[00:08:31] And I think that with the various specialists that we have, whether it's GI or any, you know, endocrine when it comes to Hashimoto's and so on,

[00:08:40] I think that there is too much of a specific organ focus without that whole person focus.

[00:08:45] So, I just wanted to mention that as something that I feel like patients sometimes get a bit frustrated about is why is that whole person approach not happening?

[00:08:55] Why are we not taking that?

[00:08:57] Because I think that there's a lot more we can do towards autoimmune issues than just treating the system specifically, which a lot of which you mentioned.

[00:09:06] So, I'm curious about if you come across that same – you have that same belief that that is, you know, that immune basis is the most important part of it.

[00:09:15] Yeah, I mean, absolutely.

[00:09:17] I hear sometimes from patients that whenever they go to doctors, they feel like they're not heard, their number, right?

[00:09:27] And the doctor just has a little time.

[00:09:29] And that might be a different problem, you know, for sure.

[00:09:33] But it's important to listen, right, to our patients.

[00:09:37] And yes, they have an autoimmune condition, but they also – you know, they're humans.

[00:09:41] They have, you know, other symptoms.

[00:09:43] They have other social issues, right, that they're dealing with.

[00:09:50] So, we need to be better listeners, right?

[00:09:53] And we need to help the patient with their chronic illness and more than just, you know, the illness, right, the human behind it.

[00:10:05] So, yes, it's very important for us to control the autoimmune disorder.

[00:10:10] And we have, you know, clinical trials that study these drugs.

[00:10:14] And we make decisions that, you know, maybe this is a treatment for you.

[00:10:20] We know that it works for, you know, most people that were in the clinical trial.

[00:10:23] So, we offer those medications.

[00:10:24] But we also have to offer a better quality of life for these patients, right?

[00:10:30] And we can achieve that by, you know, working with, you know, a physical therapist or making sure that we have a clean diet.

[00:10:40] And yes, it's true that research about these other topics, right, like diet, for example, NMS, is very controversial.

[00:10:50] And we don't have like a very strong data that says, yes, follow this diet.

[00:10:56] But we know nutrition in general, right, is good, is healthy.

[00:11:00] Like an anti-inflammatory diet would be very helpful.

[00:11:03] Right, right, right.

[00:11:04] So, we have to, like I said, right, so see the patient as a whole and treat them mind, body, and soul, right?

[00:11:15] Yeah, and that's what I'm a big advocate for because what I don't like is this approach of, okay, this is a case, right, a case of MS, a case of ulcerative colitis.

[00:11:25] And then it's like first drug, second drug, third drug, and everyone is treated the exact same no matter what nuances a patient has.

[00:11:33] So, like you said, that whole person approach is so important.

[00:11:35] So, I appreciate you doing that.

[00:11:38] So, I want to ask you a little bit about MS for, you mentioned what it is.

[00:11:42] What does someone suspected of having MS, what are some of the tests that they can do, and what are some of the tests that you run when you're suspecting and then you have MS and you're following them?

[00:11:53] Yes, so it's very important that patients that have a suspicion of MS get to a neurologist that knows and understands MS, right?

[00:12:05] That makes a huge difference.

[00:12:06] So, first challenge is getting to the neurologist.

[00:12:09] And then second challenge is getting to a neurologist that knows MS or that it is trained in MS or has that expertise.

[00:12:19] And the patient will tell us the story.

[00:12:21] Like this happened to me five years ago or two years ago.

[00:12:25] So, usually a focal neurologic deficit.

[00:12:28] So, one arm, one leg, one eye, right?

[00:12:33] They would experience an inability to use that part of their body as they would normally be able to.

[00:12:41] So, loss of vision in one eye or weakness on one arm, for example.

[00:12:46] And that symptom lasts for days to weeks to months.

[00:12:51] And then it gets better.

[00:12:53] And six months later or a year later, something else happens.

[00:12:58] So, we have to, again, be good listeners, right?

[00:13:00] Because the patient is going to tell us their story.

[00:13:03] And, of course, to support that, we can get testing done, right?

[00:13:08] And we typically would get MRI or magnetic resonance imaging of the brain and sometimes a spinal cord to look for the scars or the sclerosis that has been left there from the inflammation or the autoimmune attack.

[00:13:25] And in that, along with the history, are the most commonly utilized tools for the diagnosis of MS.

[00:13:33] And, of course, there's other things that we can do if there is a patient that quite doesn't follow what, like we said, like we say in medicine, like, oh, they don't follow the textbook, right?

[00:13:43] So, we need to do a little bit more.

[00:13:45] Okay.

[00:13:46] And stepping a little away from MS because I think that there is a category of neurological autoimmunity that you are focused on that maybe is not as well appreciated and understood as MS is.

[00:13:59] And I'm talking about those patients that have these neurological complaints and issues, and maybe it's not MS.

[00:14:06] But I seem to find that that is not really well appreciated in the medical community.

[00:14:13] Do you find that same issue with other neurological autoimmune conditions?

[00:14:19] So, in general, the autoimmune disorders that affect the central nervous system or neurological autoimmune disorders, they are rare.

[00:14:31] So, luckily, right?

[00:14:32] The most well-understood neuro autoimmune disorder is MS, but there are others.

[00:14:40] Neuromyelitis optica or NMO, for example, is another condition that's also demyelinating, meaning that we lost myelin or the covering of the nerves by an autoimmune injury.

[00:14:55] And then there's one that's more recently recognized.

[00:14:59] It's called myelin oligodendrocyte glycoprotein-associated disorder.

[00:15:06] So, MOGAD is another demyelinating disorder.

[00:15:09] So, recently described.

[00:15:12] And there's other conditions that are similar to MS, right?

[00:15:18] Demyelinating that affects the central nervous system.

[00:15:21] Even more rare, there are conditions what we call autoimmune encephalitis, meaning that the brain gets inflammation.

[00:15:32] And we can sometimes see that with other non-neurological conditions.

[00:15:36] It just gets very complicated.

[00:15:38] Like Hashimoto's, for example, right?

[00:15:40] That is a primary autoimmune thyroid disorder, but it can also affect the brain.

[00:15:47] Yeah, I'm glad you brought that up.

[00:15:48] I was going to mention that this is one of my pet peeves, too, with patients with Hashimoto's, is that there is such a singular look at only the thyroid.

[00:15:57] And we have very good research to say that Hashimoto's will impact neurological function as well, increase inflammation.

[00:16:06] There are cerebellar antibodies that cross-react as well.

[00:16:09] So, when you think about maybe a patient has Hashimoto's and they have balance problems or they have other brain fog, right?

[00:16:17] Then I think these patients can get a very good understanding of what's going on by knowing and understanding their Hashimoto's.

[00:16:24] So, I think that knowing that Hashimoto's is also a brain inflammation issue, I think that that's a very important point that I try to drill into my Hashimoto's patients.

[00:16:36] But for some reason, just not very much talked about in the medical world that you and I are in, I feel.

[00:16:42] Yeah, absolutely.

[00:16:43] Absolutely.

[00:16:43] And, you know, this is why it's better for the patients when their physicians work together, right?

[00:16:51] And if there's ever any questions or like, hey, you know, we want to get your opinion, right?

[00:16:56] And can you help us with this?

[00:16:59] And when we work together, that's better for the patients or our patients.

[00:17:03] Yeah.

[00:17:05] So, I want to ask you just a little bit about, again, maybe a little bit more detail on your approach.

[00:17:10] So, you mentioned, you touched on it a little bit with the different modalities that you use in physical therapy, occupational therapy, and then some vitamin supplements.

[00:17:19] Are there specific things that you can tell the viewer that might be helpful?

[00:17:23] Of course, everyone is different.

[00:17:24] But some specific take-home points that the viewer can use to understand their MS better and what treatment options they have that are not necessarily medications to start with, but what other things could help their MS.

[00:17:41] Okay.

[00:17:42] So, this is a very tricky question because like we said at the beginning, every person living with MS is different and they have different symptoms from each other.

[00:17:54] But I think that we still have to control the disease, right, with the inflammation.

[00:18:01] And then other things that we can do, right, it depends on the symptoms.

[00:18:05] And recently, I was, you know, listening to another podcast about, you know, diet in MS.

[00:18:11] And there's some small trials that mention, you know, the treatment of fatigue, which is a very common symptom in people with MS, often preceding the diagnosis by years.

[00:18:26] Where, you know, low-fat diet, and that means where 25% or less of their diet comes from fat sources.

[00:18:37] So, that can help reduce fatigue symptoms, right?

[00:18:42] They also mention like a Mediterranean diet, which focuses more on good plant fats, right?

[00:18:49] So, olive oil or nuts.

[00:18:51] And there's some lean meat proteins in that diet as well as a lot of leafy greens.

[00:18:57] And those two diets can help reduce fatigue, right?

[00:19:04] Of course, it's also beneficial for the rest of our health in general.

[00:19:10] And exercise is another topic that has been studied, particularly in MS patients and in individuals that do regular exercise.

[00:19:21] And that is three to five days a week of moderate to high-intensity exercise.

[00:19:29] That can help reduce or slow down the progression that we can see in some patients with MS.

[00:19:36] Okay.

[00:19:36] And I would add that probably exercise despite the fatigue, right?

[00:19:41] So, you're trying to push through the fatigue, which can be very – because patients can be so tired and they say, I can't exercise.

[00:19:47] But maybe if you can really just try to push through it, then you'll actually feel better.

[00:19:53] That's right.

[00:19:53] Which is a message I give to patients when they're in this kind of chronic – just it's a positive feedback loop that you just push a little bit and then your fatigue gets better.

[00:20:01] Then you push a little bit more and you're – yeah.

[00:20:03] That's right.

[00:20:03] Do what you can do.

[00:20:05] Wanted to mention also vitamin D.

[00:20:08] Yes.

[00:20:09] It's vitamin D3.

[00:20:10] It's another important vitamin in MS.

[00:20:13] And almost all patients with MS have vitamin D deficiency.

[00:20:18] And we introduced this vitamin to help regulate their immune system.

[00:20:24] So, it works in controlling the disease as well.

[00:20:28] Yeah.

[00:20:28] So, it's a very important vitamin to take.

[00:20:31] Absolutely, yeah.

[00:20:32] In so many conditions, I think.

[00:20:34] And not only – my message to patients is not only to just get it normalized, but to try and push and get the levels higher in a more optimal range rather than just aiming for a level of 30.

[00:20:45] Yes.

[00:20:45] So, that's kind of my approach.

[00:20:47] I want to ask you maybe about some specific patients, of course, not giving any information, but just stories of patients that have gone through this whole person care.

[00:20:59] And the listener can understand how that whole person care helped their MS as opposed to, you know, not proper care of MS.

[00:21:07] Yeah.

[00:21:07] I can think of two patients.

[00:21:10] And so, one of my patients has a more rare type of MS called primary progressive MS.

[00:21:17] This is where about 10 or 15% of people with MS will experience this.

[00:21:21] And he had gone to – he had difficulty with his legs and walking, a little stiffness, muscle stiffness, spasticity, and weakness, some back pain.

[00:21:32] And he had gone to neurosurgeons and had a surgery on his back.

[00:21:36] He had gone to other neurologists.

[00:21:38] And eventually, he came to me and we diagnosed him with primary progressive MS.

[00:21:44] We put him on FDA-approved medication.

[00:21:47] And he came walking with a cane.

[00:21:51] Now, he worked with physical therapy.

[00:21:54] We started aqua therapy.

[00:21:57] And he's been now – and then also this vitamin D supplementation.

[00:22:02] There's another supplement that's been well-studied called alpha-lipoic acid.

[00:22:09] So, we also recommended this supplement for him.

[00:22:12] It helps with supporting the nerve health.

[00:22:17] And he's been without a cane.

[00:22:21] So, walking independently would reduce pain for the last two years.

[00:22:25] And I can think of another patient, also a male patient, but with relapsing-remitting form of MS.

[00:22:33] A lot of spinal cord injury, demyelination from the MS.

[00:22:38] So, a lot of symptoms involving his legs as well.

[00:22:41] Balance, pain, a lot of pain.

[00:22:45] And he was on a lot of medications for pain control.

[00:22:51] He got off medications.

[00:22:53] And he's doing ice baths.

[00:22:57] Ice baths to help control the pain or like cryotherapy, right?

[00:23:01] So, that's helpful.

[00:23:02] And it's important to notice that that might not work for everyone.

[00:23:06] But it worked for him.

[00:23:08] And he's not taking any other medications other than his MS disease-modifying therapy to control that pain.

[00:23:14] So, that's wonderful.

[00:23:15] Yeah.

[00:23:15] It's great to hear stories like that, you know, success stories.

[00:23:18] And you mentioned alpha-lipoic acid.

[00:23:20] I think for someone that hasn't heard about that, it's a very potent antioxidant.

[00:23:24] And something that I also use for blood sugar regulation too.

[00:23:29] Because it has incredible blood sugar regulation properties.

[00:23:32] So, I've had patients that have managed to get off of their insulin by using, you know, a good amount of alpha-lipoic acid in place of that.

[00:23:40] So, it's a very, very effective supplement.

[00:23:43] And I think that in this world of that supplements get denigrated quite a bit, I think that that is certainly a great one.

[00:23:49] Can you mention what aqua therapy is?

[00:23:52] You mentioned that on the first patient.

[00:23:54] Can you tell us a little bit about aqua therapy?

[00:23:56] Yeah.

[00:23:57] So, this is a treatment modality that incorporates a physical therapy, but in a water setting.

[00:24:04] Yeah.

[00:24:05] So, people go to the pool and do their exercises in a pool.

[00:24:09] And that could be very helpful for their neurological symptoms?

[00:24:13] It helps with the process of doing the exercise.

[00:24:21] It removes that weight bearing, right?

[00:24:24] Right.

[00:24:24] So, it helps the people move better.

[00:24:26] So, if they have specificity or weakness, they can move against the resistance a little bit better and build strength, for example, or help loosen the muscle a little bit.

[00:24:36] So, this is just one example of the many benefits.

[00:24:40] Okay.

[00:24:41] I was hoping that you can give maybe a message to the patients out there that might be struggling with MS specifically.

[00:24:47] We've been talking very general if someone is either suspecting MS or is just interested from a layman's perspective on MS.

[00:24:54] But for those patients that might be struggling with MS, what are your main messages to them?

[00:25:02] Education is power, right?

[00:25:03] So, know about your MS.

[00:25:06] Learn as much as you can.

[00:25:08] Ask questions.

[00:25:09] Come prepared to your doctor's visits because you'll be able to get more out of that visit.

[00:25:16] Like I mentioned earlier, nowadays, doctors are just very busy.

[00:25:21] They're just seeing patients.

[00:25:22] They're just trying to get through the day.

[00:25:23] So, it will help a lot if you come organized with your questions and have kind of like an idea of what are the main points that you want to discuss.

[00:25:34] So, I think that that can be helpful.

[00:25:37] And, you know, get yourself a doctor that you can trust, right?

[00:25:41] So, that's very important.

[00:25:43] That's important.

[00:25:44] I think building that patient-doctor-patient relationship is very important in something as complex and chronic as MS.

[00:25:52] So, I appreciate you mentioning that.

[00:25:55] Where can people find you?

[00:25:57] Yes.

[00:25:57] So, we are located close to Mopac, north, and I-35.

[00:26:04] Our address is 2200 Park Bend Drive, Building 1, Suite 200 here in Austin, Texas.

[00:26:14] We have a website.

[00:26:15] It's msnia.com, and that's for Multiple Sclerosis and Neurology Institute of Austin.

[00:26:23] And we're on Google.

[00:26:25] We're on Instagram and Facebook.

[00:26:28] Awesome.

[00:26:28] Well, Dr. Rivas, I really appreciate everything you're doing for your patients and for joining me today on this podcast.

[00:26:34] Thank you very much for your time.

[00:26:36] Absolutely.

[00:26:37] Great pleasure.

[00:26:38] Thank you, Dr. Aktor.

[00:26:39] Thank you.

[00:26:39] Thank you.