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MSCoE - Diagnosis FAQs Frequently Asked Questions Relating to Diagnosing MS. To ask a question use one of the email addresses on the MSCoE Contact Page
This is a good question, and one that MS researchers would review. MS researchers do work with other autoimmune disorders and look for causal relationships. However, at this time there is no demonstrated connection between Agent Orange and MS. Due to a variety of disorders that are connected to Agent Orange, the VA has created a website that addresses questions, and has a research program dedicated to studying this chemical and its relationship to health. You can go online for more information at http://www.va.gov/agentorange MS has an unpredictable disease course and while this is not likely to occur, in rare cases such as this one, it can occur. We encourage you to share these medical changes with your provider to continue with appropriate treatments. 3. Does getting MS have any connection with being exposed to agent orange? There is no demonstrated connection between Agent Orange and MS, but you may want to call the Agent Orange hotline at 1-800-749-8387. There is also a VA Agent Orange website at http://www1.va.gov/agentorange/ However, if you were honorably discharged from the military you are eligible for medical services with the VA. If you are experiencing health problems you should contact your local VA medical center. For more support, we recommend that you contact Veterans service organizations (VSOs)to help with any additional concerns you have about your health benefits. VSOs frequently advocate for changes in VA law to extend benefits and services. You may wish to consider joining forces with one of the VSOs to work toward benefit changes to help veterans with MS. At the present time, there is no firm evidence to suggest that Gulf War veterans are at increased risk for multiple sclerosis or demyelinating diseases in general. The War Related Illness and Injury Study Center based at the VAMC in Washington, DC http://www.va.gov/WRIISC-DC/ have several research projects that are examining mortality related to brain tumors, ALS and MS in deployed and nondeployed Gulf War era veterans. The Longitudinal Health Study of Gulf War Era Veterans involves 30,000 veterans, is one of the largest scientific research studies ever undertaken on the health of veterans. The goal is to find out how the health status of Gulf War veterans changes over time and if it is better, worse, or the same as non-Gulf War veterans ten or more years after the war. Specific areas under study are chronic medical conditions, post-traumatic stress disorder and other psychological conditions, functional status, mortality, general health perceptions, health care utilization, and VA disability compensation between these two veteran groups. To achieve this goal, researchers are collecting information from 15,000 Gulf War veterans and 15,000 non-Gulf War military personnel who were in service during 1990-1991. They are presently collecting information from these veterans through postal questionnaire surveys and telephone interviews. For specific answers to your question, we'll have to refer you to this Gulf War registry project, which is not part of MSCoE. But we can tell you that to determine whether an exposure causes a disease, it must be shown that those exposed have a higher incidence of the disease than those not exposed. When gulf war veterans were evaluated for a number of neurological diseases, ALS stood out as being possibly increased compared to those not serving in the Gulf War. MS was not a disease that stood out as more common in Gulf War veterans. Be sure and check out the research projects and the website devoted to War Related Illnesses at http://www.va.gov/WRIISC-DC/ Currently, there is a presumptive period for a service connected benefit for MS. Individuals who are diagnosed with MS while they are in the military or within seven years of their honorable discharge are eligible for a service-connected disability. While the presumptive clause for MS is still in effect, there is work being done on this issue. The MS Centers of Excellence East and West have been working on this issue with the support of the Veterans Health Administration. Dr. Wallin of the Washington DC VA is the Principal Investigator of a grant called “Multiple Sclerosis in Gulf War Veterans” to explore this concern. The research was recently funded through VHA ORD Epidemiology. MS lesions can appear anywhere in the brain and the spinal cord but the deep white matter of the brain adjacent to the ventricles of the brain is a common and characteristic location. In addition, MRI can most easily see MS lesions in the deep white matter of the brain (compared to the spinal cord or optic nerves). The deep white matter of the frontal lobe is a common location for an MS lesion but they can be in the white matter of any lobe of the brain. Devic’s (neuromyelitis optica) is a challenging diagnosis. It is often difficult to differentiate from MS. There are now criteria to assist in making the diagnosis. These criteria are: Absolute criteria (all required): 1. Optic neuritis 2. Acute myelitis 3. No evidence of clinical disease outside of the optic nerve or spinal cord Supportive criteria (either one major criterion or two minor criteria): Major: 1. Negative brain MRI at onset (does not meet Paty radiological criteria for MS) 2. Spinal cord MRI with signal abnormality extending over >3 vertebral segments 3. CSF pleocytosis of >50 WBC/mm3 OR >5 neutrophils/mm3 Minor: 1. Bilateral optic neuritis 2. Severe optic neuritis with fixed VA worse than 20/200 in at least one eye 3. Severe, fixed, attack-related weakness (MRC grade < 2 ) in one or more limbs Looking at these criteria, your case meets many of the requirements. There is evidence of optic nerve and spinal cord involvement. One major criterion is also met from the CSF WBC of 1,000 at the initial presentation. The main question is whether there is clinical disease outside of the optic nerve or spinal cord. The presence of this clinical disease is partly addressed with MRI. The brain MRI early in the course of Devic’s is usually normal or near normal. Abnormalities on the brain MRI suggestive of demyelinating disease argue for MS rather than Devic’s. Also, the MRI from the initial episode of myelitis may be helpful. Devic’s often has extensive spinal MRI changes spanning 3 or more bony levels. MS tends to have lesions that span fewer than 3 levels, though there may be several of these smaller lesions spread along the spinal cord. Oligoclonal bands may be seen with either disease (though they are less common in Devic’s). 8. How many veterans are being treated for MS? Our VA MS data repository currently contains about 26,000 cases. For additional details and information, see our report on "Description of VHA MS Cohort" at http://www.va.gov/ms/library/vha_mscoe_desriptive report_year1_feb27_2004_1.doc There is a presumptive period for MS which is 7 years from date of discharge. Although in many cases, the veteran may not be diagnosed until well after the 7 years expired, they may still have a chance to get service connected for MS. That is if the veteran was receiving treatment for conditions that could be early symptoms of MS within the 7 year presumptive period and if their doctor provides a medical opinion linking these early symptoms with the MS diagnosis. There is no presumptive period for asbestosis as it is not a presumptive disease. You can still file a claim for service connection for asbestosis and let the VA make a determination. You would need a doctor to provide a medical opinion about the exposure during their military service. The doctor would need to know of any exposure the veteran may have had prior to military service and any exposure post-military service to be able to render an opinion linking the asbestosis with the military service. This will be the same information the VA would request of the veteran as well to make a decision on this type of claim. If you need further assistance with this matter, please contact any Veterans' Service Officer as they will be glad to assist the veteran in this matter. It appears you have had numerous diagnostic tests over the last 20 years. If after 20 years of testing and MRI scans there is no definitive evidence of MS then it would be good to pursue alternative diagnoses. Additional consultations with other neurologists, perhaps people who specialize in spinal cord injury would be extremely helpful. It is important to treat each disease with the appropriate medications and therapies for the best quality of life. The VA offers a variety of specialists in neurology that might provide a “fresh look at your case”. At the present time there are no accurate estimates of the prevalence or incidence of MS within the VA population. Part of the problem is that most veterans do not receive their care within the VA health care system so tracking down all cases would be very difficult and costly. There have been estimates of the relative risk for MS within different VA cohorts with the most recent publication listed below. Prevalence estimates within VA healthcare users are being refined by the MS Centers of Excellence at the present time. Also, the National MS Society has a committee addressing how to initiate a nationwide prevalence survey of the US. (Annals of Neurol 2004;55:65-71) I do not know of a good reference that correlates the site of lesions in MS patients with symptoms. The reason is that the correlation between lesions and symptoms is very poor. There are a number of reasons that the correlation is poor including: (1) lesions seen on MRI may have different degrees of symptoms, (2) not all damage from MS is seen by MRI, and (3) MRI does not show the degree of adaptation to injury. There are numerous complications that impair the effectiveness of MRIs in determining damage from MS. Lesions seen on MRI represent different degrees of damage. The white spots seen on the usual MRI scans are areas of damage, but there is no way to tell whether the area of damage is slight or severe. This means that the same spot on an MRI can cause different degrees of symptoms in different patients, in fact there are many areas in the brain where damage produces no immediate symptoms. Also, the degree of damage may be partially overcome by adjacent areas of the brain taking over the injured brain's function. The degree to which they can take over these functions depends on how healthy these areas are. The brains of people with more widespread damage will have less ability to take over these functions. In addition, there is damage in MS that is not seen by MRI, so you can get loss of function in areas where there are no spots. This could be because the lesions are too small to see on MRI. On the other hand, there can be subtle damage to normal appearing white matter. Yet another complication is that we could be imaging the wrong part of the body. For example, lesions in the spinal cord or optic nerves could cause symptoms, but obviously will not be seen on an MRI of the brain. Finally, some of the symptoms of MS, like fatigue and cognitive impairment, cannot be localized to any particular area of the brain. In general, to make an association between any military exposure and the development of MS requires studying a large number of veterans with and without the exposure, and then showing a significant increase in the occurrence of MS among those with the exposure. These research projects require authorization and special funding from the Department of Defense or the Department of Veterans Affairs and for veterans to participate in the study over a long period of time. For the last ten years, the VA has studied the effects of military exposure to depleted uranium and has found no association between this military exposure and veterans developing neurological disorders. For further information you can read: McDiarmid, M.A., et al., Health effects of depleted uranium on exposed Gulf War veterans: a 10-year follow-up. Journal of Toxicology and Environmental Health, 2004. 67(4): p. 277-96. Sometimes eye problems in MS are easy to diagnose and sometimes they are not. People with acute optic neuritis are often fairly straightforward to diagnose; those with gradual loss of vision may be more difficult to diagnose. MS affects the nerve bringing information from the eye to the brain, leading to visual loss. It can also affect the alignment of the eyes. However, MS does not affect the lens of the eye, or other parts involved in the optics of the eye. This means that glasses will not improve visual problems resulting from MS. Many people with MS need glasses just like people who don't have MS. The glasses will improve the part of vision due to optics problems with the eye, but will not improve MS-related problems. If people have good vision after correcting the optics of the eye (using all that equipment in the eye doctor's office) then there is no reason to suspect MS (unless other symptoms are present). Patients who have good corrected vision usually do not have any additional eye tests to diagnose MS. Occasionally, patients may have symptoms suggesting MS, yet they have a normal eye examination. In that case, a visual evoked potential (or pattern-reversed evoked potential) is done to look for subtle damage to the visual pathways that cannot be seen on a routine examination. Again, this test would not be done unless there were other symptoms suggesting MS. Hope this is helpful. VA centers in your region with MS expertise can be found on our website at http://www.va.gov/ms. The VA MS Centers of Excellence are working with others in the VA system to establish a hub and spoke system of providing expertise in MS care. We continue to work to expand our network and improve the information available. Your VA primary care provider can consult with a center in your area. In the civilian population, vaccinations have been carefully studied over a long period of time and no evidence has been found of increased risk of developing MS. These results generalize to the military population as well. People of Mexican heritage, even without a family history of MS and growing up in the generally very warm climate of the Southwest, can develop MS. There is a lot of research showing that people who grow up in a colder climate and in northern latitudes are at a somewhat greater risk of developing MS. However, while growing up in a hot, desert climate reduces your risk it does not prevent someone from developing MS. MS occurs in people who are genetically predisposed to developing it and there are multiple genes that must come together to make someone genetically predisposed. Researchers estimate that there are probably at least 10 genes that might influence the risk of getting MS. Currently, researchers have identified one of these genes called DR2. Research continues in this very important area of the influence of genetics on MS. Though those of northern European descent have the greatest risk of developing MS, the disease is found in virtually all racial and ethnic groups. At this point, there is no known relationship between PG1 and MS. The War Related Illness and Injury Center, based at the DC VAMC, has a grant that is looking at unexpected neurologic outcomes with GW1 veterans. It may take a bit of time to get an answer but we're looking into it and will update this reply as soon as we get additional information. The peak age of onset for MS is 20-50, so developing MS at age 20 is not unusual. All of the treatments and issues described on this website would apply to someone this age. One important thing to keep in mind is that this person is still young with many years ahead of them. Getting on a medication to slow down the MS (disease-modifying treatments) is especially important in a young person because we want to treat the disease early so that there will be fewer problems over their long life. There are also many issues that young people with MS must face such as employment, relationships, family, children, etc. Recognizing these issues early and addressing them is important to their overall well-being. If you are eligible for VA services, whether you are service connected or not, you can receive medical care for your MS. This care includes disease modifying therapies, physical therapy, occupational therapy and other health care services and medical equipment. It sounds like you have a history of various symptoms that are recorded in your VA medical records. It might be necessary for you to contact Veteran Service Organizations like the Paralyzed Veterans of America (http://www.pva.org/), United Spinal Association (http://www.unitedspinal.org/), and Disabled American Veterans (http://www.dav.org/ ) to help you with the appropriate paperwork to reapply for service connected compensation. The VA also provides Patient Advocates at each medical center that can also be a good resource. They will intercede on your behalf and help you work with the various parts of the organization to get the appropriate response for your particular situation To ask a question use one of the email addresses on the MSCoE Contact Page
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