00:00:00:00 - 00:00:26:18
Mary Ray
Welcome. I'm Mary Ray, Co-founder of MyMSTeam, the largest and fastest growing social network for people with MS. Already, one in nine people diagnosed with MS in the United States is a member. Worldwide, MyMSTeam has over 150,000 members that provide support and advice to each other. If you haven't checked it out yet, please do so at MyMSTeam.com.

00:00:26:20 - 00:00:49:10
Mary Ray
Today, we are very excited to have a full house. Over 350 people had preregistered for tonight's event. And I'm even more excited to welcome back one of my favorite guests who has a great sense of humor, his own YouTube channel with over 350 videos covering a range of MS topics, and an insightful video and article series on MyMSTeam,

00:00:49:12 - 00:01:11:16
Mary Ray
Dr. Aaron Boster. Dr. Boster is a neurology specialist focused on MS, and is the president and founder of the Boster Center for Multiple Sclerosis and a great friend to us here at MyMSTeam. Welcome back, Dr. Boster.

Dr. Boster
Thank you, Mary, for having me. I've been looking forward to this all week. This is going to be a really, really fun night together.

Mary Ray
I agree.

00:01:11:16 - 00:01:30:19
Mary Ray
And I got to say our last event was really popular with our members, and the feedback we received was loud and clear. The event should have been longer. I'm not kidding. People said that about a Zoom event. So because of this, we're actually doing two things. One, we're providing a recording of the last event we did with you for those who missed it.

00:01:30:19 - 00:01:51:12
Mary Ray
And there should be a link in chat. And two, we're doing another event after this one on December 10th. And there'll be a little bit more details about that after our session here today. So stay tuned for further details, folks. Dr. Boster, most of the people who know me know my personal connection to MS is through my mother-in-law, who lived with MS for over 30 years.

00:01:51:21 - 00:02:16:22
Mary Ray
But before we dig in, it'd be great for the audience who isn't familiar with your story, your connection to MS.

Dr. Boster
With pleasure. I was first introduced to MS growing up in a household with the disease. My uncle had MS from my earliest memory. I was 12 years old when I found my mother and my grandmother in the kitchen crying because they couldn't get ahold of their doctor from my uncle.

00:02:16:24 - 00:02:34:21
Dr. Boster
And at that moment, I told my mom that I would learn to do it better. I've had a very directed course through my education. And a lot of my efforts are to ensure that families never experience the feeling of loneliness and the feeling of fear that my family experienced years and years ago. And I bring that forward.

00:02:34:21 - 00:02:55:23
Dr. Boster
So I always tell people, I was a family member of someone with MS long before I learned how to pronounce neuroimmunology or any of those fancy words.

Mary Ray
Thank you so much for sharing that personal insight. Tonight, we have a lineup of really interesting questions that we collected before the event. And actually to start, we have this one opener.

00:02:55:23 - 00:03:21:22
Mary Ray
How can you tell the difference between a side effect and a symptom? And how are they managed differently? Big broad question on that.

Dr. Boster
That's an awesome question. So human beings experience stuff, right? So you experience a numbness or you experience a weakness, and you aren't necessarily aware of what's causing it, you just know you have it.

00:03:21:24 - 00:03:54:17
Dr. Boster
And so, then we work together as a team to figure out what caused that numbness, what caused that weakness. The word, symptom, in medicine has a very specific meaning. It's not a colloquial term. A symptom is a thing, subjectively, that the patient experiences. And so there's this very specific definition. If you come to me and say, Aaron, I have a numb foot, then I'm going to ask you a series of questions and do a series of exams to try to clarify what's causing the numb foot.

00:03:55:01 - 00:04:15:11
Dr. Boster
If I use an example of a medicine that has a side effect of numbness in the distal extremities, and I realized, wait a second, I put you on that medicine a month ago, and now you're telling me you have a numb foot, I'm going to track down the potential that it's a side effect of the medication. If there isn't anything like that, then I'm less likely to think so.

00:04:15:11 - 00:04:44:11
Dr. Boster
So it's all about detective work. It's all about being a good listener, and it's all about understanding the lotions and potions we use, and what side effects could occur. That's a really great question.

Mary Ray
Yeah, as a quick follow-up to your answer about being a detective, how can those living with MS, who are experiencing this at home, do their preliminary detective work to use the best description to jot down notes in preparation for meeting their doctor?

00:04:44:13 - 00:05:05:19
Dr. Boster
So the goal is not to jump on the interwebs and try to diagnose yourself, because very bluntly, that just creates fear. What's more valuable is to write down your symptoms on a piece of paper, because when you enter into the doctor's office, there's a hustle and there's a bustle, and the doctor may be rushed and you may get anxious and you might forget elements that are really important.

00:05:05:23 - 00:05:27:18
Dr. Boster
So write down the concerning things on a piece of paper and write down your questions. Now, as a pro tip, if you enter a doctor's office, and he or she says, well, hello, and you say hi, I have a list of questions. They are ethically and intellectually obligated to address them. And so it helps create a space where you can then go through it.

00:05:27:18 - 00:05:49:00
Dr. Boster
A second pro tip is to bring a loved one, a village member, a friend, a team member with you, someone who has intimate knowledge, and maybe you've talked to them about it because then if you get flustered or you're not sure, your buddy can chime in and say, well, actually, she told me da-da-da. And so those are two things that can help a whole bunch.

00:05:49:02 - 00:06:13:19
Mary Ray
That's great. Thank you for that. From a survey conducted by MyMSTeam just a few years ago, we know that there are many symptoms that people living with MS experience, and an overwhelming majority experience fatigue. Is this a common issue that you hear in your practice?

Dr. Boster
So fatigue is the most common symptom in MS.

00:06:13:21 - 00:06:34:05
Dr. Boster
It's the number one leading cause of loss of work for people impacted by MS in the United States, and it's invisible. Honey, you look so good. Oh, you don't look sick. The problem with fatigue is if you say, and I and I want you to try this out. So everybody listening tonight, when we're done with the call, go to your significant other and say, hey, I'm tired.

00:06:34:07 - 00:07:04:24
Dr. Boster
And they will say, me too. And the reality is they don't have an opportunity to experience what it's like to have MS fatigue. So it is the number one symptom and it's pervasive and it bleeds into other aspects of life. It's a major monster, and it's one that I have on the forefront of my thinking when I try to help somebody. It's my belief that when we really wrangle the disease down, and we're not always able to do that,

00:07:05:00 - 00:07:32:13
Dr. Boster
but when we do, you'll watch something magical happen because the fatigue will diminish somewhat.

Mary Ray
Got it. So this brings me to my next question, which is more about side effects. and the question came in from the audience. I actually don't have an attribution here, but what's the best way to manage, say, migraines, itching, and fatigue caused by some treatments?

00:07:32:15 - 00:07:54:08
Dr. Boster
So I think we have to keep an open mind because I don't think it's a foregone conclusion that it's caused by the treatment. So I'll give you an example. Today I saw a very nice young lady who is having headaches. And so her chief complaint when we chatted today was headaches. And when we looked at her medicines, she's on two medicines that can worsen headaches,

00:07:54:10 - 00:08:19:17
Dr. Boster
but she also has multiple sclerosis, which can increase the risk for headaches. It doubles your risk for headaches, and she is a graphic designer who works on a laptop like this, and so there's ergonomic concerns which can cause headaches, and she's profoundly stressed out about all the politics and in the world today, and this COVID pandemic that she's dealing with, which can worsen headaches.

00:08:19:19 - 00:08:39:12
Dr. Boster
So we looked at a multipronged approach. Yes, it could have been a side effect of a medicine, but I think it's naive to stop there. And so, what I would prefer to do is to look at everything in the playing field that could contribute, and try to work on all of them. For example, she's going to take a one-week drug holiday from those two drugs.

00:08:39:14 - 00:08:58:22
Dr. Boster
She's going to up her water game. She's going to up her sleep game. She's going to talk to her company about the ergonomics of her workstation. She's going to commit herself to some exercise, and I'm going to see her in a month. And then we're going to add back in things that we need to add back in.

Mary Ray
So doing a little bit of elimination, and then trying to put back. Okay.

00:08:58:22 - 00:09:20:24
Mary Ray
Great. I mean, that's fascinating. You know, there was another question that came up, still kind of related to how does one manage, in this case, symptoms. No one’s jumping to the conclusion that this is say, side effects of treatments in this case, around extremities like hands and feet, things like burning, itching, the sort of nerve pain that folks experience.

00:09:21:15 - 00:09:38:13
Mary Ray
What kind of insights do you have there about best managing those sorts of issues around extremities?

Dr. Boster
So we have to start by sharing with our doctor it's happening. Now, I don't mean that to sound silly, but all too often people think, well, there's too much going on. We're talking about so many things. Yeah, my hand feels like it's on fire, but I'll just ignore that.

00:09:38:13 - 00:10:03:22
Dr. Boster
Don't ignore that. You know, we use our hands a lot, and if that impairs the quality of your life, I'm not okay with that. And then as far as managing, you know, there's a lot of things. We can make sure that there's no drugs that are contributing to it. That's an obvious important thing to consider. Unfortunately, all too often, in MS, we can have symptoms where there's numbness, tingling, burning, yucky stuff, and we have lotions and potions.

00:10:03:22 - 00:10:19:06
Dr. Boster
You know, I have a pill for every ill. And I'm not saying you want one, or I even want to give you one, but here's my take. If the burning in your hand isn’t bad enough that you want it treated, we should treat it. If the burning in your hand isn't bad enough that you want to take a medicine for it,

00:10:19:08 - 00:10:36:14
Dr. Boster
okay, just tell me if it is. And there's a plethora of things that we can do. And pick a number between two through ten. Go ahead, Mary, pick a number.

Mary Ray
Oh, yeah. Four. Yes, four.

Dr. Boster
So let's come up with four things that we could do. So one thing we could do is we could use lidocaine cream.

00:10:36:16 - 00:10:56:08
Dr. Boster
So if you need to type for like an hour and your hand hurts, you could rub lidocaine on it and it would numb it up, and that way it wouldn't hurt so much when you're typing. So that's one thing you could do. The second thing is you can take certain antidepressants. We can get a twofer. So there are antidepressants that treat depression, but they also separately treat pain.

00:10:56:10 - 00:11:19:12
Dr. Boster
And so if we have someone that's dealing with a mood problem and they have burning, well, I got a medicine that'll do both. So I can sometimes game it out that way. Number three. We can look and see if it's related to a temperature change. For example, when my patients, in sunny Columbus, Ohio, where I live, get cold because it's about to get really cold here, their spasticity gets worse.

00:11:19:12 - 00:11:47:17
Dr. Boster
I had a patient today that shared with me. He wakes up and it's hard to bend his hands. And so he describes this sensation of achiness. It's spasticity. So I taught him a trick. I told him to put a pill of Baclofen in a in a glass of water at his bedside table when he goes to bed, and when he wakes up at three or 4 or 5 to go pee, before he actually wakes up to start the day, take the Baclofen, so that when he wakes up, his hands are loosey goosey.

00:11:47:19 - 00:12:12:22
Dr. Boster
The fourth thing is there's plenty of neuropathic pain medicines that are not addictive. They're not things that you develop a tolerance to. Things like pregabalin, which is the code name for Lyrica, or gabapentin with Neurontin. These are medicines that can be profoundly helpful in minimizing neuropathic pain: itching, burning, numbness, tingling. So my point here is that it's not one size fits all.

00:12:12:24 - 00:12:35:23
Dr. Boster
And just because you have it doesn't mean you want to treat it, but if you want to treat it, we can dig in.

Mary Ray
Right, and I guess what I'm hearing too that seems to be a refrain here is look, definitely jot down, document these sorts of challenges and issues, and absolutely communicate them with your doctor, and don't shortchange the fact that your doctor might be able to help you address it.

00:12:36:02 - 00:12:57:21
Mary Ray
You had said you know you have a pill for every ill. I'm guessing too, if I had said ten, you probably have other strategies that aren't necessarily medically related that might be like with exercise. You had mentioned earlier, I guess any number of things, diet as well. So you have your toolkit that you can help empower patients with,

00:12:57:21 - 00:13:17:11
Mary Ray
and as long as we feel confident enough to at least share the issues, you can help address that. What happens in a situation where… What should be a red flag for you when someone goes to their doctor with some of their concerns that you feel like, well, this person may not be ready to help me with multiple strategies, you know?

00:13:17:13 - 00:13:45:21
Dr. Boster
So the doctor patient relationship is an intimate relationship. It's like dating someone in some respects. It’s a very special and intimate relationship. And it's founded, like any relationship, on trust and communication. Now, sometimes patients don't recognize that. I am very, very invested in my patients’ lives. It's my goal to help them live their very best life despite having MS.

00:13:45:23 - 00:14:07:20
Dr. Boster
And when they go through struggles, I feel it. And so if you don't have that bond with your doctor, find a different doctor. I mean, I'm not for everyone, and everyone is not for me, and that's okay. And so you want to find someone that you click with, that gets you, that will listen to you in a way that's meaningful to you.

00:14:07:22 - 00:14:30:04
Dr. Boster
And that might not be the very first guy you date. It might not be the first doctor you go and see. My point is you only get to live life one time. You only have one brain and one spinal cord. You don't get another one. And I desperately need you to be your own advocate. I mean, let's face it, we're in a clinic room, and we're talking about something that you know more about than anyone.

00:14:30:04 - 00:14:54:10
Dr. Boster
You. You're a you expert. And so you're looking for a partner, a team member in your care, your clinician, who is going to be just that, a good listener, a good communicator, and someone that you can trust and communicate with.

Mary Ray
I love that phrase. First of all, you are a you expert. Kind of playing on just general, you know, here's a question that's come in around disease modifying therapies,

00:14:54:10 - 00:15:16:20
Mary Ray
DMTs, also known as. What are some of the most common long-term side effects of disease modifying therapies that you could share with the audience?

Dr. Boster
So in the United States, here in 2020, we have 23 different disease modifying therapies. So as you can imagine, I can't answer that question as a one size fits all, because there's literally 23 drugs and probably eight classes.

00:15:17:16 - 00:15:37:09
Dr. Boster
I guess what I would say if I tried to batch them, there's different things. In the ‘90s when the shots came out, that was all that we had available, and we had to be cheerleaders and say, you can do it. Taking a shot where you give yourself a jab once a day, or thrice weekly is really hard to do long-term.

00:15:37:16 - 00:15:55:05
Dr. Boster
And so one of the most common things we see with chronic use of injections is nonadherence, meaning, the person may still do it, but they don't do it exactly the way they're supposed to. And unfortunately, the medicines don't work if you don't take them the way you're supposed to. To be honest, it's the same thing with twice a day pills.

00:15:55:05 - 00:16:14:11
Dr. Boster
The data is very clear that if you take a pill twice a day, it's super hard over years to do it. So if I was to pick only one thing in an attempt to answer your question, it's a fatigue. It's not a “I need to go to bed” fatigue. It's a medicine fatigue of becoming increasingly challenged in pulling through.

00:16:14:13 - 00:16:35:23
Mary Ray
Got it. Yeah. That's interesting. This kind of leads me into this next question about how to make trade-offs in choosing treatments. You just said there's 23 different ones in the US. And so for instance, if I have symptoms that are also side effects of medication, could those symptoms be exacerbated depending on the treatment?

00:16:36:13 - 00:16:56:04
Mary Ray
What we're seeing a lot from the questions of the audience really is this desire to decouple symptoms into side effects and understand them better.

Dr. Boster
I love when people want to understand, It’s a joy for me to help somebody come to terms with these things.

00:16:56:10 - 00:17:16:04
Dr. Boster
And these are really great questions. I think that we have to first start with, what are our goals? Like, why are we doing this? We're not doing it because you're supposed to, or because somebody said to. And so I always like to start the discussion of disease modification with life goals.

00:17:16:04 - 00:17:35:10
Dr. Boster
Like not MS goals. Like life goals. Like do you want to climb Machu Picchu? Do you want to get a PhD? Do you want to have 17 children? Do you want to walk your daughter down the aisle, not wheel her down the aisle, and your daughter's only seven? What are your life goals? And the reason that's so darn important to me is that's the North Star.

00:17:35:10 - 00:18:00:22
Dr. Boster
That's why we're fighting. And we're going to do a lot of things to help you achieve those goals and not let MS make decisions or interfere. If we start there, I find that it's a much better journey over the subsequent 30 years or what have you, and then we can get into MS goals, because we have to clarify the goal of what we're trying to do with any medicine.

00:18:00:24 - 00:18:25:14
Dr. Boster
I spend a lot of time talking to families about concepts and philosophy, long before we start to talk about the name of a medicine because the medicine is a tool to achieve a goal. It’'s not the goal. And once we set forward our thoughts on what are the life goals and what are the MS goals, then we can have an engaged discussion about how do we achieve those goals.

00:18:25:14 - 00:18:44:14
Dr. Boster
Now I will be transparent with you. I list things in my head based on efficacy. Aaron's opinion of the most efficacious second, third, fourth. And when I talk to you about DMTs, I'm going to start with the most effective drug that you're eligible for, and then I'm going to tell you the good, the bad, and the ugly.

00:18:44:16 - 00:19:05:08
Dr. Boster
And if you're on board, giddy up, we're going to do that. But if you're not comfortable, then I will downgrade my option to something that I think works, still really good, but maybe less good in groups of people. And then I'm going to tell you the good, the bad, and the ugly about that. And I'm going to keep going down my list until I can find the most effective drug you're comfortable with.

00:19:05:10 - 00:19:24:21
Dr. Boster
And I chose those words very carefully because the most effective drug you're comfortable with maybe like the least effective drug, but that's the one that you're comfortable with. Because even though I start with efficacy, it's not my body. It's not my brain. It's your body and you're in charge of you. And so I have to help you figure out what works.

00:19:24:23 - 00:19:41:18
Dr. Boster
It's not okay to talk you into something that I think’s cool, because I'm not the one doing it, you are. When you go to the financial planner, the very first thing she does is assess your risk aversion. If she invests all your money on Japanese futures and you lose it all, how upset are you going to be?

00:19:41:20 - 00:20:02:14
Dr. Boster
And she may have one client that invests in bonds, and she may have another client that literally plays the Japanese stock market late at night, and neither are wrong. They both have different risk aversions and that's just human nature. And so it's my obligation to learn your risk aversion and not to keep serving stuff up that you're not okay with.

00:20:02:15 - 00:20:28:01
Dr. Boster
I have to find something that you're okay with.

Mary Ray
Do you find… I'm about to go to a poll question everybody, so get ready. But before I do, I'd like to ask you, Doctor Boster, do you find that many in your peer group of neurologists, feel that same obligation, responsibility that you do, to suss out among your patient base, their patient base of what their comfort level is?

00:20:28:01 - 00:20:44:10
Mary Ray
Do you feel that's common or is that that's unique to doctors like yourself?

Dr. Boster
Everybody's different. My way is not the right way, but it's just the way that works for me and my patients. And I do think that there are like-minded individuals, but as I said earlier, I'm not for everybody. And so it's not about finding someone like Aaron,

00:20:44:10 - 00:21:20:24
Dr. Boster
it's about finding someone that you connect with. I'll give you a great example. In the United States, 80% of people impacted by MS, don't see some specialist like myself. They don't see fellowship trained neuroimmunologists. They may see a very well-intended general neurologist. And there's a common concept that that's bad, which is not true. And they think it's bad because, well, that person may not know all the details, but I disagree with that because if you connect with your doctor or your clinician, you have a great, awesome relationship, and they're willing to work with you, and they're willing to learn, and they're willing to consider things, that's the right person for you.

00:21:21:21 - 00:21:40:05
Dr. Boster
It doesn't need to be, he up on the ivory tower, who is heralded as the very most special. That may not be relevant for you as an individual human trying to live your best life.

Mary Ray
Right. Right. Great. All right. Well, I wanted to give plenty of warning to our crew here.

00:21:40:05 - 00:21:59:20
Mary Ray
We're going to ask this first poll question to you, audience, who are joining us right now. Again, we are with Dr. Aaron Boster. We're so excited to have him back. Here's the question. What symptoms are the hardest for you to manage? What symptoms are the hardest for you to manage? And I believe you can actually only pick one here.

00:22:00:09 - 00:22:27:13
Mary Ray
You know, Dr. Boster, and just last year, MyMSTeam had fielded a survey with over 900 members of MyMSTeam who were diagnosed with MS. And we asked our members what were the common cognitive symptoms, what are their common cognitive symptoms? And the top three answers were: mind wandering, losing train of thought, not being able to find the words they want to say, and being easily distracted or having trouble concentrating.

00:22:28:01 - 00:22:49:22
Mary Ray
We're going to put this in chat too. You'll be able to find a research published in “Life With MS Cognitive Symptoms” article, and we'll put that there for you. Dr. Boster, have you heard of these sorts of cognitive issues?

Dr. Boster
Absolutely. So remember I said fatigue is the most common symptom in MS.

00:22:49:24 - 00:23:12:22
Mary Ray
Yes.

Dr. Boster
The second most common symptom is cognitive impairments. 70% of people with MS may experience some form of cognitive impairment. Now, that's not Alzheimer's, that's not, “I can't remember who I am or who you are,” but that's difficulties with thinking and memory. And rather specifically, it's executive prefrontal functioning, so it's multitasking. It's thinking quickly. It's quick shifting.

00:23:12:24 - 00:23:35:21
Dr. Boster
It's keeping lists in your head. It's those kind of tasks, and it's a beast. I'll give you an example. I learned because I'm an MS neurologist, that one of the hardest jobs out there is telemarketing. And I wouldn't have thought that until I've talked to several people impacted by MS

00:23:35:23 - 00:24:06:12
Dr. Boster
who used to be the employee of the month in their telemarketing firm, heralded as doing amazing things. And then if you fast forward several years, they were fired because of poor performance. And it's not because they're not wonderful people, and it's not because they're not trying hard, it's because in their experience, the cognitive impairments they had made them slower and slower. Because it turns out in telemarketing, you have multiple screens open at once.

00:24:06:12 - 00:24:34:09
Dr. Boster
You have multiple calls that are starting and everything is timed, which is a really hard thing for someone that has executive dysfunction. And so, yes, I hear that all the time. And we spend a tremendous amount of energy in my clinic trying to help people think clearly. It's a huge and a terribly important thing because you're not going to leave the workforce because you're in a wheelchair. You're going to leave the workforce because you can't think through the day,

00:24:34:11 - 00:24:50:04
Dr. Boster
and one of my jobs is to keep you in play. You know, I want to be like a kid's hockey coach and keep you out on the ice. And if you come in, I'll dust you off and give you hot chocolate and throw you back out on the ice, because I want you in play.

Mary Ray
You're definitely from Ohio.

00:24:50:04 - 00:25:11:21
Mary RAy
I love the hockey reference.

Dr. Boster
You don't have a lot of ice sports and science out there.

Mary Ray
Yeah. For sure. Well, we have our poll results regarding what are the most difficult symptoms to manage. And here they are, everyone. Look at this. Fatigue in the lead by a one percentage point, followed by, you guessed it, cognitive issues.

00:25:11:21 - 00:25:29:00
Mary Ray
Dr. Boster, you had called that. Now, the one thing that's also listed here that we hear quite a bit about is spasticity. And that leads me to my next question. For those who don't know what it is, what is spasticity, which you had mentioned earlier, and what do you do if you get it?

00:25:29:00 - 00:25:49:10
Mary Ray
I mean, number one, tell your doctor clearly, but-

Dr. Boster
So spasticity is very common in MS. Again, it's statistically suggested about 70% of people have it, and about 30% have it severe. And I think it's actually higher than 30% at least in my own clinical experience. Again, I live in an area that's cold.

00:25:49:12 - 00:26:07:10
Dr. Boster
Spasticity is always worse in the cold. But real quick, if I want to bring my massive arm, which is taking up the entire screen with this big bicep. I'm going to bring my giant arm. I'm going to bring this tasty beverage to my mouth. I bring it to my mouth. I have to do two things.

00:26:07:12 - 00:26:28:00
Dr. Boster
This bicep has to contract, it has to get smaller, but also this giant tricep, I'm joking, it has to get longer, it has to stretch out. Both things have to happen for me to bend my arm. And I don't say tricep, relax, and then I bring this, this way. The spinal cord and the brain, they relax the tricep

00:26:28:01 - 00:26:51:19
Dr. Boster
when I bring the bicep in. When you have damage to the descending pathways of the brain and the spinal cord, sometimes when you want to do this, you also want to do that because the tricep doesn't turn off. And so what happens is you have a tug of war between this muscle and that muscle. And that manifests in three ways.

00:26:51:21 - 00:27:08:00
Dr. Boster
Way number one is a limb that's hard to bend, like trying to bend your leg so you can get in the car, or trying to bend your legs so you can stand up. The second way is a spasm, which is like a bouncing. And so sometimes people when they put their shoe on their foot will sit there and bounce.

00:27:08:00 - 00:27:30:17
Dr. Boster
That's a spasm, that's spasticity. And the third way is a cramp, like a charley horse, like a visible contraction of the muscle belly which will drop a guy to the ground because it hurts so freaking bad. Spasticity is always worse under two conditions. The first one is when it's cold outside, and we've been kind of hinting to the fact that here in sunny Columbus, Ohio, it's about to get really cold.

00:27:30:19 - 00:28:02:10
Dr. Boster
And I'll tell you, about five weeks ago, the temperature dropped about five degrees, like over a weekend. I'm not exaggerating when I say we had no less than 50 phone calls that week from our patients saying the spasticity, the spasms, the cramps. It was all kicked up, and it was almost always worse in the morning because the second reason spasticity gets worse is when you're still. Sleeping in Ohio and you wake up in February, you've been still all night and it's cold as hay, hay outside,

00:28:02:12 - 00:28:29:01
Dr. Boster
and the result is, you're stiff. So spasticity is a beast. And here's the kicker. A lot of doctors and a lot of patients aren't aware of spasticity, so they don't know how to frame the discussion. And they know they experienced an ouchy yah yah, but they don't know why, or the doctor doesn't think about the fact that it's spasticity and may give medicines that don't work, like narcotics, which don't work to treat spasticity, for example.

00:28:29:01 - 00:28:51:12
Dr. Boster
So we have to have an understanding of what it is, and then we can figure out a path to treat it.

Mary Ray
And so that's important for our audience to know too, when experiencing that, being able to articulate, even using that word, that phrasing, and better understanding that. And so in terms of managing things like spasticity, of course, telling your doctor, but you mentioned two things, that there's not moving and then there's coldness,

00:28:51:12 - 00:29:15:24
Mary Ray
so I mean really going to movement and heat. Are those the more obvious ways or am I being a little too intuitive?

Dr. Boster
No, no. You're spot on. So for example, I have patients that travel to see me from a city that's about two hours away, and some of them can't make the two hour drive and then get out of the car and walk because they're so stiff.

00:29:16:01 - 00:29:36:20
Dr. Boster
So what they've learned to do is they drive halfway, they get out of their car, and they walk around for five minutes. They get back in their car and they finish the trip. And when they arrive at my clinic, they're good in the hood. Similarly, someone who sits at a desk and types, they may find that they can type for an hour or two hours, but if they go two and a half, they're stiff.

00:29:36:22 - 00:29:53:10
Dr. Boster
So we have to game out how long they can sit still, and so that we may find that you can sit and type for an hour and 15 minutes, and then you have to get up or you're going to start to cramp. And so if we know that, then we can change our behavior to win. Now, cold is tough.

00:29:53:10 - 00:30:11:05
Dr. Boster
I always joke that if everybody could live in San Diego, it would be perfect because I think it's like the best weather in the United States, but many of us don't have that privilege, and so we have to do other things. And I'll give you an example. Hunters socks. You probably don't even know what Hunters socks are,

00:30:11:13 - 00:30:30:04
Dr. Boster
you California lady, you. So Hunters socks are socks that have a battery with a wire in them, and they literally heat up your foot. And so I have some patients, they'll purchase Hunters gloves or Hunters socks which have a little battery, and they keep them warm. And they'll wear them during the day because it keeps them from spasming.

00:30:30:22 - 00:30:58:16
Mary Ray
That's a really great strategy. So there could be all kinds… I mean, again, checking with one's doctor, but also there are a battery of strategies to deploy when trying to manage those things. In some research that we had conducted through a survey, as well as just that poll that we saw, mobility is second to some of the cognitive issues.

00:30:58:18 - 00:31:22:08
Mary Ray
So a lot of times when people are thinking about their biggest fear, if they haven't lost it already, is losing their mobility. So the question that had come in is how can I preserve mobility?

Dr. Boster
So I think that I would rephrase that as how can I preserve the reserve, meaning the cognitive and neurological reserve,

00:31:22:18 - 00:31:46:06
Dr. Boster
but to speak specifically about mobility, first of all, we have to figure out what's the goal? And I'm and I'm not being silly. Is the goal that you walk into the store or that you do your shopping? Because depending on the state of affairs, it may behoove us to park super close and then get in the store, so you can walk in the store and then get back to your car.

00:31:46:08 - 00:32:07:08
Dr. Boster
Right? I mean, my point is that we have to think about what are the goals. Now to think about ambulation in specific, about the physics of walking. One of the least utilized techniques in medicine is physical therapy. So physical therapy is darn near magic. And there's two kinds of physical therapists in the world.

00:32:07:08 - 00:32:37:15
Dr. Boster
There's physical therapists that treat like a busted knee or like, you know, sports injury, and those are very smart men and women, and they're really good at that. And then there are neurophysical therapists, and neurophysical therapists went to extra school to learn about neurological things, including MS. And they tend to have a deeper understanding of motor fatigue, heat sensitivity, spasticity, ataxia, cognitive impairments, visual impairments, things that really impact ambulation.

00:32:37:15 - 00:33:05:12
Dr. Boster
So, if you haven't worked with a neuro PT, you should, and the reason that's so darn important is they can retrain your gait mechanics. The physical therapist doesn't really get into the why. They get into the how. You want to walk from here to here, and you have a problem with X. How do I make that better? So physical therapy is critically important as an impetus, as a beginning point to improve ambulation.

00:33:05:14 - 00:33:33:15
Dr. Boster
And then here's the important piece. Once you learn from the physical therapist, you can't stop. You're familiar with the allegory of the guy that rolled the boulder up the hill?

Mary Ray
Yeah.

Dr. Boster
Well, so that's applicable in the setting of walking in MS. If you are persistent, if you are consistent, if you're constantly working on your stretching program, on your mechanics, on your gait ambulation, if you're practicing the queuing, you can continue to make fantastic strides.

00:33:33:17 - 00:33:58:13
Dr. Boster
If you stop, you fall back. One of my tenants in my management of MS when I want patients to be four for four, one of the four is exercising as part of their lifestyle because it's so critically important to maintain ambulation.

Mary Ray
Don't stop moving.

Dr. Boster
Yeah, it's really, really important.

00:33:58:19 - 00:34:21:01
Dr. Boster
Let me share one story about a great man. This gentleman was my high school algebra teacher, and I had the honor of being his doctor later in life. He had primary progressive MS in an era where there were no treatments. Now not only was he an amazing man, he was also really tall. I mean, like 6’5”.

00:34:21:03 - 00:34:37:19
Dr. Boster
I'm a really tall 5’6”. So this guy is like way up there. He's a big man. And in his primary progressive MS had progressed to the point where he was having trouble using his walker, and he was spending more and more time sitting in a wheelchair. And he didn't want that to happen.

00:34:37:21 - 00:35:02:00
Dr. Boster
And so we came up with an exercise regimen. He went to a swimming pool with a physical therapist. He wore a life jacket and took his walker in the water, and he walked laps in the water with his walker and his life jacket for months. He came to my clinic and my MA said Dr. B, he won't do his test walk, because we do a times 25 a walk until you come out in the hallway.

00:35:02:02 - 00:35:19:13
Dr. Boster
So I came out in the hallway, and he looked at me and he said, are you ready, young man? And he picked up his walker and he walked 25 feet.

Mary Ray
Oh my gosh.

Dr. Boster
That's not a mythical story. That's a patient that I had the privilege of taking care of. That gentleman walked for several more years before he was fixed in a wheelchair.

00:35:19:14 - 00:35:42:09
Dr. Boster
Now he's passed away now, and I miss him, but I never forgot that lesson. It was really, really cool.

Mary Ray
That's amazing, and clearly a story that stuck with you over these years, and I got to say it’s inspiring. You know, this has been a tough year for many people. This pandemic has shut down gyms, pools.

00:35:43:02 - 00:35:59:03
Mary Ray
A dear friend of mine here in San Francisco, swimming is his thing. He has MS. He's in his 30s, and he cannot go to the pool. And so I think that's creating a lot of stressors for a lot of people. And this question comes from someone who wants to remain anonymous, but they say, my symptoms get worse,

00:35:59:03 - 00:36:21:22
Mary Ray
this is just general symptoms when I'm under stress, but subside when the stressors are relieved. 2020 has been a stress overload, and I feel weaker and more tired than ever before. What advice do you give? I mean, this question could go to all of us in society, how to manage stress?

Dr. Boster
So let's start by being honest with ourselves.

00:36:21:24 - 00:36:50:05
Dr. Boster
There is a global viral pandemic and there is a global mental health crisis presently. I'm being as serious as possible. There is a global mental health crisis. Mary, you have it, I have it. We're all suffering. And I would submit to you, we don't even have language, we don't have a lexicon to discuss how intense this is. My kids realized the other day that there will be textbooks studying 2020 100 years from now.

00:36:50:06 - 00:37:15:24
Dr. Boster
That's a fact. And I don't even think that we have the wherewithal to appreciate the intensity of this stress that you're referencing. So I think it's very important that we start by recognizing that it's real. So right now, you and I are not wearing masks, which is unusual because in any other forum we would be masked up and we'd be six feet apart, the whole nine yards.

00:37:16:01 - 00:37:47:22
Dr. Boster
Let's try this again. Pick a number two through ten.

Mary Ray
Three. Three.

Dr. Boster
So let's come up with my top three tips to help with stress in the COVID era. The first tip is to stop using Facebook and watching the news, not forever, but for a break, like a drug holiday, I challenge you. So if you're listening to me, I double dog dare you to take a week off of social media, says the doctor, who spends a lot of time on social media to MyMSTeam.

00:37:47:22 - 00:38:07:15
Dr. Boster
But but my point here is we are bombarded by negativity without realizing it. And there's good science actually that sometimes the time that we spend in certain social media forums is positive and wonderful, but sometimes it's not. And so one of the things that I would challenge you to do is to take a week off, a holiday.

00:38:07:17 - 00:38:39:18
Dr. Boster
It's life changing. And I've actually recommended that to patients a couple times a day, when necessary. So that's the first tip. The second tip is to fight against social isolation. Social isolation is extremely common in MS. And it's been linked to worsening depression, worsening outcomes. It's a monster. And in the COVID era, we are instructed to socially isolate like we're systemically told that we're supposed to, which is horrible.

00:38:39:18 - 00:39:14:03
Dr. Boster
So I want you to leverage smartphone technology. I bet you almost without exception, that every person who's listening right now has some form of internet communication device. And so the challenge, my second challenge is to FaceTime or chat with a video, someone that you love, or someone that you care about, your college roommate that you haven't talked to in ten years, or your auntie or your mom or your sister or your buddy, and it doesn't need to be for very long.

00:39:14:03 - 00:39:32:11
Dr. Boster
And I'm not talking about a phone call. I'm talking about a video chat where you can see them and connect with them. And if you don't believe me, just try it one time and you will experience something special, a connection. Because there is an entire world, a globe of people that are dealing with the exact same thing you are.

00:39:32:13 - 00:39:57:00
Dr. Boster
And we are social animals. We crave social interaction. And so looking at a college roommate or looking at your mom on video chat and talking for five minutes is really, really profoundly valuable. Number three is to exercise, but we have to change how we do it. So your friend is a swimmer. God bless. And right now he can't go to the pool,

00:39:57:00 - 00:40:28:19
Dr. Boster
and it's probably too cold in the water in San Francisco to swim in the ocean. And so what is he going to do? So he's got to be flexible in his exercise regimen. If you're listening to this, it means that you have internet access. And if you have internet access, then you could type into, say YouTube, multiple sclerosis yoga, and you will find hundreds of very smart people teaching you how to get your downward dog on, in a way that you can do in your living room.

00:40:28:21 - 00:40:48:12
Dr. Boster
So my point is we have to be creative because exercise is an antidepressant and exercise is healthy for us, and exercise is really, really important in MS, and we can't do it the way that we used to. We can't go to the class because the class doesn't exist. So you can join a virtual class or you can do something at your house, or you can walk your dog,

00:40:48:12 - 00:41:08:21
Dr. Boster
but we have to come up with a different tool to exercise. So those are three tips to fight the stress that we're dealing with.

Mary Ray
And what I'm hearing, what they all have in common is this idea of embracing adaptation, embrace what we have to modify, because we can't control this. We're all going through this, and this theme of

00:41:08:23 - 00:41:29:19
Mary Ray
all right. I'm sure people have heard that when they're in an exercise class, or doing yoga, or just basic stretches, or in rehab in physical therapy, try this modification. If you can't choose, try this modification. And in this world of COVID, try this modification.

00:41:29:19 - 00:41:47:19
Mary Ray
It's a brilliant way to kind of reframe this, and I think just understanding that we're all feeling this, and they're all in this world of isolation. I think it helps bring it together. And I will say on MyMSTeam, one thing that our team really works hard to do is ensure the spirit of this site does remain positive.

00:41:47:19 - 00:42:06:08
Mary Ray
One of the things that we recognize is that depression is a common comorbidity with a lot of chronic disease, including MS. And I know when someone has asked, why is that so common? And I think you had somewhat addressed it. I don't want to be too presumptuous, but social isolation is quite a bit of it,

00:42:06:08 - 00:42:30:04
Mary Ray
not to mention the sort of loss, like what we've seen in some of MyMSTeam’s research is loss of independence when you're not able to be mobile. Can you speak more about depression and MS?

Dr. Boster
I would like to. I want to come back to one critical point that you made about paradigm shifting. And and to be transparent, boys are not as good at this as girls.

00:42:30:06 - 00:42:49:13
Dr. Boster
So paradigm shifting is something that we struggle with a lot. And what I mean by that is, if you're a boy in the United States when you were 12, your dad took you outside with a 21 inch walk behind mower, and he showed you how to mow your lawn, and you've done it the same darn way every Saturday at noon, your whole adult life.

00:42:49:15 - 00:43:12:21
Dr. Boster
And if you have MS, going out on Saturday at noon in the full sun, I have had some patients that literally are on the ground. Their wife has to drag them back inside because the heat sensitivity and the motor fatigue took them out. And so I've had some guys that stop. They're stymie, they don't know what to do because they can't figure out how to get their man points

00:43:12:21 - 00:43:31:17
Dr. Boster
and mow their lawn, and so we have to paradigm shift. They have to wake up on Saturday morning before the sun is fully up, and they mow the front lawn only, and then they put the mower away. And then on Sunday, before church, they go and they mow the back lawn, and then they put the mower away. And by Sunday night, they get their man points.

00:43:31:17 - 00:43:52:12
Dr. BOster
They've accomplished the goal of making their yard look awesome. And they did it in a way that allowed them not to sit on the ground and hope their wife finds them to drag them back inside. It's all about paradigm shifting. And that's why earlier I talked about setting goals. Because when you talk about ambulation, it's not ambulation for the sake of ambulation,

00:43:52:12 - 00:44:16:00
Dr. Boster
it's goal oriented behavior. And in the setting of multiple sclerosis, where the disease can take things away from you, we have to grieve those losses. We have to admit, I really am pissed off that I can't do X or Y anymore. And then we have to paradigm shift to figure out how we can accommodate to achieve the same goal despite the loss.

00:44:16:02 - 00:44:38:12
Unknown
And I'll tell you, people who gain an understanding of that, they fare better, whether they're in a wheelchair or not, they fare better. Let's talk a little bit about depression. You brought that up, and that's a critically important point. And it's never been more important than right now. You know, November of 2020, when the whole world is on lockdown, it seems depression colors everything ugly.

00:44:38:12 - 00:45:06:22
Dr. Boster
It colors everything gray. And there's actually research that demonstrates that people impacted by MS who are depressed, get worse faster than those who don't. Allow me to say that again, people with MS who are depressed, progress faster in their neurological disability than those who don't, and it's a treatable condition. It starts by admitting that you're depressed. I'm not saying that to sound silly, but a lot of people don't want to admit that.

00:45:06:24 - 00:45:31:00
Dr. Boster
So let me help you out. My name is Aaron Boston and I suffer from depression. I see a counselor who's brilliant. I take a medicine, I sleep, I exercise, I do things that help me live my best life, despite having depression. And if you noticed, I didn't list one thing like the doctor takes a pill. He takes a pill, and he does a bunch of other stuff to live my best life despite having depression.

00:45:31:00 - 00:45:49:06
Dr. Boster
There's no shame in my game. I'm very proud to be able to thrive despite. And so in the same fashion, I think we have to start by admitting that I'm not feeling so awesome, you know, and then I am sad and blue. And then we can really start to get into innumerate ways of making that better.

00:45:49:08 - 00:46:13:02
Dr. Boster
The things I was talking about earlier about de-stressing your life, stepping away from social media for a break, FaceTiming your mom, exercising. Let me tell you a not secret. All three of those things, markedly help depression, and none of them are a pill.
Mary Ray
That's great to hear. I want to go into this next poll question, but you touch on so many different things,

00:46:13:02 - 00:46:33:20
Mary Ray
but this idea you hinted at of identity, people losing their sense of who they were, who they believe they were, and going through almost stages of grief until they get to that world of acceptance and understanding that, you know what, this is another dimension of who they are now. I got to make room for it, but it doesn't change who they are at their core.

00:46:33:20 - 00:46:50:06
Mary Ray
So thank you for breaking that down and inviting people to try to seek the help that they need to to treat that kind of isolation and perhaps, in some instances, depression. Thank you for also sharing your own personal connection to that. Not a lot of doctors do that, and I know the audience appreciates that here.

00:46:50:08 - 00:47:18:08
Mary Ray
So onto this poll question. Again, in the vein of symptoms, what, audience, with this for everyone here, what have you found most helpful in managing your symptoms? Dr. Boster, you've already talked about those who can adapt, those who kind of find a new paradigm shift, seem to seem to thrive. I'm very curious to see what our audience comes back with in terms of what they find most helpful in managing their own symptoms.

00:47:18:23 - 00:47:42:09
Dr. Boster
I’m excited to see the results also, that's a great question.

Mary Ray
Do you, as you think about that, what are some of the more, you know, interesting ways some of your patients… you shared your high school teacher’s story with the water rehabilitation in the pool. What are some other interesting- Wow, I hadn't seen that before,

00:47:42:15 - 00:48:01:15
Mary Ray
sort of managing of symptoms.

Dr. Boster
There's a bunch of things that we can do. One of my faves is horseback riding.

Mary Ray
Okay.

Dr. Boster
Yes. So, horseback riding can be really, really helpful for people impacted by MS, in part because you get to move really quick on a giant 2,000 pound animal, and that's kind of awesome,

00:48:01:15 - 00:48:21:22
Dr. Boster
and it makes you feel good. A lot of people don't get to stand up nice and tall and walk, but you can sit on a horse and be taller than everyone else, and that doesn't escape me, but the act of riding a horse uses a tremendous amount of muscles in a different way than almost any other activity.

00:48:21:24 - 00:48:44:20
Dr. Boster
And so it's actually very fantastic for core strengthening, for balance and for coordination. And so it helps a lot with core stability and strength. If anybody has ridden a horse, you get off the horse and you realize you have muscles you didn't know existed, because whoa, they really hurt. And so equine therapy is one that I think is really superb.

00:48:45:04 - 00:49:01:15
Dr. Boster
In the vein of like interesting things that people can do, that's a cool one.

Mary Ray
That's definitely, yeah that's great. I don't think people normally think about that. Just like with Alzheimer's, people don't really think about music therapy, or with autism, they don't think about equine therapy either.

00:49:01:15 - 00:49:26:20
Mary Ray
But these are all kind of unique techniques. So we have the results of how folks… Okay, most helpful. Exercise. Exercise is in the lead here followed by medication, then diet, and then complimentary treatments, sort of like acupuncture and that sort of nonmedical. So does this surprise you?

00:49:26:20 - 00:49:49:06
Mary Ray
Do these results surprise you?

Dr. Boster
Nope. They don't. I think we come back to the basics. Eating healthy is actually like a really good idea. I'm a big proponent of eating real food. I want you to eat food that has ingredients like apple, chicken, asparagus. I don't want you to eat foods that have words you can't pronounce, because guess what?

00:49:49:08 - 00:50:12:16
Dr. Boster
Those aren’t foods, those are chemicals. And in my experience, when my patients adopt a whole food, real food diet, they feel better. Allow me to repeat. They literally feel better when they avoid processed foods and fast foods and sugar-laden foods and fried foods. It's amazing what happens when you give up chemicals and soda pop, and you drink water.

00:50:12:24 - 00:50:34:05
Dr. Boster
It's really cool. So that doesn't surprise me. Exercise, which again, is one of my four tenants for winning despite having MS, it has to be part of your lifestyle. It needs to be just something that you do. And the exercise that you do might change over time. Paradigm shifting. You might come up with a different example.

00:50:34:07 - 00:50:52:13
Dr. Boster
I talked to a very special young man today. He's a remarkable human being. I love this guy, and he's legally blind, so he is completely blind in one eye, and he has pinhole, literally pinhole vision in the other eye. He has a stationary bike in his house. It's actually like a fancy Peloton, where you can log on.

00:50:52:13 - 00:51:11:12
Dr. Boster
And he loves that thing. He's addicted to it. And what he said really struck me today. He said, I can get on the Peloton, I don't have to worry about getting hit by a car. I don't have to worry about falling off a curb, I can just get on and I can truck. And I can pedal really, really hard and I can do the course. And as a blind person, he said,

00:51:11:12 - 00:51:34:00
Dr. Boster
it's empowering. That was such a cool thing that he shared with me. And I didn't think about a stationary bike as being so important, and it is.

Mary Ray
And in this world right now, too, because you said it's one of the four tenants, exercise in this world where we can't… Sometimes the parks are closed.

00:51:34:11 - 00:51:55:10
Mary Ray
Things are changing right now. Or it's just, you know, it's just difficult to find space in general, because you can't get to a gym where there might be some stationary equipment. There are a lot of solutions out there. Like you had mentioned, there are all kinds of free videos on YouTube that can accommodate all kinds of preferences of ways of exercising that you can do at home.

00:51:55:17 - 00:52:26:08
Mary Ray
Whether it's stretching or even moving in place at home, of course. What are some other sort of free solutions that you heard of? I mean, around the country, in-person patient support groups or in-person classes that might be offered by hospitals, rehabilitation pools, that sort of thing are all sort of shut off. What sort of other solutions have you heard besides Peloton? I know that there are travel equipment that doesn’t require weights that you can use, like TRX or bands.

00:52:26:10 - 00:52:50:13
Dr. Boster
I want to preface this by saying whatever it is that you're doing, you have to think it's fun. You can't do something that you think stinks because you won't do it for more than a week or two, maybe three weeks. So whatever it is that you game out, you need to think it's not horrible because we're talking about doing something as part of your lifestyle, you're not going to do something as part of your lifestyle that you think is stinky.

00:52:50:15 - 00:53:21:24
Dr. Boster
So with that said, let's talk about a couple like cool kid options. I'm curious, but I imagine in California you have the same thing we have here in Ohio. You have these stores that resell equipment like sports equipment.

Mary Ray
Yeah.

Dr. Boster
So we have like these stores like Play It Again Sports. And many times, if you look online, you can find a stationary exercise piece of equipment for under a hundred bucks, so you don't have to spend thousands of dollars on the most cool, fancy pants thing.

00:53:21:24 - 00:53:40:11
Dr. Boster
One of my patients showed me the other day, she spent $100 total, and she got a recumbent stationary bike that's in her bedroom, and it’s really cool. And it doesn't have a screen, it doesn't have any whistles, but she has her phone and she has earbuds, and she sits there in her bedroom and pedals her tush off,

00:53:40:16 - 00:54:02:24
Dr. Boster
and she loves it. And that's not a free option, but it's a relatively inexpensive option.

Mary Ray
Right, right. Cheaper than a gym, or going to the gym, and cheaper than a bike actually in fact, and with the convenience of being inside.

Dr. Boster
So let's use that theme of cheap exercise equipment. So many people listening to us right now have a piece of equipment, and I know exactly where it is.

00:54:02:24 - 00:54:21:15
Dr. Boster
It's in the spare bedroom on the second floor, or it's in their basement where they set up an exercise environment, and it has clothes hanging on it. Right.

Mary Ray
Yeah.

Dr. Boster
What I want you to do is not very feng shui. I want you to drag that sucker into the room you spend in the evening,

00:54:21:17 - 00:54:37:19
Dr. Boster
wherever you hang out between the hours of nine and 11pm, that's the room I want that equipment. And it's not very cool, but I want you to try it out anyways because here's what happens… You've had a rough day, you barely got through it all. Thank goodness gracious, you finally got the munchkins to shut up and go to sleep.

00:54:37:21 - 00:54:57:13
Dr. Boster
And so you and your spouse are sitting on the couch having adult time, which is American code for staring at the television. So we're sitting there staring at the television, and you're going to look over and say, darn it, Boster made me drag my stationary bike in the living room, and then something magical happens. Get on it during the commercial, just the commercial.

00:54:57:15 - 00:55:15:04
Dr. Boster
So every 15 minutes there's a three minute commercial. Get on the bike, pedal for three minutes, get back off. And if you're unplugged from cable and you just use Netflix at the top of every hour and at the bottom of every hour, get on for five minutes. If there's two of you, take turns. You do at the top and the bottom.

00:55:15:04 - 00:55:39:01
Dr. Boster
I do the left and the right of every hour. And what you'll find is during the classic two hours of American TV, you'll get 20-30 minutes of exercise snuck in during the commercial breaks. It's colossal, and you don't have to budget time. You don't have to put on your Lululemon. You can do it in your nightgown. You don't have to go anywhere because you're sitting there watching television anyways.

00:55:39:03 - 00:55:58:15
Dr. Boster
And all I'm asking you to do is during the commercial, pedal. It actually works remarkably well, believe it or not. I was going to say the last thing you just brought up, which is coming up with other other things to do. Stretch bands are very, very inexpensive.

00:55:59:00 - 00:56:13:24
Dr. Boster
And if you have a bungee cord in your truck, bring it inside and hold on to it really tightly, that's a stretch band. I mean, there's a bunch of ways to exercise. I mean, I can go on and on, but my point is, you have to find something that you don't hate that you can do.

00:56:14:01 - 00:56:34:03
Dr. Boster
And let me say one comment about the way that we exercise. So many red blooded Americans remember the heyday of high school football. They remember when they were the quarterback, and it's been a long time. And the thing is, they learned a style of exercise in high school. I call it the high school mentality.

00:56:34:05 - 00:56:52:06
Dr. Boster
If you can run a mile, I can run two miles, and if I can run two miles, I can run four miles. And if I stop, I quit everything. It's this binary high school mentality. And as adult human beings, particularly as adult human beings living their best life despite having MS, we have to throw the high school mentality out the window.

00:56:52:08 - 00:57:16:09
Dr. Boster
This is not about setting records. This is not about setting personal bests. This is not about beating the neighbor. This is about logging in some time. So here's what I tell many of my patients. If you go to the exercise environment, you get full credit. I don't care what you do. If you get onto the elliptical, you get credit for exercising, because it's a trick.

00:57:16:09 - 00:57:36:22
Dr. Boster
I know that if you get on it, you'll probably move a little bit. And if I can get you to get on the elliptical thrice weekly, eventually you're probably going to do a little bit of exercise. Because my thing is, I just want to get you in the habit that it's normal to get on the elliptical. You'll take care of the exercise on your own.

00:57:36:24 - 00:58:01:18
Dr. Boster
And instead of saying, I'll start with five minutes and next week I'll do ten, and the next week or 15. No, no, no, I want you to do five minutes until you don't even think twice about doing five minutes. And when you can crush five minutes, then I want you to do six minutes, not ten, six. And I want you to rock six minutes like it's your job, again and again, and again until six minutes is no big deal.

00:58:01:20 - 00:58:20:17
Dr. Boster
You might do six minutes for the next four months. I don't care, I just want thrice weekly for you to get on the elliptical during the commercial, and I want you to pedal, pedal, pedal. And we can slowly ease into a lifestyle and exercise, and sometimes you don't even realize it.

Mary Ray
Habits are interesting that way, bad ones as well.

00:58:20:17 - 00:58:41:24
Mary Ray
So what I thought we could do, and you've just given everybody sort of a playbook on maybe how to get more habitual about a really important tenant. And before we close, I would love you to remind everybody what your four tenants are regarding managing MS.

Dr. Boster
So I want my patients to be four for four in their fight against MS.

00:58:42:00 - 00:59:00:07
Dr. Boster
And when I say I want you to be four for four, it's because there are four things that I'm aware of that slow the disease down. So I want you to have four of them. So the first one is to not smoke things. So taking a carbon based material and lighting it on fire, and then sucking in the smoke is extremely pro-inflammatory,

00:59:00:09 - 00:59:20:13
Dr. Boster
and it doubles the risk to develop MS. And if you have MS, it speeds up the disease by 50%. So many of the first-line MS medicines slow it down by 30%. So by quitting smoking, you can have a larger impact on your disease than by taking a shot, which is insane, but it's true. So that's the first one

00:59:20:13 - 00:59:48:03
Dr. Boster
in being four for four. The second thing is to supplement low levels of vitamin D, and low levels of vitamin D drive MS faster. Levels under 50 are correlated with things that we don't like. Levels over 50 are correlated with really better outcomes. I had the privilege of talking to a young lady in Texas today on a telemedicine consult, and she lives literally like next to Mexico.

00:59:48:03 - 01:00:06:21
Dr. Boster
And I assumed incorrectly that she would be a bronze goddess. I mean, she is a bronze goddess, but I assumed she'd have a vitamin D level that was super high. It was 14. And so we have to check the vitamin D level, and we have to… So someone wrote it in the comments, E or D.

Mary Ray
D like dog, vitamin D, vitamin D.

01:00:07:02 - 01:00:29:16
Dr. Boster
And so what we're talking about doing here is supplementing low levels of vitamin D to drive the level up above the level of 50. So that's number two. Now there's other things about diet that I'm not talking about, but suffice to say we're going to supplement vitamin D. The third thing is that we want to exercise as part of your lifestyle, something that you and I have been talking about a little bit.

01:00:29:22 - 01:00:44:13
Dr. Boster
And the fourth thing is to take an MS medicine and make sure it's working. So those are the four things, when I want you to be four for four in your fight against MS. And I actually ask my patients, and I write it down on the chart, are you four for four?

01:00:44:13 - 01:01:07:02
Dr. Boster
Are you three for four? Are you two for four? Are you one for four? If you're three for four, that's a 75%. How comfortable are you getting a 75%? I'm not very comfortable with that.

Mary Ray
Right. Well, I really appreciate this, Dr. Boster. And we have many more questions. And honestly, to me, that's just another opportunity to kind of connect with you.

Dr. Boster
I would love it.

01:01:07:02 - 01:01:28:17
Mary Ray
And I want to share the details about that next event. Thank you, everyone, for joining, but here’s more details. So we have an entire webinar devoted to Doctor Boster called the Up Theres and The Down Theres, and it'll be on Thursday, December 10th. And there is a signup link in the chat, I think right now.

01:01:28:17 - 01:01:51:09
Mary Ray
So you can look and click there and preregister. Just for a sneak peek, Dr. Boster, remind people what the up theres are and the down theres.

Dr. Boster
Yeah, for sure. One time, a long time ago, I heard a patient referred to her down theres. And so she comes from a culture where it's not, it's not cool to talk about your personal private parts.

01:01:51:11 - 01:02:10:24
Dr. Boster
And she made reference to her down theres, and it struck me. So I talk all the time about the down theres: bowel, bladder and sexual function. Those are the down theres, and it's been my experience that human adults really like when the down theres work, like we're big fans of controlling our bowel, controlling our bladder, and having meaningful intercourse.

01:02:11:01 - 01:02:35:16
Dr. Boster
And so I'm very keen on making sure the down theres work and they're invisible. So if you have bladder incontinence or erectile dysfunction, or if you have profound constipation, honey, you look so good. You can't see it and yet it's a huge proponent of quality of life. And so the down theres are important to me. The up theres are also very important to me.

01:02:35:16 - 01:02:54:13
Dr. Boster
They're also invisible and they also are major proponents of quality life. Mood, which you and I have talked about a bit today, energy, which we also talked about, and cognition. And so when I'm talking to someone and I say, how are you doing? They say, I'm doing great. I'll say, are you really doing great or are you being socially polite?

01:02:54:15 - 01:03:09:21
Dr. Boster
And then when they say, no, no, I'm doing super, I say, okay, let's talk about the down theres. And sometimes they'll say crap. Why do you have to bring that up? But my point is, is that as we try to help people live their best lives, we want to make sure that the up theres and the down theres are working great.

01:03:09:21 - 01:03:28:19
Dr. Boster
And if they're not, we want to bring to bear everything we know how to do to optimize them.

Mary Ray
Fantastic. Well, we're all looking forward to just about four weeks from now, December 10th. Be sure to register. And thank you for joining us. And Dr. Boster, and thank you, everyone, for being here. This has been fantastic advice.

01:03:28:19 - 01:03:50:20
Mary Ray
The information support doesn't end here, everybody. If you are not already a member of MyMSTeam, please go there, sign up, connect with people who’ve been on this call here, and share some of the insights that you have, and how best you manage your own symptoms. You'll find people in the activity feed who have been there as well, and who can appreciate having a positive attitude about what's going on.

01:03:51:09 - 01:05:01:23
Mary Ray
If you'd like to become a member, just go to MyMSTeam.com and sign up for free. Remember, you are not alone. And thank you again so much, Dr. Boster. And thank you everyone for joining us for our latest Dr. Boster MyMSTeam event. Take care. We'll see you next time.

Dr. Boster
Take care guys. Have a great evening.

Mary Ray
Cheers.