Neurologic Exams: The Difficulty of Detecting Neurologic Disease

Early Detection of MS

Early detection of neurologic disease, including multiple sclerosis, is not easy. No single test can diagnose MS. Plus, the symptoms are not always obvious to the patient and their doctors at the onset of the disease. And there lies a dilemma: early diagnosis of MS enables earlier intervention. Early intervention in the form of Disease Modifying Therapy (DMT) can decrease the percentage of high-risk patients who go on to develop MS. (Read more about early treatment of MS in our blog here). Therefore, while challenging, early detection is critical as it makes the greatest impact on future treatment and disability. Symptoms need to be recognized and acted on quickly.

There are no symptoms, physical findings, or laboratory tests that can by themselves determine if you have MS. In fact, a diagnosis involves a process of elimination, ruling out other possible causes of whatever symptoms the patient is experiencing. Before a diagnosis of MS is considered definitive, a careful study of medical history, a neurologic exam, and various lab tests including an MRI, spinal fluid analysis, and blood tests are conducted to exclude other possible causes.

What’s Involved in Neurologic Exams

In the best-case scenario, the patient makes their way to  see a neurologist or an MS specialist.  Even so, a thorough and consistent evaluation is not always possible — even at an MS center. First, neurologic assessments are difficult even for trained neurologists. Assessments are lengthy and involved. The list of what’s required includes:

• A thorough medical history
• An extensive physical examination
• Calculation of disease-specific scales (like disability scores) that include detailed neuropsychological evaluation of poorly recognized cognitive issues
• Time for the doctor and their staff to synthesize all the information

What Makes Neurologic Assessment Difficult

From a holistic perspective, neurologic assessments are fraught with challenges. Here’s why:

1. It’s time consuming. In-person neurologic examinations often take more than 90 minutes.
2. Many years of post-medical school training is required to acquire the expertise and clinical acumen to conduct an accurate assessment.
3. It’s time sensitive. As mentioned above, early detection is key to mitigating MS progression. That means when a patient senses something is wrong, they need to be able to see a specialist as soon as possible.
4. Our overburdened health care system means that a patient may instead wait months to schedule an in-office appointment and neurologic exam.
5. The results of the neurologic examination can be variable. Most striking is that even when you have two MS specialists performing the same standardized tests, the findings are subjective and vary from provider to provider.

An online medical educational resource describes the challenge of neurologic exams as follows: “Of all the assessments you conduct on your patients, neurological assessment is probably the most nuanced and challenging to master.”

Trends Challenging Treatment of Neurologic Diseases

Two trends exacerbate the situation. Supply and demand are moving in opposite directions. The number of patients with neurologic conditions is growing while there is a shortage of neurologists available to see them. In fact, at this time fewer than 50% of patients with neurologic conditions are seen by neurologists.

In 2013, an NIH study reported on a nationwide shortfall in its ability to provide neurology services. At the time of the report, the average wait time for new patients to see a neurologist had increased in just two years by 24%, from 28.1 business days to 34.5 business days. The shortfall has continued and is expected to worsen over the next two decades. The number of neurologists is projected to shrink by 20% over the next 20 years.  A 2022 report from the American Academy of Neurology characterizes the shortage of neurologists in the U.S. as a “grave threat” to providing high-quality patient care and to the specialty of neurology.

Primary care physicians, while many are quite talented, are also overwhelmed by the number of patients they must care for and are limited by the time available to spend with each patient. They often spend less than 15 minutes with each patient.  Primary care physician tend to focus on pressing medical issues other than neurologic complaints. Fewer than one-half of primary care physicians even perform a neurologic exam.

What’s Involved in a Neurologic Exam

To fully understand the complexity of neurologic assessment, it’s helpful to review its many components. While the exam may vary between practices, it generally includes cognitive testing, motor strength and control, sensory function, gait (walking), cranial nerve testing, and balance. During the exam, skills such as coordination, language comprehension, fluency of speech, eye control, and many other skills are evaluated. Here’s a rundown:

• Cognitive examination: Assessment of level of alertness, awareness, concentration, and memory
• Mood assessment: A two item and nine-item Patient Health Questionnaires, PHQ-2 and PHQ-9 may be used to screen for depression.
• Motor testing: An evaluation of the patient’s movements, strength, and muscle tone
• Sensory Examination: Testing of sensation to sharp and light touch, temperature, position, and vibration. Among these tests, the ability to sense vibration will be examined with a vibrating tuning fork.
• Reflexes: The healthcare provider checks various reflexes.
• Walking and coordination: Evaluating a patient’s gait (walking) includes coordination, balance, vision, muscle strength, and sensation. In addition to the effect of coordination on gait, coordination is tested separately. A few tasks will identify coordination issues.
• Language: Evaluation of fluency and comprehension.
• Cranial nerve examination. Assessment of the 12 pairs of cranial nerves that emerge from the brainstem.

BeCare MS Link Solution

BeCare MS Link has been developed to address both the complexity of neurologic exams and the shortage of neurologists. Our mobile app offers remote, ongoing monitoring of MS – effectively empowering MS patients to conduct assessments at home. The free app for patients delivers quantified neurologic results that replicate most of the testing described above. The patient can perform these tests on the app at home, or in a doctor’s waiting room. The results can help guide non-specialists in decision making. The 13 gamified activities plus the “About Me” questionnaires in the BeCare MS Link provide comprehensive data – covering the range of in-office testing described above.

Using our app, an MS patient can see their results in about 15 minutes whenever they want. Patients may choose to update the results when they feel a change or just when they need reassurance.

With the results in hand, the patient can reach out to their physicians to alert them of any changes. Via the BeCare MS Link Physician’s Portal, physicians can see a more detailed interpretation of the results and be more able to act when, and if, they need to.

Interested in checking it out our app? Go to the Google Play or the App Store, and download the BeCare MS Link now.