Сергей Пузанов – Multiple Sclerosis. Everything you need to know (страница 13)

The rigid paper idyll of 1996 held ground for seventeen years, until the march of technology forced Fred Lublin's committee to audit its own rules. In 2013, scientists finally admitted the old classification system was blind: it evaluated purely outward symptoms while completely ignoring the warfare inside the skull. With the arrival of high-powered MRI scanners, it became obvious that the disease could "remain silent" clinically for years while continuously burning out fresh sectors of the brain. Lublin upgraded the system, ruthlessly liquidating the rare fourth type (PRMS) and hardcoding rigid markers—descriptors of activity and progression. From then on, disease courses stopped being static labels: MS was split into "active" and "not active," based on whether a scanner spotted fresh hotspots. Around the same era, new players entered the board: Clinically Isolated Syndrome (CIS), which flags the very first neurological alarm bell, and Radiologically Isolated Syndrome (RIS), where symptoms are non-existent but the tomograph already catches plaques.

Medicine tried desperately to make its paper rooms more flexible, but it only delayed the inevitable. Fresh data from clinical registries was prepping a total alternative to Lublin’s classification: PIRA, or Progression Independent of Relapse Activity. For a long time, doctors believed that during the relapsing-remitting phase, disability only climbs in tiny steps during physical relapses. However, massive recent studies that over-analyzed data from tens of thousands of patients exposed a terrifying truth. It turned out that even when a person goes years without a single flare-up and their MRI scans remain completely clean, multiple sclerosis quietly and continuously burns out the nervous system from within. Smoldering neurodegeneration, as it turned out, is responsible for 80 to 85% of long-term functional decline. This hidden atrophy doesn't wait around for a doctor to officially switch a patient's label to "secondary-progressive"—it fires up from day one of the disease, transforming the division of MS into separate courses into a bureaucratic formality.

Picture the spinal cord as a highway with a dozen lanes: you’re driving smoothly in your lane, listening to your favorite music, and don't give a damn about the state of the asphalt. When multiple sclerosis assaults your lane, you plow into a pothole and experience your first "relapse"—to feel fine again, you just need a course of pulse therapy and a lane change. The slow expansion of a lesion forces you to switch lanes regularly, but as long as there are enough lanes for everyone on the road, it doesn't bother you, and you register it as a "relapsing-remitting course." From time to time, you hit potholes; doctors log "relapses" and extinguish them with hormones. When potholes take over half the road, cars start swerving aggressively and traffic slows down—I’m sure you’ve found yourself in that bottleneck. The true disaster, however, unfolds when practically no lanes are left. Traffic grinds to an absolute halt, and the doctor utters the terrifying words: "secondary-progressive sclerosis." Then again, if your car features a spectacular suspension or if you happened to drive down a lucky lane, you might never notice the potholes at all—in which case, the sclerosis is classified as "primary-progressive."

The situation with the brain is roughly the same, except instead of a highway, you should visualize a massive drifting track. This track is truly titanic, meaning there is far more room to steer around the potholes—which explains why the brain possesses vastly superior neuroplasticity compared to the spinal cord. This is partly anchored in cell counts: the brain carries 86 billion neurons, while the spinal cord holds only 15 million. It’s also critical that 25% of the brain's axons aren't covered in myelin at all, whereas in the spinal cord, that applies to only 5 to 10%.

Following the 2013 classification rewrite, it took another decade for cutting-edge neurologists to admit that Lublin’s concept of "isolated rooms" wasn't just outdated—it was actively harming patients. The actual tectonic shift toward the "continuum" model occurred in October 2024 at the main European ECTRIMS Congress in Copenhagen, when an international panel of experts officially rolled out a massive overhaul of the McDonald diagnostic criteria. Professor Xavier Montalban and his colleagues dealt a heavy blow to the bureaucratic fragmentation of the disease. The 2024 framework erased the foundational border between relapsing and progressive sclerosis, merging them into a single, indivisible diagnostic box: the continuum.

MS was declared a single, indivisible biological process that flows uniformly through a person's entire life. Clinical medicine finally woke up to a harsh reality: while an RRMS patient injects first-line DMTs and celebrates "clean" scans, the slow fire of PIRA is continuously burning out the free lanes of their highway. This revolution inverted the old philosophy of treatment. The escalation strategy—where heavy weapons like Ocrevus or Cladribine were hoarded for a "rainy day" while waiting for an official transition to the secondary-progressive stage—was exposed as a dangerous misconception. The new paradigm demands attacking the disease with maximum force immediately after the very first alarm bell. The objective is to lock down the hidden neurodegeneration and repave the highway before the cars grind into a permanent, incurable traffic jam.

As a multiple sclerosis patient myself, I sincerely hope that the "continuum" concept takes root and completely replaces the harmful "escalation" strategy. Then again, we have to look reality in the eye—it is highly unlikely that the paradigm will shift dramatically over the next few years. The division of multiple sclerosis into separate courses is so deeply entrenched in the medical world that even those who understand the disease correctly are forced to use the abbreviations RRMS, PPMS, and SPMS. Don't forget that this classification is hardcoded into every official source—textbooks, clinical manuals, and clinical trial protocols. Overturning this approach will require many people to utter the terrifying words: "I have been wrong my entire professional life." Consequently, it will likely take a generational turnover of neurologists. But on a macro level, isn't it deeply ironic that Charcot, who first described sclerosis back in 1868, turned out to be completely right in the end?

On Relapses and Remissions of Multiple Sclerosis

The most dangerous myth in the entire MS treatment grid is the concept of relapses and remissions. Frankly, the situation is identical with other autoimmune conditions: their "remissions" reflect a clinical pause, not a biological one. Psoriasis, rheumatoid arthritis, Crohn's disease, Hashimoto's thyroiditis—none of these diseases have true remissions; they only have the illusion of them. Once an autoimmune error occurs, the immune system fires up like a self-sustaining nuclear reactor. The chain of destruction never hits pause just because a patient happens to feel better. Do lymphocytes ever stop a war before a virus is completely wiped out? In autoimmune diseases, they operate exactly the same way—except the body's own tissues are cast in the role of the virus.

The fact that MS symptoms can appear and vanish was clocked back in the first half of the 20th century, long before autoimmune diseases were even discovered. Ever since, it has been an accepted dogma that the disease strikes in sudden bursts, or "relapses". When symptoms stop progressing, doctors declare that the relapse is over and the disease has hit pause—entering "remission". One reason this belief is so bulletproof is that the healthcare machinery hates gray zones. The slow, gradual decline of sick patients is simply too messy for standardized metrics. Over time, the system settled into an artificial equilibrium. The relapse and remission model lives on in the public consciousness largely because the entire global MS treatment market is engineered around it.

A "relapse" is defined as the appearance of new symptoms or the worsening of old ones, sticking around for at least 24 hours. A "remission" is a window where the patient's condition improves, and symptoms disappear or back off significantly. The most common track of multiple sclerosis is considered to be the relapsing-remitting course (RRMS)—a track where bursts of symptoms alternate with windows of calm. It is a baseline assumption that entering remission simply requires "extinguishing" burning lesions with a course of corticosteroids. This became the core component of the treatment model: if you hit a relapse, you get pulse therapy, then you take your DMTs and live your life—right up until the next relapse. The vast majority of neurologists and patients share a rock-solid conviction: if lesions aren't burning, multiple sclerosis has gone to sleep, and the destruction of nervous tissue has stopped.