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What goes on inside the head of doctors when deciding on the best course of treatment for a patient with multiple sclerosis? In Therapeutic Advances in Chronic Disease, Inojosa and colleagues likened the decision-making process to a highly strategic game of chess, with the ultimate aim being to “checkmate” the disease.

“In current times with more and better options, complex strategies may be necessary to take advantage of the available resources,” they wrote.

“Using analogies with one of the most popular board games in history (chess), we reinforce in this review the focus on the long-term strategic approach for the treatment of MS patients, beginning on the first suspect of the disease with radiologically or clinically isolated syndrome, through the first diagnosis and up to further disease scenarios such as increased disease activity or therapeutic adverse events.”

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Let’s think of the neurologist as the ultimate chess player whose main goal is to win the battle against multiple sclerosis. In this scenario, like all chess players, neurologists should be well-acquainted with the different strategies and tactics that can be used to manage patients with the disease.

The key goal is to stabilize or slow disease progression. This is best begun when the patient first demonstrates symptoms of multiple sclerosis, which is often the diagnosis of a clinically isolated syndrome.

Read more about multiple sclerosis etiology

The best opening move is to prescribe a disease-modifying therapy (DMT), since the early use of DMTs is currently recommended for maximum effect. If the patient develops further inflammatory events, a diagnosis of multiple sclerosis according to the McDonald criteria should be considered. The McDonald criteria for diagnosing multiple sclerosis allow for an early and sensitive diagnosis to be made while preserving a high degree of specificity.

Including Patients on the Team

At this point, physicians should educate their patients on what to expect clinically, including the nature of symptoms, complications, and relapses. The patient should be made to understand that follow-ups will need to be conducted at regular intervals and that they must be strictly adhered to. 

Read more about multiple sclerosis patient education

In the Multiple Sclerosis Journal, Kalb and colleagues provided a fact sheet of things that newly diagnosed multiple sclerosis patients should be aware of: 

  • Cognitive impairment may present limitations in the workplace and in social settings. 
  • Patients who are significantly impaired cognitively may experience challenges in holding onto a job or finding new employment. 
  • A decline in information processing is associated with lower income. 
  • Patients may find it difficult to perform everyday life tasks, such as using the internet. 
  • Patients may struggle with mood and behavioral problems. 
  • Patients with cognitive impairment may struggle to drive a vehicle safely. 

This makes for a harrowing conversation between physician and patient, but it is best to be honest from the very onset in order to adjust patients’ expectations.

Staying Ahead of the Disease

Returning to the chess analogy, it is important that physicians remain agile in their decision-making process to stay one step ahead of the disease. This means keeping an open mind about the choice of DMTs and when to escalate treatment, factoring in the economic impact of certain drugs, and keeping an eye on current and future research. 

Inojosa and colleagues summarized the ideal approach when evaluating treatment options for multiple sclerosis patients: 

  1. Determining the needs of the patient
  2. Finding ways to achieve the stated objectives
  3. Comparing possible treatment strategies
  4. Blunder-checking before taking any decisive action
  5. Performing a re-evaluation of current strategies. 

To overcome multiple sclerosis, we need a new breed of physicians who are willing to leverage the collective experience of their entire team and take into consideration all possible avenues for slowing the progression of the disease before committing to a particular treatment strategy. 

“This MS–chess analogy reflects several similarities in both strategic approaches. In the lifelong challenge to fight against MS, neurologists share personal characteristics, mentality, and actions with grand chess masters,” Inojosa and colleagues concluded. “Both MS and chess require study and playing, theory and practice, in order to become a great MS chess master and dominate the game against this challenging heterogeneous disease.”


Kalb R, Beier M, Benedict RH, et al. Recommendations for cognitive screening and management in multiple sclerosis careMult Scler. 2018;24(13):1665-1680. doi:10.1177/1352458518803785

Inojosa H, Proschmann U, Akgün K, Ziemssen T. The need for a strategic therapeutic approach: multiple sclerosis in checkTher Adv Chronic Dis. 2022;13:20406223211063032. doi:10.1177/20406223211063032