Earlier today, CIONIC announced three new Centers of Excellence, as well as the appointment of Enrique Alvarez, MD, PhD, associate professor of neuroimmunology at University of Colorado School of Medicine and the vice chair of clinical research for the department of neurology, to CIONIC’s Scientific Advisory Board. I had an opportunity to sit down with Dr. Alvarez to discuss his work at the forefront of multiple sclerosis (MS) care, as well as why he is excited to join the CIONIC SAB.
Dr. Alvarez is a neuroimmunologist and sees patients with autoimmune conditions affecting the brain and spinal cord, including MS. Neuroimmunology is a discipline within neurology and addresses complex medical conditions like multiple sclerosis which present so differently on an individual level. Neuroimmunology investigates the interactions between the nervous system and the immune system. It focuses on understanding how immune responses impact neurological health and vice versa.
Neuroimmunologists study conditions where the immune system mistakenly attacks the nervous system, such as MS. They explore the underlying mechanisms driving these diseases, identify potential targets for treatment, and develop strategies to modulate immune responses to preserve neurological function.
It is this deep specialization that allows neuroimmunologists to gain a more comprehensive understanding of complex medical conditions and adjust treatment to improve outcomes for their patients.
From Medical School to MS Neuroimmunologist
Dr. Alvarez always knew he wanted to go to medical school. In his words, “I always joked that I didn’t have much of an option — I knew I was going to medical school. The only option was which specialty in medicine I would choose. I like science and medicine, and have always been interested in balancing patient care and research.”
He attended medical school at the University of Colorado and spent a year interning there before moving to St. Louis to do his neurology residency at Wash U, which was followed by a three-year fellowship through the National MS Society at Wash U before he ultimately returned to University of Colorado School of Medicine.
When asked how he chose neurology, he said, “I was fascinated by the thinking process for the field. While other fields are more concrete–where something like a blood test can demonstrate a clear diagnosis–neurology involves talking to patients, understanding how symptoms develop, and connecting the dots. It is an interesting puzzle, and there is always more to learn.”
When asked about his interest in MS specifically, it was a calling. “MS neuroimmunology was interesting to me because it’s such a unique disease. It is a younger patient population with fewer additional diseases but it presents so individually. Because of this, it’s a condition that must be studied deeply. In doing so, there was a lot we could do, both regarding treatment options as well as symptomatic interventions to improve quality of life.”
“Being a neuroimmunologist is a way to be highly focused on one thing. For patients with conditions under [a neuroimmunologist’s] care, we can really get good at managing a lot of the symptoms that a generalist may not recognize. In neurology, and specifically with MS, there are a lot of symptoms that are unclear. When you’re focused you have more comfort in understanding what is and is not part of MS,” he went on.
Current Areas of Focus
“As my career has progressed, the percentage of time spent on patient work and research has changed. When I started my career, my focus was primarily patient work, but today I spend more time on research. I love research, but I am always interested in clinical questions, specifically what kinds of questions patients have and how we answer them,” he says. “As faculty, I can stay close to the clinical side of the field which I love, while also progressing research.”
Dr. Alvarez is currently leading research on many different topics to advance understanding and efficacy of multiple sclerosis treatment. His research on biomarkers began when he was a fellow and continues today.
Biomarkers research assists with understanding many aspects of multiple sclerosis, from early detection to disease progression and management. This work investigates what proteins might be available to evaluate in spinal fluid (learn more in this recent conversation with Dr. Alvarez following ECTRIMS last year). As part of this ongoing work, Dr. Alvarez works “in collaboration with others to provide samples, think through the types of patient populations to evaluate, and conduct ongoing analysis.”
Dr. Alvarez is also investigating the comparative effectiveness of different disease-modifying therapies (DMTs) used to treat MS over time, and evaluating the benefits and risks for how and when to use high-efficacy drugs in the course of an individual’s MS treatment [cit].
“I’m very interested in treatment paradigms and de-escalation. The key is preventing the advancement of disability earlier, so this often means starting with high-efficacy drugs. As we age, our immune systems become less effective, so it becomes less likely for individuals living with MS to have a relapse,” he said. “What we are looking at is how do we adjust care over time to account for this change and provide optimal patient care.”
Dr. Alvarez also collaborates closely with other neurologists and, in particular, neuroimmunologists specializing in MS care. In his words, “There are a small number of MS neuroimmunologists. We all know each other. We specialize in different things: disease-modifying therapies, how to diagnose MS (MRIs, blood-based biomarkers), rare things that might point to bigger trends, etc. Because there are different areas of specialization, we conduct research and educate each other as we advance the collective understanding of multiple sclerosis.”
The Importance of Mobility and MS Care
Dr. Alvarez talks a lot about preventing disability progression as early as possible. One critical piece of the puzzle is prescribing the right DMTs and other therapeutics at the right time during an individual’s disease progression. Another piece is the symptomatic interventions that individuals can do over time to manage symptoms and maintain mobility.
As Dr. Alvarez thinks about mobility, he shared some advice for individuals early in their MS journey. “Do everything you can to prevent disability. During the first 6–12 months it’s easy to crawl into denial, but the younger you are, the faster you bounce back. Keep compensating — stay active. Emphasize wellness in whatever way is right for you — diet, exercise, etc. Most importantly, stay active physically and mentally — all the things that general medicine recommends for everyone, but that we’re never good at doing. It’s easy when we’re busy to deprioritize exercise and physical activity, and it gets hard to become active the older we are.”
Promising New Technology
As part of CIONIC’s Centers of Excellence initiative, UCHealth University of Colorado Hospital is now a facility where experts in neurologic care, including Dr. Alvarez, will be able to integrate the Neural Sleeve into treatment for patients.
He first learned of the Neural Sleeve when he saw it on a patient. This individual had been using functional electrical stimulation (FES) for mobility, but it wasn’t providing ankle support or correcting inversion during gait, which was resulting in an uncomfortable slapping effect for the patient.
“He was able to get better control of his gait with the Neural Sleeve. Between the app access where we could make real-time adjustments, as well as increased stability with the additional control points, the Neural Sleeve corrected his issues. Not only did it get rid of the slap, it also fixed the inversion and increased ankle stability.”
“When I first saw the Neural Sleeve, it was fairly new, but it looked like it was a different type of product and a few patients had told me they were using it and found it was really helping. Through being part of the SAB, especially since we’re on the first version of the Neural Sleeve, I’m also excited to see how can we use it from a research perspective, as well as collaborate with CIONIC to improve the overall product experience,” Dr. Alvarez said.
“At times, it feels like people can lose hope about how much they can do to positively impact their disability levels. By staying active and continuing exercise, for example with the Neural Sleeve, you can slow down the delay or progression associated with MS, as well as regain the confidence to get out and about,” he added.
One of the things the CIONIC team is most excited to collaborate on is progress over time and measuring outcomes. As Dr. Alvarez says, “You can send people to movement labs, but what is the right measure in a clinical environment? The 25-foot walk test is important, but only a moment in time. Because the Neural Sleeve is used longer-term, there will be better measures that will be more reflective of the real benefits of exercise for individuals living with MS.”
“When things are working it all works,” he concluded.
Our work at CIONIC is in many ways just getting started. In collaboration with leading medical experts like Dr. Alvarez, we look forward to a future where the millions of people living with mobility differences have access to better care, and where advances in technology are deployed to help people with disabilities live more freely and independently.
