Multiple sclerosis (MS) is an autoimmune disease of the brain and nerves that’s still considered incurable. However, MS may be put into remission, and different diets and complementary approaches are promoted to do so. In this post, we review conventional treatments and complementary approaches to MS.
Disclaimer: This post is not a recommendation for any particular type of MS treatment. Make sure to discuss your options with your personal doctor; none of the complementary approaches described below should be used to replace medical treatment. The goal of this post is simply to inform our readers about the science and evidence behind some potential complementary approaches to MS, which may or may not be effective.
Conventional MS Treatment
Although there is no universal cure for MS, several therapies have proven effective in preventing the progression and relapses of the disease. There are no known therapies that promote the regeneration of these deficits because MS damages neurons in the brain [1].
Spontaneous recovery is rare if the damage to the neurons has progressed longer than 6 months [1].
MS’s long-term disability progresses slowly over many years. As a result, many treatments mitigate the short-term symptoms of the disease [2].
1) Glucocorticoids
A patient with MS (relapsing-remitting MS or primary progressive MS) will commonly face relapses or attacks, which are flare-ups of new or recurring symptoms. Administration of high doses of glucocorticoids (methylprednisolone) or corticosteroids is the current routine therapy for acute relapses [3, 2].
The advantages of using glucocorticoids include rapid functional recovery in patients with acute attacks [2].
Limitations
Administration of intravenous glucocorticoid can lead to potential side effects such as reddening of the face, ankle swelling, and a metallic taste in the mouth. Oral administration of glucocorticoids has more side effects including disturbed sleep, mood changes, and stomach problems [3].
Also, glucocorticoids only mitigate the short-term symptoms of MS without dealing with the long-term effects [2, 4].
High doses of glucocorticoids will not affect long-term disease improvement because of the treatment’s limited effects on MS lesions in the brain. The irreversible damages are not being regenerated [5].
Glucocorticoids may also have detrimental effects on bone density, increasing the risk of bone fracture [6].
2) Disease-Modifying Therapies
Disease-modifying therapies (DMTs) were created and approved to manage the long-term effects of MS by slowing the natural course of the disease. Clinical studies have demonstrated that disease-modifying therapies (interferon beta, glatiramer acetate) have anti-inflammatory effects and slows the progression in relapsing-remitting multiple sclerosis (RRMS) patients [7].
Some disease-modifying therapies (IFNb-1a) promote nerve growth factors (NGF) to support the repair of neurological damage, leading to a decrease in lesion activities and disease relapse rates [8].
Disease-modifying treatments (IFNb, glatiramer acetate) also reduce the attack rates or relapses in relapsing-remitting multiple sclerosis patients and is effective at mitigating those attacks in the earlier stages [2].
Limitations
Some common adverse side effects of disease-modifying therapies (IFNb, glatiramer acetate) include bruising, redness of the skin, pain, irritation, skin lesions, swelling, and sometimes cell death (necrosis) [9, 10].
Other rare potential side effects of disease-modifying therapies (IFNb) include immune system problems (psoriasis), insomnia, hearing loss, hair loss (alopecia), and in more severe and rare cases, liver damage [9, 11].
Primary progressive multiple sclerosis (PPMS) is characterized by the progressive worsening of neurologic functioning from the onset of the disease, usually targeting one part of the brain (usually the spinal cord). As the disease progresses, the symptoms increases.
Most of the disease-modifying therapy drugs (IFNb, glatiramer acetate) were approved and effective for relapsing-remitting MS. Most of these drugs are not effective against primary progressive MS [2, 7].
3) Ocrelizumab
Primary progressive MS is problematic and tricky because patients do not respond to currently available treatments. About 10% of the patients have primary progressive MS, which accumulates neurological deterioration without relapses [12].
On March 28, 2017, the FDA approved ocrelizumab (produced by Hoffmann-La Roche) as the first treatment for primary progressive MS [13, 14].
Ocrelizumab is a biologic immunosuppressive drug (anti-CD20 monoclonal antibody) that binds to immune cells (B cells) and prevents those cells from exerting harmful effects on the body [15].
During clinical trials, ocrelizumab has reduced relapse rates by 46%-47% and disability progression by 40%. Ocrelizumab also incredibly reduced inflammation and decreased the progression of lesions in the brain [16].
Limitations and Contraindications
Ocrelizumab is contraindicated in patients with hepatitis B or allergic reactions to ocrelizumab. It can increase the risk for respiratory tract infections, viral infections of the brain (Progressive Multifocal Leukoencephalopathy), or breast cancer [17].
Ocrelizumab is a relatively new, approved drug and the FDA required Hoffmann-La Roche to continue post-marketing surveillance (phase IV trials) and report any risks, side effects, or adverse effects associated with the drug [18].
4) Neuromuscular Electrical Stimulation
Neuromuscular electrical stimulation can be used to treat some of the physical symptoms of MS such as mobility problems, fatigue, and tremors.
Neuromuscular electrical stimulation has been effective in treating muscle spasms, muscle pain, and muscle degeneration (disuse atrophy) [19].
It has also demonstrated efficacy in alleviating some of the symptoms of lower urinary tract complications in MS, such as incontinence [20].
Despite all of these effects, further studies are needed to validate the results [21, 19].
The Wahls Protocol Review
The Wahls Protocol developed by Dr. Terry Wahls involves a modified paleolithic diet with antioxidants, nutritional supplements, stretching, neuromuscular stimulation, and strengthening exercises. The purpose of this regimen is to increase the quality of life and combat fatigue, a disabling symptom of multiple sclerosis [22].
The Wahls Protocol diet claims to [23]:
- reduce inflammation
- improve mitochondrial function
- correct nutritional deficiencies that contribute to the disease
- reduce oxidative stress and protect the nerve cells by providing dietary antioxidants
Important nutrients in the Wahls Protocol include vitamin D, calcium, magnesium, omega-3 fatty acids, coenzyme Q, and dietary enzymes [24].
The Wahls Protocol is categorized into 3 levels – Wahls Diet (allows gluten-free grains and legumes), Wahls Paleo, and Wahls Paleo Plus with varying levels of restrictions. The Wahls Paleo Plus recommends using fats liberally and reducing proteins to enter ketosis.
The following are foods and recommendations related to the Wahls Protocol Diets [25]:
- Green leafy vegetables – recommended 3 servings
- Sulfur-rich vegetables such as cruciferous vegetables, onion-family vegetables, and mushrooms – recommended 3 servings
- Intensely colored fruits or vegetables – recommended 3 servings
- Omega-3 oils – encouraged 2 tablespoons
- Animal protein – encouraged 4 ounces or more
- Organic meats – at least 1 serving per week
- Plant protein – encouraged 4 ounces or more
- Nutritional yeast – encouraged 1 tablespoon
- Alternative types of milk (soy, almond, peanut, rice, and coconut) – encouraged, subjective to individual choice
- Kelp – encouraged ¼ teaspoon
- Green algae – encouraged ¼-1 teaspoon
- Gluten-free starchy vegetables and fruits – allowed only 2 servings per week
- Added fats, including coconut oil, avocados, olive oils, nuts, and seeds
The protocol also recommends eating 2 meals a day and fasting 12 – 16 hours every day (including sleep time).
Potential Mechanism
1) It is a mild ketogenic diet.
Ketogenic diets have shown beneficial effects on many neurological diseases including epilepsy, Alzheimer’s, and Parkinson’s diseases [26].
A ketogenic diet might help with MS by:
- Inhibiting mTOR, thus suppressing Th1 and Th17 dominance, while increasing Treg [27]
- Reducing glucose metabolism, which protects against glutamate-induced toxicity and oxidative stress in the brain [28]
- Activating autophagy, which allows for cellular clean up of damaged myelin and neurons [29]
- Supporting myelination [30]
- Increasing Sirt1 (important for cognitive function, brain, and synaptic plasticity) and BDNF levels by ketone bodies [31, 32]
2) Eliminates common food irritants
The Wahls Protocol eliminates gluten, dairy, and certain legumes, which are some of the most inflammatory foods for sensitive people with autoimmunity.
By eliminating gluten, the diet may reduce leaky gut and leaky brain through the zonulin pathway. Dairy protein butyrophilin is similar to proteins on myelin, which could trigger MS [33].
Legumes contain lectins, but they are allowed on the Wahls protocol if prepared properly to reduce lectins and other harmful substances.
3) It is a micronutrient-dense diet that may support the mitochondria.
The basis of the Wahls Protocol is that it supplies a lot of nutrients and antioxidants.
The mitochondrial enzyme that consumes oxygen (complex IV) can be blocked by nitric oxide, which is generated in high levels around active MS lesions [34, 35]. This can cause symptoms of low oxygen, increased oxidative stress, and subsequently brain degeneration.
The mitochondria, therefore, is a potential therapeutic target for MS treatment. However, a challenge in devising such therapy is that it is difficult to ensure that these antioxidants enter the brain, the affected cells, and the mitochondria [36].
Additional studies would be necessary to test whether this diet improves MS outcomes through supporting mitochondrial function.
By providing a lot of fats and other micronutrients, this diet also provides building blocks that support brain health and brain regeneration [37, 38].
4) More Than a Diet
Management of autoimmune diseases typically involves much more than diet alone. The Wahls Protocol addresses these other factors by recommending:
- Exercise, which helps stimulate neuronal regeneration by increasing BDNF and NGF
- Neuromuscular stimulation, which helps reduces spasms and muscle wasting
- Meditation and stress management, which reduces inflammation
- Reducing toxic load, which is a risk factor and may cause or worsen MS
Is It Effective?
In the few studies that are available, this diet seems to have a disease-modifying effect. It not only reduces symptoms but also helps with the regeneration of the destroyed neuronal tissues beyond what conventional treatments could do.
For Dr. Terry Wahls herself, the diet, in combination with exercise and neuromuscular electrical stimulation, reversed most of her MS symptoms. In a short pilot study involving 12 MS patients, the diet, together with exercise, stretching, massage, and meditation, significantly reduced fatigue [39, 40, 25].
However, currently available evidence doesn’t allow for definite conclusions. Additional larger and controlled studies would be necessary to demonstrate the safety and effectiveness of this protocol.
The Swank Diet Review
The Swank diet was developed in the 50s before multiple sclerosis was well understood as an autoimmune disease. Interestingly, the term “autoimmune” was not used in any of Dr. Swank’s published reports, including ones that were published as late as in the 90s.
This diet is based on the (incorrect or incomplete) assumption that saturated fat consumption caused MS because the incidence of MS seemed to be higher in regions and during times of higher fat consumption. The author, however, was aware that saturated fats or fat consumption can’t be the sole cause of MS [41].
The Swank diet, developed by Dr. Roy Swank, consists of eating foods with very low saturated fat (less than 20 grams a day). Butterfats and hydrogenated oils are eliminated from this diet. The diet contains lean meats such as fish, seafood, skinless turkey, and the white meat of the chicken. These meats are supplemented with skimmed milk, vegetables, cereal, nuts, and one egg a day [42].
The diet diminished the frequency of attacks and the severity of MS in 47 patients treated by Dr. Swank, but the study is old and observational (lacks a control group) [41].
So far only one cohort study has examined the relationship between fat consumption and MS risks. This study reported that low consumption of omega-3 fatty acids, but not high consumption of saturated or animal fats, was associated with increased MS risks [43].
A recent controlled study of 31 patients demonstrated that a low-fat diet supplemented with fish oil decreased the number of MS relapses [44].
In summary, there’s no solid scientific background and clinical evidence to support the Swank Diet as a dietary regimen for MS.
Complementary Approaches Multiple Sclerosis
Reminder: none of the complementary approaches described below should be used to replace MS medical treatment. Make sure to discuss your options with your personal doctor and see if any of these approaches may be a valuable addition to your standard treatment.
Possibly Effective:
1) Physiotherapy and Exercise
Physical therapy, or rehabilitation exercises, are helpful in reducing fatigue in patients who are not bed-bound [45].
A meta-analysis of many clinical studies demonstrated that exercise therapy is generally safe for MS with the exception of falls. The odds of relapse triggered by exercise is low [46]. However, care should be taken to prevent the exacerbation of symptoms from body heat generated by exercise.
These exercise therapy for MS can be beneficial to patients not experiencing an exacerbation [47, 48].
2) Chiropractic Medicine for Pain Relief
Pain medication carries the risk of addiction. Chiropractic medicine serves as a viable alternative to the mitigation of chronic pain caused by MS [49]. However, the lack of knowledge and moderate uptake of chiropractic medicine has been the limiting factor for widespread use [50].
Spinal manipulation in chiropractic medicine has been shown to mitigate acute and chronic lower back pain. This technique alleviates pressure and stiffness caused by other tissues in previous injuries or degenerative conditions [49].
Although chiropractic medicine shows strong potential to be a physical treatment for MS, more studies are needed to validate the efficacy of these treatments [51].
3) Massage Therapy
Massage therapy may help with MS, with benefits including [51]:
- Pain reduction
- Reduced spasms
- Improved circulation
- Increased joint and limb mobility
- Decreased fatigue
The conditions that cause fatigue in MS are not well defined. Damages to the (central) nervous system such as MS lesions and inflammation can contribute to fatigue. Massage therapy has been shown to diminish fatigue and pain in MS patients [52].
Tight muscle tension can cause direct pain in the muscles by activating the pain receptors and restricting blood flow to that area (ischemia) [53].
Massage helps reduce the tension in the muscles leading to pain and spasm reduction. Massage also increases blood flow to affected areas. Other benefits of massage include relaxation and sleep improvement [54].
Relaxation caused by massage therapy also reduces anxiety and stress levels by increasing parasympathetic nervous system activity and decreasing cortisol [55].
Stress reduction not only increases the quality of life in MS patients but also helps manage physical symptoms [53].
Massage may be a safe, non-invasive complementary option that helps manage stress and the physical symptoms of MS [56].
4) Reflexology
Reflexology is one of the most common and low-cost treatments in complementary medicine [57].
Reflexology is the study of how one part of the body is related to another. Application of the appropriate pressure and massage will stimulate other parts of the body, exerting its therapeutic effects [58].
Reflexology applies pressure with the thumb and fingers to specific points of the feet that are related to internal organs or glands [51].
Foot reflexology therapy effectively increases blood and lymph circulation, which helps stabilize the movement of muscles, joints, and tendons. This improvement in mobility also reinforces muscle strength and promotes relaxation [59].
The following are potential benefits of reflexology in the context of MS [60, 57]
- Reducing pain
- Stopping muscle spasms
- Reducing bladder and bowel problems
- Improving mobility
- Decreasing fatigue
In a randomized, sham-controlled clinical trial (53 participants) on reflexology, specific reflexology treatment has demonstrated alleviation in mobility, sensation, and urinary symptoms in MS patients [61].
Supplements for MS
Insufficient Evidence:
No valid clinical evidence supports the use of these supplements as complementary approaches to MS. Below is a summary of up-to-date animal studies, cell-based research, or low-quality clinical trials which should spark further investigation. However, you shouldn’t interpret them as supportive of any health benefit.
Omega-3 Fatty Acids
Low intake of omega-3 fatty acids can increase the risk of MS [51].
Omega-3s can be found in fish, fish oil, flaxseeds, flaxseed oil, soy products, walnuts, hemp and chia seeds, and more [62].
Some of these fatty acids, such as DHA, can cross the blood-brain barrier and act as a major component of neuronal cell membranes. These compounds can not only act as an anti-inflammatory agent but also an inhibitor to T cell transportation to the brain (inhibiting MMP-9) [62].
MS patients have elevated transportation for T cells (elevated MMP-9 proteins and mRNA) in the (central) nervous system. Omega-3 FA inhibits T-cell migration through the blood-brain barrier [63].
In a study of 312 participants, taking omega-3s showed no significant difference compared to the controls. However, the results displayed a slight trend to improvement in the omega-3 treated subjects. The diet of the participants was a confounding effect in the study [64].
Vitamin D3
Vitamin D modulates the immune system. Low vitamin D3 has been associated with MS risks. Among MS patients, lower levels of vitamin D is associated with worse clinical outcomes [65].
Clinical trials have shown certain immune-supporting effects of vitamin D supplementation in MS patients, but they failed to confirm a significant improvement in symptoms [65].
However, since vitamin D supplementation is generally safe, it may be recommended as part of the treatment plan for MS by some doctors.
