Wellness Practices That Can Improve Multiple Sclerosis Outcomes

By Mary R. Rensel, MD

There’s growing evidence that multiple sclerosis (MS) and vascular comorbidities make for a toxic combination. Based on the North American Research Committee on Multiple Sclerosis (NARCOMS) database, we know that when the two intersect, mortality rates tend to rise.

Patients with MS who have diabetes, high blood pressure, coronary artery disease or another vascular comorbidity experience onset of ambulatory disabilities six years earlier than other MS patients do, on average, according to a large analysis of outcomes from the NARCOMS Registry (Neurology. 2010;74:1041-1047). And that time quickens with each additional comorbidity.

If we can help prevent vascular conditions through lifestyle strategies, we can improve or maintain quality of life for our patients with MS.

5 recommendations for MS patients

At Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research, we advise patients with MS to see their primary care provider (PCP) regularly. PCPs provide health screenings, vascular risk management, immunizations and management of other health conditions that may not be handled routinely by a neurologist.

However, neurologists do play a role in supporting wellness and preventive medical care. For MS patients of all ages and disease stages, we recommend the following.

1) A low-salt Mediterranean diet. Recent evidence (Neurol Sci. 2017;38:389-398 and J Neurol Neurosurg Psychiatry. 2015;86:26-31) points to sodium intake as a potential factor in MS disease activity. Moderate or high amounts of salt in the diet can increase the risk of relapses and the formation of new lesions. Data suggests limiting sodium intake to less than 2,000 mg a day in individuals with MS and less than 1,500 mg a day for those with MS and heart disease risk factors (NHLBI, Implementing Recommendations for Dietary Salt Reduction).

Most studies concur that the Mediterranean diet — rich in fish, olive oil, whole grains, vegetables and nuts — is an effective anti-inflammatory diet. That makes it a wise choice for those with inflammatory disorders like MS. Some research shows that a Mediterranean-style diet helps maintain brain health and may reduce the risk of MS (Alzheimers Dement. 2017 May 19 [Epub ahead of print]).

2) At least 150 minutes of moderate movement per week. Regular aerobic exercise can improve fatigue from MS (Ann Neurol. 1996;39:432-441) as well as some brain repair functions (Neurobiol Learn Mem. 2017;144:77-85). At the Mellen Center, we recommend that patients with MS follow the same exercise guidelines as the general population: 150 minutes of moderate movement per week. A combination of aerobic activities and stretching has helped many of our patients improve stamina and reduce MS symptoms. Physical and occupational therapists are central to developing appropriate exercise programs, which often incorporate yoga and Pilates.

3) Vitamin D levels between 40 and 70 ng/mL. Various studies suggest a link between vitamin D and MS, as reviewed by Mokry and colleagues in their recent Mendelian randomization study (PLoS Med. 2015;12:e1001866), which was strongly supportive of such a link. People with higher levels of vitamin D are less likely to develop MS (JAMA. 2006;296:2832-2838), and people experiencing MS relapses have lower vitamin D levels than when they’re clinically stable (Ann Neurol. 2010;67:618-624).

The evidence for vitamin D supplementation in MS is inconclusive, but having 40 to 70 ng/mL seems to help minimize disease progression and brain lesions in the majority of studies (Lancet Neurol. 2010;9:599-612 and Neurology. 2010;74:1852-1859, among others). At the Mellen Center, we conduct testing and adjust dosage of vitamin D supplementation for patients with MS annually.

4) No smoking or tobacco products. Smokers have a higher risk of autoimmune conditions, including MS. Smokers with MS have more neurological disability, as well as more brain lesions and higher risk of brain atrophy (J Neurol Neurosurg Psychiatry. 2016;87:181-187). Smokers who quit have less progression of MS disability (JAMA Neurol. 2015;72:1117-1123).

Strategies such as pharmacologic interventions can improve smoking cessation rates by 50 to 150 percent. That’s why we regularly address tobacco use during office visits and offer both counseling and pharmacologic aids to maximize likelihood of cessation success (Nicotine Tob Res. 2008;10:507-517).

5) Routine mental health screening. Depression is more common in MS patients than in the general population and can lead to worsening fatigue and cognitive function (J Neurol Neurosurg Psychiatry. 2005;76:469-475). Moreover, psychological stress has been linked to the emergence of new MS brain lesions (Neurology. 2000;55:55-61). Evidence shows that screening and management of psychological comorbidities, including connecting patients with a cognitive behavioral therapist when needed, improves not only quality of life but also MS outcomes.

Make time for wellness assessments

Patients with MS often find additional wellness advice online — but much of it isn’t supported by scientific evidence. Making patients aware of evidence-based recommendations can prevent them from becoming distracted by, or spending money on, unproven products and behaviors.

Having sufficient time to discuss wellness issues at routine medical visits may not be possible. That’s why the Mellen Center offers wellness assessments in supplemental sessions, including one-on-one wellness and integrative medicine assessments with advanced practice providers. Another option is shared medical appointments, where groups of MS patients learn about and practice nutrition, yoga, guided imagery and other wellness strategies. We also offer access to multiple wellness providers in physical, occupational and speech therapy sessions and work in collaboration with Cleveland Clinic’s Wellness Institute.

New study to identify best MS wellness interventions

In the next few months, we at Cleveland Clinic will begin a study on wellness interventions and MS outcomes. While there have been numerous studies on the effect of wellness on MS with comorbidities, this study will evaluate MS alone. One goal is to identify and quantify the most beneficial wellness interventions.

Dr. Rensel is Director of the Multiple Sclerosis Health and Wellness Initiative at Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research. She is board-certified in neurology and integrative holistic medicine.