Multiple Sclerosis and Complementary Health Approaches: What the Science Says
Clinical Guidelines, Scientific Literature, Info for Patients:
Multiple Sclerosis and Complementary Health Approaches
Physical and Psychological Approaches
There is some limited evidence suggesting beneficial short-term effects of yoga on fatigue and mood in people with MS, but scientific studies overall had a high risk of bias and definitive conclusions could not be drawn.
What Does the Research Show?
- A 2020 systematic review and meta-analysis of 10 randomized controlled trials involving 693 patients evaluated the effect of yoga intervention on the quality of life and fatigue in patients with MS. The meta-analysis found that the effect of yoga intervention on fatigue in patients with MS was significantly better compared to the typical MS care group, but did not show significant difference compared to the exercise group.
- The 2014 evidence-based guidelines from the American Academy of Neurology concluded that the data are inadequate to assess the effect of yoga on disability, spasticity, fatigue, cognition, mood, balance, or walking speed in people with MS.
- In the studies included in a 2014 systematic review and meta-analysis, yoga was not associated with serious adverse events.
- People with certain medical conditions, including MS, should modify or avoid some yoga poses.
There is insufficient evidence to support the use of reflexology for most symptoms of MS, including pain, health-related quality of life, disability, spasticity, fatigue, depression, and others. However, 2014 evidence-based guidelines from the American Academy of Neurology concluded that, based on four studies, reflexology is possibly effective for reducing MS-associated paresthesia over 11 weeks.
What Does the Research Show?
- The 2014 evidence-based guidelines from the American Academy of Neurology concluded that, based on four studies, reflexology is possibly effective for reducing MS-associated paresthesia over 11 weeks. However, the guidelines state that data are inadequate to support or refute the use of reflexology for pain, health-related quality of life, disability, spasticity, fatigue, cognition, bowel or bladder function, depression, anxiety, or insomnia in MS.
- A 2011 update of a systematic review evaluating the evidence of 23 randomized controlled trials of reflexology in patients with any type of health condition found that 8 studies suggested that reflexology is effective for several conditions, including MS. However, the reviewers concluded that the best clinical evidence does not demonstrate convincingly that reflexology is an effective treatment for any condition.
Reflexology is generally considered safe for most people; however, vigorous pressure applied to the feet may cause discomfort for some people.
There is some limited, low-level evidence that suggests that magnet therapy may have modest beneficial effects on spasticity outcomes in people with MS, but the studies have been of low methodological quality. There are also some data from two studies, suggesting that magnet therapy may be useful in reducing fatigue in people with relapsing-remitting MS.
What Does the Research Show?
- A small 2016 study (63 participants) on electromagnetic therapy for multiple sclerosis–related paresthesia pain found that 60 days of twice weekly pulsed electro-magnetic field (PEMF) therapy for 20 minutes per session was effective in reducing pain in people with multiple sclerosis. A smaller reduction in pain was also found after 30 days of PEMF treatment. No recent research is available on static magnet therapy for paresthesia pain from multiple sclerosis.
- The 2014 evidence-based guidelines from the American Academy of Neurology concluded that magnet therapy is probably effective for reducing fatigue in relapsing-remitting MS, and probably ineffective for reducing depression in relapsing-remitting MS over 15 weeks. There is insufficient evidence to support the use of magnet therapy for reducing MS-related disability, bladder control problems, or spasticity, or on improving cognition, mobility, sensation, or vision.
- A 2013 Cochrane review of 9 randomized controlled trials involving a total of 301 participants concluded that there is “low level” evidence for non-pharmacological interventions, including magnetic stimulation for beneficial effects on spasticity outcomes in people with MS. The studies included in the review were of low methodological quality and had high risk of bias.
- Magnets may interfere with the functioning of some medical devices (e.g., pacemaker, insulin pump) and may not be safe for some people. Otherwise, magnets are generally considered safe when applied to the skin.
- Reports of side effects or complications have been rare.
Hyperbaric Oxygen Therapy
Although hyperbaric oxygen therapy is often heavily marketed to people with MS, there are no consistent data that support the use of hyperbaric oxygen therapy for the treatment of MS.
What Does the Research Show?
- A 2010 meta-analysis of 12 randomized studies concluded that hyperbaric oxygen therapy does not produce any clinically significant benefits in MS.
- A 2004 Cochrane review had similar findings. The review of nine studies of hyperbaric oxygen therapy for the treatment of multiple sclerosis found no consistent evidence to confirm a beneficial effect. The reviewers also noted that based on available evidence, routine use is not justified.
When safety guidelines are strictly adhered to, hyperbaric oxygen therapy appears to be generally safe. The predominant complication is pressure equalization problems within the middle ear. Serious complications are rare.
Orally administered cannabinoids (cannabis extract, synthetic tetrahydrocannabinol [THC]), mucosally delivered cannabinoids (cannabis THC and cannabidiol [CBD] extract oral spray, nabiximols (brand name Sativex), and smoked cannabis have all been studied for therapeutic effects in MS. Based on available evidence, cannabinoids may relieve spasticity and/or pain in people with MS; however, no marijuana-derived medications are approved by the U.S. Food and Drug Administration to treat MS. Sativex has received regulatory approval in more than 25 countries outside the United States for the treatment of spasticity (muscle stiffness/spasm) due to MS. There are insufficient data to determine if using marijuana ameliorates symptoms of MS. Additionally, the psychoactive properties and other potential adverse effects need to be considered. Sativex is licensed in the United Kingdom for use as an add-on treatment for MS-related spasticity when people have shown inadequate response to other symptomatic treatments or found their side effects intolerable.
There is insufficient data to determine if smoking marijuana ameliorates symptoms of MS. Additionally, the psychoactive properties and other potential adverse effects need to be considered.
What Does the Research Show?
- A 2022 Cochrane review of 25 randomized controlled trials involving a total of 3763 participants found that compared with placebo, nabiximols probably reduces the severity of spasticity in the short term in people with MS. The reviewers were less certain about the effect on chronic neurological pain and health-related quality of life. A 2018 systematic review and meta-analysis of 17 trials involving a total of 3,161 participants found limited efficacy of cannabinoids such as THC, CBD, THC:CBD formulations, pharmaceutical cannabinoids (dronabinol and nabilone), smoked cannabis, and oral cannabinoid extracts for the treatment of spasticity, pain, and bladder dysfunction in patients with MS. Another 2018 systematic review of 11 reviews providing data from 32 studies (including 10 moderate-to-high quality randomized controlled trials) found sufficient evidence that cannabinoids may be effective for symptoms of pain and/or spasticity in MS. A 2015 systematic review and meta-analysis of 79 trials (involving 6,462 participants) found moderate-quality evidence to support the use of cannabinoids for the treatment of chronic pain and spasticity in people with MS.
- Oral cannabinoids. The 2014 evidence-based guidelines issued by the American Academy of Neurology concluded that oral cannabis extract is established as effective for reducing patient-reported spasticity symptoms and pain. This subjective benefit is possibly maintained for 1 year. The guidelines also concluded that THC is probably effective for reducing patient-reported symptoms of spasticity and pain. This subjective benefit is possibly maintained for 1 year. However, the guidelines state that oral cannabis extract and THC are probably ineffective for reducing both objective spasticity measures and MS-related tremor symptoms. Oral cannabis extract and THC are possibly effective for reducing symptoms and objective measures of spasticity over 1 year.
- Oromucosal cannabinoid spray. The 2014 American Academy of Neurology evidence-based guidelines concluded that Sativex oromucosal cannabinoid spray is probably effective for improving subjective spasticity symptoms and is probably ineffective for reducing objective spasticity measures over 6 weeks or bladder incontinence episodes over 10 weeks. Further, the guidelines state that Sativex oromucosal spray is possibly ineffective for reducing MS-related tremor over 15 weeks. In addition, a 2010-reported meta-analysis from 666 MS patients who had spasticity that was not well controlled using existing treatments were given either nabiximols (363) or placebo (303). Results showed nabiximols effects are typically seen within 3 weeks. Furthermore, about one-third of the MS patients given nabiximols had a 30 percent improvement from baseline. The authors noted the treatment appeared reasonably safe.
- Smoked cannabis. Based on two small studies, the 2014 evidence-based guidelines issued by the American Academy of Neurology concluded that data are inadequate to determine the safety or efficacy of smoked cannabis used for spasticity/pain, balance/posture, and cognition.
- In the studies that were the basis for the 2014 American Academy of Neurology guidelines, cannabinoids were generally well tolerated, although some serious adverse effects were reported. Mild or moderate side effects including dizziness, somnolence, drowsiness, lightheadedness, memory disturbance, and difficulty concentrating were more common in participants receiving cannabinoids vs placebo. Less common effects included increased appetite, nausea, vomiting, constipation, dry/sore mouth, myalgia, seizures, and others. The guidelines noted that because cannabinoids have known psychoactive properties, their potential for psychopathologic and neurocognitive adverse effects is a concern, especially in a patient population that may be vulnerable due to underlying disorders.
- The guidelines recommend that clinicians counsel patients about the potential for psychopathologic/cognitive and other adverse events associated with cannabinoids. Sativex oromucosal cannabinoid spray is not approved by the U.S. Food and Drug Administration and is unavailable in the United States. Further, the guidelines suggest caution should be exercised with regard to extrapolation of results of trials of standardized oral cannabis extract (which are unavailable commercially) to other nonstandardized, nonregulated cannabis extracts (which may be commercially available in states with medical marijuana laws).
- Although people sometimes think that CBD products are completely safe, they may not be. Unlike Epidiolex (the purified CBD product sold as an FDA-approved prescription drug), over-the-counter CBD products may contain more or less CBD than stated on their labels, and because of inadequate quality control, they may also contain contaminants, such as THC.
According to 2014 clinical practice guidelines issued by the American Academy of Neurology, there is strong evidence that Ginkgo biloba is ineffective for improving cognitive function in people with MS. The guidelines also state that there is weak evidence that Ginkgo biloba is possibly effective for reducing fatigue.
What Does the Research Show?
- The 2014 evidence-based guidelines from the American Academy of Neurology concluded that Ginkgo biloba is ineffective for improving cognitive function in people with MS, but that it is possibly effective over 4 weeks for reducing fatigue in MS. These conclusions are based on four small studies.
- A 2012 randomized controlled trial involving 120 participants with MS with some cognitive impairment found that Ginkgo biloba twice a day for 12 weeks did not improve cognitive performance.
- A 2011 Cochrane review of four randomized controlled trials evaluated pharmacologic treatments, including Ginkgo biloba, for memory disorder in MS. The reviewers concluded that based on available evidence, there is no convincing evidence to support the use of Ginkgo biloba as an effective treatment for memory disorder in MS patients.
- Side effects of ginkgo may include headache, nausea, gastrointestinal upset, diarrhea, dizziness, or allergic skin reactions. More severe allergic reactions have occasionally been reported.
- There are some data from animal models to suggest that ginkgo can have an effect on the pharmacokinetics of several drugs; however, current available clinical evidence suggests that low doses do not pose a risk for clinically relevant herb-drug interactions.
- Fresh ginkgo seeds contain large amounts of ginkgotoxin, which can cause serious adverse reactions, including seizures and death. Roasted seeds can also be toxic. Products made from standardized ginkgo leaf extracts contain little ginkgotoxin and appear to be safe when used orally and appropriately.
- National Toxicology Program (NTP) studies showed that rats and mice developed tumors after being given a specific ginkgo extract for up to 2 years. Further studies are needed to find out what substances in ginkgo caused the tumors and whether taking ginkgo as a dietary supplement affects the risk of cancer in people.
Omega-3 Fatty Acid Supplementation
There is insufficient data to assess any real beneficial effects of omega-3 fatty acid supplementation on MS. 2014 evidence-based guidelines from the American Academy of Neurology concluded that a low-fat diet with fish oil supplementation is probably ineffective for reducing MS-related relapse, disability, or MRI lesions, or for improving fatigue or quality of life.
What Does the Research Show?
- The 2014 evidence-based guidelines from the American Academy of Neurology concluded that, based on three reviewed studies, a low-fat diet with fish oil supplementation is probably ineffective for reducing MS-related relapse, disability, or MRI lesions, or for improving fatigue or quality of life.
- A 2020 Cochrane review of 30 trials examining dietary interventions, including polyunsaturated fatty acids (PUFAs) and dietary plans with recommendations for specific whole foods, macronutrients, and natural health products, concluded that PUFA administration may not differ when compared to alternatives with regards to relapse rate, disability worsening, or overall clinical status in people with MS; however, evidence is uncertain.
- Omega-3 fatty acid supplements usually do not have negative side effects. When side effects do occur, they typically consist of minor gastrointestinal symptoms.
To date, results of studies have been conflicting as to whether vitamin D may provide a therapeutic benefit for people with MS. A 2018 Cochrane review found very low-quality evidence suggesting no benefit of vitamin D for patient-improving outcomes among people with MS. However, findings from a 2018 meta-analysis suggest that vitamin D supplementation may have a therapeutic role in the treatment of MS. Further high-quality studies are needed before definitive conclusions can be drawn.
What Does the Research Show?
- A 2018 Cochrane review of 12 randomized controlled trials involving a total of 933 participants with MS found very low-quality evidence suggesting no benefit of vitamin D for patient-important outcomes. The reviewers concluded that vitamins D appears to have no effect on recurrence of relapse, worsening of disability, and MRI lesions. Effects on health-related quality of life and fatigue were unclear.
- A 2018 meta-analysis of 12 studies involving a total of 950 participants found that vitamin D may be useful in the treatment of MS; however, the findings were not sufficient to recommend vitamin D supplementation at present.
- Results of a large, 5-year randomized trial in 468 participants with MS suggest that low blood levels of vitamin D may be a risk factor for long-term disease activity and progression. However, more studies need to be conducted to determine if vitamin D supplementation affects disease course and progression.
- Limited intervention studies in MS suggest that vitamin D supplements are generally well tolerated in MS.
- High doses may cause fatigue, abdominal cramps, nausea, vomiting, renal damage, and other adverse effects.
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