Integrated Traditional & Western Medicine: Getting Results in Multiple Sclerosis Management

By Angela Carroll Adv. Dip. H.Sc. (Nat.), Adv. Dip. H.Sc. (Acu.), Adv. Dip. H.M.

The idea of successfully managing a condition like Multiple Sclerosis (MS) is an exciting one. However, the reality of dealing with MS in our clinics is often overwhelming and fraught with trepidation and confusion. What is MS? How does it start? What perpetuates the condition? Can it really be successfully "cured"? In this article I hope to give you a clearer picture of what MS is and what its drivers are; I will also be making suggestions for treatments you can use to help your MS patients.

MS is an Inflammatory Condition

MS is a major cause of neurological disability in Western societies and is the most common chronic disabling central nervous system (CNS) disease in young people. It is an autoimmune, inflammatory, demyelinating condition of the CNS. It is characterised by lesions consisting of inflammatory demyelination with glial scar formation and axonal loss. Axonal loss seems to be driven by inflammation and autoimmune destruction of tissue. The target antigen of the immune response has not been identified,1 though studies have shown that tissue damage is induced by a variety of different components of the immune system, including T-cells, autoantibodies and activated effector cells, such as macrophages and microgalia.

Blood-Brain Barrier Disruption

An interesting question researchers have been studying is how can inflammatory mediators get access to the brain and spinal cord tissue? Surely the blood-brain barrier (BBB) would prevent their passage? Normally, the endothelial cells lining the blood vessels supplying the CNS provide a tight barrier, preventing the passage of antibodies and inflammatory cells. However, in MS, for unknown reasons, the BBB is "leaky". These leaks result in the movement of inflammatory cells and cytokines into the CNS and subsequent destruction of CNS tissues. It is for this reason that BBB disruption has been considered one of the early problems in MS. However, whether BBB dysfunction is the cause or the consequence of MS is still disputed.

Repeated Attacks Impair Repair

Oligodendrocytes are the cells responsible for the formation of the myelin sheaths, though unfortunately these cells cannot completely rebuild a destroyed myelin sheath. When an oligodendrocyte repairs damaged myelin in MS, the newly-formed myelin sheaths are thinner and often not as effective as the original ones. Repeated MS attacks lead to fewer effective remyelinations and the formation of scar-like plaques around the damaged axons. This demyelination and scar formation reduces neuronal transmission efficiency and causes the symptoms typical of MS.

Why is There No One Consistent Therapy That Works?

There is currently no single treatment option available for MS patients that satisfactorily addresses all the various aspects of this disease. This may be due to the fact that MS is not the same in all patients and its aetiology is complex. Research at the Mayo Clinic in the US has identified four different MS patterns, each of which expresses its own individual type of lesion. Patterns I and II show close similarities to T-cell mediated autoimmune encephalomyelitis, while Patterns III and IV are associated with oligodendrocyte dystrophy, possibly induced by a virus or toxin-inducing demyelination, rather than due solely to autoimmunity.

Viral Infections May Causes MS

Viral infections may trigger MS. Herpes virus infection correlates with MS risk, as does infection with Epstein-Barr virus (EBV). EBV produces a cytokine similar to interleukin (IL)-10 called vIL-10. The vIL-10 may elicit a host immune response capable of neutralising or depleting IL-10, or the vIL-10 could compete with IL-10, but fail to perform an essential IL-10 function, that is: anti-inflammatory activity and assisting the immune system to recognize self from non-self.4 Additionally, it has been speculated that an increased load or altered presentation of EBV proteins cross-react with cellular antigens triggers and perpetuate the pathogenic processes that result in MS.

Metabolic Contributors to MS Pathology

There are a number of metabolic factors that may be linked to development and/or progression of MS. Recent research on MS has revealed a swathe of contributing factors to this condition, including homocysteine levels. Homocysteine levels are higher in patients with MS than in controls Hyperhomocysteinaemia (HHCy) has been associated with cognitive impairment in various neurological diseases, including MS. Hypomethylation related to HHCy is the most likely mechanism of impairment of cognitive functions

Disordered lipid metabolism is also found in MS. The enzyme phospholipase A2 (PLA2) acts on arachidonic acid to produce inflammatory cytokines. This enzyme is more active in MS patients, possibly contributing to the inflammation seen in these patients.

Brain Changes May Cause MS

Changes in CNS cell activity and neurotransmitter activity may contribute to MS pathology. Microglia are a type of immmune cell that acts as the first and main form of active immune defence in the CNS. These cells become activated in a broad spectrum of inflammatory neurodegenerative diseases, including MS. Inflammation activates microglia, which then act to destroy neurons; these activated microglia are widely believed to be the principal source of inflammation induced neuronal degeneration in MS.

Matrix metalloproteinases (MMPs) are myelinotoxic enzymes produced by activated immune cells. In patients with MS, increased amounts of MMP-9 are produced by CNS microglial cells in comparison with control cells.

Changes in neurotransmitter levels are also implicated in aetiology of MS. The neuroexcitotoxic compound, glutamate is present in higher levels in the cerebrospinal fluid of MS patients during relapses, compared to controls and MS patients before relapses.

Nutritional Considerations for Ms Patients

A number of nutritional deficiencies are linked to MS. For example, compared to healthy controls, MS patients have been found to have deficiencies in iron and calcium. Low concentrations of antioxidant vitamins beta carotene, retinol, alpha tocopherol and ascorbic acid have also been observed in serum or cerebrospinal fluid of MS patients.

Interestingly, MS has an increasing prevalence in populations residing at higher latitudes. Low vitamin D levels correlate strongly with high MS risk. The CNS converts vitamin D into a biologically active hormone with anti-inflammatory and neuro-protective functions. So daily sunlight exposure or vitamin D3 supplementation should be considered as an important aspect of MS treatment.

Addressing MS in a Clinical Setting: Herbal Help

Multiple sclerosis is a complex disease and calls for integrated treatment approaches to address the metabolic, inflammatory and immunological aspects of the disease.  Based on all the research findings discussed, the following are some suggested herbal treatments that you may use for your MS patients to improve their symptoms and slow the progression of their disease:

1. Scutellaria baicalensis (Huang Qin): Scutellaria baicalensis is an important medicinal herb widely used for the treatment of various inflammatory diseases in Asia.  In an experimental model, Scutellaria reduced inflammatory cytokines. This will help reduce the autoimmune component of MS. Additionally, in an experimental mouse MS model, pre-treatment with Scutellaria for three days prior to induction of experimental MS reduced time to onset, severity and incidence of MS. The results suggest that Scutellaria might be effective in the treatment of MS.
2. Centella asiatica (Gotu Kola): This herb is traditionally used to improve memory and treat neurological disorders. A study found a dose dependent inhibitory effect of Centella on the activity of enzymes that are associated with increased PLA2 activity in the brain; addressing aspects of lipid dysregulation and inflammatory precursors.
3. Rehmannia glutinosa (Sheng Di Huang): Research has found rehmannia inhibits tumour necrosis factor (TNF)-alpha secretion by inflammation-activated cells in the CNS, having an anti-inflammatory action in the CNS.
4. Silybum marianum: Silibinin is the major pharmacologically active compound of Silybum marianum fruit extract. Research in an experimental mouse MS model showed that silibinin significantly reduced the histological signs of demyelination and inflammation. The researchers demonstrated that silibinin down-regulated the secretion of pro-inflammatory cytokines and up-regulated anti-inflammatory cytokines both in vivo and ex vivo. These results indicate that silibinin is both immunosuppressive and immunomodulatory in MS.
5. Curcuma longa (Jiang Huang): Curcumin, the active component of Curcuma longa, has been shown to ameliorate MS by regulating many of the inflammatory cytokines associated with this autoimmune disease.

Also worth considering if viral infection is suspected as a triggering factor in your MS patient, are antiviral herbs. There are many antiviral TCM formulas that will help to reduce or suppress EBV infection. These should be selected on the basis of patient pattern presentation.

Addressing MS in a Clinical Setting: Nutritional Support

These nutritional recommendations may also be useful for your MS patients:

1. Vitamin D3: Long-term supplementation of Vitamin D is associated with a decreased MS incidence. Supplement vitamin D3 at approximately 2000 to 3000IU daily. Additionally, osteoporosis is commonly seen in MS; vitamin D is essential for healthy bone structure and is a useful prophylactic treatment.
2. Fish oil: Purified fish oils have a broad range of benefits in the MS patient. Fish oils are omega-3 oils and are anti-inflammatory. By increasing omega-3 oil concentration the disordered lipid metabolism seen in MS is better balanced. In a study done on relapsing MS patients, fish oil supplementation over six months reduced MS symptoms and reduced relapsed rates. Fish oil supplementation will be more effective at reducing inflammation if excessive trans and saturated fats in the diet are avoided. Of benefit too, is the finding that treatment with fish oil dose-dependently inhibited the inflammation induced production of MMP-9.
3. Folate, Vitamins B12, B6: Homocysteine (HCy) levels are reduced by folate and vitamin B6 and B12 through methylation of HCy; having the benefits of reducing HCy-induced inflammation and oxidative damage in the CNS. The expression of latent viral oncogenes and RNA is under a strict epigenetic control via DNA methylation and histone modifications that result in a complete silencing of the EBV genome in memory B cells. Folate, vitamin B6 and B12 are essential for this methylation action. Adequate intake of these nutrients, may therefore reduce EBV expression.
4. Magnesium: Magnesium reduces the production of the neuroexcitatory amino acid, glutamate, thereby protecting the brain. Magnesium is also well known for its role in energy production and inducing relaxation of muscles and the nervous system.
5. Resveratrol: Resveratrol, a compound found in plant products such as red grapes, exhibits antioxidant and anti-inflammatory properties. Research has shown resveratrol treatment decreased the clinical symptoms and inflammatory responses in the experimental mouse MS model. Furthermore, significant apoptosis was observed in inflammatory cells in the spinal cord of mice that were treated with resveratrol compared with the control mice. Resveratrol triggered high levels of apoptosis in activated T-cells. Resveratrol administration also led to significant down-regulation of certain cytokines and chemokines in experimental mice, including TNF-alpha, IFN-gamma and IL-17. In the eye, axonal damage and loss of neurons correlate with permanent vision loss and neurologic disability in patients with MS. Resveratrol stimulates the protective substance SIRT1. SIRT1 activators provide an important potential therapy to prevent the neuronal damage that leads to permanent neurologic disability in optic neuritis in MS patients.

As well as these herbs and nutrients it may be advisable to recommend your MS patients avoid artificial sweetners such as aspartate, which is toxic to the CNS.  Also, ensure they avoid cigarette smoke as smoking is a strong risk factor for MS development. Finally, make sure your MS patients get daily sunlight exposure; just 15 to 30 minutes of sun per day on bare skin will increase vitamin D production.

Taking a Broad View of MS Management

Although many of the previously recommended management options include nutritionals, combining them with the appropriate TCM herbal formula, as discussed in other articles in this newsletter, gives a broader range of activity and successfully addresses many of the contributing factors in MS onset, progression and prognosis. Incorporating these herbal, nutritional and lifestyle recommendations into your MS treatment protocol will give you more confidence in addressing this complex autoimmune condition with consequent benefits to your MS patients’ health.