DCs Treating the Multiple Sclerosis Patient

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

FROM:   ACA News ~ May 2015

By Lori A. Burkhart

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Multiple Sclerosis (MS) is the most common disabling neurological disease of young adults, according to the National Institutes of Health (NIH), most often appearing when people are between 20 and 40 years old. However, it can also affect children and adults over 40. The U.S. National Library of Medicine defines MS as an autoimmune disease that affects the central nervous system (brain and spinal cord). The myelin sheath, a protective membrane that wraps around the axon of a nerve cell, is destroyed in a patient with MS; this is caused by inflammation. That damage causes nerve signals to slow down or stop. MS affects women more than men.

Since doctors of chiropractic are recognized as primary contact neuromusculoskeletal specialists, most will have patients with undiagnosed MS come into their practices. The DC will diagnose the patient, treat certain symptoms and make the appropriate referrals.

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Diagnosis

Diagnosis of MS is complicated in that it can be severe or mild and can go into remission. NIH points out that initial symptoms often are double or blurred vision, red-green color distortion or blindness in one eye. Most MS patients experience muscle weakness in their extremities and difficulty with coordination and balance.

According to Larry Wyatt, DC, DACBR, FICC, professor and senior faculty, division of clinical sciences at Texas Chiropractic College, MS is diagnosed in a number of ways, as its clinical course is distinctive in each patient and there are different types of MS. Some patients with obvious MS are diagnosed by clinical signs and symptoms (i.e., attacks) alone. These patients will have MS attacks that often relapse for months or even years. In other patients further testing is necessary. Magnetic resonance imaging (MRI), often with gadolinium enhancement, is the mainstay of diagnosis in most cases. “Patients with MS will very often have multiple high-signal intensity lesions in the brain and/or spinal cord on T2-weighted images,” Dr. Wyatt says. “In addition, cerebrospinal fluid analysis for immunoglobulin content can be quite helpful. There is a specific set of criteria, called the McDonald Criteria, which outline the findings necessary for the diagnosis of the different forms of MS.”

Jason West, DC, DCBCN, a fourth-generation DC who operates a clinic in Pocatello, Idaho, says the majority of the diagnosis comes from the patient history, but he points out that usually when patients with MS come in, they already are diagnosed and they are unhappy with their medical treatment options. “If they weren’t diagnosed, one of the standards is to do an MRI and look for white lesions, and there is also a spinal tap to look for antibodies,” Dr. West says. “Usually these patients have a history of peripheral neuropathy or neurological disease or processes occurring.”

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Symptom Management

There is no cure for MS. There is only management of symptoms, and MDs typically treat with medications such as corticosteroids and interferon. In most cases there is a natural, although unpredictable, course of remissions and exacerbations. Dr. Wyatt points out that this can make it difficult to ascertain the effectiveness of any therapeutic regimen. “From the perspective of the chiropractic physician, treatment is focused on the management of the neuromusculoskeletal sequelae of the disease,” he says. “Manual therapies and rehabilitation can be quite helpful in managing those sequelae, but there is no evidence to support the idea that such therapies will alter the course of the disease. Therapeutic exercise seems to show the most promise. Nutritional therapy has not been shown to alter the course of the disease.”

“Neuromusculoskeletal adjustments are one way to balance the body, and those are palliative to patients with MS,” Dr. West says. He thinks of MS as a dysfunctional immune disease and says, “The worse thing we can do is give immunosuppressant therapy that knocks down the immune system.” He continues, “Perhaps the medical treatment is working for some people, but I usually have people come in to my office who say, ‘I’ve been put on Enbrel or Humera or methotrexate, and I feel awful.’” He adds that these patients are actively looking for treatment options. “I am not anti-medicine, and in some cases, patients need short-term anti-inflammatories,” he says. “As a profession, we do a fantastic job on MS if the DC has the confidence to treat it, especially because we treat nerves.”

From an overall wellness perspective, Dr. West tells patients not to abuse their bodies, to eat well and to have the right environment. He points out that there are a lot of emotional problems associated with chronic diseases. “I tell patients whether it’s prayer, meditation, emotional release or counseling, you have to deal with the emotions. I am hands-off on how they do that, but it is something they need to do.”

Generally, Drs. Wyatt and West are unaware of any definitive contraindications to manual therapy for MS specifically, save for those contraindications that would apply to all patients. But Dr. Wyatt cautions, “That being said, the use of modalities in patients with MS who experience sensory losses may be contraindicated, as the patient would be unable to voice any adverse reactions as they wouldn’t be able to feel the sensations associated with such reactions. As to manipulation, the general rules of contraindications would apply.”

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Integrative Care and Evidence

Integrative care with a multidisciplinary team of healthcare providers is the best approach to MS, according to Dr. Wyatt. “There is no one therapy that is considered the gold standard per se,” Dr. Wyatt says. “Instead, a management scheme aimed at reducing the number and severity of attacks, addressing physical disabilities and adverse effects on normal activities of daily living, and handling the psychosocial aspects of the disease is critical.”

MS can be a devastating disease with life-altering and many times life-shortening consequences. Dr. Wyatt notes that patients will often search for any therapy that might be helpful, out of desperation. “There is no panacea for MS, and to take advantage of the psychological vulnerability of the patients by using unproven and sometimes dangerous therapies is unethical, at best,” he says.

Dr. Wyatt adds that DCs need to understand that the disease often remits intermittently, and clinicians might be fooled into a false sense of therapy effectiveness because of these remissions. “There are myriad alternative therapies that claim to be beneficial in the management of MS patients,” Dr. Wyatt warns, adding, “There is scant evidence to support such therapies. It behooves the clinician to investigate any such therapies for a solid evidence base before applying them to an MS patient.”

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Research: MS and Chiropractic

Chiropractic is used to treat symptoms associated with MS, but more research is needed. MS patients often rely on chiropractic for relief, and more education and research to support its use would go a long way toward alleviating the suffering of these patients.

      MS and Chiropractic in the United Kingdom

A study in the United Kingdom (U.K.) states that many of the musculoskeletal symptoms associated with multiple sclerosis (MS) can be managed with physical therapy; chiropractors are well placed to deliver this, but the extent of their involvement in the team management of MS in the U.K. is unknown. The study investigated the level of awareness and use of chiropractic by MS patients at U.K. MS Therapy Centres. Ninety-one percent of respondents had used complementary therapy modalities of some kind, with physiotherapy being the most popular (52 percent), followed by massage (44 percent), then chiropractic (42 percent). Of those who had used chiropractic, 68 percent used it to manage their MS symptoms and most would recommend it to others with MS. Just under half had consulted their general practitioner for approval prior to receiving the treatment, with 79 percent obtaining support. Of those who did not use chiropractic, 78 percent cited lack of knowledge about chiropractic as the main reason. All of the MS therapy centers contacted during the study offered physiotherapy and massage, but none offered chiropractic. There is moderate uptake of chiropractic by people with MS in the U.K. together with a willingness to recommend it. Further awareness of the potential benefits of chiropractic among stakeholders may help its integration into the team management of MS.

Elizabeth A. Carson, Gabrielle Swait, Ian P. Johnson, and Christina Cunliffe
Chiropractic Care Amongst People With Multiple Sclerosis: A Survey of MS Therapy Centres in the UK
Clinical Chiropractic 2009 (Mar); 12 (1): 23–27

      Veterans With MS

In the first study that specifically explored complementary and alternative medicine (CAM) use in veterans with multiple sclerosis (MS), 451 veterans were surveyed. CAM use among veterans with MS was widespread, with 37 percent of respondents reporting current or past use. The numbers for chiropractic revealed that 15 percent were using chiropractic and another 15 percent desired to use it. The report concludes that CAM use is prevalent among veterans with MS who receive VHA health care. Many of the surveyed nonusers desire CAM services. VA healthcare providers who work with MS patients would be well served to be knowledgeable about, screen for, and use CAM when appropriate. Particular attention to the likelihood of CAM use among highly educated patients in poor health is warranted.

Duncan G . Campbell, PhD; Aaron P. Turner, PhD; Rhonda M. Williams, PhD; Michael Hatzakis Jr, MD; James D. Bowen, MD; Arthur Rodriquez, MD, MS; Jodie K. Haselkorn, MD, MPH
Complementary and Alternative Medicine Use in Veterans With Multiple Sclerosis: Prevalence and Demographic Associations
J Rehabil Res Dev. 2006 (Jan); 43 (1): 99–110

      Chiropractic to Treat Chronic Pain in MS Patients

The study states that 5 to 10 percent of MS patients will enter a long-term care facility. The majority of MS patients suffer from some type of pain syndrome, which can be divided into three categories: acute, subacute or paroxysmal and chronic. Chronic pain syndromes have been anecdotally reported to respond to mechanical treatments. Chiropractic has shown efficacy in the treatment of chronic spinal pain. Chiropractic may represent a viable treatment option for the MS patient suffering from chronic pain syndromes. Preliminary findings from this clinic suggest that chiropractic may represent one treatment alternative for chronic pain in MS patients in a long-term care facility. Further studies will be needed to definitively determine the efficacy of chiropractic for the management of chronic pain in the MS patient.

Paul Dougherty, and Dana Lawrence
Chiropractic Management of Musculoskeletal Pain in the Multiple Sclerosis Patient
Clinical Chiropractic 2005 (Jun); 8 (2): 57–65

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